{"id":8439,"date":"2017-08-20T17:46:14","date_gmt":"2017-08-20T21:46:14","guid":{"rendered":"http:\/\/blogs.nejm.org\/hiv-id-observations\/?p=8439"},"modified":"2017-08-28T13:32:44","modified_gmt":"2017-08-28T17:32:44","slug":"two-quick-thoughts-inspired-inpatient-id-consults-inspirational-baseball-poster","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/two-quick-thoughts-inspired-inpatient-id-consults-inspirational-baseball-poster\/2017\/08\/20\/","title":{"rendered":"Two Quick Thoughts Inspired by Inpatient ID Consults, and An Inspirational Baseball Poster"},"content":{"rendered":"<div id=\"attachment_8441\" style=\"width: 282px\" class=\"wp-caption alignright\"><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/08\/mount-ararat.jpg\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-8441\" class=\"wp-image-8441\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/08\/mount-ararat-300x200.jpg\" alt=\"\" width=\"272\" height=\"181\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/08\/mount-ararat-300x200.jpg 300w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/08\/mount-ararat.jpg 550w\" sizes=\"auto, (max-width: 272px) 100vw, 272px\" \/><\/a><p id=\"caption-attachment-8441\" class=\"wp-caption-text\">Mount Ararat, original source of daptomycin.<\/p><\/div>\n<p>A couple of quick thoughts for those of us doing inpatient care these days:<\/p>\n<p><strong>Thought One: \u00a0Is daptomycin now preferred over vancomycin in most clinical settings?\u00a0<\/strong><\/p>\n<p>It&#8217;s taken a while, but we&#8217;re getting there &#8212; close to that Gladwelllian &#8220;tipping point&#8221;. \u00a0Allow this recap of vancomycin&#8217;s problems:<\/p>\n<ul>\n<li>The growing recognition that higher drug levels &#8212; the levels we <em>want<\/em> &#8212; bring with them more side effects.<\/li>\n<li>The extraordinary hassle and imprecision of monitoring vancomycin levels.<\/li>\n<li>The enormous variability in dosing due to differences in clearance from patient-to-patient.<\/li>\n<li>The lengthy vancomycin infusion time (at least 60 minutes\/dose) which, if you have a patient on every 8 hour dosing, means they are spending many of their waking hours receiving vancomycin.<\/li>\n<\/ul>\n<p>If you add to these issues the substantial\u00a0decrease in daptomycin&#8217;s cost since it went generic, it&#8217;s hard to justify using vancomycin over daptomycin for many non-pneumonia indications these days.<\/p>\n<p>Daptomycin is far from perfect, but if it replaces vancomycin there will be few tears shed on its behalf &#8212; vancomycin isn&#8217;t such\u00a0a great drug either. Beta lactams are preferred over both of them for susceptible organisms.<\/p>\n<p>And for the next time there&#8217;s a lull in the conversation with your friends, here are some<a href=\"https:\/\/www.idstewardship.com\/five-interesting-things-know-daptomycin\/\" target=\"_blank\" rel=\"noopener noreferrer\"> fun facts about daptomycin<\/a>, including how it was discovered on Mount Ararat in Turkey.<\/p>\n<p><strong>Thought Two: Outpatient parenteral antimicrobial therapy (OPAT) should be avoided whenever possible.<\/strong><\/p>\n<p>Two recent studies highlight\u00a0the hazards associated with sending patients out of the hospital with intravenous lines to complete antibiotic therapy:<\/p>\n<ol>\n<li>Out of 339 patients prospectively studied from two academic medical centers, <strong><a href=\"https:\/\/academic.oup.com\/cid\/article-abstract\/doi\/10.1093\/cid\/cix733\/4083610\/Rates-of-and-Risk-Factors-for-Adverse-Drug-Events?redirectedFrom=fulltext\" target=\"_blank\" rel=\"noopener noreferrer\">18% experienced a significant adverse drug event<\/a><\/strong>, most commonly during\u00a0the first two weeks after discharge. Note that most retrospective analyses have even higher rates, probably because many are discharged without being in an organized OPAT program.<\/li>\n<li>In people who inject drugs &#8212; a particularly challenging patient population who increasingly have &#8220;indications&#8221; for OPAT &#8212; a whopping <strong><a href=\"https:\/\/academic.oup.com\/ofid\/article\/3847628\/Risk-Factors-Associated-with-Outpatient-Parenteral\" target=\"_blank\" rel=\"noopener noreferrer\">61% failed their OPAT course.<\/a><\/strong><\/li>\n<\/ol>\n<p>Aside from the medical challenges\u00a0of OPAT, there&#8217;s also the clinical service side &#8212; which is dismal. Since payers typically do not\u00a0reimburse providers for monitoring OPAT, this gives us ID doctors two terrible\u00a0choices &#8212; provide the service for free because it&#8217;s good for patients or, alternatively, refuse to do it and document (leverage) the\u00a0suboptimal care to get institutional funding.<\/p>\n<p>The former is an example of our being &#8220;too nice&#8221;; the latter just makes me uncomfortable, but is increasingly required.<\/p>\n<p>Bottom line: \u00a0we should strive to give oral over IV antibiotics\u00a0at discharge for all patients, except when the data\u00a0strongly support parenteral therapy. Oral treatment is\u00a0safer, cheaper, and usually just as effective.<\/p>\n<p><strong>Finally, given the current political climate,\u00a0isn&#8217;t this\u00a0poster just awesome?<\/strong><\/p>\n<p><a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/08\/mel-allen-poster.png\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-8440\" src=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/08\/mel-allen-poster.png\" alt=\"\" width=\"429\" height=\"182\" srcset=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/08\/mel-allen-poster.png 997w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/08\/mel-allen-poster-300x127.png 300w, https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/08\/mel-allen-poster-768x326.png 768w\" sizes=\"auto, (max-width: 429px) 100vw, 429px\" \/><\/a><\/p>\n<p>It&#8217;s a subway poster from\u00a01950, published by the Institute for American Democracy.<\/p>\n<p>And as a baseball-crazy ID doctor, of course <a href=\"http:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/guessing-idhiv-doctors-political-affiliation-easy\/2016\/10\/09\/\" target=\"_blank\" rel=\"noopener noreferrer\">I love it!<\/a><\/p>\n<p>&nbsp;<\/p>\n<p><a href=\"https:\/\/secure.jwatch.org\/registerm?cpc=JWATCH&amp;promo=OJFOBLOG&amp;step=1\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-925\" src=\"https:\/\/blogs.nejm.org\/hiv-id-observations\/wp-content\/uploads\/sites\/2\/2017\/03\/hivJWAd540x250.jpg\" alt=\"Register Now for more NEJM Journal Watch Content\" width=\"540\" height=\"250\" \/><\/a><\/p>\n<p><span style=\"text-indent: 20px;width: auto;padding: 0px 4px 0px 0px;text-align: center;font: bold 11px\/20px 'Helvetica Neue',Helvetica,sans-serif;color: #ffffff;background: #bd081c no-repeat scroll 3px 50% \/ 14px 14px;cursor: pointer\">Save<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A couple of quick thoughts for those of us doing inpatient care these days: Thought One: \u00a0Is daptomycin now preferred over vancomycin in most clinical settings?\u00a0 It&#8217;s taken a while, but we&#8217;re getting there &#8212; close to that Gladwelllian &#8220;tipping point&#8221;. \u00a0Allow this recap of vancomycin&#8217;s problems: The growing recognition that higher drug levels &#8212; [&hellip;]<\/p>\n","protected":false},"author":6,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[3],"tags":[102,265,674,971],"class_list":["post-8439","post","type-post","status-publish","format-standard","hentry","category-health-care","tag-baseball","tag-daptomycin","tag-opat","tag-vancomycin"],"post_mailing_queue_ids":[],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8439","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/comments?post=8439"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/posts\/8439\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/media?parent=8439"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/categories?post=8439"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/hiv-id-observations\/index.php\/wp-json\/wp\/v2\/tags?post=8439"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}