Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
How do you approach using fecal microbiota therapy for recurrent Clostridioides difficile infection in immunocompromised patients?
We generally do not do the single donor FMT via colonoscopy, that was popular 5-10 years ago. We do offer both the oral and enema-based products, with a slight preference for the oral-based product due to ease of use.
For patients admitted while taking chronic outpatient opioids, how do you decide whether to resume their baseline opioid regimen at discharge versus tapering or modifying therapy during hospitalization?
I'm not sure there's a single right answer here. My only recommendation is for patients who are on chronic outpatient opiates: please talk to their ambulatory clinician before making any significant changes. Their ambulatory doctor knows them over time and can give you advice regarding what's happen...
For patients admitted while taking chronic outpatient opioids, how do you decide whether to resume their baseline opioid regimen at discharge versus tapering or modifying therapy during hospitalization?
I'm not sure there's a single right answer here. My only recommendation is for patients who are on chronic outpatient opiates: please talk to their ambulatory clinician before making any significant changes. Their ambulatory doctor knows them over time and can give you advice regarding what's happen...
Have you changed your approach to delaying hip surgery in the context of decompensated CHF given the findings of the HIP-ATTACK study?
That is an interesting question. Patients with a hip fracture have a high mortality, and delaying surgery could contribute to this mortality. On the other side of the pendulum is acute heart failure. Patients with acute heart failure have increased mortality in the perioperative period. Some of this...
How do you manage resistant infections that persist after stopping antibiotic therapy in patients with non-CF bronchiectasis?
In patients with non-CF bronchiectasis who continue to have infections after completing antibiotics, I first obtain repeat sputum cultures to identify the organism and check for any resistance patterns. I also review adherence to airway clearance techniques, as inadequate mucus clearance often contr...
Do you routinely observe inpatients for 24 hours after transitioning from IV empiric antibiotics to an oral regimen prior to discharge when the source of infection is unclear?
To be sure, this is a big question with much nuance and should be broken down into component parts. To begin with, the lack of a source is not, in and of itself, a clear justification for continued hospitalization. What should drive the decision for discharge is established clinical stability and an...
Do you routinely discontinue atypical coverage in community-acquired pneumonia when PCR testing (i.e., respiratory pathogen panel) is negative for atypical organisms?
In community-acquired pneumonia (CAP), here is how I approach the decision to discontinue atypical coverage (e.g., azithromycin or doxycycline) when respiratory pathogen panel PCR testing is negative for atypical organisms (most commonly, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneum...
Should asymptomatic esophageal candidiasis identified incidentally on endoscopy be treated?
Yes, in our practice, we do treat asymptomatic esophageal candidiasis when found incidentally on endoscopy. A few things to consider: 1) While patients may be asymptomatic at the time of the endoscopy, untreated disease can lead to the future development of complications/symptoms, such as odynophagi...
Do you consider holding PPIs in patients hospitalized with infections like pneumonia or C. diff colitis?
My practice is to try to get patients off PPIs if at all possible, and the hospital can be a good time to have that conversation with them. This is assuming no active indication for them (recent ulcer/upper GI bleed, H.pylori therapy, etc.) Use of PPIs has been associated with a higher incidence of ...
What is your approach to optimizing pre-operative hemoglobin in patients with sickle cell disease?
This is always a question that has to be hyper-individualized. The research, and therefore the associated professional guidance, is thin. The American Society of Hematology (ASH) 2020 Guidelines for Sickle Cell Disease: Transfusion Support and the NHLBI Expert Panel Report (2014) are the only profes...