In the News

Adding aspirin or NSAID to anticoagulant doubles bleeding risk, guidelines on Clostridium difficile and surgical-site infections, and more.

Adding aspirin or NSAID to anticoagulant doubles bleeding risk

Taking aspirin or an NSAID while on anticoagulant therapy significantly increases the risk of bleeding in patients who have had a venous thromboembolism (VTE), a recent study found.

Researchers conducted a prospective analysis of observational data from the EINSTEIN trials, which compared treatment with rivaroxaban or enoxaparin-vitamin K antagonist (VKA) in more than 8,000 patients with deep venous thrombosis or pulmonary embolism between 2007 and 2009. The researchers looked at days of aspirin or NSAID use while patients were on one of the anticoagulants and instances of clinically relevant or major bleeding. Results were published in the June JAMA Internal Medicine.

Taking an NSAID or aspirin while on an anticoagulant significantly increased the risk of either type of bleeding compared to taking an anticoagulant alone. With NSAIDs, there were 37.5 clinically relevant bleeding events and 6.5 major bleeds per 100 patient-years compared to 16.6 and 2.0, respectively, in those not taking NSAIDs (hazard ratio [HR] for clinically relevant bleeding events, 1.77; 95% CI, 1.46 to 2.14 and HR for major bleeds, 2.37; 95% CI, 1.51 to 3.75). For patients on aspirin, the risk of clinically relevant bleeding was 36.6 per 100 patient-years, compared to 16.9 per 100 patient-years not on aspirin (HR, 1.70; 95% CI, 1.38 to 2.11). Major bleeding rates were 4.8 per 100 patient-years in aspirin-taking patients compared to 2.2 during aspirin nonuse (HR, 1.50; 95% CI, 0.86 to 2.62).

The authors concluded that in patients on anticoagulant therapy due to a VTE, concomitant use of an NSAID or aspirin is associated with about a doubling of the risk of bleeding. They noted that bleeding rates were similar on either of the anticoagulant regimens (rivaroxaban or enoxaparin-VKA) and that the study wasn't powered to determine whether use of selective COX-2 NSAIDs reduced the risk of bleeding.

Even though the study protocol discouraged physicians from using NSAIDs or aspirin, 22% of the participating patients took NSAIDs at some point during follow-up. Combined with the exclusion of patients with increased bleeding risk from the trial, this indicates that the study results may actually underestimate the bleeding risk of combining these drugs in practice. The study authors urged physicians “to combine anticoagulation with either NSAID or aspirin therapy with caution and only if genuinely indicated, with no similarly effective and safer alternative treatment available.”

C. diff, surgical-site infection guidelines released

Several professional groups recently released joint guidelines for preventing Clostridium difficile infections and surgical-site infections in hospitals.

Recommendations for care of C. difficile patients include the following:

  • Treat C. difficile patients in separate rooms from the general patient population, and use gloves and gowns when providing care, as well as dedicated equipment and patient care items.
  • Wear gloves and wash hands with soap and water before and after every encounter, as C. difficile is resistant to alcohol-based products.
  • Implement a lab-based alert system to provide immediate notification to clinical workers of newly diagnosed patients.
  • Create a reporting system to capture the burden of infection at your facility and assess the efficacy of prevention tactics like hand hygiene and contact precautions.

More research is needed before recommendations can be made on using probiotics, restricting use of gastric acid suppressants, and requiring that visitors wear gloves and gowns, the guidelines noted. It's also important to select antibiotics that pose a lower risk for C. difficile when possible, they said.

Recommendations for preventing surgical-site infections, which occur in as many as 5% of patients undergoing surgery, include the following:

  • Follow protocols for proper hair removal, preoperative skin disinfection, and control of blood glucose levels in cardiac patients.
  • Adhere to appropriate antimicrobial prescribing practices before and after surgery.
  • Conduct postoperative surveillance by reviewing microbiology reports, patient medical records, and surgeon and patient surveys and by screening for readmission or return to the operating room.

The practice recommendations were published in the June Infection Control and Hospital Epidemiology and are a collaborative effort of the Society for Healthcare Epidemiology of America, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and The Joint Commission.

SHEA/IDSA issue updated CAUTI guidelines

Experts recently released updated guidelines on preventing catheter-associated urinary tract infections (CAUTIs) in the hospital.

The guidelines, updated from 2008, were issued by the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America (IDSA), the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and the Joint Commission.

Recommendations include the following:

  • Provide and implement written guidelines for catheter use, insertion and maintenance, including acceptable indications for indwelling catheter use;
  • Ensure that only trained, dedicated personnel insert urinary catheters;
  • Implement a system for documenting full information in the patient record, such as a physician order for catheter placement, indications for insertion, date and time of insertion, name of person who did insertion, etc.;
  • Perform surveillance for CAUTI if indicated on the basis of facility risk assessment or regulatory requirements, on metrics such as CAUTI rates, catheter-days for certain patient groups, etc.;
  • Provide education and training on topics such as insertion, care and maintenance of catheters, and assess health care professional competency;
  • Implement a facility-wide program to identify and remove catheters that aren't necessary; and
  • Establish a system to analyze and report data on catheter use and adverse events from use.

The guidelines were published in the May Infection Control and Hospital Epidemiology.

Teledermatology is reliable for initial triage, biopsy decisions in inpatients

Remote dermatology consultations are reliable for initial triage and biopsy decisions in hospitalized patients, a recent study found.

Researchers conducted a prospective study of 50 inpatients who were hospitalized for any reason and for whom an inpatient dermatology consultation was requested at an academic medical center between Sept. 1, 2012 and April 31, 2013. Each participant was evaluated separately by both an in-person dermatologist and two independent teledermatologists. Study outcomes were measured by agreement about when patients needed to be seen (same day, next day, later in hospitalization, or as an outpatient) and whether to biopsy. Results were published in the April JAMA Dermatology.

The in-person dermatologists and the teledermatologists agreed, on average, 95% of the time about whether a patient should have a biopsy (Cohen κ coefficients for decision to biopsy concordance with in-person doctor, 0.35 for teledermatologist 1 and 0.61 for teledermatologist 2). They agreed 90% of the time, on average, about whether a patient should be seen the same day (Kendall τ rank correlation coefficients for triage concordance for in-person vs. teledermatologists 1 and 2, 0.41 and 0.48 respectively).

In general, teledermatologists were able to triage 60% of consultations to occur the next day or later, and were able to triage about 10% of patients to be seen as outpatients after discharge. When a teledermatologist didn't find it necessary to see the patient the same day or to biopsy but the in-patient dermatologist did, the disagreement was based on different practice styles: they still both agreed on the diagnosis in these cases. “Some level of variation is to be expected when comparing triage and management decisions between clinicians,” the authors noted.

Triage via teledermatology can potentially increase efficiency by referring a portion of patients to outpatient consultation, and by “batching” patients who can be seen later so that a consulting dermatologist can decrease trips to the hospital, the authors wrote. It also may be possible to manage some patients via teledermatology alone, though the study design didn't allow for it, they noted. An invited commenter agreed the study suggests teledermatology can be used reliably to decide how urgently a patient should be evaluated. He added that to provide consistently effective care in this way will require standardizing the kind of information gathered and presented to the consultant, the photography used, and the way information is delivered.

Methadone safety clinical practice guideline released

Recent guidelines for prescribing methadone for opioid addiction and pain management offer advice for primary care and subspecialty clinicians about safety and electrocardiogram monitoring to identify patients at high risk for cardiac problems.

The American Pain Society convened an expert panel that reviewed more than 3,700 scientific abstracts under the direction of the Oregon Evidence-based Practice Center to develop the new methadone safety guideline, which appeared in The Journal of Pain in April.

According to the guideline, clinicians should perform an individualized medical and behavioral risk evaluation to assess risks and benefits of methadone (strong recommendation, low-quality evidence). Careful patient selection for methadone is essential and should be based on a thorough history, review of medical records, and physical examination. Assessment results can be used to stratify patients based on their risk for substance abuse, drug interactions, and arrhythmias.

The guidelines recommend educating and counseling patients before prescribing methadone about the indications for treatment and goals of therapy, availability of alternative therapies, and specific plans for monitoring therapy, adjusting doses, and dealing with potential adverse effects (strong recommendation, low-quality evidence).

Clinicians should do an electrocardiogram (ECG) before starting methadone in patients with risk factors for QTc interval prolongation, and consider doing an ECG before starting methadone in patients not known to be at higher risk. Buprenorphine is an option for patients being treated for opioid addiction who have risk factors for prolonged QTc intervals.

Clinicians should begin methadone at low doses based on the indication for treatment and prior opioid exposure status, titrate doses slowly, and monitor patients for sedation (strong recommendation, moderate-quality evidence). Methadone should be withheld if there is evidence of sedation.

Clinicians should conduct urine drug screens before starting methadone and at regular intervals in patients prescribed methadone for opioid addiction (strong recommendation, low-quality evidence). Also, patients prescribed methadone for chronic pain who have risk factors for drug abuse should undergo urine drug testing before starting methadone and at regular intervals thereafter. Clinicians can consider urine drug testing in all patients regardless of assessed risk status (strong recommendation, low-quality evidence).

Recommendations released on managing brain swelling after stroke

The American Heart Association/American Stroke Association recently released recommendations for managing cerebral or cerebellar swelling after an ischemic stroke.

A writing group used available literature and expert opinion to develop its recommendations, which underwent thorough peer review and were published in the April Stroke. The recommendations include the following categories: definition and clinical presentation, neuroimaging, triage, airway and mechanical ventilation, hemodynamic support and blood pressure management, glucose management, temperature management, intracranial pressure management, recognition of deterioration, medical and neurosurgical options in a deteriorated patient, biomarkers, and outcome and family discussion.

The statement recommended that standardized terms and definitions be established for severe hemispheric and cerebellar edema caused by infarction to facilitate further studies of incidence, prevalence, risk factors and outcomes. Use of decompressive craniectomy should also be studied further, the statement said.

“Brain swelling is the cause of significant neurological morbidity and mortality in acute brain injury, yet fundamental, basic research in this area with immediate clinical relevance has been lacking,” the authors wrote, calling for an “urgent agenda” for additional research. They also advocated for development and validation of patient-centered outcome measures that take severity of illness into account.

Memory problems common, under-recognized in older heart failure patients

Many more elderly patients with heart failure have cognitive impairment than their treating cardiologists realize, a recent study found.

Researchers at multiple sites in France studied 912 ambulatory heart failure patients age 70 or above treated by cardiologists between January and November 2009. On average, the patients' heart failure had been diagnosed 4.4 years earlier and mean ejection fraction was 43.6%. Patients in the study were given the delayed recall Memory Impairment Screen (MIS-D). Results were published in the April American Journal of Cardiology.

The 291 participating cardiologists suspected that 109 patients (12% of the total) had memory impairment. However, results on the MIS-D revealed that 45.6% of the patients had memory impairment (95% CI, 42.4% to 48.8%) and 23.4% had severe memory impairment (95% CI, 20.6% to 26.1%). The study found an association between greater memory impairment and more severe heart failure class. However, this finding was no longer significant when adjusted for older age, lower education level, depression, history of stroke, renal failure and less physical activity (all independent predictors of impairment).

Researchers concluded that memory impairment is common among older patients with heart failure and that screening tools such as the MIS-D could help identify patients at risk. Identification of these patients is important because management of their disease requires “complex pharmacological therapy, diet and fluid restrictions, monitored physical activity and patient education that can be difficult to understand, remember and manage for patients with cognitive impairment,” the authors wrote.

The mechanism for the association between impairment and heart failure is not known, the study authors said, although they offered 3 possibilities: common risk factors such as hypertension, diabetes or dyslipidemia; focal brain vascular lesions or chronic ischemia; and decreased cardiac output leading to inadequate cerebral perfusion. Regardless of the cause, better identification of impairment could allow physicians to take steps (such as pill boxes or nurse visits) to improve heart failure patients' ability to care for themselves.

Bacteremia associated with greater risk of MI, stroke

Inpatients have a greater risk for myocardial infarction (MI) and stroke within the first 30 days of being hospitalized for community-acquired bacteremia, a recent study found.

In a population-based cohort study in Northern Denmark from 1992-2011, researchers examined 4,389 inpatients with positive blood cultures for bacteremia obtained on the day of admission. Each of these patients was matched with up to 10 general population controls (n=43,831) and up to 5 acutely admitted non-bacteremic controls (n=21,893), with matching across age, gender and time. Incident events of MI and stroke in the following 365 days were gleaned from population-based databases, and multivariable regression analyses were used to assess the relative risks for MI and stroke among bacteremia patients and controls.

Risk of MI or stroke within 30 days of community acquired-bacteremia admission was 3.6%, compared to 0.2% among population controls (adjusted relative risk [RR], 20.86; 95% CI, 15.38 to 28.29) and 1.7% among hospitalized controls (adjusted RR, 2.18; 95% CI, 1.80 to 2.65). The risks remained increased, though not as dramatically, from 31 to 180 days after bacteremia compared to population controls (adjusted hazard ratio [HR], 1.64; 95% CI, 1.18 to 2.27), but not compared to hospitalized controls (adjusted hazard ratio, 0.95; 95% CI, 0.69 to 1.32). Patients with Staphylococcus aureus bacteremia were at a particularly increased risk for stroke. There were no differences in risk after 6 months.

Thirty-day mortality risk among bacteremia patients was 15.7% vs. 7.9% in hospitalized controls; at one year, the death risk was 29.7% for bacteremia patients, 23.9% for hospitalized controls, and 5.8% for population controls. Results were published in the April 1 Circulation.

Study limitations include reverse causation bias, given that heart failure and stroke are known risk factors for infection. Also, severe infection may lead to death before MI/stroke is diagnosed in inpatients, the authors noted. “There is a need for a better understanding of the mechanisms including metabolic supply/demand mismatch and embolic events that may increase the risk for cardiovascular events following severe infection,” the authors wrote. Such knowledge may lead to more targeted prevention and treatment, they said.