Dr. Chace
Clinical question: Does early thiamine administration improve mortality outcomes for patients with alcohol use disorder who are hospitalized for pneumonia?
Background: Wernicke’s Encephalopathy (WE) is a devastating neurological condition that affects patients with alcohol use disorder (AUD). It can be precipitated by acute illness and is fatal in up to 20% of patients. Thiamine deficiency has been thought to cause WE and, although it has long been considered the standard of care for the treatment and prevention of WE, thiamine is not universally administered to hospitalized patients with AUD.
Study design: Retrospective cohort study
Setting: Data was collected from 670 geographically diverse, nonprofit, nongovernmental, community, and teaching hospitals in rural and urban areas that participated in the Premier Healthcare Database between 2010 and 2015. Combined, these hospitals account for 25% of all U.S. inpatient admissions.
Synopsis: Patients with both a principal or secondary International Classification of Diseases (ICD-9) diagnosis of pneumonia and an alcohol-related ICD-9 diagnosis who also received benzodiazepines in the first two days of hospitalization were included (totaling 36,732 patients). Patients were considered to have been treated with thiamine if they received any thiamine at all by hospital day two. Patients receiving thiamine were more likely to be male and/or to have liver disease, coagulopathy, or fluid or electrolyte disorders, and were less likely to have Medicare insurance. There was substantial variability in thiamine administration across hospitals and, notably, 28% of patients received no thiamine at all.
Thiamine treatment was associated with significantly lower 14-day mortality (20% lower odds, P <0.001). The likelihood of ICU admission did not vary by thiamine treatment status, but those who received thiamine were less likely to require invasive mechanical ventilation (20.9% versus 25.5%) or vasopressors (8.8% versus 12.8%). There was no significant difference in outcomes for those who received low- versus high-dose thiamine.
Limitations include possible undercounting of patients with AUD by using ICD-9 codes, given restrictions on clinical data when reviewing de-identified charts.
This study is the largest to date on the benefit of thiamine, and the first large study of the effectiveness of thiamine use in the U.S.
Bottom line: Administration of thiamine to patients with AUD hospitalized for pneumonia is associated with a significant reduction in mortality and morbidity. The current underutilization of thiamine treatment in patients with AUD presents an opportunity to save lives.
Citation: Baron SW, et al. Early treatment with thiamine and mortality among patients with alcohol use disorder who are hospitalized for pneumonia. J Hosp Med. 2022;17(8):585-93.
Dr. Chace is an assistant clinical professor of internal medicine and pediatrics at the University of California, San Diego.