Wholesome Sleep for Healthcare Professionals (Deshpande, 10/25/2023)

 A link to a recording of this presentation is available HERE. 

So many pearls in this week's Grand Rounds by SMGR Sleep Medicine Dr. Abijit Desphande. Everyone sleeps, right? And almost everyone has trouble sleeping, right? Well, Dr. Deshpande has a myriad of suggestions for how you might sleep more and sleep better. . .Stay tuned for my notes coming soon. 

Empiric Antibiotics and Antibiotic Stewardship (Green & Patel 10/18/2023)

LINK to a recording of the presentation is available HERE. 

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It is with deep gratitude and great joy that I can say proudly that we did Grand Rounds in a room together at SSRRH for the first time since February 2020! It has been over three years since we gathered today in Conference Rooms A/B at SSRRH, and while we have had some magnificent zoom talks together in the interim, it felt both deliciously indulgent and so very right to be sitting together fighting the AV equipment. Together. We had 22 esteemed live attendees, and another 31 online. And that was even without serving breakfast (which will be available starting next week). A guest appearance from our very own Dr. Rick Flinders was icing on the cake.

And I haven't even started talking about the presentation yet -- which was excellent.

Many thanks to our antibiotic experts, Dr. Gary Green and Pharmacist Omi Patel, for both inspiring the reunion and giving an excellent opening talk on Empiric Antibiotics and Antibiotic Stewardship at SSRRH. The recording will be available shortly and the empiric antibiotic guidelines and the antibiogram are both available on the SSRRH intranet.

As for my notes:

We are so lucky to have the camaraderie and support of our pharmacists at SSRRH for improved antibiotic management of hospitalized patients. They are truly partners and educators for our clinicians.

Antibiotic stewardship program includes several important pharmacy driven protocols. These evidence-based pharmacy driven protocols include: 

• Renal adjustments of antibiotics
• Pharmacokinetic review of vancomycin and aminoglycoside (i.e. vancomycin dosing "per pharmacy protocol")
• Automatic stops for medications like azithromycin and oseltamivir (when indicated)
• Transitioning from IV to PO antibiotics
• Extended infusions of beta lactam antibiotics (meropenem, cefepime, cefazolin, and zosyn)
• Probiotics for floor patients at high risk for C Diff colitis

Omi Patel reviewed the importance of these protocols and gave us a preview of an upcoming QT monitoring protocol as well. 

Then Dr. Gary Green then filled us in on highlights of the ASP 2022-2023 Empiric Antibiotic Guidelines

These include:

Skin and Soft Tissue Infections (SSTI): a review on clinical assessment of cellulitis, most commonly strep vs. staph infections, including a reminder that staph infections tend to have a more demarcated (i.e. easy to draw) line between infected and uninfected tissue compared to strep infections, which tend to have a more "feathered edge". Don't forget that strep is also famous for causing lymphangitis ("streaking and tenderness" above the level of the actual cellulitis).

When treating SSTI, remember, "Cefazolin is your friend." -Gary Green, MD

Bullae are common later in SSTI and should not be cultured or removed (creating a wound)

If there is concern for toxin-mediated cellulitis (e.g. early bullae, <24 hours from cellulitis onset), consider the addition of clindamycin as an anti-toxin medication. Reminder that clindamycin works on ribosomes, which gives it its anti-toxin properties.

Vancomycin, while bactericidal, is still a very slowwwwwwwwwwwww bactericidal drug, and Dr. Green reports lots of failures in treatment of SSTI. Don't use it if you don't need it.

In the setting of fluctuance (carbuncles or furuncles), you should definitely consider ca-MRSA as the likely culprit. Cultures are imperative, and consider Septra or doxy as first line oral outpatient abx. Dalbavancin ER is sometimes used in the ED for patients for whom compliance can be challenging.

slide c/o Dr. Green, Omi Patel, PharmD

(Note that Ceftaroline, a 4th gen, is the first cephalosporin with activity against MRSA). 

Diabetic foot infections are a totally different thing than cellulitis and should NOT be misdiagnosed. They are often characterized by a diabetic foot ulcer (and can include osteomyelitis). Outpatient treatment for diabetic foot infections first line are Augmentin and/or moxifloxacin. If you are concerned about MRSA, you could add septra or doxy to those first-line drugs. Inpatient treatment for diabetic foot infections are a start with vanc/zosyn, but culture quickly and drop vanc as soon as culture does not reveal MRSA. Remember the combination of v/z is nephrotoxic and should only be continued if clinically indicated. 

Additionally, do not use abx to treat lower extremity venous stasis, which often presents with dependent rubor (redness). If you believe this is erythema of gravity, lift the legs above the level of the heart to see if rubor improves. Venous stasis is chronic and can present with some mild tenderness and even mild warmth. Do not treat in the absence of active infection. 

Diverticulitis and intra-abdominal infections

outpatient empiric abx: Augmentin OR ciprofloxacin plus metronidazole

inpatient empiric abx: Pip/taz (i.e. Zosyn) or ceftriaxone plus metronidazole . The Zosyn should be delivered as an extended infusion whenever possible. Ceftriaxone plus metro does miss enterococcus, but, as Dr. Green said "enterococcus is generally the bridesmaid and never the bride" -- meaning, it may  be present but is often not the cause of the infection. 

Pancreatitis should NOT be treated with abx. Unless it is necrotizing. In rare cases of necrotizing pancreatitis, the drug of choice (with good evidence for improved outcomes) is meropenem. 

UTI is where the largest system-wide change in empiric abx comes in. 

First off, Asymptomatic bacteriuria (AB) is too often in appropriately treated with abx. Dr. Green said that 50% of inappropriate abx are attributed to treatment for asymptomatic bacteriuria. The bladder is transiently colonized and the presence of bacteria on culture does not indicate infection in the absence of symptoms. So, in other words, do NOT treat AB with antibiotics. The exceptions are: 1) pregnant patients and 2) transplant patients. 

Based on our local antibiogram, nitrofurantoin (aka Macrobid) is the empiric antibiotic of choice for uncomplicated outpatient UTI. Additional options include TMP/SMX and ciprofloxacin, though there is more resistance to both of these abx than there is to Macrobid. The one downside to Macrobid, we al know, is that it does not have good renal penetration and should not be used for pyelonephritis.

In complicated UTI (defined as neurogenic bladder, Foley catheter present, suprapubic catheter, and/or recurrent UTI), 

Okay, now for complicated UTI and/or pyelonephritis in hospitalized patients. The new drug of choice is Cefoxitin (2gm q6 hours). This is for two reasons: 1) Ceftriaxone has never been a great UTI drug, it is hepatically metabolize and not renally cleared). 2) Our local sensitivities for e coli are down to 88% at SSRRH. Once under 90%, it is no longer a reliable empiric abx. 

Other drugs to consider for complicated UTI are aztreonam and cipro IV. 

A note on ceftriaxone: While we should no longer be using ceftriaxone for pyelonephritis or complicated UTI in hospitalized patients for the above reasons, Ceftriaxone (2gm, per Dr. Green 1gm is a homeopathic dose) remains an excellent choice for both community acquired pneumonia and gonorrhea. 

And finally, 

Community acquired pneumonia. Empiric guidelines still recommend ceftriaxone plus either azithro or doxycycline. Both Dr. Green and I agree that doxycycline is probably a better choice in most patients due to the QT prolongation and increased CV mortality that occur with azithromycin.

Another reasonable option for CAP. is levofloxacin. 

For Aspiration Pneumonia, SSRRH and Dr. Green's empiric guidelines differ slightly from the IDSA on aspiration pneumonia, recommending Zosyn, particularly in frail patients with teeth (pearl: if patients have no teeth, you don not have to worry about anaerobes). Hospital acquired and Ventilator associated PNA should get ID involved, abx include pip/tazo and/or cefepime. 

Weight Stigma and Fatphobia (Erlanger - 10/11/23)

 A recording of this presentation can be viewed HERE.

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This is one of those Grand Rounds that should be seen and heard (not read), so I am going to keep my notes very short. Please watch the recording at the above link. Prepare to feel challenged.

Dr. Lisa Erlanger, a family physician at University of Washington,  is an advocate for weight-inclusive care and a compelling speaker with plenty of evocative things to say, many of which challenge the way that we were taught to think about obesity.  

Dr. Erlanger encouraged us to reconsider the (generally accepted) notion that obesity is a disease, and encouraged us, rather, to consider how "anti-fat bias" in healthcare providers and "weight stigma" are actually causing tremendous harm to patients -- so much harm, in fact, that they may be responsible for poor outcomes in this population.

Here are a few of Dr. Erlanger's talking points to ponder:

1) There is no evidence that increased adiposity causes increased morbidity and mortality.

2) "A starving fat person does not make a tiny person." In other words, patients at the higher end of the weight spectrum are not going get to "normal" weight or "normal BMI" by dieting, so asking them to do so is inappropriate.

3) Obese patients consistently experience inequities (and often harm) in their interactions with healthcare providers: less warmth and emotional rapport, less time, less eye contact, more patronizing, adn more assumptions made on health based on size.

4) Weight cycling -- restriction of calories or increased use of calories in order to lose weight -- is harmful. It leads to 5-10% decrease in body weight over a short period of time, but ultimately leads to disordered eating and even higher weight and BMI. 

If anyone wants a copy of Dr. Erlanger's slides with references, please contact me (Veronica Jordan) at jordanv@sutterhealth.org. 

Perioperative Evaluation (Schneider - 10/4/23)

Sorry, there is no recording available for this session. 

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Thank you to our very own Dr. Dave Schneider for an excellent presentation on Perioperative Evaluation. Unfortunately, I forgot to hit "record" on the zoom meeting, so we do not have a recorded version of his presentation. Sorry about that!

My notes:

First off, "clearance for surgery" is not our job!  Our job is to assess each patient's perioperative risks and optimize and manage those risk factors as they head into surgery. Do note that there are gender and race disparities in those who receive surgical interventions (BIPOC patients receive fewer PCI interventions, fewer orthoplasties and have increased mortality when undergoing these procedures).

The new-ish term for perioperative cardiovascular complications is Myocardial Injury after Non-Cardiac Surgery (aka MINS). 5-19% of surgical patients will experience MINS, 84% will be asymptomatic. MINS is associated with increased morbidity and mortality.

The American College of Cardiology (ACC) last updated their Guidelines for Perioperative Cardiovascular Evaluation and Management for patients undergoing non-cardiac surgery in 2014. These old guidelines are available here. The flow diagram is a doozy and the recommendations are confusing: 

In classic Schneider-fashion, Dr. Schneider invented an acronym to summarize their 2014 recommendations. It is called E-A-R-L-I

E: Emergent: if a surgery is emergent--> take patient to the OR and deal with the negative outcomes later

A: ACS: if the patient has s/sx of ACS, manage per guidelines

R: Risk assess --> use any of several tools (e.g. RCRI, NSQUIP calculator, MICA calculator, see below for more info)

L: Limitation of function --> if patient unable to  perform at 4 METs using the Duke Activity Scale, optimize their functional status before proceeding to surgery

I: Impact on decision? --> Yes or No? If the cardiac stress test outcome will change how/when you will proceed with surgery, then go ahead with a stress test. If not, then proceed to the OR.

The European Society of Cardiology (ESC) updated their guidelines on perioperative management more recently in 2022. And their guidelines are much more simple than those of the ACC. They are summarized here by the ACC. In essence, they say: 

Is the surgery. . .

Emergent? -->  Proceed to surgery without delay, cardiac testing is not feasible

Urgent? --> Proceed to surgery without unnecessary delay (using a multidisciplinary team to determine about individualized cardiac testing)

Time-Sensitive? --> Do the surgery ASAP

Their guidelines are summarized in this lovely flow charts. Don't you just love flow charts?

***

Should you check a Hemoglobin and Renal function in all patients pre-operatively? The answer is no, but your should check in intermediate and high risk patients. 

Don't forget, for everyone, advise smoking cessation!

There are two risks to consider in evaluating patients: 1) the risk of the surgery itself (e.g. highest risk includes intra-thoracic, vascular) and 2) the risk of the patient

• If the surgery is low risk, no CV assessment needs to be made
• If the surgery is intermediate risk, and the patient is either >65 or with CV risk factors, get an EKG and check functional capacity
• If the surgery is HIGH risk, consider EKG and biomarkers** for patients older than 45, definitely get them for patients >65 or with CV risk factors. If the patient has known CVD, get a cardiology consultation and make a multidisciplinary decision. 

**Note: Biomarkers referred to above include BNP and/or Cardiac Troponin (also in table above). They have been shown to predict MI. Either one is predictive and do not change outcomes. 

There are several risk calculators to help you determine your patient's  risk level:

1) Revised Cardiac Risk Index (RCRI), which Dr. Schneider shortens to DRC4 (diabetes, risky surgery, CAD, CHF, CVD, Cr>2)

2) The NSQUIP calculator

3) Gupta's Perioperative MICA calculator

Each calculator is slightly different and variably useful depending on the patient in front of you. All three of these have been validated and you should get familiar with all of them.

Okay, now for a few pearls:

• There is NO benefit to coronary revascularization before surgery.
• Labs and other tests should only be done pre-operatively if you were going to do them anyway
• Coag testing is usually unnecessary unless patient is on warfarin. Family Hx and PMH are just as predictive of bleeding (e.g. if patient has history of prior bleed, or family member has bleeding problem, patient has higher risk of bleed)
• Only get a pre-op EKG if the patient has known CVD, CV risk factors >65 and they are having an intermediate/high risk surgery
• TTE only needed if patient has known valvular lesion and no TTE in the last year. You may consider if new onset dyspnea or change in status of their HF
• Pre-op CXR is NOT recommended (Choosing Wisely, ACR 2017)

What about medications?

Statins: if a patient is on a statin, continue it (okay to miss a few days due to NPO, etc.). Perioperative initiation is reasonable if someone is getting vascular surgery

Beta blockers: if patient is already on BB, continue them perioperatively (perioperative withdrawal has 4x increased mortality). You may consider decreasing BB dose due to risk of hypotension after surgery. You can consider starting a BB at least one week (up to 28 days) prior to cardiac surgery if high risk patient and high risk surgery. 

Other anti-hypertensives: post-op hypotension is a common problem. Consider holding all BP meds on day of surgery, add them back slowly post-op, ?one at a time

ASA: it is okay to go to the OR on aspirin. Also okay to stop ASA in high bleeding risk patients (e.g. those on DOAC or warfarin as well). Continuing ASA has been shown to be cardioprotective: decreased MI by 56% and decreased composite CV outcomes. There is a non-significant increased bleeding risk if you continue ASA.

What about patients with recent drug eluting stents (DES)? Delay elective surgery for up to 6 months if possible so as not to interrupt DAPT.