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Inpatient Insights

Patients who survive hospitalization for influenza, sepsis, or other serious illnesses are known to have an increased risk for developing CV, neurological, and other conditions after discharge, but it has been difficult to determine the extent to which patients who were hospitalized for severe COVID-19 have this type of risk. The authors of a recent study published in the August 2023 issue of JAMA Internal Medicine attempted to determine the risk of newly developed medical and mental health conditions within 1 year following hospitalization for severe COVID-19 compared with flu or sepsis.

The researchers, led by Kieran L. Quinn, MD, PhD, of the Sinai Health and University Health Network in Toronto conducted a population-based cohort study to compare risks of incident CV, neurological, and mental health conditions and rheumatoid arthritis in 1 year following COVID-19 hospitalization against three comparator groups: prepandemic hospitalization for influenza, and hospitalization for sepsis before and during the COVID-19 pandemic. The study results indicated that hospitalization for COVID-19 was associated with an increased 1-year risk of venous thromboembolic disease compared with flu but with no increased risks of developing selected ischemic and nonischemic cerebrovascular and CV disorders, neurological disorders, rheumatoid arthritis, or mental health conditions.

The authors suggest that many of the postacute consequences of COVID-19 may be related to the severity of infectious illness necessitating hospitalization rather than being direct consequences of infection with SARS-CoV-2. ■

 

Evaluating antimicrobial duration for Gram-negative bacteremia in patients with neutropenia

Short courses of antimicrobials have been increasingly demonstrated as noninferior to prolonged therapy for management of Gram-negative bloodstream infections (BSIs) given the lower risk of Clostridioides difficile infection and emergence of multidrug-resistant organisms. Clinical data have not been available on the effectiveness of short courses of antimicrobials on immunocompromised patients. A recent study published online on June 6, 2023, in Transplant Infectious Disease sought to close this gap through a retrospective cohort study involving patients with neutropenia as a result of hematopoietic stem cell transplantation or hematologic malignancy.

The study involved about 200 patients at the Mayo Clinic (Rochester) between July 2018 and April 2022 with monomicrobial Gram-negative BSIs involving E. coli, P. aeruginosa, or Klebsiella species. Patients were classified as having received short (<10 days), intermediate (11–14 days), or prolonged (>14 days) treatment with cefepime or carbapenem. The effect of the treatment duration on outcomes was evaluated, with a primary outcome of a composite of all-cause mortality and microbiologic relapse within 90 days after therapy completion.

No significant difference in the primary composite endpoint was observed for either intermediate or prolonged course treatment versus short course treatment. The authors suggest that their data support the use of short course treatment for Gram-negative BSIs among immunocompromised patients with neutropenia. ■

 

Is procalcitonin testing effective for detecting BSI at admission?

Serum procalcitonin is often ordered at admission for patients with suspected sepsis and bloodstream infections (BSIs), but its performance characteristics have been unclear. A recent study published in Critical Care Medicine on July 3, 2023, used a retrospective cohort study to evaluate use patterns and performance characteristics of procalcitonin-on-admission testing in patients with suspected BSI with or without sepsis.

Almost 75,000 adult inpatients at 65 hospitals who had blood cultures and procalcitonin drawn within 24 hours of admission were included in the study. Results of the study indicated that median procalcitonin levels varied considerably by pathogen, BSI source, and acute illness severity. At a ≥0.5 ng/mL cutoff, sensitivity for BSI detection was 68.2% overall, ranging between 58.0% for enterococcal BSI without sepsis and 96.4% for pneumococcal sepsis. Procalcitonin-on-admission testing displayed moderate discrimination for overall BSI and showed no additional utility in key subgroups. Empiric antibiotic use proportions were not different between blood culture–sampled patients with a positive procalcitonin (39.7%) and negative procalcitonin (38.4%) at admission.

The authors concluded that procalcitonin-on-admission testing demonstrated poor sensitivity in ruling out BSI and moderate to poor discrimination for both bacteremic sepsis and occult BSI and did not appear to meaningfully alter empiric antibiotic usage. They urge diagnostic stewardship of procalcitonin-on-admission testing and risk assessment of admission procalcitonin-guided clinical decisions. ■

 

Alteplase could be alternative to tenecteplase for large vessel occlusion stroke

I.V. thrombolysis is the standard of care for the treatment of acute ischemic stroke within 4.5 hours of symptom onset. Tenecteplase, a genetically modified variant of alteplase, has recently been shown to be a safe and effective alternative to alteplase for treatment of large vessel occlusion (LVO) stroke. The question remained, however, as to whether I.V. tenecteplase is as safe and efficacious as I.V. alteplase in patients with LVO stroke and whether the treatment effect differs by occlusion site. A group of researchers led by Mohammed Almekhlafi, MD, of the Cumming School of Medicine at the University of Calgary (Canada), sought to answer this question through a study published online in JAMA Neurology on July 10, 2023.

The study involved a prespecified analysis of the ACT randomized clinical trial that enrolled patients from 22 primary and comprehensive stroke centers across Canada between December 10, 2019, and January 25, 2022. A total of 1,600 patients 18 years and older with a disabling ischemic stroke within 4.5 hours of symptom onset were randomly assigned to receive either I.V. tenecteplase or alteplase and were monitored for up to 120 days. The primary outcome was the proportion of modified Rankin scale (mRS) score of 0–1 at 90 days.

Among 520 patients with LVO, an mRS score of 0–1 at 90 days was achieved in 86 participants (32.7%) in the tenecteplase group versus 76 (29.6%) in the alteplase group. These findings indicate that I.V. tenecteplase conferred similar reperfusion, safety, and functional outcomes compared to alteplase among patients with LVO. Given the ease of administration of tenecteplase (which can be administered via bolus) versus alteplase and the comparable safety and efficacy between both thrombolytics, the authors conclude that tenecteplase could be used as a first-line thrombolytic agent for patients with LVO stroke. ■

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