One-year survival did not differ between the patients on the hospitalist-orthopedic comanagement service (70.5%) versus those in the standard care group (70.6%). The hospitalist-orthopedic comanagement model was associated with shorter time to surgery and shorter length of stay (8.4 versus 10.6 days). According to multivariate analysis, independent predictors of mortality were: American Society of Anesthesiologists (ASA) class III or IV (hazard ratio 4.2, 95% CI, 2.21, 7.99), admission from a nursing home (hazard ratio 2.24, 95% CI, 1.73, 2.90), and inpatient complications such as renal failure, myocardial infarction, or ICU admission (hazard ratio 1.85, CI 95%, 1.45, 2.35).
The authors note that prior studies demonstrated benefits from hospitalist involvement only after one year of implementation. This study was performed during the first year of the hospitalist-orthopedic comanagement team.
Bottom line: Hospitalist-orthopedic comanagement of patients with hip fracture reduces length of stay and does not negatively affect long-term mortality.
Citation: Batsis JA, Phy MP, Melton LJ, et al. Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2:219-225.
How Effective Are First-Line, Second-Line Antibiotics for AECB?
Background: Antibiotics are frequently used for treatment of acute exacerbations of chronic bronchitis (AECB). However, in this era of increasing microbial resistance, there are insufficient data comparing the efficacy and safety of first-line antibiotics (ampicillin, amoxicillin, doxycycline, trimethoprim-sulfamethoxazole [Bactrim, Cotrima, Septra]) with second-line antibiotics (amoxicillin-clavulanic acid [Augmentin], macrolides, second- and third-generation cephalosporins, and fluoroquinolones).
Study design: Meta-analysis of randomized controlled trials (RCT).
Synopsis: Authors included 12 RCTs from 1981 to 2000, enrolling 2,261 adult patients comparing the efficacy and toxicity of first-line with second-line antibiotics for AECB in inpatient and outpatient settings. The authors measured treatment success, drug-related adverse events, all-cause mortality and pathogen eradication.
They concluded that administration of first-line antibiotics was associated with lower treatment success than administration of second-line antibiotics (odd ratio [OR] 0.51, 95% CI, 0.34 to 0.75). However, no differences were found with regard to all-cause mortality (OR 0.64, 95% CI, 0.25 to 3.35), adverse effects (OR 0.75, 95% CI, 0.39 to 1.45), or treatment success in microbiologically evaluable patients (OR 0.56, 95% CI, 0.22 to 1.43). Some limitations of this meta-analysis include:
- Inadequate data to stratify patients according to risk factors for poor outcome;
- Trials included inpatients as well as outpatients (likely with varying disease severity); and
- Trials were conducted in different time periods with changing patterns of anti-microbial resistance.
Bottom line: In patients with AECB, second-line antibiotics are more effective than first-line antibiotics with no differences in safety or mortality.
Citation: Dimopoulos G, Siempos II, Korbila IP, et al. Comparison of first-line with second-line antibiotics for acute exacerbations of chronic bronchitis. Chest. 2007;132:447-455.
Do Probiotic Drinks Reduce Antibiotic-Associated Diarrhea?
Background: Patients on antibiotics experience diarrhea as a side effect 5%-25% of the time, of which C. difficile is the cause in 15%-25% of these cases. Probiotics, such as Streptococcus thermophilus, Enterococcus species, Saccharomyces species, and Lactobacillus species are live microorganisms that can safely be used to treat diarrhea associated with antibiotic use.
Study design: Randomized, double-blind, placebo controlled
Setting: Three London hospitals
Synopsis: The study enrolled 135 hospitalized patients over age 50 who were prescribed antibiotics.
The treatment group received a probiotic yogurt drink containing Lactobacillus casei, L. bulgaricus, and S. thermophilus; the placebo group received a sterile milkshake. Subjects consumed the drinks twice daily within 48 hours of starting antibiotic therapy and continued for one week after antibiotic use.
There was a significant reduction of diarrhea in the probiotic group (p=0.007); the number needed to treat (NNT) was five. There was also a significant decrease in diarrhea caused by C. difficile (p=0.001), the secondary outcome, with an NNT of six.