Category Archives: Internal Medicine

Internal Medicine

Patrick Hemming, MD: Depression, Anxiety Treatment by the Internal Medicine Physician – MD Magazine

This interview segment with Patrick Hemming, MD, involved a discussion of some of the major takeaways from his talk Depression and Anxiety Treatment by the Internal Medicine Physician, presented at the 2024 American College of Physicians (ACP) Internal Medicine Meeting.

During his ACP 2024 talk, Hemming described depressive disorders, anxiety disorders, recent changes to screening guidelines, and other elements he felt internists should be made aware of in the mental health space.

I go over screening guidelines, and the screening guidelines have changed in the last year, Hemming explained. If you go by the United States Preventive Services Task Force, they now recommend that really we should be screening all patients over 18 for depression, regardless of what your practice. Just last year, the recommendation that we should screen all patients 18 to 64, for anxiety disorders, that's new and has never been recommended before.

Hemming noted that the changes to guidelines for internists are not small and they do signify larger changes occurring in the mental health space.

Quality reporting for Medicare and Medicaid now starts to look at whether we're screening and whether we're getting people set up with treatment, Hemming said. Then that impacts payment schedules and things like that, that our practices are going to directly see results from in addition to our patients who are now being screened for new things.

Hemming later expressed that, while in psychiatric practices medication is adjusted and feedback will occur more rapidly, in primary care it is less possible to do so.

(We discussed) how we are going to follow up with patients, understanding the goals of treating some targets using things like our PHQ-9 or our GAD-7 for anxiety disorders, Hemming said. And, something very important for me in this talk is to point out that although we have created numbers for these things, this is not treating blood pressure. In blood pressure, we can create a goal for systolic blood pressure of 130 and get people under that and feel pretty good about ourselves

Hemming noted that unlike traditional situations with blood pressure, if internists are treating patients with a PHQ-9 number, this is not actually not what the patient cares about. He noted that they need to understand that such a patient may be having difficulties in their personal relationships, at work, or in their sense of achievement in life.

For additional information on this interview, view the full discussion posted above.

The quotes used here were edited for the purposes of clarity. Hemming has no relationships with entities whose primary business is marketing, selling, producing, re-selling, or distributing healthcare products used by or on patients.

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Patrick Hemming, MD: Depression, Anxiety Treatment by the Internal Medicine Physician - MD Magazine

Internal Medicine

UConn Health’s Dr. Rebecca Andrews Takes on New National Role – UConn Today – University of Connecticut

UConn Healths Dr. Rebecca Andrews continues her national leadership roles with the American College of Physicians, now as chair-elect of its board of regents.

Representing internal medicine physicians, related subspecialists, and medical students, the ACP is the largest medical specialty organization and the second-largest physician group in the U.S.

I am thrilled that I have been elected into the position of chair of the board of regents, Andrews says. This role guides development of organizational policy that is utilized to advocate for improvements, changes, and important issues that face our patients as well as internal medicine physicians across the country and the world.

Andrews is a professor of medicine in the UConn School of Medicine and serves as the UConn Internal Medicine Residency Programs associate program director as well as its director of ambulatory education. She is a primary care physician, director of primary care, and clinical lead for UConn Healths Patient Centered Medical Home and Comprehensive Pain Center.

The basis of every industrialized country with superb health outcomes and life expectancy is robust primary care, Andrews says. Given this is my area of passion and practice, I feel particularly positioned to be a voice for the American College of Physicians, who have been tireless in improving care quality, access and delivery for our patients with such initiatives as patients before paperwork advocating for what we all want the opportunity to provide excellent care for patients in a less burdensome system.

The board of regents is the ACPs main policy-making body. Andrews installation as chair-elect took place at the ACPs annual meeting in Boston Saturday. She starts her term as board chair next year. In that capacity her responsibilities will include overseeing policy creation, presiding over committee meetings including the boards executive committee, and maintaining fiduciary goals.

Andrews is a 2002 graduate of the UConn School of Medicine and a 2006 graduate of the internal medicine residency program that today she helps direct. Her connection with the ACP goes back more than 20 years, when she first became involved as a medical student. She later would join the ACPs early physician council. In 2010, a year after she returned to UConn Health as faculty physician, she was elected a Fellow of the College (FACP), an honorary designation that recognizes ongoing individual service and contributions to practice of medicine. She since has served on several national committees and in several leadership roles on the ACPs Connecticut chapter.

Especially now, as life expectancy has decreased for Americans for the first time in decades, righting the direction of health care is especially important, Andrews says.

Andrews joined the ACPs board of regents two years ago following a four-year term as the governor of the Connecticut chapter and a one-year term chairing the ACPs board of governors. The chair of the board of regents and the president are the ACPs two highest-level officers. The chair may act on behalf of the president when the president is unavailable.

The American College of Physicians has more than 160,000 members which include internal medicine physicians, related subspecialists, and medical students representing nearly 150 countries.

Andrews also is a member of the Gold Humanism Honor Society, a community of more than 45,000 medical students, physicians, and other leaders whove been recognized for their compassionate care.

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UConn Health's Dr. Rebecca Andrews Takes on New National Role - UConn Today - University of Connecticut

Internal Medicine

Women are less likely to die when treated by female doctors, study suggests – Yahoo! Voices

Hospitalized women are less likely to die or be readmitted to the hospital if they are treated by female doctors, a study published Monday in the Annals of Internal Medicine found.

In the study of people ages 65 and older, 8.15% of women treated by female physicians died within 30 days, compared with 8.38% of women treated by male physicians.

Although the difference between the two groups seems small, the researchers say erasing the gap could save 5,000 womens lives each year.

The study included nearly 800,000 male and female patients hospitalized from 2016 through 2019. All patients were covered by Medicare. For male hospitalized patients, the gender of the doctor didnt appear to have an effect on risk of death or hospital readmission.

The data alone doesnt explain why women fare better when treated by other women. But other studies suggest that women are less likely to experience miscommunication, misunderstanding and bias when treated by female doctors, said lead study author Dr. Atsushi Miyawaki, a senior assistant professor of health services research at the University of Tokyo Graduate School of Medicine.

The new research is part of a growing field of study examining why women and minorities tend to receive worse medical care than men and white patients. For example, women and minority patients are up to 30% more likely to be misdiagnosed than white men.

Our pain and our symptoms are often dismissed, said Dr. Megan Ranney, dean of the Yale School of Public Health. It may be that women physicians are more aware of that and are more empathetic.

Research shows that women are less likely than men to receive intensive care but more likely to report having negative experiences with health care, having their concerns dismissed, and having their heart or pain symptoms ignored, the authors wrote in the new study. Male physicians are also more likely than female doctors to underestimate womens risk of stroke.

Part of the problem, Miyawaki said, is that medical students get limited training in womens health issues.

Dr. Ronald Wyatt, who is Black, said his 27-year-old daughter recently had trouble getting an accurate diagnosis for her shortness of breath. An emergency room physician told her the problem was caused by asthma. It took two more trips to the emergency room for his daughter to learn that she actually had a blood clot in her lungs, a potentially life-threatening situation.

There is a tendency for doctors to harbor sexist stereotypes about women, regardless of age, such as the notion that womens symptoms are more emotional or their pain is less severe or more psychological in origin, said Wyatt, former chief science and chief medical officer at the Society to Improve Diagnosis in Medicine, a nonprofit research and advocacy group.

Women seem to experience fewer of these problems when treated by other women.

For example, a study published JAMA Surgery in 2021 found that women patients developed fewer complications if their surgeon was female. Another JAMA Surgery study published in 2023 found all patients had fewer complications and shorter hospital stays if they were operated on by female surgeons, who worked more slowly than their male counterparts.

Women primary care doctors also tend to spend more time with their patients, Ranney said. Although that extra attention is great for patients, it also means that women see fewer patients per day and earn less, on average, than male doctors.

Dr. Ashish Jha, dean of the Brown University School of Public Health, said several studies suggest that female doctors follow medical evidence and guidelines, and that their patients have better outcomes.

Theres lots of variation between women and men physicians, said Jha, who was not involved in the new study. Women tend to be better at communication, listening to patients, speaking openly. Patients report that communication is better. You put these things together, and you can understand why there are small but important differences.

The authors of the study said its also possible that women are more forthcoming about sensitive issues with female physicians, allowing them to make more informed diagnoses.

That doesnt mean that women should switch doctors, said Dr. Preeti Malani, a professor of medicine at the University of Michigan. For an individual patient, the differences in mortality and readmission rates seen in the new study are tiny.

It would be a mistake to suggest that people need to find physicians of the same gender or race as themselves, Jha said. The bigger issue is that we need to understand why these differences exist.

Malani said shes curious about what women doctors are doing to prevent patients from needing to be readmitted soon after discharge. How much care and thought is going into that discharge plan? Malani asked. Is that where women are succeeding? What can we learn about cultural humility and asking the right questions?

Others arent convinced that the new study proves a physicians gender makes a big difference.

Few hospitalized patients are treated by a single doctor, said Dr. Hardeep Singh, a professor at Baylor College of Medicine in Houston and a patient safety researcher at the Michael E. DeBakey VA Medical Center.

Hospital patients are treated by teams of physicians, especially if they need specialist care, in addition to nurses and other professionals, Singh said.

How often do you see the same doc every day in the hospital? Singh asked. The point is that its not a one-man or one-woman show. Outcomes are unlikely to depend on one individual, but rather on a clinical team and the local context of care. One name may appear on your bill, but the care is team-based.

However, Singh said his research on misdiagnoses shows that doctors in general need to do a better job listening to patients.

Jha said hed like the health system to learn what women doctors are doing right when they treat other women, then teach all physicians to practice that way.

We should train everyone to be better at generating trust and being worthy of trust, Jha said.

Wyatt said the country needs to take several steps to better care for women patients, including de-biasing training to teach doctors to overcome stereotypes. The health care system also needs to increase the number of women physicians in leadership, recruit more female doctors and do a better job at retaining them. All physicians also need more understanding of how adverse childhood experiences affect patient health, particularly for women, he said.

More than once Ive had white female patients tell me they came to be because I listened and they trusted me, Wyatt said.

This article was originally published on NBCNews.com

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Women are less likely to die when treated by female doctors, study suggests - Yahoo! Voices

Internal Medicine

Are female doctors the key to keeping patients alive longer? – – Study Finds

LOS ANGELES A doctors gender matters when it comes to your health. Researchers from UCLA have found that patients receiving treatment from female physicians have lower mortality rates and fewer hospital readmissions compared to those treated by male doctors. Female patients seemed to benefit the most from this female doctor effect.

The study, published in the journal Annals of Internal Medicine, analyzed Medicare claims data from 2016 to 2019 for over 700,000 patients. They found that the mortality rate for female patients was 8.15 percent when receiving care from female physicians, compared to 8.38 percent when the physician was male. While this difference may seem small, its considered clinically significant by researchers.

Male patients also fared better under the care of female doctors, though the difference was less pronounced. Their mortality rate was 10.15 percent with female physicians, compared to 10.23 percent with male physicians.

A similar pattern emerged for hospital readmission rates. Patients were less likely to return to the hospital within 30 days of discharge if a female doctor saw them during their initial visit. Researchers propose several possible explanations for their findings.

What our findings indicate is that female and male physicians practice medicine differently, and these differences have a meaningful impact on patients health outcomes, says study senior author Dr. Yusuke Tsugawa, associate professor-in-residence of medicine in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA, in a media release.

One potential factor is that male doctors might underestimate the severity of illness in their female patients. Previous research has shown that male physicians tend to downplay womens pain levels, gastrointestinal and cardiovascular symptoms, and even their risk of stroke. This could lead to delayed diagnoses or incomplete treatment.

Communication may also play a role. Female doctors might be better at communicating with their female patients, creating a more open and trusting relationship. This could make women more likely to share important health information that leads to better diagnoses and treatment plans. Also, female patients may simply feel more comfortable with female physicians, especially when it comes to sensitive examinations or detailed health discussions.

But why do female patients seem to benefit more from having a female doctor than male patients do? The UCLA team says more research is necessary to untangle this question. Dr. Tsugawa stresses that understanding how and why male and female physicians practice differently could lead to interventions that improve patient care across the board.

Further research on the underlying mechanisms linking physician gender with patient outcomes, and why the benefit of receiving the treatment from female physicians is larger for female patients, has the potential to improve patient outcomes across the board, explains Dr. Tsugawa.

The study also highlights the importance of gender equity in the medical field. Despite providing high-quality care, female physicians often earn less than their male counterparts. Dr. Tsugawa argues this pay gap should be eliminated.

It is important to note that female physicians provide high-quality care, and therefore, having more female physicians benefits patients from a societal point-of-view, explains Dr. Tsugawa.

This study is similar to what Harvard University researchers found during their 2020 survey about the care received between male and female doctors. According to the Harvard study, patients who receive care at a hospital from a female physician are less likely to die. They were also less likely to be hospitalized again compared to being seen by a male doctor.

This UCLA study doesnt mean you should switch doctors based on gender alone. Many factors contribute to the quality of care, including a physicians training, experience, and bedside manner.

However, the findings do suggest that the way male and female doctors approach patient care may differ in ways that impact health outcomes. As researchers continue to explore this fascinating topic, the hope is that the insights gained can be used to optimize medical care for everyone, regardless of the gender of the patient or the physician.

StudyFinds Matt Higgins contributed to this report.

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Are female doctors the key to keeping patients alive longer? - - Study Finds

Internal Medicine

Anne Thorndike, MD, MPH: Discussing Treatment Approaches for Patients with Obesity – MD Magazine

A recent presentation at the American College of Physicians (ACP) Internal Medicine Meeting in Boston looked at several questions regarding obesity such as how effective lifestyle interventions or pharmacologic interventions for the treatment of obesity and how for internal medicine physicians to engage in a shared decision making discussion to develop a plan.

This talk was presented at ACP by Anne Thorndike, MD, MPH, alongside 2 other presenters. Thorndike is known for her work as associate professor of medicine at the Division of General Internal Medicine of Massachusetts General Hospital as well as Harvard Medical School.

Thorndike was interviewed by the HCPLive editorial team at ACP on the topics covered in the presentation, with the initial question being what led to her decision to contribute to the presentation.

For a long time, my clinical work was actually focused on working with people to modify lifestyle behaviors to prevent obesity and cardiometabolic disease, Thorndike said. My research also focuses on nutrition and nutrition security, using different strategies to help people make healthier food choices and to exercise. So I've had a long standing interest in lifestyle modification and also I think the timing of these new medications has put lifestyle modification in a new light.

Thorndike noted that the combination of discussing new obesity medications and lifestyle changes represented a list of interesting things for clinicians to consider moving forward in helping patients to be healthier.

Later, she was asked if they highlighted any specific challenges or considerations when developing treatment plans for patients with obesity that go beyond standard guidelines.

I think that it's important to acknowledge that the strongest evidence for lifestyle modification comes from trials that showed that multicomponent behavioral interventions are the most effective way to change lifestyle and lose 5 - 10% body weight, Thorndike said. So that is one of the factors that's going to get highlighted in this talk is that multicomponent behavioral interventions can result in 5 - 10% weight loss, whereas the medications when used at the highest dose, can produce 15 - 20% weight loss.

Thorndike added, however, that it is important for patients to understand that even if one does not achieve such high weight loss numbers, one can actually achieve a lot of health benefits such as reductions in blood pressure, lipids, hemoglobin A1C, and reducing your risk for diabetes.

She added the numerous other health benefits which can involve improvement of depression symptoms, reducing sleep apnea, improving pain from knee arthritis, and reducing fatty liver.

To learn more about Thorndikes presentation, view the full interview segment posted above.

The quotes contained in this summary were edited for clarity. Thorndike has no relationships with entities whose primary business is selling, producing, marketing, re-selling, or distributing healthcare products used by or on patients.

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Anne Thorndike, MD, MPH: Discussing Treatment Approaches for Patients with Obesity - MD Magazine

Internal Medicine

Prolonged Medical Fasting May Benefit Pain Symptoms in Fibromyalgia – MD Magazine

Credit: Josh Milgate/Unsplash

A prolonged therapeutic fasting intervention, integrated into a multimodal medical approach, has the potential to benefit patients with fibromyalgia regarding their pain and psychosomatic symptoms, according to new research.1

Application of medically supervised fasting of a maximum of 600 kcal daily, for an average of 7 to 8 days, led to improvements in multiple disease-specific parameters, including quality of life, functionality, and pain perception, among a single-center population with fibromyalgia.

Our data suggest feasibility, safety, and potential advantages of medically supervised fasting for patients with fibromyalgia syndrome, when embedded in a multimodal therapeutic inpatient approach, wrote the investigative team, led by Daniela A. Koppold, department of internal medicine and nature based therapies, Immanuel Hospital Berlin.

Fibromyalgias complexities arise from diagnostic challenges, as no radiological or laboratory markers can confirm its presence, and clinical presentation can fluctuate between individual patients.2 Typically, diagnosis is determined through pain scales and a history of persistent pain in at least four of five body regions for 3 months. The chronic pain disorder commonly occurs concomitantly in patients with rheumatological diseases.

Given the conditions complexity, rheumatological organizational guidelines stress the importance of multimodal treatment approaches, with preference for non-pharmacological interventions over medications.3 Dietary interventions, while not yet incorporated into these guidelines, have shown an effect on quality of life and pain perception in preliminary trial data.

In this observational study, Koppold and colleagues assessed the feasibility and impact of prolonged therapeutic fasting embedded into a multimodal treatment setting on inpatients with fibromyalgia.1 Participants, recruited from February 2018 to December 2020 at the investigators institution in Germany, completed questionnaires at hospital admission and discharge, and 3, 6, and 12 months later.

The Fibromyalgia Impact Questionnaire (FIQ), a validated questionnaire specifically used for the symptomatic presentations of fibromyalgia, was used to determine the feasibility and effectiveness of prolonged therapeutic fasting in fibromyalgia management. An improvement of 14% is acknowledged as the minimal clinically important difference (MCID) in the FIQ.

For analysis, baseline values (V0) and vital signs were compared with measurements at later visits (V1 to V4) through unadjusted t-tests. Overall, the study population comprised 168 female and 8 male patients exhibiting fibromyalgia and following a therapeutic fasting intervention during the study period. Of this population, 90% fasted, lasting between 3 and 12 days, with an average of 7.6 days.

Upon analysis, Koppold and colleagues identified a significant improvement in fibromyalgia manifestations in the FIQ. The FIQ total score dropped from 58.3 11.1 to 44.6 15.5 between admission and discharge, a reduction of 13.7 13.9 points (P <.001). Translating to a decrease of 23.5%, investigators noted the marked reduction in the total score is larger than the MCID of 14%.

These strong improvements in the total score occurred due to large effects in the Overall and Symptoms subscores (P <.0001), as well as a slight benefit in the Function subscore (P = .0328) and a clinically significant effect in the pain subscore (P <.0001).

Reductions in pain (1.1 2.5; P <.001) and improvements in quality of life (WHO-5, +4.9 12.3; P <.001) identified in V1 were sustained across the entire study period of one year. On the other hand, improvements in mindfulness (P <.001), anxiety (P <.0001), and depression (P <.0001) observed during inpatient treatment were not sustained over the long term.

Safety data showed no serious adverse events were reported during the inpatient stay for any participant. Given the potential for positive effects on presentations of fibromyalgia, Koppold and colleagues suggested the need to study prolonged medical fasting in outpatient settings and whether the duration of the fast could show similar effects.

In general, if a safe and feasible intervention of 510 days were able to lower disease burden in FMS in the medium and long term, giving it further attention seems worthwhile, they wrote.

References

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Prolonged Medical Fasting May Benefit Pain Symptoms in Fibromyalgia - MD Magazine

Internal Medicine

Discussing Ways to Approach Improving Obesity Care with Melanie Jay, MD – MD Magazine

In this interview segment, Melanie Jay, MD, MS, general internist and associate professor at NYU Langone Health, spoke on additional takeaways from her conference presentation on advancing equity in obesity care, given at the 2024 American College of Physicians (ACP) Internal Medicine Meeting.

Jay, who is board-certified in obesity medicine, spoke with the HCPLive editorial team about several different topics connected to obesity. First, Jay was asked whether her talk covered glucagon-like peptide-1 receptor agonists (GLP-1-RAs) such as Ozempic as a topic of interest.

We didn't go into the different GLP-1-receptor agonists that are so popular like semaglutide and tirzepatide, Jay said. We had one question about whether we can think about obesity like addiction and what the overlaps are. So then I did a little discussion about how in the brain, we have both homeostatic mechanisms that regulate how hungry we are, and how much we're eating and our metabolism. Then there's hedonic mechanisms, as well, that are pleasure centers. The GLP-1s, I think, work on both.

Jay noted the importance and necessity of additional research on such a topic, adding the unique finding that there had been evidence suggesting GLP-1 receptor agonists led to fewer cravings for alcohol among users.

Later, Jay was asked about the role she sees technology playing in the future of obesity care, especially in terms of personalized treatment plans and patient engagement.

I think telehealth, for instance, since-COVID has blossomed everywhere, Jay said. And weight management, because we want to check in a lot with our patients and follow them to make it convenient for people, making it so that follow up care can really be delivered in telehealth. It always is good to examine our patients the first time, but in follow up, we can check in with them via telehealth and they don't have to leave their jobs or get child care to come in and get adequate care.

Jay also noted that patient-generated health datas best integration is still being researched, adding that it is important to figure out the interface likely to make it so that there is not an increased workload but engagement is improved.

To learn more information from this conference interview, view the video posted above.

The quotes contained in this discussion were edited for the purposes of clarity. Jay had no relevant disclosures.

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Discussing Ways to Approach Improving Obesity Care with Melanie Jay, MD - MD Magazine

Internal Medicine

Timothy Wilt, MD, MPH: Discussing Colorectal Cancer Screening Options Recommended by ACP – MD Magazine

Although the US Preventive Services Task Force updated its colorectal cancer screening recommendation to lower the screening age from 50 to 45, the American College of Physicians (ACP) still suggests starting screening at age 50, citing uncertainty about the benefits versus harms of screening asymptomatic average-risk adults 45 - 49 years of age.1,2

Additionally, ACP does not recommend certain screening tests endorsed by other organizations, again attributed to considerations regarding the burden and costs associated with different screening modalities.

In an interview with HCPLive at the 2024 American College of Physicians (ACP) Internal Medicine Meeting in Boston, Timothy Wilt, MD, MPH, professor of medicine and public health in the division of general internal medicine at the Minneapolis VA Health Care System, explained potential pros and cons to several available colorectal cancer screening options and which ones ACP does and does not recommend.

He specifically highlighted the effectiveness of fecal immunochemical (FIT) tests but pointed out they need to be repeated on a regular basis, also mentioning ACP recommends FIT testing every other year rather than annually due to similar benefits and reduced burdens and costs.

Colonoscopy is generally considered to be the gold standard for colorectal cancer screening and does not need to be done as often as other tests, but Wilt was careful to highlight the greater burden, cost, and difficulty associated with it, including the preparation, the need to undergo sedation, finding someone to drive you to and from the appointment, and the risk of harm such as perforations and bleeding.

Wilt also noted A stool-based test is only good as a triage test. If it's positive, those individuals have to go on and get a direct visualization such as a colonoscopy, and mentioned FIT and colonoscopy are the only tests ACP recommends, calling attention to various issues with stool DNA tests and CT colonography.

Although he recognized that some patients prefer to focus on other aspects of their health if they are not concerned with their current risk of colorectal cancer, Wilt said Colorectal cancer screening works. I recommend that you get screened, I recommend we begin at age 50. And do it on a regular basis, either with the FIT test every 2 years, or colonoscopy every 10 years.

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Timothy Wilt, MD, MPH: Discussing Colorectal Cancer Screening Options Recommended by ACP - MD Magazine

Internal Medicine

‘Sluggish’ Hospital Uptake of Newer Antibiotics for Gram-Negative Infections – Medpage Today

Hospital uptake of newer antibiotics to treat multidrug-resistant gram-negative bacteria was low over a 5-year period, according to a retrospective cohort study.

Fully 41.5% of episodes of difficult-to-treat resistant (DTR) gram-negative infections were treated exclusively with older, generic agents, which were largely ones with suboptimal safety-efficacy profiles, Sameer Kadri, MD, of the National Institutes of Health Clinical Center in Bethesda, Maryland, and colleagues, reported in the Annals of Internal Medicine. The findings were also presented at the American College of Physicians meeting in Boston.

Use of new antibiotics gradually increased across the study period from January 2016 to June 2021, but gains were uneven across agents. The most commonly used next-generation antibiotics during that time frame were ceftolozane-tazobactam (Zerbaxa) and ceftazidime-avibactam (Avycaz).

Other more recently approved antibiotics -- cefiderocol (Fetroja), eravacycline (Fetroja), imipenem-cilastatin-relebactam (Recarbrio), and meropenem-vaborbactam (Vabomere) -- had more sluggish uptake, Kadri and colleagues wrote. And not even a single hospital used plazomicin (Zemdri) after its FDA approval in 2018 for complicated gram-negative urinary tract infections.

"The two most used 'new' antibiotics, ceftazidime-avibactam and ceftolozane-tazobactam, are themselves a decade old and have largely occupied the carbapenem-resistant Enterobacterales and multidrug-resistant [Pseudomonas] aeruginosa niches," the authors wrote. "On the other hand, the five subsequently approved gram-negative antibiotics with partially overlapping pathogen spectrums were markedly underutilized."

Of concern, 79.3% of DTR gram-negative infections were treated with traditional agents known to have suboptimal safety or efficacy, such as polymyxins, aminoglycosides, tigecycline, and chloramphenicol.

"Given the high mortality risk associated with DTR infections, such treatment gaps could risk patient lives," Kadri's group wrote.

They suggested policy change: "Few overall treatment opportunities in the U.S. market and sluggish utilization trajectories for recently approved antibiotics observed in our study reinforce the need for pull incentives," such as subscription models for new antibiotics piloted in the United Kingdom, they suggested, pointing to the PASTEUR bill as a potential solution to provide that funding.

"Why are these next-generation antibiotics not being used more often?" wrote Jessica Howard-Anderson, MD, of Emory University School of Medicine in Atlanta, and Helen Boucher, MD, of Tufts Medical Center in Boston. "Antimicrobial stewardship is frequently cited -- however, this represents a fundamental misunderstanding of stewardship, which aims to use the right drug, for the right patient, at the right time," they wrote in an accompanying editorial.

Cost may be one factor, the editorialists posited. Mean wholesale price for a day's dosage averaged across the seven new antibiotics noted in the study was $1,036.69 versus $173.41 for traditional agents.

Another factor may be that clinical trials that evaluated the new antibiotics did not always enroll patients that would need the drugs in practice, Howard-Anderson and Boucher wrote. "Clinicians are therefore left wondering whether these new antibiotics are applicable to their patients."

The study analyzed inpatient admissions from a large retrospective administrative database. Between January 2019 and June 2021, 362,142 inpatient encounters occurred across 299 hospitals that indicated one or more cultures with a gram-negative organism. Of these, 0.7% (2,551) were hospitalizations for DTR gram-negative infections. Overall, the DTR infection prevalence among hospitalized patients was 72.7 episodes per 10,000 inpatient encounters.

P. aeruginosa was the most common DTR pathogen, occurring in 48.2% of infections, followed by Acinetobacter baumannii complex (22%). Enterobacterales species accounted for 23% of infections and other gram-negative pathogens accounted for the remaining 6.8%. Of DTR infections, 42.9% were respiratory tract infections and 8.36% were bloodstream infections.

Several patient factors were associated with increased probability of being one of the 58.8% who were treated with newer, next-generation antibiotics. DTR bloodstream infection was a big factor, with newer agents used for about 72% of these compared with 57% of non-bloodstream infections. Patients presenting with do-not-resuscitate status, acute liver failure, and with pathogenic A. baumannii complex or infections caused by other non-pseudomonal non-fermenters were less likely to receive newer antibiotics.

However, age, gender, race/ethnicity, and ICU admissions were not associated with the probability of receiving newer versus traditional antibiotics, nor were mechanical ventilation or presentation at the hospital with neurologic, renal, or respiratory failure.

Of 299 study hospitals, 107 did not prescribe any of the newer antibiotics for DTR infections over the study period. However, only 3.9% of all DTR episodes occurred in the non-prescribing hospitals, most of which were relatively small, with fewer than 100 beds.

Researchers also found that geographical region mattered. For example, in the Midwest, the marginally adjusted probability of hospitals using newer antibiotics was about 61% versus 34% in the Western states. Also, hospitals that reported susceptibility of the infection to newer agents were more likely to use those agents (60% vs 54% for those with no reporting of susceptibility to the agents). However, urban location, teaching status, and technological or bed capacity did not appear to affect patients' probability of receiving newer antibiotics.

Hospital bed capacity was "the strongest factor associated with nonuse" of newer agents: hospitals with fewer than 100 beds had a 28% probability of using new antibiotics, whereas those with 300 or more beds had a 95% probability of using new antibiotics. In particular, smaller rural hospitals and smaller urban hospitals with low baseline prevalence of antibiotic resistance were less likely to use newer antibiotics.

At baseline, the median age of patients with DTR gram-negative infections was 61 years, 58.5% were men, and 49.1% were non-Hispanic whites. The median Elixhauser Comorbidity Index was 5. About one-third of patients were admitted to the ICU, 22.2% required mechanical ventilation, and 17.6% needed vasopressors. Approximately one in five patients with DTR gram-negative infections died. Mortality was higher in patients with DTR bloodstream infections (32%) compared with a 20% mortality rate among those without bloodstream infections.

"The study did have limitations," Howard-Anderson and Boucher cautioned, noting that "medical records were not reviewed to determine the rationale for antibiotic therapy or to determine if the antibiotic was intended to treat the DTR pathogen."

Also, the study didn't cover a period recent enough to have seen the full effects of Infectious Diseases Society of America guidelines on antimicrobial resistance first published in September 2020, they added.

Katherine Kahn is a staff writer at MedPage Today, covering the infectious diseases beat. She has been a medical writer for over 15 years.

Disclosures

The study was funded by the FDA Center for Drug Evaluation and Research.

Kadri reported no ties to industry. One study served on a clinical advisory board for Beckman Coulter.

Howard-Anderson and Boucher reported no relationships with industry.

Primary Source

Annals of Internal Medicine

Source Reference: Strich JR, et al "Assessing clinician utilization of next-generation antibiotics against resistant gram-negative infections in U.S. hospitals" Ann Intern Med 2024; DOI: 10.7326/M23-2309.

Secondary Source

Annals of Internal Medicine

Source Reference: Howard-Anderson J, Boucher HW "New antibiotics for resistant infections: What happens after approval?" Ann Intern Med 2024; DOI: 10.7326/M24-0192.

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'Sluggish' Hospital Uptake of Newer Antibiotics for Gram-Negative Infections - Medpage Today

Internal Medicine

Elizabeth Cerceo, MD, on How to Address Health Care’s Impact on Climate Change – MD Magazine

The health care industry accounts for approximately 5% of total greenhouse gas and toxic air emissions, coming primarily from the United States and contributing directly to the ongoing climate crisis.1

Given the health care sectors notable contributions to climate change, mitigation and adaptation efforts fall heavily on physicians and key stakeholders, a topic Elizabeth Cerceo, MD, associate internal medicine program director and director of environmental health in the division of hospital medicine at Cooper University Health Care, discussed in her session at the 2024 American College of Physicians (ACP) Internal Medicine Meeting in Boston.

Specifically, she referenced the importance of leveraging direct patient education, noting Health care providers, health care professionals, whether it's nurses, physicians, we are all very trusted messengers by the public, so when they hear a message that comes from us about climate-related health factors or impacts of climate change, they will listen to us much more than they'll listen to politicians or other places where they may be hearing messages.

Although Cerceo described how physicians generally like to be fully educated on a topic before they discuss it with their patients, she said the strength of the current data should make health care providers feel empowered and like opening up that conversation will ultimately benefit the patient, regardless of how up-to-date you are on the most recent climate-related information.

Beyond ensuring that physicians themselves are educated on climate change and its link to health care, Cerceo also emphasized the importance of educating trainees and perhaps other physicians who may not yet be aware of or well-versed on the health consequences associated with climate change.

New research is coming down the pike fast and furious, she added. We're seeing studies where you can demonstrate the path of physiologic linkages. We don't just have correlation, association studies anymore, but we have that more foundational data that shows that these are real effects that are happening, and we can demonstrate why.

Despite the mounting body of evidence supporting the growing climate crisis, Cerceo explained that patients receptiveness toward climate-related topics when discussing their health tends to depend on how the conversation is framed. Beyond counseling her patients on the need to be careful about their exposure to certain environmental factors like air pollution, she also described the importance of providing them with tangible things they should be doing or a linkage that appeals to their direct experiences.

Although Cerceo described the expansion of the conversation and research surrounding climate change as encouraging, she was also careful to note that it is not enough, saying Things really need to accelerate, and we need to keep our foot on the gas pedal. Now is not the time to sit back and think, oh, you know, there's been a few positive steps, let's rest on our accolades It has to be all physicians recognizing the inter-linkages between us and our environment, and that we need to be mindful of this and incorporating it into our daily practice.

Reference:

1. Eckelman MJ, Huang K, Lagasse R, et al. Health Care Pollution And Public Health Damage In The United States: An Update. Health Affairs. https://doi.org/10.1377/hlthaff.2020.01247

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Elizabeth Cerceo, MD, on How to Address Health Care's Impact on Climate Change - MD Magazine