What's new in hospital medicine

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

GENERAL HOSPITAL MEDICINE

Small-volume blood collection tubes to reduce anemia in the intensive care unit (October 2023)

Patients in the intensive care unit (ICU) undergo numerous blood draws that could contribute to anemia, but the magnitude and clinical significance are unknown. In a recent trial, switching to small-volume blood collection tubes led to a smaller decline in hemoglobin and a slightly reduced need for transfusion without compromising laboratory analysis [1]. Use of smaller collection tubes may be a useful approach to minimizing anemia in ICU patients. (See "Use of blood products in the critically ill", section on 'Preventing and treating other causes of anemia'.)

ACIP recommendations for 2023-24 seasonal influenza vaccination (September 2023)

The Advisory Committee on Immunization Practices (ACIP) issued new recommendations for seasonal influenza vaccination in August 2023 (table 1) [2]. The antigenic composition has been updated. In addition, the ACIP now states that egg allergy alone no longer necessitates additional safety measures for influenza vaccination, including with egg-based vaccines, beyond those recommended for any recipient of any vaccine, regardless of severity of previous reaction to egg. All vaccines should be administered in settings where personnel and equipment needed for prompt recognition and treatment of acute hypersensitivity reactions are available. This is consistent with our previous guidance. (See "Seasonal influenza vaccination in adults", section on 'Antigenic composition'.)

Updated COVID-19 mRNA vaccine recommendations (September 2023)

The US Food and Drug Administration and Centers for Disease Control and Prevention have updated COVID-19 vaccine authorizations and recommendations [3,4]. Available COVID-19 vaccines have been updated to target Omicron variant XBB.1.5 (Moderna COVID-19 vaccine 2023-2024 formula, Pfizer COVID-19 vaccine 2023-2024 formula, and Novavax 2023-2024 formula); bivalent vaccines are no longer available. An updated 2023-2024 formula vaccine is recommended for all individuals aged six months and older. Immunocompetent individuals five years and older should receive one updated vaccine, regardless of prior vaccination history. For individuals who are four years or younger or have an immunocompromising condition (table 2), the number of recommended updated vaccines depends on their vaccination history. Our approach to COVID-19 vaccination is consistent with these recommendations. (See "COVID-19: Vaccines", section on 'Indications and vaccine selection' and "COVID-19: Vaccines", section on 'Benefits of vaccination'.)

HOSPITAL CARDIOVASCULAR MEDICINE

Liberal transfusion strategy for acute myocardial infarction (December 2023)

Restrictive transfusion (transfusing at a lower hemoglobin, typically <7 or 8 g/dL) is appropriate for most patients based on evidence from randomized trials, but trial data for patients with acute myocardial infarction (MI) have been slower to accumulate. In the MINT trial, which randomly assigned 3504 patients with acute MI and anemia to a restrictive or liberal (transfusing for hemoglobin <10 g/dL) strategy, there was a trend toward better outcomes with the liberal strategy without an increased risk of adverse events [5]. We now suggest a liberal strategy for acute MI. A slightly lower hemoglobin may be reasonable for stable, asymptomatic patients, and patients with hemodynamic instability may require a higher hemoglobin. (See "Indications and hemoglobin thresholds for RBC transfusion in adults", section on 'Acute MI'.)

Pericardiocentesis risks in patients with pulmonary hypertension (November 2023)

Case series suggest that patients with pulmonary hypertension (PH) may be at risk for hemodynamic collapse during pericardiocentesis, but data are limited and conflicting. A National Inpatient Sample database study of over 95,000 adults (including nearly 8000 with PH) who underwent pericardiocentesis assessed in-hospital outcomes [6]. In patients with PH, pericardiocentesis was associated with higher adjusted rates of in-hospital mortality and postprocedure shock than in patients without PH. These findings suggest that hemodynamic monitoring during pericardiocentesis is particularly important in patients with PH. (See "Pericardial effusion: Approach to management", section on 'Pulmonary hypertension'.)

Virtual inpatient consultation to optimize medical therapy for heart failure (August 2023)

Patients with systolic heart failure (HF) benefit from a multidrug medical regimen, but barriers to achieving optimal therapy include therapeutic inertia, adverse effects, and polypharmacy. In a recent randomized trial in nearly 200 inpatients with systolic HF, virtual consultation by an HF cardiologist and pharmacist resulted in more appropriate changes to medical therapy than usual care [7]. In particular, compared with the usual care group, more patients in the virtual consultation group had intensification of HF therapy or initiation of new HF medications. Inpatients with HF benefit from specialist review of their medical regimen, which may result in durable changes that lead to lower risks of mortality or future HF hospitalizations. (See "Systems-based strategies to reduce hospitalizations in patients with heart failure", section on 'Decision support'.)

HOSPITAL GASTROENTEROLOGY

Paracentesis for hospitalized patients with cirrhosis and ascites (November 2023)

Patients with cirrhosis complicated by ascites are at risk for spontaneous bacterial peritonitis and other complications. However, the magnitude of risk associated with deferring diagnostic paracentesis in such patients when they are hospitalized is uncertain. In a large database study comparing late (ie, ≥24 hours) or no paracentesis with early paracentesis in hospitalized patients with ascites, late paracentesis or no paracentesis was associated with higher risk of acute kidney injury (odds ratio [OR] 2.2 and 1.3, respectively) and inpatient mortality (OR 1.5 and 1.4, respectively) [8]. These data support performing diagnostic paracentesis within 24 hours of hospital admission, which is consistent with our practice. (See "Diagnostic and therapeutic abdominal paracentesis", section on 'Indications'.)

Timing of appendectomy for uncomplicated appendicitis (November 2023)

Appendectomy is traditionally performed urgently to reduce the risk of perforation. However, a large randomized trial showed that patients with uncomplicated appendicitis (including those with appendicolith on computed tomography) who had an in-hospital delay of up to 24 hours before surgery had no increased risk of perforation or other complications compared with those who underwent surgery within 8 hours [9]. Given these data and general acceptance of antibiotic management of these patients, we suggest performing appendectomy within 24 hours of presentation in patients with uncomplicated appendicitis who elect to undergo surgery. (See "Management of acute appendicitis in adults", section on 'Timing of appendectomy'.)

HOSPITAL HEMATOLOGY

Delayed diagnosis of acquired hemophilia A (September 2023)

Acquired hemophilia A (AHA) is a potentially life-threatening bleeding disorder caused by autoantibodies against coagulation factor VIII. Risk factors include older age, cancer, autoimmune disorders, and the postpartum state. In a recent series of 34 individuals with AHA followed for 15 years, diagnostic delays were common (affecting 44 percent of the patients), with a median delay of four months between bleeding onset and diagnosis [10]. The most common reason for the delay was failure to obtain coagulation testing. This study emphasizes the importance of evaluating new-onset unexplained bleeding. (See "Acquired hemophilia A (and other acquired coagulation factor inhibitors)", section on 'Typical presentation and clinical findings'.)

Thrombocytopenia and thrombosis syndrome with adenovirus infection (August 2023)

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a rare, autoantibody-mediated syndrome of thrombocytopenia and thrombosis (central venous thrombosis is common) that can occur after vaccination with an adenoviral-vectored COVID-19 vaccine. The clinical syndrome is similar to heparin-induced thrombocytopenia. A new report describes two individuals with a similar syndrome and VITT-like autoantibodies following documented adenovirus infection [11]. Neither patient had COVID-19 and neither received a COVID-19 vaccine. This finding suggests that a component of the adenoviral sequence may provide the source of the neoantigen. The inflammatory response to infection could provide the "second hit" that causes the syndrome. (See "COVID-19: Vaccine-induced immune thrombotic thrombocytopenia (VITT)", section on 'Mechanisms/triggers of antibody formation'.)

HOSPITAL INFECTIOUS DISEASES

Emerging microbiologic colonization in mechanically ventilated patients (January 2024)

Mechanically ventilated patients act as reservoirs for hospital-acquired pathogens, including Staphylococcus, Pseudomonas, and Aspergillus species. However, a recent surveillance study of 51 acute care and long-term health care facilities reported the emergence of two additional species in mechanically ventilated patients, Acinetobacter baumannii (31 percent of patients, and one-half were carbapenem-resistant) and Candida auris (7 percent, and one-third were newly identified) [12]. Clinicians should be aware of emerging microbiologic species in their local facility so that appropriate surveillance can be conducted and antimicrobial therapy initiated, if indicated. (See "Clinical and physiologic complications of mechanical ventilation: Overview", section on 'Aspiration and ventilator-associated pneumonia and microbial colonization'.)

Nasal decolonization in intensive care units (November 2023)

To reduce hospital-acquired infections, many hospitals provide nasal decolonization with either mupirocin or an iodophor to all patients in intensive care units (ICUs). In a cluster-randomized trial in over 130 hospitals that used universal nasal mupirocin and daily chlorhexidine bathing for ICU patients, switching to nasal iodophor was associated with a higher rate of Staphylococcus aureus growth on clinical cultures than continuing with mupirocin [13]. There was no difference in the rate of bloodstream infection from any pathogen. For hospitals that elect to use nasal decolonization in the ICU, we suggest mupirocin rather than iodophors. This practice may be particularly beneficial in ICUs with high rates of S. aureus infections, including methicillin-resistant strains. (See "Nosocomial infections in the intensive care unit: Epidemiology and prevention", section on 'Patient bathing plus decolonization'.)

Adverse effects with piperacillin-tazobactam versus cefepime (November 2023)

Observational data have raised concerns for nephrotoxicity with piperacillin-tazobactam (when given with vancomycin) and neurotoxicity with cefepime. In an open-label trial of over 2500 patients randomly assigned to piperacillin-tazobactam versus cefepime, the incidence of major kidney events was comparable between groups (9 versus 10 percent), including among the 1900 patients who also received vancomycin [14]. Median antibiotic use was three days. Although the incidence of neurotoxicity (primarily delirium) was higher with cefepime (21 versus 17 percent), imbalances in baseline delirium rates reduce confidence in that finding. These data reduce concern for nephrotoxicity with short-term coadministration of piperacillin-tazobactam and vancomycin (eg, for initial empiric therapy). For those who warrant prolonged therapy with vancomycin plus an antipseudomonal agent, we weigh the uncertain risks of nephrotoxicity and neurotoxicity when choosing between piperacillin-tazobactam and cefepime. (See "Beta-lactam antibiotics: Mechanisms of action and resistance and adverse effects", section on 'Renal reactions'.)

Sulbactam-durlobactam for Acinetobacter infections (November 2023)

Antibiotic options for infections due to Acinetobacter spp are limited due to high rates of resistance. The US Food and Drug Administration recently approved a new beta-lactam/beta-lactamase inhibitor antibiotic, sulbactam-durlobactam. In an international randomized trial of 125 patients with carbapenem-resistant Acinetobacter infection (mainly hospital-acquired or ventilator-associated pneumonia), sulbactam-durlobactam resulted in a trend toward lower all-cause mortality that was not statistically significant (19 versus 32 percent) and a higher clinical cure rate (62 versus 40 percent) compared with colistin [15]. We reserve this agent for patients with hospital-acquired pneumonia or bacteremia due to susceptible Acinetobacter baumannii complex isolates that are resistant to other first-line agents (ie, other beta-lactams, carbapenems, and fluoroquinolones). (See "Acinetobacter infection: Treatment and prevention", section on 'First-line antibiotics'.)

Convalescent plasma in mechanically ventilated patients with COVID-19 (November 2023)

Most randomized trials have not demonstrated a benefit for convalescent plasma in hospitalized patients with COVID-19, and we do not routinely use it in this setting. However, an open-label trial of 475 patients who were mechanically ventilated for severe COVID-19 did report a reduction in 28-day mortality with high-titer convalescent plasma compared with standard care (35 versus 45 percent) [16]. The inconsistency of this finding compared with the lack of effect in most other trials decreases confidence in the mortality benefit. Furthermore, the value of convalescent plasma against Omicron variants and in the context of contemporary management remains uncertain, as only a few patients in the trial had Omicron infection and most received only dexamethasone without other immunomodulatory agents. (See "COVID-19: Management in hospitalized adults", section on 'Limited role for antibody-based therapies (monoclonal antibodies and convalescent plasma)'.)

Role of glucocorticoids for tuberculous meningitis in patients with HIV (October 2023)

Glucocorticoids are an adjunctive therapy for tuberculous (TB) meningitis; however, data for patients with HIV infection are limited. In a randomized trial including 520 adults with TB meningitis and HIV in Vietnam and Indonesia (approximately one-half with CD4 cell count ≤50/microL), mortality over 12-month follow-up was comparable when a dexamethasone taper or placebo was added to antituberculous therapy (44 versus 49 percent) [17]. The incidence of immune reconstitution inflammatory syndrome during the first six months and the number of patients with adverse events were similar. We continue to suggest adjunctive glucocorticoid therapy for patients with HIV and TB meningitis; while available data do not clearly demonstrate improved survival, it may confer a small reduction in mortality with no increased risk of significant adverse effects. (See "Central nervous system tuberculosis: Treatment and prognosis", section on 'Glucocorticoids'.)

Polymicrobial sepsis from platelet transfusion (October 2023)

The risk of transfusion-transmitted bacterial infection is exceedingly low. However, a recent report documented seven cases of polymicrobial sepsis across six different states, three of which were fatal, from platelet transfusions [18]. An investigation determined the source to be the manufacturing facility of the apheresis platelet collection sets. This report highlights the importance of reporting suspected transfusion reactions to facilitate such investigations and the need for ongoing vigilance, despite the overall high and continuously improving safety of blood products. (See "Transfusion-transmitted bacterial infection", section on 'Microbiology'.)

Adjunctive immunomodulators for severe COVID-19 (August 2023)

For patients hospitalized for COVID-19 who require high-flow oxygen or ventilatory support, we suggest adding baricitinib or tocilizumab to dexamethasone to further reduce mortality. Other immunomodulatory agents may also improve outcomes. In a randomized trial of patients with severe COVID-19, most of whom were on remdesivir and glucocorticoids, infliximab and abatacept each reduced 28-day mortality compared with placebo (10 and 11 versus 15 percent) but did not improve time to clinical improvement [19]. The trial did not detect a benefit with cenicriviroc. Despite their potential efficacy, we do not routinely use infliximab or abatacept for COVID-19, because they do not offer clear advantages over baricitinib or tocilizumab, which have more established benefit and, in the United States, are approved for this indication. (See "COVID-19: Management in hospitalized adults", section on 'Limited roles for alternative immunomodulators'.)

Revised Duke criteria for diagnosis of infective endocarditis (August 2023)

The Duke criteria for diagnosis of infective endocarditis (IE) have been revised to reflect changes in the epidemiology of IE, as well as new imaging and diagnostic tools [20]. The 2023 Duke-International Society for Cardiovascular Infectious Disease criteria classify Enterococcus faecalis as a typical cause of IE regardless of acquisition site (eg, community or healthcare associated) or presence of a primary extracardiac focus; previously E. faecalis was included as a major criterion only if community acquired and in the absence of a primary focus. The criteria also incorporate advances in microbiologic diagnostic testing, such as tissue polymerase chain reaction (such as amplicon or metagenomic sequencing and in situ hybridization). Advances in imaging include improved understanding of the diagnostic utility of cardiac computed tomography (CT) and fluorodeoxyglucose positron emission tomography with CT for detection of IE. (See "Clinical manifestations and evaluation of adults with suspected left-sided native valve endocarditis", section on 'Basis for Duke criteria revision'.)

HOSPITAL NEUROLOGY

Time window to start dual antiplatelet therapy for high-risk TIA or minor ischemic stroke (January 2024)

There is evidence from several randomized trials that early initiation of short-term dual antiplatelet therapy (DAPT) for select patients with high-risk transient ischemic attack (TIA) or minor ischemic stroke reduces the risk of recurrent ischemic stroke. The evidence comes from trials that started DAPT within 12 to 24 hours of symptom onset. Results from the recent INSPIRES trial suggest that DAPT is still beneficial when started up to 72 hours after symptom onset [21]. Although the time window is extended by the results from INSPIRES, we start DAPT as soon as possible for patients with high-risk TIA or minor ischemic stroke. (See "Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack", section on 'High-risk TIA and minor ischemic stroke'.)

Low-dose dexamethasone for severe migraine in adults (October 2023)

Parenteral dexamethasone is used along with short-acting abortive therapies to reduce migraine recurrence for patients with severe symptoms, but optimal dosing is uncertain. Prior trials have reported benefit at doses ranging from 8 to 24 mg. In a recent trial of 209 adults with moderate to severe migraine presenting to the emergency department treated with metoclopramide and intravenous (IV) dexamethasone, rates of sustained relief at 48 hours were similar between groups randomly assigned to 4 versus 16 mg of dexamethasone [22]. Rates of immediate headache relief and medication use in the week following discharge were also similar. These results support our preference for adjunctive dexamethasone at a dose of 4 mg IV to reduce migraine recurrence. (See "Acute treatment of migraine in adults", section on 'Abortive therapy plus parenteral dexamethasone'.)

Using head CT alone to exclude aneurysmal subarachnoid hemorrhage (July 2023)

Diagnosing aneurysmal subarachnoid hemorrhage (SAH) can be challenging in patients with isolated headache whose initial bleeding is minor because head computed tomography (CT) can miss small bleeds. Morbidity and mortality risk associated with misdiagnosis causes many centers to perform a follow-up lumbar puncture to assess for blood in the cerebrospinal fluid in patients with no evidence of bleeding on CT. However, the sensitivity of high-quality head CT ranges from 95.5 to 100 percent among patients with isolated headache when performed within six hours of the onset of symptoms, potentially rendering a follow-up lumbar puncture unnecessary. Updated guidelines from the American Heart Association now endorse use of head CT to exclude SAH for selected patients when imaging performed within six hours of symptom onset is normal [23]. For properly selected patients (table 3), we agree with using head CT alone when performed within six hours of headache onset to exclude SAH. (See "Aneurysmal subarachnoid hemorrhage: Clinical manifestations and diagnosis", section on 'Need for lumbar puncture when early CT is negative'.)

HOSPITAL PULMONOLOGY AND CRITICAL CARE MEDICINE

Extracorporeal cardiopulmonary resuscitation (December 2023)

Extracorporeal cardiopulmonary resuscitation (ECPR) is being increasingly used, but data are limited and the benefits are uncertain. In a recent meta-analysis of 11 studies (10,000 patients) who underwent CPR, compared with standard CPR, ECPR was associated with decreased in-hospital mortality and increased long-term favorable neurologic outcome and survival at one year [24]. The benefit of ECPR was confined to patients with in-hospital cardiac arrest. These data support the growing practice of ECPR in select patients likely to benefit. (See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)", section on 'Sudden cardiac arrest (extracorporeal cardiopulmonary resuscitation)'.)

Guidelines for primary spontaneous pneumothorax (December 2023)

The British Thoracic Society (BTS) has recently issued new guidelines for the management of primary spontaneous pneumothorax (PSP) [25]. Major changes since 2010 include a symptom- rather than size-based approach. For patients with mild symptoms who are stable following adequate analgesia, monitored observation is preferred, while those with significant dyspnea should undergo a drainage procedure (eg, aspiration or catheter/chest tube thoracostomy). Also promoted was ambulatory management in select patients with adequate outpatient support. We agree with these recommendations. (See "Treatment of primary spontaneous pneumothorax in adults", section on 'Initial evaluation and management'.)

Heart rate control in septic shock (December 2023)

Beta blockade has the potential to limit harm from the adrenergic overdrive that occurs in septic shock. However, data to support heart rate control in patients with septic shock are limited. In a recent, unblinded randomized trial of 126 patients with septic shock-related tachycardia (heart rate ≥95/min) who were receiving norepinephrine, the beta blocker landiolol did not reduce organ failure as measured by the sequential organ failure assessment score [26]. Furthermore, landiolol was associated with increased 28-day mortality compared with standard care (37 versus 25 percent). We continue to avoid the routine use of beta blockers in patients with septic shock. (See "Investigational and ineffective pharmacologic therapies for sepsis", section on 'Heart rate control'.)

No benefit to tight glucose control in critically ill patients (December 2023)

In earlier studies that showed benefit from tight glucose control in critically ill patients, early parenteral nutrition was a potential variable that influenced the outcome. In a recent study of over 9000 patients in whom parenteral nutrition was withheld for a week, 90-day mortality, duration of intensive care unit care, and several other outcomes (eg, infections) were similar when liberal glucose control was compared with tight glucose control [27]. These results are consistent with more recent studies that support the use of liberal rather than tight targets for glucose control in critically ill patients. (See "Glycemic control in critically ill adult and pediatric patients", section on 'Adults'.)

Pulmonary embolism in patients with severe COPD exacerbation (September 2023)

Pulmonary embolism (PE) is an important potential trigger for COPD exacerbation. In a recent multicenter study, 1580 patients with COPD who were admitted to the hospital with acute worsening of respiratory symptoms were all screened for PE with computed tomography pulmonary angiogram within 48 hours of admission [28]. PE was identified in 266 (17 percent), with 166 patients (11 percent) having PE involving the main or lobar pulmonary arteries. Purulent sputum production decreased the odds of PE by 60 percent. We suggest obtaining imaging for PE in patients requiring admission for COPD exacerbation who do not have evidence of other triggers (eg, infection or heart failure). (See "COPD exacerbations: Clinical manifestations and evaluation", section on 'Triggers' and "COPD exacerbations: Clinical manifestations and evaluation", section on 'Additional testing'.)

High-flow oxygen for acute hypoxemic respiratory failure (August 2023)

In adult patients with acute nonhypercapnic hypoxemic respiratory failure, the benefits of high-flow oxygen delivered via nasal cannulae (HFNC) compared with conventional low-flow oxygen (COT) are unclear. A recent meta-analysis of six trials (over 2700 patients with acute hypoxemic respiratory failure) reported that while HFNC did not reduce 28-day mortality compared with COT, it did significantly reduce the rate of reintubation (relative risk 0.89, 95% CI 0.81-0.97) [29]. These data support the use of HFNC in patients with acute hypoxemic respiratory failure who have escalating oxygen needs. (See "Evaluation and management of the nonventilated, hospitalized adult patient with acute hypoxemia", section on 'Humidified, high-flow oxygen delivered via nasal cannulae (HFNC)'.)