Bottom line: Clinical cure rates of C. diff with fidaxomicin are noninferior to those with vancomycin; however, fidaxomicin is associated with a significantly lower rate of recurrence among those infected with the non-NAP1/BI/027 strain.
Citation: Louie TJ, Miller MA, Mullane KM, et al. Fidaxomicin versus vancomycin for Clostridium difficile infection. N Engl J Med. 2011;364(5):422-431.
ACP Guideline Discourages Use of Intensive Insulin Therapy in Hospitalized Patients
Clinical question: Does the use of intensive insulin therapy (IIT) to achieve tight glycemic control in hospitalized patients (whether in the SICU, MICU, or on the general medicine floor) improve important health outcomes?
Background: Hyperglycemia is a common finding in hospitalized patients and is associated with prolonged length of stay (LOS), death, and worsening health outcomes. Despite this, prospective studies have yet to provide consistent evidence that using IIT to achieve strict glycemic control (80 mg/dL-110 mg/dL) improves outcomes in hospitalized patients.
Study design: Systematic review of MEDLINE and the Cochrane Database of Systematic Reviews from 1950 to January 2010.
Setting: Trials included subjects with myocardial infarction, stroke, and brain injury, as well as those in perioperative settings and ICUs.
Synopsis: The review informing this guideline meta-analyzed 21 trials and found that IIT did not improve short-term mortality, long-term mortality, infection rates, LOS, or the need for renal replacement therapy. Furthermore, IIT was associated with a sixfold increase in risk for severe hypoglycemia in all hospital settings.
Based on these findings, the American College of Physicians (ACP) issued three recommendations:
- To not use IIT to strictly control blood glucose in non-SICU/non-MICU patients with or without diabetes (strong recommendation, moderate-quality evidence);
- To not use IIT to normalize blood glucose in SICU or MICU patients with or without diabetes (strong recommendation, high-quality evidence); and
- To consider a target blood glucose level of 140 mg to 200 mg if insulin therapy is used in SICU or MICU patients (weak recommendation, moderate-quality evidence).
Bottom line: The ACP recommends against using IIT to strictly control blood glucose (80 mg/dL-180 mg/dL) in hospitalized patients, whether in the SICU, MICU, or on the general medicine floor.
Citation: Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011;154(4):260-267.
Limited Benefits Seen with Hospitalist-Neurosurgeon Comanagement
Clinical question: Does hospitalist-neurosurgeon comanagement improve patient outcomes?
Background: The shared management of surgical patients between surgeons and hospitalists is increasingly common despite limited data supporting its effectiveness in reducing costs or improving patient outcomes.
Study design: Single-center, retrospective study.
Setting: Tertiary-care academic medical center.
Synopsis: Data were collected on the 7,596 patients who were admitted to the neurosurgical service of the University of California San Francisco Medical Center from June 1, 2005, to December 31, 2008. The study looked at 4,203 patients (55.3%) admitted before July 1, 2007, when hospitalist comanagement was implemented, and 3,393 patients (44.7%) after comanagement began. Of those admitted during the post-implementation period, 988 (29.1%) were comanaged.
After adjusting for patient characteristics and background trends, and accounting for clustering at the physician level, no differences were found in patient mortality rate, readmissions, or LOS after implementation of comanagement. No consistent improvements were seen in patient satisfaction.
However, physician and staff perceptions of safety and quality of care were significantly better after comanagement. There was a moderate decrease in adjusted hospital costs after implementation (adjusted cost ratio 0.94, range 0.88-1.00) equivalent to a cost savings of about $1,439 per hospitalization.