Internal Medicine Residency News, June 8, 2015

June 8, 2015

From the Director

We are in our second week of iCOMPARE…thanks to everyone for your feedback and your hard work to transition the schedules. We had a great State of the Department Grand Rounds on Friday by Dr. Klotman, and please mark your calendars for the next THREE Friday mornings to see Nilesh, Coral and Bonike give their grand rounds!! The SAR dinner was amazing…loved seeing everyone all dressed up, and the roasts were hilarious. Of course, what happens at SAR dinner stays at SAR dinner, but what a great time. Thanks to Jen, Lynsey, Lauren and Tia for your outstanding planning and to Amit Bhaskar and Joe Brogan for emceeing. We’ve also gotten universally outstanding feedback on the transition of morning report to Duke from DRH. Thanks Bonike and Venu!

Kudos this week to Jess Morris for helping out at the VA from Jessie Seidelman, and to LiWen Huang for an excellent chair’s presentation.

What is on the books for the rest of June? ERAS opens, so the fellowship-bound JARs can start to upload applications. Also, we have our housestaff picnic and potluck on June 13th at Elodie Farms. Picture day is TOMORROW at 9 am outside the Trent Semans Center due to our “rain out” on Friday.

This week’s pubmed from the program goes to Stephanie Giattino! Mohammad S, Giattino S.L., Keenan R.T. Current and Emerging Therapies for Gout. Curr Treat Options in Rheum. 2015; 1(2):143-155

Have a great week!
Aimee

What did I read this week?

(submitted by Coral Giovacchini, MD)

Reference:

Torres, Antoni et al. The Effect of Corticosteroids on Treatment Failure among Hospitalized Patients with Severe Community-Acquired Pneumonia and High Inflammatory Response: A Randomized Clinical Trial. JAMA. 2015; 313(7):677-86

Why Did I Read This:

This is an article that has been getting lots of press recently (including a discussion at the recent International American Thoracic Society Conference) relating to a very common problem that we see in our patient population admitted to Duke.

Background:

Community-acquired pneumonia (CAP) is a leading cause of infection related death in the US. Despite the numerous resources available to treat CAP, treatment failure, which is estimated to complicate up to 20% of CAP cases, continues to be associated with a significantly higher mortality. Because of this association, treatment failure has been used as a surrogate marker of mortality.

Several previous studies have investigated the role of corticosteroids in moderating the host inflammatory response secondary to infectious pneumonia; however, because of mixed results of patient outcomes in heterogeneous populations the use of corticosteroids in the treatment of CAP remains controversial. The authors of this study suggest that corticosteroid use in previous studies may not have demonstrated favorable effects because of the broad application to all-comers with CAP, regardless of the severity of presentation. They further hypothesized that in patients presenting with severe CAP (presumably conveying a more severe inflammatory cascade), the application of corticosteroids could modify the cytokine response and decrease rates of treatment failure for this specific patient population.

Study Methods & Results:

The authors designed a prospective multicenter, randomized, double-blind, placebo-controlled trial in patients presenting with severe CAP and a documented “high inflammatory response”, ultimately randomizing 120 adult patients over the time between 2004 and 2012. Critical eligibility criteria included age 18 years or older, clinical symptoms suggestive of pneumonia, documented infiltrate by chest xray, meeting criteria for “severe CAP” (i.e. high PSI risk class), and a serum CRP >150mg/L. Notably, patients were excluded if they were already on steroids at the time of admission, met criteria for HCAP, had uncontrolled DM or other immunocompromising state, or were diagnosed with influenza A.

Enrolled patients were randomized to receive either IV methylprednisolone at a dose of 0.5mg/kg or placebo q12h for the first 5 days of their treatment. Antibiotic choices were guideline-based.

The primary outcome measure was treatment failure. Treatment failure was defined as:

“Early”: clinical deterioration within 72 hours (including development of shock, need for mechanical ventilation, or death)
“Late”: clinical deterioration between 72-120 hours by the same above listed parameters, radiographic progression of infiltrates, persistent severe respiratory failure (Pa02/Fi02 ratio <200mmHg + RR >30 but not requiring intubation), or death.

All patients had sputum, urine, and blood cultures as well as nasopharyngeal swabs sent, in addition to routine serum laboratories. Further, CRP, procalcitonin, IL6, IL8 and IL10 were monitored on admission, then again on treatment days 3 and 7.

The only noted differences between the groups after randomization was a difference in higher levels of presentation with septic shock and higher levels of admission serum procalcitonin levels in the placebo group and interestingly a non-significant trend toward higher serum CRP in the methylprednisolone group. Overall 90 (75%) of the enrolled patients were admitted to ICU level care, with the remainder of patients on step-down ward care.

The authors performed both an intention to treat and per-protocol analyses of the results. Choices in antibiotic therapy, time to antibiotic administration and overall distribution of isolated pathogens were similar across the groups, with Streptococcus pneumoniae most commonly isolated in both groups. Interestingly, there was “improved” microbiologic diagnosis in the methylprednisolone group. The intention to treat analysis indicated that there was a statistically significant decrease in overall treatment failure in the methylprednisolone group compared to placebo (13% VS. 31%, p=0.02); however the 18% difference between the groups was due to a difference in “late” treatment failure, attributable to radiographic progression. This was also noted in the per-protocol analysis. There was no overall statistically significant difference in either time to clinical stability or in-hospital mortality between the groups.

Discussion and Commentary:

This article is interesting in that it superficially concludes that there is a statistically significant improvement in treatment failure in patients presenting with severe CAP and an elevated CRP treated with IV methylprednisolone. In the discussion, the authors state that the study “demonstrated that the acute administration of methylprednisolone was associated with less treatment failure and a lower inflammatory response” in this prospective patient population; however, the component of late treatment failure driving this outcome was progression of a radiographic infiltrate after 3 days without any other clinical differences between the patient groups (i.e. methylprednisolone did not decrease mortality, nor did it significantly decrease need for mechanical ventilation). The clinical significance of a progressive infiltrate is rather controversial given no other changes in patient outcomes, as we know that radiographic progression can occur even while a patient is clinically improving, and radiographic improvement often lags well behind clinical improvement. There was a trend in more rapid decline in CRP levels, which some critics have postulated might be related to a blunting of the Jarisch-Herxheimer reaction to higher cytokine release after the initiation of antibiotics in patients with a high bacterial load (i.e. similar to the rational for steroid use in meningococcal meningitis). More studies are likely warranted to evaluate whether reducing radiographic progression of infiltrates in pneumonia translate into benefits in patient outcome prior to a change in practice.

QI Corner

Congratulations everyone on a great year! This week we will be having a PSQC meeting - our last of the year - to reflect on the year and plan for the next. We are working on publishing the "Full Fever Workup" project that some of you helped out with, and we would love to hear feedback from everyone as we move the manuscript towards submission.

5:30pm, Wednesday

Med Res Library

Food, as always

Clinic Corner

It is that time of year…

After 3 years at the DOC, we say goodbye to our SARs…and the patients will really miss you…I often hear from patients, months after the SARs have left, how much patients miss you!!

Goodbye and best of luck from all of us at the DOC..

A few reminders for the rest of us!

Welcome to the new interns..Thurs AM June 25 you will see them at the DOC for orientation…some will then start Monday June 29..so we welcome them!

Need nutritionist for a Medicaid pt? Sheila White, will see pts either at home or in clinic, just write in followup section…

You will all be emailed copies of the new Thrive Guide..as well as it being on the Med Hub home page under ambulatory. We have updated it, and will do our best to keep it updated, so use it when you have a questions, and give any suggestions for improvements to me!

See Thrive Guide addendums for ideas for Margney referrals, and depression algorithm and more!

New info in OSA addendum about referral to Ambroise Chaing of Pulm for OSA eval, and when to use the option of home OSA testing (when pretest prob high, and it is much more cost effective!)

Please remember to copy the attending in the follow-up section of the Maestro note..and if a pt no showed you need to do nothing to the note if you didn’t open it..if you want to call the pt and have them reschedule, that would be awesome!

We know from studies that the MD calling is the best way to have the pt come back!

I hope you get to meet our new admin director Lisa Lowe (Jessica Simo in the former similar role)

And lastly , on call?

You should get email the week prior with on call guidelines from the Thrive guide –let me know if you don’t !

Thanks for all your great work at the DOC!

Lynn and the DOC Team!

From the Chief Residents

Grand Rounds

Fri., June 12: Dr Nilesh Patel, Chief Resident

Noon Conference

Date

Topic

Lecturer

Time

Vendor

6/8/15

Cardiac hemodynamics and the Physical Exam

Thomas Bashore