Updates in Hospital Medicine-Slides

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This summary covers key 2023 hospital medicine studies addressing common clinical questions:

1. <strong>Steroids in severe pneumonia:</strong> The CAPE COD trial (Dequin et al., NEJM 2023) showed early hydrocortisone (200 mg/day for 4 days) in severe ICU-admitted community-acquired pneumonia reduced 28-day mortality (6.2% vs 11.9%, NNT 18), decreased intubation and vasopressor needs, with no increase in infections or GI bleeds, but increased insulin use. Conclusion: hydrocortisone benefits patients with severe hypoxemia.

2. <strong>Sepsis fluid vs pressors:</strong> The CLOVERS trial (NHLBI, NEJM 2023) randomized 1563 patients with sepsis-induced hypotension (after initial 1-3L fluids) to restrictive fluid plus early vasopressors vs liberal fluids. No mortality difference at 90 days was seen (14.0% vs 14.9%). Clinicians can choose either strategy after initial resuscitation focusing on perfusion.

3. <strong>Postoperative VTE prophylaxis:</strong> The PREVENT-CLOT trial (METRC, NEJM 2023) compared aspirin vs enoxaparin after operative extremity fractures in 12,000+ patients. Aspirin was noninferior for preventing fatal VTE and PE, but had higher DVT rates (2.51% vs 1.71%). Enoxaparin remains preferred for DVT prevention after traumatic fractures.

4. <strong>Transient inpatient AFib recurrence:</strong> The AFOTS study (McIntyre et al., Ann Intern Med 2023) in 278 adults without prior AF found new transient AF during hospitalization recurred in ~33% within one year (vs 5% controls). Most episodes were asymptomatic and self-limited, underscoring high recurrence risk even if transient.

5. <strong>Diuresis in acute heart failure:</strong> Pooled analysis of DOSE, ROSE, ATHENA-HF trials (Chen et al., J Hosp Med 2023) demonstrated targeting ~3.5 L net negative fluid balance by 48 hours improved creatinine, dyspnea, and reduced 60-day rehospitalization/death risk. Aggressive decongestion up front is safe and beneficial.

6. <strong>Pip-tazo vs cefepime toxicity:</strong> The ACORN trial (Qian et al., JAMA 2023) randomized 2511 patients initiating either antibiotic for gram-negative infections. Pip-tazo did not increase acute kidney injury or death compared to cefepime, but cefepime caused more neurotoxicity (delirium/coma). Pip-tazo is not more nephrotoxic.

7. <strong>Holding ACEi/ARBs before non-cardiac surgery:</strong> The POISE-3 trial (Marcucci et al., Ann Intern Med 2023) of 7490 hypertensive patients found no difference in 30-day major adverse cardiovascular events whether ACEi/ARBs were held or continued. Continuing perioperatively is reasonable if hypotension risk is low.

8. <strong>Asymptomatic inpatient hypertension:</strong> A VA retrospective cohort (Anderson et al., JAMA Intern Med 2023) in older adults showed intensive hypertension treatment (especially IV meds) within 48 hrs of hospitalization increased adverse events including AKI, ICU transfer, and did not improve outcomes. Conclusion: do not treat asymptomatic inpatient hypertension aggressively.

<strong>Bottom line clinical pearls:</strong>
- Use hydrocortisone early in severe CAP with hypoxemia.
- After initial sepsis fluid boluses, either fluids or pressors can be prioritized focusing on perfusion.
- Enoxaparin remains superior to aspirin for DVT prophylaxis post-fracture.
- 1/3 of hospitalized patients with new AF recur within one year.
- Aim for aggressive net negative fluid balance (~3.5L) in acute heart failure.
- Pip-tazo does not cause more AKI than cefepime, but cefepime causes more neurotoxicity.
- Perioperative ACEi/ARB continuation is safe if low risk of hypotension.
- Avoid intensive treatment of asymptomatic hypertension in older hospitalized non-cardiac patients.

These studies refine evidence-based hospital medicine, balancing benefits and harms to optimize patient care.
Keywords
hospital medicine 2023
severe pneumonia steroids
CAPE COD trial
sepsis fluid resuscitation
CLOVERS trial
postoperative VTE prophylaxis
PREVENT-CLOT trial
transient inpatient atrial fibrillation
acute heart failure diuresis
antibiotic toxicity pip-tazo vs cefepime