Recommendations and resources
1) Avoid medication-related harm in older patients (>65 years) receiving 5 or more regularly used medicines by performing a complete medication review and deprescribing whenever appropriate.
Studies show that the risk of medication-related harm rises once the number of regularly prescribed medicines exceeds five; this risk increases exponentially as the number reaches eight or more. Medicines that deserve particular attention are benzodiazepines and other sedative-hypnotics, anti-psychotics, hypoglycaemic agents, antithrombotic agents, anti-hypertensives, and anti-anginal agents.
Trying to achieve aggressive treatment targets, such as BP <130/80 or HbA1c Discontinuation should be considered where past indications for specific medicines are no longer valid, the risk of harm outweighs the benefits within a patient’s remaining life span, or medicines are associated with past toxicity or non-adherence.
2) Don’t request daily full blood counts, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) as measures of response to antibiotic treatment if patients are clinically improving.
The decision on whether or not to cease antibiotic treatment or switch from intravenous (IV) to oral antibiotics should be guided by the results of microbiological cultures indicating bacterial species and antimicrobial sensitivities, and evidence of defervescence and improved clinical status rather than by changes in the levels of white cell count (WCC) from a full blood count, C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR).
However, these markers can help to predict poor prognosis in patients with severe infections in whom the clinical response may be difficult to determine (e.g. immunosuppressed patients or those who are critically ill or those at risk of drug-resistant hospital-acquired infections). In these cases, the failure of markedly elevated CRP and WCC to decrease by specified amounts would suggest that the antimicrobial therapy is not being effective. While no references could be found that explicitly support not using ESR or CRP in mild to moderate infections, available evidence suggests that their use is only of benefit in severe infections.
3) Once patients have become afebrile (non-feverish) and are clinically improving, don’t continue prescribing intravenous antibiotics to those with uncomplicated infections and no high-risk features if they are tolerant of oral antibiotics.
Patients with uncomplicated infections not requiring prolonged antibiotic therapy and with no high-risk features should be switched from intravenous (IV) to oral antibiotics once they are afebrile, clinically improving and able to tolerate oral medication. In hospital, this often occurs by day three. Exceptions to this rule are those suffering life threatening or deep-seated infections (such as suspected endocarditis, osteomyelitis or meningitis), and high risk patients (such as immunocompromised patients including from HIV, intravenous drug use, underlying advanced cancer, or documented multi-resistant bacteraemia or hospital-acquired infection).
There is no evidence to support the belief that oral medications are insufficiently bioavailable to be as effective as IV medications, or that the same agent must be used both IV and orally.
The scope for early IV-to-oral conversion has broadened, owing to the advent of newer, more potent oral agents that achieve higher and more consistent serum and tissue concentration. Moreover, earlier switchover from IV-to-oral therapy reduces the risk of cannula-related infections, carries no risk of thrombophlebitis, and allows for earlier discharge and reduced cost.
4) Don’t request Holter monitoring, carotid duplex scans, echocardiography, electroencephalograms (EEGs) or telemetry in patients with first presentation of uncomplicated syncope and no high risk features.
Holter monitoring, carotid duplex scans, echocardiography, electroencephalograms (EEGs) and telemetry have very low diagnostic yield in patients with uncomplicated syncope and no clinical features of, or risk factors for, the following:
- arrhythmia (e.g. palpitations preceding syncope, exertional syncope, unheralded syncope, history suggestive of heart failure or ischaemic heart disease)
- carotid stenosis (syncope would need to be associated with focal neurological symptoms or signs suggestive of transient ischaemic attack),
- cardiac valvular disorders (e.g. definite heart murmurs) or
- seizures (very rarely present as syncope with no other epileptic features e.g. tongue biting, urinary incontinence, post-ictal confusion, muscle pain).
Most syncopal episodes are vasovagal or secondary to postural hypotension for which careful history and lying and standing blood pressure measurements are the most important diagnostic criteria combined with standard 12-lead ECG.
5) Don’t request computerised tomography pulmonary angiography (CTPA) as first-choice investigation in non-pregnant adult patients with low risk of pulmonary thromboembolism (PTE) by Wells’ score (score <= 4); imaging can be avoided in low risk patients if D-dimer test is negative after adjusting for age.
The D-dimer test is highly sensitive for deep vein thrombosis and pulmonary thromboembolism, such that a negative result in non-pregnant adults (adjusted for age) rules out this condition in patients with low pre-test probability. A positive result is however non-specific and may be due to many other conditions apart from PTE. In ruling out PTE, D-dimer assay should be the first choice investigation in patients classified as being low risk according to the Well’s score (equal to or less than 4).
These considerations are heightened by the risks associated with CTPA testing such as radiation exposure and incidental imaging findings, e.g. lung nodules and adrenal lesions that may provoke further investigations and diagnosis of isolated small subsegmental emboli whose natural history is unknown and for which anticoagulation is not yet shown to be of benefit. There is however a 1-3% failure rate with a low risk Well’s score and negative D-dimer prediction method, so close follow-up is indicated in all patients in whom a D-dimer has been requested. Note that laboratories do not report age adjusted values, though it is well known that D-dimer levels rise with age in the presence of co-morbidities.
An example of age adjustment, endorsed by the clinical guidelines committee of the American College of Physicians (see reference from Raja et al below) quotes an upper limit of normal for D-dimer tests equal to age × 10 ug/L, rather than a generic upper limit of 500 ug/L. Clinical judgement is necessary in applying this adjustment method, with some reports adopting a more conservative formulae of age x 5 ug/L.
The Well’s score is computed as follows:
|Clinical signs and symptoms of deep venous thrombosis
|Alternative diagnosis less likely
|Heart rate >100/min
|Previous pulmonary embolism or deep venous thrombosis
|Malignancy (receiving treatment, treated within last 6 months or palliative)
Modified Wells score (mWS) of ≤4 = low risk patients, >4 = high risk patients
Reference: Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer. Thromb Haemost. 2000:83 (3): 416–20.
Note: D-dimer is routinely elevated from the first trimester and gestational age normative D-dimer levels have not been sufficiently validated to allow their use as a risk stratification tool in pregnancy. Most pregnant women with no clinical evidence of DVT will have negative lower limb venous Doppler as pulmonary emboli originate in the pelvic veins, which are not accurately evaluated with duplex compression Doppler ultrasound. In such cases, ventilation perfusion lung scanning is the test of choice, due to lower breast dose than CTPA in pregnant women with suspected pulmonary embolism provided chest radiograph is normal and an alternative diagnosis such as neoplasia or aortic dissection, that are detectable with CT and not with VQ, is not suspected.