In This Edition
Literature at a Glance: A guide to this month’s studies
- PPI use with clopidrogrel in ACS.
- Chlorhexidine sponge use reduces line infections.
- Extended thienopyridine use does not benefit DES patients.
- CABG is revascularization choice for severe CAD.
- Pre-treated CVC use reduces bloodstream infections.
- Hospitalist use grows in U.S.
- Sepsis order set improves outcomes.
- Admission day predicts acute PE mortality.
PEDIATRIC HM LITerature
Early Transition to Oral Therapy in Acute Osteomyelitis in Children Associated with Fewer Complications I By Mark Shen, MD
Clinical question: Can acute osteomyelitis in children be managed with early transition to oral antimicrobial therapy?
Background: Traditional treatment of acute osteomyelitis in children has involved prolonged intravenous antimicrobial therapy, typically greater than three to four weeks in duration. Small studies suggest the feasibility of a transition to prolonged oral therapy after an initial response to intravenous antimicrobial agents.
Study design: Retrospective, cohort study.
Setting: 29 freestanding children’s hospitals.
Synopsis: Using the Pediatric Health Information System (PHIS) database, 1,969 children were identified via ICD-9-CM codes as having been hospitalized with acute osteomyelitis—and without comorbid conditions—between January 2000 and June 2005. Rehospitalizations were reviewed for complications of both treatment failure and the treatment itself. More than half (1,021) of the children underwent central venous catheterization for prolonged intravenous (IV) therapy; 948 were assigned to the oral therapy group. No significant differences in treatment failure existed between the two groups (5% in the IV group; 4% in the oral group).
Overall, the clinical characteristics of the two groups were indistinguishable. Propensity score analysis was used to handle possible patient-level confounders; a validation study was performed to address misclassifications in assignment. No significant confounding effects were found.
Secondary findings included marked variation across hospitals in the use of oral therapy and increased treatment complications in the IV group. Although unmeasured factors not present in an administrative database may affect results, the strikingly similar groups and outcomes suggest the data are relevant.
Bottom line: Early transition to oral therapy for acute osteomyelitis in children does not increase treatment failure and is associated with fewer treatment complications.
Reference: Zaoutis T, Localio AR, Leckerman K, Saddlemire S, Bertoch D, Keren R. Prolonged intravenous therapy versus early transition to oral antimicrobial therapy for acute osteomyelitis in children. Pediatrics. 2009;123:636-642.
Reviewed by Pediatric Editor Mark Shen, MD, medical director of hospital medicine at Dell Children’s Medical Center, Austin, Texas.
PPI Use with Clopidogrel in Acute Coronary Syndrome Is Associated with Readmissions and Mortality
Clinical question: Does concomitant use of clopidogrel and a proton pump inhibitor (PPI) following hospitalization for acute coronary syndrome (ACS) lead to adverse outcomes?
Background: Prophylactic PPIs often are prescribed with clopidogrel to reduce the risk of gastrointestinal bleeding. Mechanistic studies have shown that omeprazole decreases the platelet-inhibitory effect of clopidogrel, raising concerns that PPIs might interfere with clopidogrel’s beneficial effects. The clinical significance of this finding is unknown.
Study design: Retrospective cohort study.
Setting: 127 VA hospitals.
Synopsis: Investigators used data from the Cardiac Care Follow-up Clinical Study and VA pharmacy records to examine 8,205 male veterans who were hospitalized for ACS and treated with clopidogrel. Patients who filled prescriptions for both clopidogrel and a PPI were at significantly higher risk for death or readmission with ACS compared with those who filled prescriptions for clopidogrel only (adjusted odds ratio, 1.25; 95% confidence interval, 1.11-1.41). Patients who filled prescriptions for PPIs alone had similar risk for adverse events as those who took neither medication.
Subanalyses found similarly increased risk among patients prescribed omeprazole and rabeprazole, but those taking lanzoprazole and pantoprazole were not examined due to the small sample size. Although causality cannot be inferred from this observational study, and the risk associated with combined clopidigrel and PPI use appeared small, alternatives for gastric acid reduction exist. Thus, it may be prudent to restrict PPI use to patients who have a clear indication for their use until more definitive clinical trials can be conducted.