WEBVTT
00:00:19.199 --> 00:00:21.280
Hello and welcome to Inpatient Update.
00:00:21.440 --> 00:00:27.440
I'm your host, Mason Turner, and this is your podcast for practice changing evidence for the working hospitalist.
00:00:27.920 --> 00:00:29.679
Today on the show, I'm joined by Dr.
00:00:29.839 --> 00:00:36.079
Austin White as we delve into recent studies on a couple of hospital medicine controversies.
00:00:36.399 --> 00:00:40.159
Should we be treating asymptomatic hypertension in the hospital?
00:00:40.399 --> 00:00:45.679
Should we be giving antibiotics to patients admitted with pneumonia and a positive viral panel?
00:00:45.920 --> 00:00:46.640
Well, Dr.
00:00:46.719 --> 00:00:48.799
White, thank you so much for being with me here today.
00:00:49.039 --> 00:00:49.359
Thank you.
00:00:49.439 --> 00:00:50.240
Thank you for having me.
00:00:50.560 --> 00:00:52.079
For the audience, Dr.
00:00:52.240 --> 00:00:58.880
Austin White is one of my colleagues, a rapidly rising superstar in my division.
00:00:59.039 --> 00:01:00.960
Another thing of note is uh Dr.
00:01:01.039 --> 00:01:02.719
White does a lot of nights with us.
00:01:02.880 --> 00:01:07.840
I'm excited to have a nocturnist's perspective on this or a semi-nocturnist.
00:01:08.079 --> 00:01:22.000
And in that vein, Austin, have you ever gotten a page overnight from a nurse that says Miss Jones has a blood pressure of systolics of let's go 204?
00:01:22.640 --> 00:01:23.280
Oh no.
00:01:23.519 --> 00:01:26.400
Anything in that range sound like something you've ever had to deal with?
00:01:26.799 --> 00:01:27.760
Every single night.
00:01:27.920 --> 00:01:28.159
Yes.
00:01:28.400 --> 00:01:29.280
Maybe not that high.
00:01:29.359 --> 00:01:30.640
That high is a little bit too high.
00:01:30.879 --> 00:01:32.400
But every night I'm constantly picked.
00:01:32.719 --> 00:01:33.840
What do you do when you get that page?
00:01:33.920 --> 00:01:35.200
What's what's your go-to response?
00:01:35.280 --> 00:01:36.239
What's your go-to reaction?
00:01:36.719 --> 00:01:42.239
So whenever I'm chatted that that blood pressure, I always ask, are there any symptoms?
00:01:42.400 --> 00:01:44.159
And usually it's a no.
00:01:44.560 --> 00:01:46.239
And we'll move on from there.
00:01:46.400 --> 00:01:51.200
But um yeah, it's a constant uh question from from nursing.
00:01:51.519 --> 00:01:52.159
Yeah, agreed.
00:01:52.239 --> 00:02:00.959
I kind of my rule of thumb, honestly, in the way I I genuinely practice is I as long as that first digit isn't a two, I feel pretty comfortable holding the line.
00:02:01.040 --> 00:02:13.919
I say, let's like restart their home orals, or even I'll say, let's get them started on something a little bit oral just to do something, just to make honestly to make myself a little bit, but mostly everyone else feel a little more comfortable.
00:02:14.080 --> 00:02:17.039
The patient and the nurse feel a little more comfortable that we're treating it.
00:02:17.280 --> 00:02:24.319
So I'll usually throw maybe a PO carvatolol and then sort of scheduling it and planning on it forward.
00:02:24.560 --> 00:02:31.599
I think a lot of our sort of default order sets that you can order as PRNs for hypertension, 180 is usually the number.
00:02:31.680 --> 00:02:37.120
And I think our order set that like page MD if greater than is probably 180.
00:02:37.199 --> 00:02:42.080
That's kind of like my so I think of like the default number of like you're getting a page if it's higher than that.
00:02:42.240 --> 00:02:47.280
And usually the nurses are pretty good about we don't hear from them if it's not more than 180.
00:02:47.919 --> 00:02:50.879
Speak for yourself depending on the nurse.
00:02:51.439 --> 00:03:00.879
So at night it's definitely a different ball game where um if it reads red and they're in their kind of vital sign sheet, I'll get paged about it usually.
00:03:01.199 --> 00:03:08.319
So there's a lot of acknowledge the the message for 160, 170, and I'll give a thumbs up.
00:03:08.479 --> 00:03:10.159
But you know, I have no symptoms.
00:03:10.240 --> 00:03:11.840
I'm I'm less interested.
00:03:12.000 --> 00:03:15.759
But at night, you definitely get paged more regarding those numbers.
00:03:16.080 --> 00:03:23.360
And so I I have this discussion because this is one of those things that that I've heard about and has been on my radar for a long time.
00:03:23.520 --> 00:03:27.520
This is something we treat, we over-treat inpatient hypertension.
00:03:27.840 --> 00:03:35.840
It ended up as number one on the list of things we do for no reason and the things we do for no reason session at SHM this year.
00:03:36.159 --> 00:03:41.439
This was their number one thing treating inpatient hypertension with PRNs or one-time meds.
00:03:42.080 --> 00:03:47.520
And so it's the kind of thing that I I've kind of heard that, I've been aware of that.
00:03:48.000 --> 00:04:02.479
I hadn't been totally up to date on all the data and then saw this study came out just recently that kind of shined lights on are we just are we just doing it for no reason or are we doing it for no reason and actively harming patients?
00:04:02.639 --> 00:04:03.840
Which obviously makes a big difference.
00:04:04.000 --> 00:04:12.719
If we're doing it for no reason and it drops the um blood pressure of the overnight provider and helps save save a page and the nurse and all of that, then it's one thing.
00:04:12.800 --> 00:04:15.439
But if we're actively harming patients by doing it, it's another.
00:04:15.520 --> 00:04:19.680
And so that's what the study specifically looked in to try and find.
00:04:19.920 --> 00:04:26.160
Um, and so this was in published in Jam Internal Medicine, and it was published in 2025.
00:04:26.319 --> 00:04:32.319
It was entitled As Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals.
00:04:32.560 --> 00:04:36.959
It was um a retrospective cohort study.
00:04:37.120 --> 00:04:52.319
What they did is they took patients over multiple years, everyone that got admitted to the hospital, and then they broke things down into patients receiving either one or more PRN antihypertensive versus people who didn't receive any antihypertensive.
00:04:52.480 --> 00:05:03.360
And the primary outcome they looked at was acute kidney injury, and then a secondary um outcome of two aggressive blood pressure drops.
00:05:03.519 --> 00:05:14.399
So they looked at how many of the patients got dropped greater than 25% within three hours, and then also a composite outcome of myocardial infarction stroke or death.
00:05:15.360 --> 00:05:23.439
And so the big headline result was that all of these things were worse in the patients that got the PRNs.
00:05:23.600 --> 00:05:29.759
So the AKIs were, I think, 23% more likely to have an AKI.
00:05:30.000 --> 00:05:40.639
Um, there was a hazard ratio of 1.23 that was statistically significant, um, a statistically significant hazard ratio of 1.5 for the rapid drop in blood pressure.
00:05:40.959 --> 00:05:49.279
And um anytime you've got uh a composite outcome with stroke, heart attack, and dying, I'm gonna be particularly interested.
00:05:49.439 --> 00:05:56.319
And was also statistically significant, more in the group that got treated with PRNs with a hazard ratio of 1.6.
00:05:56.720 --> 00:05:59.839
And they looked into the these things a little bit deeper.
00:05:59.920 --> 00:06:20.319
And IV patients that got IV antihypertensives were even worse, more likely to get an AKI, with the hazard ratio being 1.6 instead of 1.23, versus less, but still significantly significant if they're just getting that oral kind of like me giving if I give just that one time Carvatolol, that would put me in that bucket.
00:06:20.560 --> 00:06:24.000
Still showed that there was harm there in the primary outcome.
00:06:24.240 --> 00:06:27.600
Um and so that's sort of the big picture of this.
00:06:27.759 --> 00:06:43.600
I found it helpful to see numbers that state the patients that are being treated with PRN antihypertensive, one-time antihypertensives for an elevated blood pressure were actually seeing worse outcomes.
00:06:44.160 --> 00:06:51.439
It definitely made me think back on my nights and try to remember did I do something for no reason, potentially cause harm.
00:06:51.600 --> 00:06:54.079
It's I mean, it's very clear.
00:06:54.160 --> 00:07:07.199
Um, although it's a retrospective study, it's very clear that giving a one-time blood pressure medication with asymptomatic hypertension causes uh at the very least AKIs and potential harm for patients.
00:07:07.360 --> 00:07:09.279
It's kind of my main takeaway from this.
00:07:09.519 --> 00:07:09.839
Yeah.
00:07:10.319 --> 00:07:10.959
Definitely.
00:07:11.120 --> 00:07:14.639
I it's another one of those times where it's almost like a comfort blanket study.
00:07:15.040 --> 00:07:16.800
That it's like, it's okay.
00:07:17.120 --> 00:07:20.480
You're not making things worse by not doing anything.
00:07:20.959 --> 00:07:21.439
I am with you.
00:07:21.519 --> 00:07:23.680
You mentioned the fact that it's a retrospective trial.
00:07:23.759 --> 00:07:25.680
And I do like, I am on board with this.
00:07:25.839 --> 00:07:32.800
I am on board that we are treating in general almost all of the time, we're treating inpatient hypertension unnecessarily.
00:07:32.879 --> 00:07:39.519
I'm on board that it's something we do for no reason, but we haven't had that randomized control trial that really proves it.
00:07:39.600 --> 00:07:43.279
Because one of my problems with the study and looking through this, I'm like, okay, yeah, I get it.
00:07:43.360 --> 00:07:57.360
We we kind of tried to group patients and and balance them like it was a randomized control tile, essentially control the patients by making sure comorbides were the same in each group and they didn't eliminate very many diagnoses, like people have cardiac stuff, everything.
00:07:57.439 --> 00:08:00.079
They tried to include a lot of stuff, had a large N.
00:08:00.800 --> 00:08:12.079
But Austin, patients that have an even higher blood pressure, don't you think they're more likely to get the as-needed treatment?
00:08:12.399 --> 00:08:18.240
Are people are we kind of just like self-selecting the patients that are otherwise sicker?
00:08:18.319 --> 00:08:21.759
And and maybe this is correlation, not causation.
00:08:22.079 --> 00:08:32.639
Yeah, I saw that with the 140 to 150, the one that um like if you're treating that number, it's kind of like a no duh, it's gonna cause an AKI.
00:08:32.720 --> 00:08:33.600
Uh yeah, exactly.
00:08:33.679 --> 00:08:38.720
Yeah, they and I hadn't didn't sort of mention that in the rundown, but they did do sort of a subgroup analysis.
00:08:38.799 --> 00:08:52.000
And that was the only time I saw that in this study they broke it down to just specific blood pressure groups, and that 140 to 159, which you and I are hardly not even tempted to be treating that, it sounds like from our discussion.
00:08:52.159 --> 00:08:57.919
If you treat those numbers, then you're dropping people who were already not high.
00:08:58.080 --> 00:09:03.440
I mean, that's that's almost normal for I'm stressed out and in the hospital or I'm in pain or whatever.
00:09:03.679 --> 00:09:07.440
Um, if you're treating that with antihypertensive, you're gonna particularly see problems.
00:09:07.600 --> 00:09:16.399
Now, again, I'm on board, but sort of the contrarian or the I want to be like, is this study itself gonna really change my practice in me?
00:09:16.559 --> 00:09:23.120
I'm I'm uh I'm a little bit tentative because it's not, it's not a randomized control trial, may have just correlation here.
00:09:23.200 --> 00:09:24.879
And that's even they said that in the discussion.
00:09:24.960 --> 00:09:36.399
They're like this basically, they think what this study gives us is more ammo to say someone needs to be doing a randomized control trial that will be the nail in the coffin that can really change practice.
00:09:36.639 --> 00:09:45.759
It and it gives me more ammunition at night, at very least, for for these or if it's below 180, more reassured, like I don't need to treat this.
00:09:46.080 --> 00:09:48.559
Now, obviously, we're not talking about hypertensive emergency.
00:09:48.720 --> 00:10:00.000
If the patient's got a terrible headache, is having chest pain, is having this bad shortness of breath along with it, if we're seeing or flash pulmonary edema, if we're having an AKI, any of that end organ damage, totally different bucket.
00:10:00.080 --> 00:10:01.440
You need to be treating that blood pressure.
00:10:01.600 --> 00:10:15.840
But for the patient that is asymptomatic hypertension, that along with the AHA guidelines, there are new guidelines from 2024, and that's basically do not treat asymptomatic elevated blood pressure acutely.
00:10:16.000 --> 00:10:20.399
And specifically mentioning treatment should generally be the exception and not the rule.
00:10:20.559 --> 00:10:30.720
I mentioned that session with the uh the things we do for no reason session at this most recent SA recent SHM conference, and they gave uh a compelling argument.
00:10:30.799 --> 00:10:38.720
There was, I think it was a 2018 article they put out about things we do for no reading reason treating, acutely treating inpatient hypertension.
00:10:38.879 --> 00:10:57.120
And a couple of things they mentioned that were somewhat was compelling were there was one outpatient study that they mentioned where essentially it was folks in the office looking to see if they come in and in the office they have a blood pressure of systolic of greater than 180, greater than 200.
00:10:57.200 --> 00:11:06.559
I think they even went up to they had a cohort that was greater than 220 and looking at if you send those patients to the hospital or you send them home, how likely are they to have a cardiac event?
00:11:06.639 --> 00:11:08.399
And I think it was the next 30 days.
00:11:08.639 --> 00:11:11.679
And there was no statistically significant difference between the two.
00:11:11.840 --> 00:11:20.320
So this person who's at home and you're not treating this number, obviously, you're not treating acutely, um, is doing just as good as the person who came into the hospital.
00:11:20.559 --> 00:11:31.919
Again, just like your patient, if you've got a patient who's otherwise healthy and he's here for a leg fracture and he's just in terrible pain, the takeaway is he's probably gonna do fine.
00:11:32.080 --> 00:11:35.840
If he was at home, he'd be have that blood pressure probably, and he'd be doing fine.
00:11:36.159 --> 00:11:42.879
And so we can pretty much ignore that number and just instead treat the underlying cause, like let's be treating this patient's pain.
00:11:42.960 --> 00:11:49.279
And that also kind of patients that come in, they're hypertensive, we'll get calls to admit them all the time at night.
00:11:49.440 --> 00:12:02.799
And I have to think back, and I'm tempted just because the number is scary, but then I think back to my outpatient days as a resident, and I say, Well, I've had patients that are that high, and I start them on a blood pressure medication, and if they're asymptomatic, we send them home.
00:12:02.879 --> 00:12:03.039
Right.
00:12:03.200 --> 00:12:06.240
I I don't know, I don't recommend they go to the emergency department.
00:12:06.399 --> 00:12:14.159
So it kind of makes you think back on your practice as well at night and say, Oh, maybe I didn't need to treat that number.
00:12:14.480 --> 00:12:20.879
Another kind of interesting point they made that I think as much as anything calmed me down.
00:12:20.960 --> 00:12:22.000
They made a couple of points.
00:12:22.159 --> 00:12:31.919
One was there had been a test where I presume they did this with an A-line, where they put a bunch of fit guys, let them loose in a gym, and measured their blood pressure during weight lifting.
00:12:34.000 --> 00:12:34.320
I don't know.
00:12:34.559 --> 00:12:36.320
I don't I don't know the mechanisms up here.
00:12:36.879 --> 00:12:39.360
I don't know if they're just like sitting there right by interesting.
00:12:40.399 --> 00:12:46.399
And then, like, if it's an A-line, if they're doing because I think one of these was uh doing squats and or no, they did leg press.
00:12:46.559 --> 00:12:49.360
So maybe they kept their heart at the same level.
00:12:49.600 --> 00:13:02.720
Um but these these guys, their blood pressures in a curl reached up to 240 over 160, and when they did leg presses, it would reach up to 325 over 245.
00:13:02.799 --> 00:13:04.320
So these blood pressures are crazy high.
00:13:04.399 --> 00:13:14.639
And the point, like the point being your body is made to temporarily withstand very high blood pressure, they do it physiologically.
00:13:14.879 --> 00:13:24.000
Um and so it's not something that's gonna cause a problem for us in certainly minutes or even hours.
00:13:24.320 --> 00:13:31.200
Obviously, we know long-term management of hypertension is incredibly important, but short term, the body is able to manage it.
00:13:31.360 --> 00:13:42.720
And another thing they did was showed us some like cerebral blood flow curves and how they really plateaued, and no matter how much higher, how much higher the blood pressure was getting, the cerebral blood flow was pretty constant.
00:13:42.879 --> 00:13:46.799
But then once you start to overcorrect that blood pressure, it drops off a cliff.
00:13:46.879 --> 00:13:48.960
And so explaining some, what are these bad outcomes?
00:13:49.120 --> 00:13:54.320
If you're dropping that blood pressure, then you're dropping them off the curve where then they're not perfusing their brain.
00:13:54.480 --> 00:14:03.440
Um, and so you're certainly causing more harm than good most of the time, particularly if you've got a patient you don't have any reason to think they can't tolerate that high blood pressure.
00:14:03.519 --> 00:14:05.840
They should be able to tolerate crazy high numbers.
00:14:06.080 --> 00:14:09.919
Um, though I don't think any of us are letting a 325 over 245.
00:14:10.639 --> 00:14:10.879
No.
00:14:11.440 --> 00:14:18.320
It's it's yeah, it's where I think we're all kind of starting to find that we shouldn't be treating these blood pressures.
00:14:18.480 --> 00:14:30.480
It's just gonna have to take a lot of teaching and reassurance from for both providers as well as with staff and patients and kind of flipping that narrative of no, no, we don't need to treat these.
00:14:30.639 --> 00:14:37.600
And we've got more data that will need to be obtained in order to really make these big, these big cultural shifts.
00:14:37.840 --> 00:15:00.639
And I do think, I mean, if anyone's out there and and is starting to organize or can get the randomized control trial organized, that would, I think, change everything and how well we can sell this on an institutional level and really change order sets, change institutional policies, change culture with nurses confidently tell patients because it's a tough fight to fight, and we need that fully definitive data.
00:15:00.879 --> 00:15:01.200
All right.
00:15:01.360 --> 00:15:02.159
So what do you think?
00:15:02.240 --> 00:15:04.799
Is this gonna change the practice going forward?
00:15:04.879 --> 00:15:05.919
And if so, how?
00:15:06.639 --> 00:15:07.600
Overall, yes.
00:15:07.759 --> 00:15:10.240
It'll make me reassured for under 180.
00:15:10.320 --> 00:15:11.440
We don't need to do anything.
00:15:11.679 --> 00:15:12.799
Keep steady.
00:15:12.879 --> 00:15:29.679
And I, you know, this gives me a little bit more ammunition and more comfortability to say above 180 as well, just you know, have let it ride at night and come up with a better plan daytime if we think that we've um eliminated all other sources of potential hypertension.
00:15:29.840 --> 00:15:33.200
And hopefully, yes, it'll change my practice for the better.
00:15:33.679 --> 00:15:44.399
If anything, start start something light and world going forward and keep my eyes open for that randomized controlled trial that can can put a nail in this coffin and and really change culture.
00:15:48.000 --> 00:15:52.320
Next thing, kind of keeping with the things maybe we do for no reason.
00:15:52.559 --> 00:16:04.639
So this is a article called Associations Between Antibiotic Use and Outcomes in Patients Hospitalized with Community Acquired Pneumonia, but with positive respiratory viral assays.
00:16:04.879 --> 00:16:15.919
So this was a really cool article that infectious disease seem to have done in response to ATS, uh, American Thoracic Society.
00:16:16.000 --> 00:16:24.720
And I like it when you've got two different societies that don't agree, and then one of them decides to try to prove the other wrong and kind of clap back with it.
00:16:24.960 --> 00:16:48.879
So it it came in response to ATS guidelines who recommended to treat with antibiotics, even if there was a positive viral assay, claiming that it would decrease mortality, decrease poor outcomes because of the rate of they felt that there was a high rate of bacterial coinfection with these um with these viruses.
00:16:49.279 --> 00:16:59.759
But infectious disease seemed to disagree and they endorsed more low coinfection rates, um, as well as there's no such thing as a safe medication, including antibiotics.
00:16:59.919 --> 00:17:06.559
All these things had adverse um events, and that can include AKI, um drug rash, etc.
00:17:07.039 --> 00:17:23.279
Um, so this um this article was a again a retrospective um multi-center five hospital study over um many years, 2015 to 2024.
00:17:23.839 --> 00:17:37.119
Um, and there they uh they sought out patients that had a positive um respiratory viral assay within the first 48 hours of them being admitted, and then had clinical signs of pneumonia.
00:17:37.200 --> 00:17:42.160
So tachynea, hypoxia, chest imaging that was concerning for pneumonia.
00:17:42.319 --> 00:17:58.079
And then they decided to see whether or not antibiotics made a difference in their in their uh clinical course from either a very short antibiotic of zero to one day, or full uh cap treatment, which is five to seven days.
00:17:58.240 --> 00:18:01.279
And the headline here was it didn't make a difference.
00:18:01.519 --> 00:18:14.480
You could not treat them with antibiotics, or you could treat them with antibiotics, and it didn't make a significant difference in the mortality, didn't make a difference in the ICU admission rate after 48 hours or length of stay.
00:18:14.720 --> 00:18:18.160
So it kind of definitively said, no, we don't think so.
00:18:18.319 --> 00:18:26.000
We don't think treating these patients with pneumonia symptoms with a positive viral assay makes a difference.
00:18:26.160 --> 00:18:39.680
So disagreed, and we've got kind of uh two differing societies now, and now it kind of leaves us in the middle of uh with being internal medicine primary for these patients, deciding on what to do.
00:18:39.920 --> 00:18:40.880
What was your thoughts?
00:18:41.200 --> 00:18:52.799
Yeah, this was this was fun, and and like I said at the top, like we're we're addressing a controversy here, and um, it's a little bit nerdy for this to be like this is drama, but it's about as high drama as this gets.
00:18:52.960 --> 00:18:57.359
It's about as high drama as uh evidence for inpatient medicine gets.
00:18:57.440 --> 00:18:59.599
So boom, we're excited today.
00:18:59.839 --> 00:19:24.000
Um, but it it this was another thing that I heard mention of um at the SHM conference that there was uh updates in the guidelines talk, and they had this little graph that was like a bridge, and it was the IDSA and the thoracic association agreeing on guidelines and putting out guidelines together, and then it's like all of a sudden schism and things are breaking and they're going different ways.
00:19:24.240 --> 00:19:25.920
So it's dramatic.
00:19:26.079 --> 00:19:39.440
And I think this is an impressive feather in the cap of the IDSA to say our recommendation that we do not routinely recommend antibiotics for folks that get admitted for pneumonia and have a positive viral panel.
00:19:39.599 --> 00:19:42.400
I think this is this is backing them up pretty well.
00:19:42.640 --> 00:19:50.160
The question I have on it though is how much is this changing our routine and our day-to-day practice?
00:19:50.319 --> 00:19:51.200
What are your thoughts?
00:19:51.359 --> 00:19:58.480
Before we read this article, before we looked at this drama with the guidelines, what would have been your go-to?
00:19:58.640 --> 00:20:02.319
You've got someone who fits in the inclusion criteria of this study.
00:20:02.400 --> 00:20:06.400
So you've got someone you admit, they are hypoxic.
00:20:06.480 --> 00:20:09.119
They said less than 95 on room air.
00:20:09.200 --> 00:20:16.400
So maybe they're on a little bit of oxygen, maybe they're on a lot of oxygen, uh, maybe they're on no oxygen and just sort of flirting with that less than 95.
00:20:16.480 --> 00:20:17.599
They're tachypnic.
00:20:18.079 --> 00:20:23.839
And the inclusion criteria was chest imaging was ordered, but they didn't do any assessment of that testing.
00:20:24.240 --> 00:20:28.160
Um, so you get that patient and you're admitting them to your surface.
00:20:28.319 --> 00:20:33.599
And I mean, I'll pretty much guarantee you they're they're gonna that's part of why we do zero to two days, I'm sure.
00:20:33.680 --> 00:20:38.559
Is they've gotten a dose of ceftriaxin and a zipin or something in the ED.
00:20:39.039 --> 00:20:47.039
But if you're admitting that patient going forward, are you continuing them on antibiotics or are you were you not before before reading this?
00:20:47.680 --> 00:21:10.319
There was a patient I had pretty recently, um, 30-year-old, relatively healthy, you know, no other comorbidities, had a bad viral infection, diagnosed it right away, and he was a hyp, you know, tachycardic in 120s, hypoxic, needing a few liters, and decided not to continue antibiotics from the ED.
00:21:10.559 --> 00:21:21.279
And to try and explain that to patients as well as family when they look that sick, you know, goes back to the there's no such thing as a benign medication.
00:21:21.440 --> 00:21:22.799
Everything has adverse effects.
00:21:22.960 --> 00:21:37.359
So before I was not doing it, um, was not treating, you know, these uh patients with a positive viral culture, unless I something in their story made me suspect superimposed bacterial infection, so I would not be treating it.
00:21:37.599 --> 00:21:43.200
This just gives me more ammo to really say and and more comfortability to say it doesn't matter.
00:21:43.839 --> 00:21:52.160
I was practicing similar to you that if I didn't have a reason to and I thought the virus was the reason for their pneumonia, I wasn't routinely giving antibiotics.
00:21:52.400 --> 00:21:56.799
So going forward, who who do you think's which which path are you going down?
00:21:56.880 --> 00:22:01.279
Are you team thoracic society or are you team ID society.
00:22:01.680 --> 00:22:04.720
100% team ID all the way.
00:22:04.880 --> 00:22:11.680
And I'll continue to feel support with this article and continue to not give these guys antibiotics.
00:22:11.920 --> 00:22:13.279
They have the positive viral assay.
00:22:13.519 --> 00:22:13.839
100%.
00:22:14.240 --> 00:22:16.319
Two for two, we're team IDSA.
00:22:16.880 --> 00:22:28.720
Inpatient Update officially disagrees with the recommendation that you give all patients you admit with a positive viral panel in respiratory symptoms, antibiotics.
00:22:28.880 --> 00:22:33.359
Before we had this study, I would have said, these experts say this, this, these experts say this.
00:22:33.519 --> 00:22:34.400
It's hard to say.
00:22:34.559 --> 00:22:35.039
I don't know.
00:22:35.200 --> 00:22:38.559
Maybe I'm going to go the more conservative route and give everyone antibiotics.
00:22:38.640 --> 00:22:48.160
So I really do think I'm glad they did the study, and it totally puts me in the bucket of, to be clear, the guideline of not routinely recommending.
00:22:48.240 --> 00:22:52.960
And now, again, similar to our other study, this trial has its limitations.
00:22:53.119 --> 00:22:54.880
This is not a randomized controlled trial.
00:22:54.960 --> 00:22:56.079
It's retrospective.
00:22:56.400 --> 00:23:07.279
And so similarly, I think there's some degree that the patients could have self-selected that sicker patients are going to end up more likely to get the antibiotics.
00:23:07.440 --> 00:23:10.319
So it just makes things a little more complicated there.
00:23:10.559 --> 00:23:16.160
Honestly, any of these people, if you end up in the ICU, it's hard to imagine you're not getting antibiotics and getting that conservative treatment.
00:23:16.319 --> 00:23:23.279
Because similarly, not only did they not they didn't do better with antibiotics, they also didn't do worse with antibiotics.
00:23:23.359 --> 00:23:23.680
They didn't.
00:23:23.920 --> 00:23:27.839
This was all no statistically significant changes, including like rates of C.
00:23:28.000 --> 00:23:28.720
diff and all of that.
00:23:28.799 --> 00:23:33.359
And so, yes, there are complications with antibiotics, but we're not seeing that those patients do worse off.
00:23:33.599 --> 00:23:41.680
I do want to be a good steward of antibiotics, but honestly, in my data practice, what I care more is what's going to be best for my patient.
00:23:41.920 --> 00:23:44.720
So if they don't need antibiotics, I won't give it to them.
00:23:44.799 --> 00:23:46.880
But if they seem like they need it, I'll give it to them.
00:23:46.960 --> 00:23:56.640
But definitely not routinely giving everyone who has comes in flu, COVID, RSV, antibiotics if I don't think they have a bacterial pneumonia.
00:23:56.799 --> 00:23:58.079
I wasn't doing that before.
00:23:58.400 --> 00:24:08.240
One thing I really liked about this study, um, and we keep saying, oh, it's retrospective, but they didn't pool any any punches with who they selected.
00:24:08.319 --> 00:24:14.559
They over 30% of them on the initial selection went to the ICU.
00:24:14.720 --> 00:24:34.240
Um and then on the continued, you know, after um being excluded for procalcitonin elevation and um and short stays, these guys were still, you know, over 20% of them still went to the ICU, no matter if they got short dose, short um, short dose of antibiotics or longer dose.
00:24:34.400 --> 00:24:35.920
You know, these guys are pretty sick.
00:24:36.000 --> 00:24:43.680
And I think this kind of speaks to we're learning more about viruses and how sick a person can be with just the virus.
00:24:43.839 --> 00:24:51.599
And I think that's partly because of COVID times, and then partly because we're we're seeing almost any virus can do this.
00:24:51.920 --> 00:24:59.920
There's some in the study they say they note um adenovirus and like rhinovirus.
00:25:00.079 --> 00:25:08.640
Um, over 90% of them got antibiotics because we're just we keep thinking, oh, you know, I I don't think this virus can cause this.
00:25:08.799 --> 00:25:13.519
But now we're showing in this study, like, no, these viruses can make you pretty sick.
00:25:13.680 --> 00:25:19.200
And giving them antibiotics just because it's a quote weaker virus may not make a lot of sense.
00:25:19.440 --> 00:25:23.839
So um it's it's an interesting um division that we have now.
00:25:24.160 --> 00:25:40.240
I'm sure the IDSA would have loved to see that the patients without antibiotics actually do it better from at least either like a length of because I expected to see like I was looking at like the C diff numbers and the length of stay numbers and thought, like, if we're not giving them antibiotics and tying them to that, are they getting out of the hospital quicker?
00:25:40.559 --> 00:25:41.599
Yeah, none of that.
00:25:41.680 --> 00:25:42.640
All of that, yeah.
00:25:42.880 --> 00:25:45.279
It was it was it was 50-50.
00:25:45.599 --> 00:25:50.880
Is this study actively changing your your practice in any way going forward?
00:25:51.279 --> 00:25:58.319
It's actively changing and continuing to do what I'm doing and not giving these guys antibiotics.
00:25:58.720 --> 00:26:00.640
Sometimes no change is a change.
00:26:01.440 --> 00:26:12.160
But it makes me more confident when I can go into the room and tell patients and loved ones, no, we we are okay to hold off antibiotics for now.
00:26:12.319 --> 00:26:15.680
But that's the reason you're in the hospital to continue to monitor clinically.
00:26:15.759 --> 00:26:21.519
We we can't we don't have a crystal ball to know if there's superimposed bacterial infection, but that's why you're here.
00:26:21.599 --> 00:26:29.920
If you don't get better, it's no harm to continue to to monitor you and then change, change based on how you do clinically.
00:26:30.240 --> 00:26:35.279
Similarly to our first study, this is this is kind of what I was doing, anyways.
00:26:35.359 --> 00:26:40.400
If I thought the virus was the cause, I wasn't giving antibiotics, but it's probably moving me on the margin.
00:26:40.480 --> 00:26:43.839
So like I'm gonna be that rhino, that adenovirus.
00:26:44.000 --> 00:26:50.640
In more patients, I'm gonna be saying it's gonna just that move me that little bit that I'm that much more likely.
00:26:50.720 --> 00:26:55.599
If I've got a patient coming in and I can hang this on a virus, then I'll do it.
00:26:55.680 --> 00:27:05.839
And then if they get worse or give me any reason, then low threshold to start antibiotics, I'm probably not gonna make anything worse if I do, if I think they really need it, but it will move me that little bit going forward.
00:27:09.039 --> 00:27:19.519
Recapping when it comes to urgent one-time hypertension, acute hypertension in the hospital setting, the data supports you not treating that.
00:27:19.680 --> 00:27:22.640
In fact, outcomes are worse in the patients that it gets treated.
00:27:22.720 --> 00:27:30.559
This is something we generally do for no reason, but we're really looking for that randomized control tile that tells us absolutely it's the wrong thing to do.
00:27:30.720 --> 00:27:44.240
If you're giving something, you should be gentle in what you're giving them because you're going to cause more harm by dropping a patient quickly than you are by letting them stay at a hypertensive number over the course of hours in the hospital.
00:27:44.400 --> 00:27:44.880
That's right.
00:27:45.039 --> 00:27:58.960
And when it comes to patients that are admitted with hypoxia, evidence of pneumonia, who have a positive virus, you do not need to do antibiotics in those patients unless you think they actually have a bacterial component.
00:27:59.119 --> 00:28:00.720
Inpatient update, Dr.
00:28:00.880 --> 00:28:01.680
Turner, Dr.
00:28:01.759 --> 00:28:12.480
White, our team IDSA, and we do not think those patients admitted with viral pneumonia routinely need antibiotics going forward.
00:28:15.920 --> 00:28:16.799
Thank you so much.
00:28:16.960 --> 00:28:21.359
It's it's been a joy, it's been a pleasure, and I'd love to have you on the show again sometime.
00:28:21.599 --> 00:28:22.160
I appreciate it.
00:28:22.480 --> 00:28:25.119
More controversial articles are always fun.
00:28:25.519 --> 00:28:25.839
Right.
00:28:26.000 --> 00:28:30.319
And to our audience, um, thank you so much for joining us.
00:28:30.559 --> 00:28:36.000
And if you find this useful, please send it and share it with your colleagues or classmates.
00:28:36.160 --> 00:28:48.880
And if you've got any new evidence you think we should be talking about, and or you are a provider, a specialist, a nurse, a pharmacist, or anyone with value-added insight into the management of hospitalized patients, please reach out to me.
00:28:49.039 --> 00:28:58.400
You can reach out to me directly or contact Inpatient Update on social email social media or email me at podcast at inpatientupdate.com.
00:28:59.119 --> 00:29:00.880
Thank you so much for being with me, Dr.
00:29:00.960 --> 00:29:02.640
White, and thank you to the audience.
00:29:02.880 --> 00:29:04.880
This has been Inpatient Update.
00:00:19.199 --> 00:00:21.280
Hello and welcome to Inpatient Update.
00:00:21.440 --> 00:00:27.440
I'm your host, Mason Turner, and this is your podcast for practice changing evidence for the working hospitalist.
00:00:27.920 --> 00:00:29.679
Today on the show, I'm joined by Dr.
00:00:29.839 --> 00:00:36.079
Austin White as we delve into recent studies on a couple of hospital medicine controversies.
00:00:36.399 --> 00:00:40.159
Should we be treating asymptomatic hypertension in the hospital?
00:00:40.399 --> 00:00:45.679
Should we be giving antibiotics to patients admitted with pneumonia and a positive viral panel?
00:00:45.920 --> 00:00:46.640
Well, Dr.
00:00:46.719 --> 00:00:48.799
White, thank you so much for being with me here today.
00:00:49.039 --> 00:00:49.359
Thank you.
00:00:49.439 --> 00:00:50.240
Thank you for having me.
00:00:50.560 --> 00:00:52.079
For the audience, Dr.
00:00:52.240 --> 00:00:58.880
Austin White is one of my colleagues, a rapidly rising superstar in my division.
00:00:59.039 --> 00:01:00.960
Another thing of note is uh Dr.
00:01:01.039 --> 00:01:02.719
White does a lot of nights with us.
00:01:02.880 --> 00:01:07.840
I'm excited to have a nocturnist's perspective on this or a semi-nocturnist.
00:01:08.079 --> 00:01:22.000
And in that vein, Austin, have you ever gotten a page overnight from a nurse that says Miss Jones has a blood pressure of systolics of let's go 204?
00:01:22.640 --> 00:01:23.280
Oh no.
00:01:23.519 --> 00:01:26.400
Anything in that range sound like something you've ever had to deal with?
00:01:26.799 --> 00:01:27.760
Every single night.
00:01:27.920 --> 00:01:28.159
Yes.
00:01:28.400 --> 00:01:29.280
Maybe not that high.
00:01:29.359 --> 00:01:30.640
That high is a little bit too high.
00:01:30.879 --> 00:01:32.400
But every night I'm constantly picked.
00:01:32.719 --> 00:01:33.840
What do you do when you get that page?
00:01:33.920 --> 00:01:35.200
What's what's your go-to response?
00:01:35.280 --> 00:01:36.239
What's your go-to reaction?
00:01:36.719 --> 00:01:42.239
So whenever I'm chatted that that blood pressure, I always ask, are there any symptoms?
00:01:42.400 --> 00:01:44.159
And usually it's a no.
00:01:44.560 --> 00:01:46.239
And we'll move on from there.
00:01:46.400 --> 00:01:51.200
But um yeah, it's a constant uh question from from nursing.
00:01:51.519 --> 00:01:52.159
Yeah, agreed.
00:01:52.239 --> 00:02:00.959
I kind of my rule of thumb, honestly, in the way I I genuinely practice is I as long as that first digit isn't a two, I feel pretty comfortable holding the line.
00:02:01.040 --> 00:02:13.919
I say, let's like restart their home orals, or even I'll say, let's get them started on something a little bit oral just to do something, just to make honestly to make myself a little bit, but mostly everyone else feel a little more comfortable.
00:02:14.080 --> 00:02:17.039
The patient and the nurse feel a little more comfortable that we're treating it.
00:02:17.280 --> 00:02:24.319
So I'll usually throw maybe a PO carvatolol and then sort of scheduling it and planning on it forward.
00:02:24.560 --> 00:02:31.599
I think a lot of our sort of default order sets that you can order as PRNs for hypertension, 180 is usually the number.
00:02:31.680 --> 00:02:37.120
And I think our order set that like page MD if greater than is probably 180.
00:02:37.199 --> 00:02:42.080
That's kind of like my so I think of like the default number of like you're getting a page if it's higher than that.
00:02:42.240 --> 00:02:47.280
And usually the nurses are pretty good about we don't hear from them if it's not more than 180.
00:02:47.919 --> 00:02:50.879
Speak for yourself depending on the nurse.
00:02:51.439 --> 00:03:00.879
So at night it's definitely a different ball game where um if it reads red and they're in their kind of vital sign sheet, I'll get paged about it usually.
00:03:01.199 --> 00:03:08.319
So there's a lot of acknowledge the the message for 160, 170, and I'll give a thumbs up.
00:03:08.479 --> 00:03:10.159
But you know, I have no symptoms.
00:03:10.240 --> 00:03:11.840
I'm I'm less interested.
00:03:12.000 --> 00:03:15.759
But at night, you definitely get paged more regarding those numbers.
00:03:16.080 --> 00:03:23.360
And so I I have this discussion because this is one of those things that that I've heard about and has been on my radar for a long time.
00:03:23.520 --> 00:03:27.520
This is something we treat, we over-treat inpatient hypertension.
00:03:27.840 --> 00:03:35.840
It ended up as number one on the list of things we do for no reason and the things we do for no reason session at SHM this year.
00:03:36.159 --> 00:03:41.439
This was their number one thing treating inpatient hypertension with PRNs or one-time meds.
00:03:42.080 --> 00:03:47.520
And so it's the kind of thing that I I've kind of heard that, I've been aware of that.
00:03:48.000 --> 00:04:02.479
I hadn't been totally up to date on all the data and then saw this study came out just recently that kind of shined lights on are we just are we just doing it for no reason or are we doing it for no reason and actively harming patients?
00:04:02.639 --> 00:04:03.840
Which obviously makes a big difference.
00:04:04.000 --> 00:04:12.719
If we're doing it for no reason and it drops the um blood pressure of the overnight provider and helps save save a page and the nurse and all of that, then it's one thing.
00:04:12.800 --> 00:04:15.439
But if we're actively harming patients by doing it, it's another.
00:04:15.520 --> 00:04:19.680
And so that's what the study specifically looked in to try and find.
00:04:19.920 --> 00:04:26.160
Um, and so this was in published in Jam Internal Medicine, and it was published in 2025.
00:04:26.319 --> 00:04:32.319
It was entitled As Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals.
00:04:32.560 --> 00:04:36.959
It was um a retrospective cohort study.
00:04:37.120 --> 00:04:52.319
What they did is they took patients over multiple years, everyone that got admitted to the hospital, and then they broke things down into patients receiving either one or more PRN antihypertensive versus people who didn't receive any antihypertensive.
00:04:52.480 --> 00:05:03.360
And the primary outcome they looked at was acute kidney injury, and then a secondary um outcome of two aggressive blood pressure drops.
00:05:03.519 --> 00:05:14.399
So they looked at how many of the patients got dropped greater than 25% within three hours, and then also a composite outcome of myocardial infarction stroke or death.
00:05:15.360 --> 00:05:23.439
And so the big headline result was that all of these things were worse in the patients that got the PRNs.
00:05:23.600 --> 00:05:29.759
So the AKIs were, I think, 23% more likely to have an AKI.
00:05:30.000 --> 00:05:40.639
Um, there was a hazard ratio of 1.23 that was statistically significant, um, a statistically significant hazard ratio of 1.5 for the rapid drop in blood pressure.
00:05:40.959 --> 00:05:49.279
And um anytime you've got uh a composite outcome with stroke, heart attack, and dying, I'm gonna be particularly interested.
00:05:49.439 --> 00:05:56.319
And was also statistically significant, more in the group that got treated with PRNs with a hazard ratio of 1.6.
00:05:56.720 --> 00:05:59.839
And they looked into the these things a little bit deeper.
00:05:59.920 --> 00:06:20.319
And IV patients that got IV antihypertensives were even worse, more likely to get an AKI, with the hazard ratio being 1.6 instead of 1.23, versus less, but still significantly significant if they're just getting that oral kind of like me giving if I give just that one time Carvatolol, that would put me in that bucket.
00:06:20.560 --> 00:06:24.000
Still showed that there was harm there in the primary outcome.
00:06:24.240 --> 00:06:27.600
Um and so that's sort of the big picture of this.
00:06:27.759 --> 00:06:43.600
I found it helpful to see numbers that state the patients that are being treated with PRN antihypertensive, one-time antihypertensives for an elevated blood pressure were actually seeing worse outcomes.
00:06:44.160 --> 00:06:51.439
It definitely made me think back on my nights and try to remember did I do something for no reason, potentially cause harm.
00:06:51.600 --> 00:06:54.079
It's I mean, it's very clear.
00:06:54.160 --> 00:07:07.199
Um, although it's a retrospective study, it's very clear that giving a one-time blood pressure medication with asymptomatic hypertension causes uh at the very least AKIs and potential harm for patients.
00:07:07.360 --> 00:07:09.279
It's kind of my main takeaway from this.
00:07:09.519 --> 00:07:09.839
Yeah.
00:07:10.319 --> 00:07:10.959
Definitely.
00:07:11.120 --> 00:07:14.639
I it's another one of those times where it's almost like a comfort blanket study.
00:07:15.040 --> 00:07:16.800
That it's like, it's okay.
00:07:17.120 --> 00:07:20.480
You're not making things worse by not doing anything.
00:07:20.959 --> 00:07:21.439
I am with you.
00:07:21.519 --> 00:07:23.680
You mentioned the fact that it's a retrospective trial.
00:07:23.759 --> 00:07:25.680
And I do like, I am on board with this.
00:07:25.839 --> 00:07:32.800
I am on board that we are treating in general almost all of the time, we're treating inpatient hypertension unnecessarily.
00:07:32.879 --> 00:07:39.519
I'm on board that it's something we do for no reason, but we haven't had that randomized control trial that really proves it.
00:07:39.600 --> 00:07:43.279
Because one of my problems with the study and looking through this, I'm like, okay, yeah, I get it.
00:07:43.360 --> 00:07:57.360
We we kind of tried to group patients and and balance them like it was a randomized control tile, essentially control the patients by making sure comorbides were the same in each group and they didn't eliminate very many diagnoses, like people have cardiac stuff, everything.
00:07:57.439 --> 00:08:00.079
They tried to include a lot of stuff, had a large N.
00:08:00.800 --> 00:08:12.079
But Austin, patients that have an even higher blood pressure, don't you think they're more likely to get the as-needed treatment?
00:08:12.399 --> 00:08:18.240
Are people are we kind of just like self-selecting the patients that are otherwise sicker?
00:08:18.319 --> 00:08:21.759
And and maybe this is correlation, not causation.
00:08:22.079 --> 00:08:32.639
Yeah, I saw that with the 140 to 150, the one that um like if you're treating that number, it's kind of like a no duh, it's gonna cause an AKI.
00:08:32.720 --> 00:08:33.600
Uh yeah, exactly.
00:08:33.679 --> 00:08:38.720
Yeah, they and I hadn't didn't sort of mention that in the rundown, but they did do sort of a subgroup analysis.
00:08:38.799 --> 00:08:52.000
And that was the only time I saw that in this study they broke it down to just specific blood pressure groups, and that 140 to 159, which you and I are hardly not even tempted to be treating that, it sounds like from our discussion.
00:08:52.159 --> 00:08:57.919
If you treat those numbers, then you're dropping people who were already not high.
00:08:58.080 --> 00:09:03.440
I mean, that's that's almost normal for I'm stressed out and in the hospital or I'm in pain or whatever.
00:09:03.679 --> 00:09:07.440
Um, if you're treating that with antihypertensive, you're gonna particularly see problems.
00:09:07.600 --> 00:09:16.399
Now, again, I'm on board, but sort of the contrarian or the I want to be like, is this study itself gonna really change my practice in me?
00:09:16.559 --> 00:09:23.120
I'm I'm uh I'm a little bit tentative because it's not, it's not a randomized control trial, may have just correlation here.
00:09:23.200 --> 00:09:24.879
And that's even they said that in the discussion.
00:09:24.960 --> 00:09:36.399
They're like this basically, they think what this study gives us is more ammo to say someone needs to be doing a randomized control trial that will be the nail in the coffin that can really change practice.
00:09:36.639 --> 00:09:45.759
It and it gives me more ammunition at night, at very least, for for these or if it's below 180, more reassured, like I don't need to treat this.
00:09:46.080 --> 00:09:48.559
Now, obviously, we're not talking about hypertensive emergency.
00:09:48.720 --> 00:10:00.000
If the patient's got a terrible headache, is having chest pain, is having this bad shortness of breath along with it, if we're seeing or flash pulmonary edema, if we're having an AKI, any of that end organ damage, totally different bucket.
00:10:00.080 --> 00:10:01.440
You need to be treating that blood pressure.
00:10:01.600 --> 00:10:15.840
But for the patient that is asymptomatic hypertension, that along with the AHA guidelines, there are new guidelines from 2024, and that's basically do not treat asymptomatic elevated blood pressure acutely.
00:10:16.000 --> 00:10:20.399
And specifically mentioning treatment should generally be the exception and not the rule.
00:10:20.559 --> 00:10:30.720
I mentioned that session with the uh the things we do for no reason session at this most recent SA recent SHM conference, and they gave uh a compelling argument.
00:10:30.799 --> 00:10:38.720
There was, I think it was a 2018 article they put out about things we do for no reading reason treating, acutely treating inpatient hypertension.
00:10:38.879 --> 00:10:57.120
And a couple of things they mentioned that were somewhat was compelling were there was one outpatient study that they mentioned where essentially it was folks in the office looking to see if they come in and in the office they have a blood pressure of systolic of greater than 180, greater than 200.
00:10:57.200 --> 00:11:06.559
I think they even went up to they had a cohort that was greater than 220 and looking at if you send those patients to the hospital or you send them home, how likely are they to have a cardiac event?
00:11:06.639 --> 00:11:08.399
And I think it was the next 30 days.
00:11:08.639 --> 00:11:11.679
And there was no statistically significant difference between the two.
00:11:11.840 --> 00:11:20.320
So this person who's at home and you're not treating this number, obviously, you're not treating acutely, um, is doing just as good as the person who came into the hospital.
00:11:20.559 --> 00:11:31.919
Again, just like your patient, if you've got a patient who's otherwise healthy and he's here for a leg fracture and he's just in terrible pain, the takeaway is he's probably gonna do fine.
00:11:32.080 --> 00:11:35.840
If he was at home, he'd be have that blood pressure probably, and he'd be doing fine.
00:11:36.159 --> 00:11:42.879
And so we can pretty much ignore that number and just instead treat the underlying cause, like let's be treating this patient's pain.
00:11:42.960 --> 00:11:49.279
And that also kind of patients that come in, they're hypertensive, we'll get calls to admit them all the time at night.
00:11:49.440 --> 00:12:02.799
And I have to think back, and I'm tempted just because the number is scary, but then I think back to my outpatient days as a resident, and I say, Well, I've had patients that are that high, and I start them on a blood pressure medication, and if they're asymptomatic, we send them home.
00:12:02.879 --> 00:12:03.039
Right.
00:12:03.200 --> 00:12:06.240
I I don't know, I don't recommend they go to the emergency department.
00:12:06.399 --> 00:12:14.159
So it kind of makes you think back on your practice as well at night and say, Oh, maybe I didn't need to treat that number.
00:12:14.480 --> 00:12:20.879
Another kind of interesting point they made that I think as much as anything calmed me down.
00:12:20.960 --> 00:12:22.000
They made a couple of points.
00:12:22.159 --> 00:12:31.919
One was there had been a test where I presume they did this with an A-line, where they put a bunch of fit guys, let them loose in a gym, and measured their blood pressure during weight lifting.
00:12:34.000 --> 00:12:34.320
I don't know.
00:12:34.559 --> 00:12:36.320
I don't I don't know the mechanisms up here.
00:12:36.879 --> 00:12:39.360
I don't know if they're just like sitting there right by interesting.
00:12:40.399 --> 00:12:46.399
And then, like, if it's an A-line, if they're doing because I think one of these was uh doing squats and or no, they did leg press.
00:12:46.559 --> 00:12:49.360
So maybe they kept their heart at the same level.
00:12:49.600 --> 00:13:02.720
Um but these these guys, their blood pressures in a curl reached up to 240 over 160, and when they did leg presses, it would reach up to 325 over 245.
00:13:02.799 --> 00:13:04.320
So these blood pressures are crazy high.
00:13:04.399 --> 00:13:14.639
And the point, like the point being your body is made to temporarily withstand very high blood pressure, they do it physiologically.
00:13:14.879 --> 00:13:24.000
Um and so it's not something that's gonna cause a problem for us in certainly minutes or even hours.
00:13:24.320 --> 00:13:31.200
Obviously, we know long-term management of hypertension is incredibly important, but short term, the body is able to manage it.
00:13:31.360 --> 00:13:42.720
And another thing they did was showed us some like cerebral blood flow curves and how they really plateaued, and no matter how much higher, how much higher the blood pressure was getting, the cerebral blood flow was pretty constant.
00:13:42.879 --> 00:13:46.799
But then once you start to overcorrect that blood pressure, it drops off a cliff.
00:13:46.879 --> 00:13:48.960
And so explaining some, what are these bad outcomes?
00:13:49.120 --> 00:13:54.320
If you're dropping that blood pressure, then you're dropping them off the curve where then they're not perfusing their brain.
00:13:54.480 --> 00:14:03.440
Um, and so you're certainly causing more harm than good most of the time, particularly if you've got a patient you don't have any reason to think they can't tolerate that high blood pressure.
00:14:03.519 --> 00:14:05.840
They should be able to tolerate crazy high numbers.
00:14:06.080 --> 00:14:09.919
Um, though I don't think any of us are letting a 325 over 245.
00:14:10.639 --> 00:14:10.879
No.
00:14:11.440 --> 00:14:18.320
It's it's yeah, it's where I think we're all kind of starting to find that we shouldn't be treating these blood pressures.
00:14:18.480 --> 00:14:30.480
It's just gonna have to take a lot of teaching and reassurance from for both providers as well as with staff and patients and kind of flipping that narrative of no, no, we don't need to treat these.
00:14:30.639 --> 00:14:37.600
And we've got more data that will need to be obtained in order to really make these big, these big cultural shifts.
00:14:37.840 --> 00:15:00.639
And I do think, I mean, if anyone's out there and and is starting to organize or can get the randomized control trial organized, that would, I think, change everything and how well we can sell this on an institutional level and really change order sets, change institutional policies, change culture with nurses confidently tell patients because it's a tough fight to fight, and we need that fully definitive data.
00:15:00.879 --> 00:15:01.200
All right.
00:15:01.360 --> 00:15:02.159
So what do you think?
00:15:02.240 --> 00:15:04.799
Is this gonna change the practice going forward?
00:15:04.879 --> 00:15:05.919
And if so, how?
00:15:06.639 --> 00:15:07.600
Overall, yes.
00:15:07.759 --> 00:15:10.240
It'll make me reassured for under 180.
00:15:10.320 --> 00:15:11.440
We don't need to do anything.
00:15:11.679 --> 00:15:12.799
Keep steady.
00:15:12.879 --> 00:15:29.679
And I, you know, this gives me a little bit more ammunition and more comfortability to say above 180 as well, just you know, have let it ride at night and come up with a better plan daytime if we think that we've um eliminated all other sources of potential hypertension.
00:15:29.840 --> 00:15:33.200
And hopefully, yes, it'll change my practice for the better.
00:15:33.679 --> 00:15:44.399
If anything, start start something light and world going forward and keep my eyes open for that randomized controlled trial that can can put a nail in this coffin and and really change culture.
00:15:48.000 --> 00:15:52.320
Next thing, kind of keeping with the things maybe we do for no reason.
00:15:52.559 --> 00:16:04.639
So this is a article called Associations Between Antibiotic Use and Outcomes in Patients Hospitalized with Community Acquired Pneumonia, but with positive respiratory viral assays.
00:16:04.879 --> 00:16:15.919
So this was a really cool article that infectious disease seem to have done in response to ATS, uh, American Thoracic Society.
00:16:16.000 --> 00:16:24.720
And I like it when you've got two different societies that don't agree, and then one of them decides to try to prove the other wrong and kind of clap back with it.
00:16:24.960 --> 00:16:48.879
So it it came in response to ATS guidelines who recommended to treat with antibiotics, even if there was a positive viral assay, claiming that it would decrease mortality, decrease poor outcomes because of the rate of they felt that there was a high rate of bacterial coinfection with these um with these viruses.
00:16:49.279 --> 00:16:59.759
But infectious disease seemed to disagree and they endorsed more low coinfection rates, um, as well as there's no such thing as a safe medication, including antibiotics.
00:16:59.919 --> 00:17:06.559
All these things had adverse um events, and that can include AKI, um drug rash, etc.
00:17:07.039 --> 00:17:23.279
Um, so this um this article was a again a retrospective um multi-center five hospital study over um many years, 2015 to 2024.
00:17:23.839 --> 00:17:37.119
Um, and there they uh they sought out patients that had a positive um respiratory viral assay within the first 48 hours of them being admitted, and then had clinical signs of pneumonia.
00:17:37.200 --> 00:17:42.160
So tachynea, hypoxia, chest imaging that was concerning for pneumonia.
00:17:42.319 --> 00:17:58.079
And then they decided to see whether or not antibiotics made a difference in their in their uh clinical course from either a very short antibiotic of zero to one day, or full uh cap treatment, which is five to seven days.
00:17:58.240 --> 00:18:01.279
And the headline here was it didn't make a difference.
00:18:01.519 --> 00:18:14.480
You could not treat them with antibiotics, or you could treat them with antibiotics, and it didn't make a significant difference in the mortality, didn't make a difference in the ICU admission rate after 48 hours or length of stay.
00:18:14.720 --> 00:18:18.160
So it kind of definitively said, no, we don't think so.
00:18:18.319 --> 00:18:26.000
We don't think treating these patients with pneumonia symptoms with a positive viral assay makes a difference.
00:18:26.160 --> 00:18:39.680
So disagreed, and we've got kind of uh two differing societies now, and now it kind of leaves us in the middle of uh with being internal medicine primary for these patients, deciding on what to do.
00:18:39.920 --> 00:18:40.880
What was your thoughts?
00:18:41.200 --> 00:18:52.799
Yeah, this was this was fun, and and like I said at the top, like we're we're addressing a controversy here, and um, it's a little bit nerdy for this to be like this is drama, but it's about as high drama as this gets.
00:18:52.960 --> 00:18:57.359
It's about as high drama as uh evidence for inpatient medicine gets.
00:18:57.440 --> 00:18:59.599
So boom, we're excited today.
00:18:59.839 --> 00:19:24.000
Um, but it it this was another thing that I heard mention of um at the SHM conference that there was uh updates in the guidelines talk, and they had this little graph that was like a bridge, and it was the IDSA and the thoracic association agreeing on guidelines and putting out guidelines together, and then it's like all of a sudden schism and things are breaking and they're going different ways.
00:19:24.240 --> 00:19:25.920
So it's dramatic.
00:19:26.079 --> 00:19:39.440
And I think this is an impressive feather in the cap of the IDSA to say our recommendation that we do not routinely recommend antibiotics for folks that get admitted for pneumonia and have a positive viral panel.
00:19:39.599 --> 00:19:42.400
I think this is this is backing them up pretty well.
00:19:42.640 --> 00:19:50.160
The question I have on it though is how much is this changing our routine and our day-to-day practice?
00:19:50.319 --> 00:19:51.200
What are your thoughts?
00:19:51.359 --> 00:19:58.480
Before we read this article, before we looked at this drama with the guidelines, what would have been your go-to?
00:19:58.640 --> 00:20:02.319
You've got someone who fits in the inclusion criteria of this study.
00:20:02.400 --> 00:20:06.400
So you've got someone you admit, they are hypoxic.
00:20:06.480 --> 00:20:09.119
They said less than 95 on room air.
00:20:09.200 --> 00:20:16.400
So maybe they're on a little bit of oxygen, maybe they're on a lot of oxygen, uh, maybe they're on no oxygen and just sort of flirting with that less than 95.
00:20:16.480 --> 00:20:17.599
They're tachypnic.
00:20:18.079 --> 00:20:23.839
And the inclusion criteria was chest imaging was ordered, but they didn't do any assessment of that testing.
00:20:24.240 --> 00:20:28.160
Um, so you get that patient and you're admitting them to your surface.
00:20:28.319 --> 00:20:33.599
And I mean, I'll pretty much guarantee you they're they're gonna that's part of why we do zero to two days, I'm sure.
00:20:33.680 --> 00:20:38.559
Is they've gotten a dose of ceftriaxin and a zipin or something in the ED.
00:20:39.039 --> 00:20:47.039
But if you're admitting that patient going forward, are you continuing them on antibiotics or are you were you not before before reading this?
00:20:47.680 --> 00:21:10.319
There was a patient I had pretty recently, um, 30-year-old, relatively healthy, you know, no other comorbidities, had a bad viral infection, diagnosed it right away, and he was a hyp, you know, tachycardic in 120s, hypoxic, needing a few liters, and decided not to continue antibiotics from the ED.
00:21:10.559 --> 00:21:21.279
And to try and explain that to patients as well as family when they look that sick, you know, goes back to the there's no such thing as a benign medication.
00:21:21.440 --> 00:21:22.799
Everything has adverse effects.
00:21:22.960 --> 00:21:37.359
So before I was not doing it, um, was not treating, you know, these uh patients with a positive viral culture, unless I something in their story made me suspect superimposed bacterial infection, so I would not be treating it.
00:21:37.599 --> 00:21:43.200
This just gives me more ammo to really say and and more comfortability to say it doesn't matter.
00:21:43.839 --> 00:21:52.160
I was practicing similar to you that if I didn't have a reason to and I thought the virus was the reason for their pneumonia, I wasn't routinely giving antibiotics.
00:21:52.400 --> 00:21:56.799
So going forward, who who do you think's which which path are you going down?
00:21:56.880 --> 00:22:01.279
Are you team thoracic society or are you team ID society.
00:22:01.680 --> 00:22:04.720
100% team ID all the way.
00:22:04.880 --> 00:22:11.680
And I'll continue to feel support with this article and continue to not give these guys antibiotics.
00:22:11.920 --> 00:22:13.279
They have the positive viral assay.
00:22:13.519 --> 00:22:13.839
100%.
00:22:14.240 --> 00:22:16.319
Two for two, we're team IDSA.
00:22:16.880 --> 00:22:28.720
Inpatient Update officially disagrees with the recommendation that you give all patients you admit with a positive viral panel in respiratory symptoms, antibiotics.
00:22:28.880 --> 00:22:33.359
Before we had this study, I would have said, these experts say this, this, these experts say this.
00:22:33.519 --> 00:22:34.400
It's hard to say.
00:22:34.559 --> 00:22:35.039
I don't know.
00:22:35.200 --> 00:22:38.559
Maybe I'm going to go the more conservative route and give everyone antibiotics.
00:22:38.640 --> 00:22:48.160
So I really do think I'm glad they did the study, and it totally puts me in the bucket of, to be clear, the guideline of not routinely recommending.
00:22:48.240 --> 00:22:52.960
And now, again, similar to our other study, this trial has its limitations.
00:22:53.119 --> 00:22:54.880
This is not a randomized controlled trial.
00:22:54.960 --> 00:22:56.079
It's retrospective.
00:22:56.400 --> 00:23:07.279
And so similarly, I think there's some degree that the patients could have self-selected that sicker patients are going to end up more likely to get the antibiotics.
00:23:07.440 --> 00:23:10.319
So it just makes things a little more complicated there.
00:23:10.559 --> 00:23:16.160
Honestly, any of these people, if you end up in the ICU, it's hard to imagine you're not getting antibiotics and getting that conservative treatment.
00:23:16.319 --> 00:23:23.279
Because similarly, not only did they not they didn't do better with antibiotics, they also didn't do worse with antibiotics.
00:23:23.359 --> 00:23:23.680
They didn't.
00:23:23.920 --> 00:23:27.839
This was all no statistically significant changes, including like rates of C.
00:23:28.000 --> 00:23:28.720
diff and all of that.
00:23:28.799 --> 00:23:33.359
And so, yes, there are complications with antibiotics, but we're not seeing that those patients do worse off.
00:23:33.599 --> 00:23:41.680
I do want to be a good steward of antibiotics, but honestly, in my data practice, what I care more is what's going to be best for my patient.
00:23:41.920 --> 00:23:44.720
So if they don't need antibiotics, I won't give it to them.
00:23:44.799 --> 00:23:46.880
But if they seem like they need it, I'll give it to them.
00:23:46.960 --> 00:23:56.640
But definitely not routinely giving everyone who has comes in flu, COVID, RSV, antibiotics if I don't think they have a bacterial pneumonia.
00:23:56.799 --> 00:23:58.079
I wasn't doing that before.
00:23:58.400 --> 00:24:08.240
One thing I really liked about this study, um, and we keep saying, oh, it's retrospective, but they didn't pool any any punches with who they selected.
00:24:08.319 --> 00:24:14.559
They over 30% of them on the initial selection went to the ICU.
00:24:14.720 --> 00:24:34.240
Um and then on the continued, you know, after um being excluded for procalcitonin elevation and um and short stays, these guys were still, you know, over 20% of them still went to the ICU, no matter if they got short dose, short um, short dose of antibiotics or longer dose.
00:24:34.400 --> 00:24:35.920
You know, these guys are pretty sick.
00:24:36.000 --> 00:24:43.680
And I think this kind of speaks to we're learning more about viruses and how sick a person can be with just the virus.
00:24:43.839 --> 00:24:51.599
And I think that's partly because of COVID times, and then partly because we're we're seeing almost any virus can do this.
00:24:51.920 --> 00:24:59.920
There's some in the study they say they note um adenovirus and like rhinovirus.
00:25:00.079 --> 00:25:08.640
Um, over 90% of them got antibiotics because we're just we keep thinking, oh, you know, I I don't think this virus can cause this.
00:25:08.799 --> 00:25:13.519
But now we're showing in this study, like, no, these viruses can make you pretty sick.
00:25:13.680 --> 00:25:19.200
And giving them antibiotics just because it's a quote weaker virus may not make a lot of sense.
00:25:19.440 --> 00:25:23.839
So um it's it's an interesting um division that we have now.
00:25:24.160 --> 00:25:40.240
I'm sure the IDSA would have loved to see that the patients without antibiotics actually do it better from at least either like a length of because I expected to see like I was looking at like the C diff numbers and the length of stay numbers and thought, like, if we're not giving them antibiotics and tying them to that, are they getting out of the hospital quicker?
00:25:40.559 --> 00:25:41.599
Yeah, none of that.
00:25:41.680 --> 00:25:42.640
All of that, yeah.
00:25:42.880 --> 00:25:45.279
It was it was it was 50-50.
00:25:45.599 --> 00:25:50.880
Is this study actively changing your your practice in any way going forward?
00:25:51.279 --> 00:25:58.319
It's actively changing and continuing to do what I'm doing and not giving these guys antibiotics.
00:25:58.720 --> 00:26:00.640
Sometimes no change is a change.
00:26:01.440 --> 00:26:12.160
But it makes me more confident when I can go into the room and tell patients and loved ones, no, we we are okay to hold off antibiotics for now.
00:26:12.319 --> 00:26:15.680
But that's the reason you're in the hospital to continue to monitor clinically.
00:26:15.759 --> 00:26:21.519
We we can't we don't have a crystal ball to know if there's superimposed bacterial infection, but that's why you're here.
00:26:21.599 --> 00:26:29.920
If you don't get better, it's no harm to continue to to monitor you and then change, change based on how you do clinically.
00:26:30.240 --> 00:26:35.279
Similarly to our first study, this is this is kind of what I was doing, anyways.
00:26:35.359 --> 00:26:40.400
If I thought the virus was the cause, I wasn't giving antibiotics, but it's probably moving me on the margin.
00:26:40.480 --> 00:26:43.839
So like I'm gonna be that rhino, that adenovirus.
00:26:44.000 --> 00:26:50.640
In more patients, I'm gonna be saying it's gonna just that move me that little bit that I'm that much more likely.
00:26:50.720 --> 00:26:55.599
If I've got a patient coming in and I can hang this on a virus, then I'll do it.
00:26:55.680 --> 00:27:05.839
And then if they get worse or give me any reason, then low threshold to start antibiotics, I'm probably not gonna make anything worse if I do, if I think they really need it, but it will move me that little bit going forward.
00:27:09.039 --> 00:27:19.519
Recapping when it comes to urgent one-time hypertension, acute hypertension in the hospital setting, the data supports you not treating that.
00:27:19.680 --> 00:27:22.640
In fact, outcomes are worse in the patients that it gets treated.
00:27:22.720 --> 00:27:30.559
This is something we generally do for no reason, but we're really looking for that randomized control tile that tells us absolutely it's the wrong thing to do.
00:27:30.720 --> 00:27:44.240
If you're giving something, you should be gentle in what you're giving them because you're going to cause more harm by dropping a patient quickly than you are by letting them stay at a hypertensive number over the course of hours in the hospital.
00:27:44.400 --> 00:27:44.880
That's right.
00:27:45.039 --> 00:27:58.960
And when it comes to patients that are admitted with hypoxia, evidence of pneumonia, who have a positive virus, you do not need to do antibiotics in those patients unless you think they actually have a bacterial component.
00:27:59.119 --> 00:28:00.720
Inpatient update, Dr.
00:28:00.880 --> 00:28:01.680
Turner, Dr.
00:28:01.759 --> 00:28:12.480
White, our team IDSA, and we do not think those patients admitted with viral pneumonia routinely need antibiotics going forward.
00:28:15.920 --> 00:28:16.799
Thank you so much.
00:28:16.960 --> 00:28:21.359
It's it's been a joy, it's been a pleasure, and I'd love to have you on the show again sometime.
00:28:21.599 --> 00:28:22.160
I appreciate it.
00:28:22.480 --> 00:28:25.119
More controversial articles are always fun.
00:28:25.519 --> 00:28:25.839
Right.
00:28:26.000 --> 00:28:30.319
And to our audience, um, thank you so much for joining us.
00:28:30.559 --> 00:28:36.000
And if you find this useful, please send it and share it with your colleagues or classmates.
00:28:36.160 --> 00:28:48.880
And if you've got any new evidence you think we should be talking about, and or you are a provider, a specialist, a nurse, a pharmacist, or anyone with value-added insight into the management of hospitalized patients, please reach out to me.
00:28:49.039 --> 00:28:58.400
You can reach out to me directly or contact Inpatient Update on social email social media or email me at podcast at inpatientupdate.com.
00:28:59.119 --> 00:29:00.880
Thank you so much for being with me, Dr.
00:29:00.960 --> 00:29:02.640
White, and thank you to the audience.
00:29:02.880 --> 00:29:04.880
This has been Inpatient Update.
