American Society for Clinical Pathology suggests using CRP instead of ESR to look for inflammation in patients with undiagnosed conditions.
The Infectious Diseases Society advises against treating asymptomatic bacteruria with antibiotics.
Updated guidelines from the American Academy of Dermatology does not recommend routine use of antibiotics for the treatment of bilateral swelling and redness of the legs unless there is clear evidence of infection.
Don’t routinely use antibiotics to treat bilateral swelling and redness of the lower leg unless there is clear evidence of infection
Most cases of bilateral leg swelling are due to venous insufficiency.
At the June 26th 2014 Pharmacy and Therapeutics Committee meeting, discussion ensued with the Cardiologist and Hematologist members of the committee regarding the treatment of Deep Vein Thrombosis (DVT) on an outpatient basis. This concept is not new, and is reviewed in the 2012 CHEST Antithrombotic Therapy and Prevention of Thrombosis 9th ed. Guidelines, UpToDate and other references. The issue is that we occasionally find patients who have no other reason to be hospitalized except that they are waiting for their INR to become therapeutic. As referenced, options for outpatient treatment include bridging with Low Molecular Weight Heparin (LMWH) until the INR becomes therapeutic. Additionally, section 5.5 of the Chest 2012 guidelines recommends early discharge over standard discharge for patients with low risk PE whose home circumstances are adequate after five inpatient days.
There are four criteria that may be used to help identify patients who are NOT candidates for outpatient treatment:
- Presence of massive DVT (eg, iliofemoral DVT)
- Presence of symptomatic pulmonary embolism
- High risk of bleeding with anticoagulant therapy
- Presence of comorbid conditions or other factors that warrant in-hospital care
While initial treatment is recommended at home over hospital, this recommendation is conditional on the adequacy of home circumstances. Our intent is to evaluate a pathway at the September Pharmacy and Therapeutics Committee meeting that will aid physicians in the decision process. If your patient does not meet the criteria to remain in the hospital, we urge you to consider outpatient bridging therapy with LMWH and utilizing the Anticoagulation Clinic at Centegra.
For the convenience of clinicians a list of approved antibiotics for the treatment of pneumonia is available here. A quick link is also added to the right sidebar.
Did you wonder what all the fuss about DVT prophylaxis is about and why it is part of every admission order set? Look at this article from CDC reviewing the data on DVT and its prevention in hospitalized patients.
The addition of Prevnar 13 to the pneumococcal vaccination protocol has certainly made the algorithm a bit more complicated. This is the updated workflow.
Updated Guidelines for the Diagnosis and Management of Lung Cancer
As lung cancer is the leading cause of cancer related deaths worldwide American College of Chest Physicians have released updated guidelines of the diagnosis and treatment of lung cancer.
These guidelines specifically address:
- Epidemiology of Lung Cancer
- Molecular Biology of Lung Cancer
- Chemoprevention of Lung Cancer
- Treatment of Tobacco use in Lung Cancer
- Evaluation of Pulmonary nodules
- Clinical evaluation of patients with Lung Cancer
- Establishing a diagnosis of Lung Cancer
- Physiologic evaluation prior to surgery
- Stage Classification of Lung Cancer
- Lung Cancer treatment
Diagnosis and Management of Lung Cancer, 3rd ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines
Frank C. Detterbeck, MD, FCCP; Sandra Zelman Lewis, PhD; Rebecca Diekemper, MPH; Doreen Addrizzo-Harris, MD, FCCP; W. Michael Alberts, MD, MBA, FCCP
Chest. 2013;143(5_suppl):7S–37S. doi:10.1378/chest.12–2377
The Infectious Disease Society of America has published the 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host
The ACR Manual on Contrast Media  recommends the following options for premedication in the acute setting in patients undergoing planned contrast enhanced imaging procedure (e.g. CT Pulmonary Angiogram). Options #1 or #2 should be used in all Emergency Department situations unless there is an extreme urgency.
IV steroids have not been shown to be effective when administered less than 4 to 6 hours prior to contrast injection
In Decreasing Order of Desirability
- Methylprednisolone sodium succinate (Solu-Medrol®) 200 mg intravenously every 4 hours (q4h) until contrast study required plus diphenhydramine 50 mg IV 1 hour prior to contrast injection .
- Dexamethasone sodium sulfate (Decadron®) 7.5 mg or betamethasone 6.0 mg intravenously q4h until contrast study must be done in patent with known allergy to methylpred-nisolone, aspirin, or non-steroidal anti-inflammatory drugs, especially if asthmatic. Also diphenhydramine 50 mg IV 1hour prior to contrast injection.
- Omit steroids entirely and give diphenhydramine 50 mg IV.