Inpatient Update

We treat flu, RSV, COVID and pneumococcal pneumonia in the hospital. Are we doing enough to prevent the next admission?

In this episode of Inpatient Update, Dr. Mason Turner reviews the vaccine decisions hospitalists should be making before discharge: who qualifies, what has changed, and when a hospitalization is an appropriate opportunity to vaccinate.

Along the way, we revisit an eye-opening heart failure trial with Dr. Emily Reams, listen to the public ACIP deliberations behind expanded vaccine recommendations, and discuss how evidence-based recommendations fit with shared decision-making.

1. Flu vaccination belongs on the discharge checklist.

In PANDA II, hospitals in China were randomized to offer free influenza vaccination before discharge or provide usual care for patients hospitalized with acute heart failure and NYHA class III–IV symptoms.

Death or readmission within one year occurred in 41.2% versus 47.0% of patients—an absolute difference of approximately 5.8 percentage points, or NNT ≈18 for the composite outcome in this study population.

Anderson CS, et al. Influenza vaccination to improve outcomes for patients with acute heart failure—PANDA II. Lancet. 2025;406:1020–1031.

Practice change: Offer eligible, clinically appropriate patients their seasonal flu vaccine before discharge. September–October is ideal for most adults, but vaccination remains appropriate later while influenza circulates. CDC influenza guidance.

2. RSV vaccination now includes high-risk adults starting at age 50.

A single dose is recommended for previously unvaccinated adults:

• Age 75 and older
• Age 50–74 with increased risk of severe RSV disease, including conditions such as heart failure, coronary artery disease, COPD and asthma

RSV vaccination is not currently annual. Review the full risk criteria and prior vaccination history. CDC RSV guidance.

The expanded DAN-RSV randomized trial found approximately 70% protection against RSV-related respiratory hospitalization.

Lassen MC, et al. Bivalent RSV Prefusion F Vaccine to Prevent Hospitalizations in Adults. NEJM Evidence. Published August 29, 2026.

3. Pneumococcal vaccination starts at 50—or earlier with qualifying risk factors.

Assess vaccination status in all adults age 50 and older, and adults 19–49 with qualifying conditions, including diabetes, cigarette smoking, alcohol use disorder, chronic lung disease and chronic heart disease.

The appropriate vaccine and schedule depend on previous doses. Review the vaccine history and coordinate with pharmacy. CDC pneumococcal recommendations.

Kobayashi M, et al. Expanded Recommendations for Use of Pneumococcal Conjugate Vaccines Among Adults Aged ≥50 Years. MMWR. 2025;74:1–8.

4. COVID protection needs updating, even in previously vaccinated patients.

This episode follows the AAFP’s 2026–2027 recommendations: an updated COVID vaccine for adults, with two seasonal doses six months apart for adults age 65 and older. The linked guidance covers nonpregnant, immunocompetent adults; pregnancy and immunocompromise have separate recommendations. AAFP 2026–2027 respiratory vaccine guidance.

In the observational VISION study, receipt of the 2025–2026 vaccine was associated with 53% effectiveness against COVID-related hospitalization in immunocompetent adults age 65 and older.

Wiegand RE, et al. Interim Estimated Effectiveness of 2025–2026 COVID-19 Vaccines in Adults Using a Test-Negative Design. JAMA Network Open. 2026;9:e2625152.

The updated Pfizer 2026–2027 formulation received FDA approval on August 27, 2026. Check local availability and product eligibility with pharmacy.

5. Hospitalization itself is not a reason to defer vaccination.

Moderate or severe acute illness is a precaution, but once the patient improves, hospitalization or discharge can be an appropriate opportunity to vaccinate. Make vaccine history and eligibility part of discharge planning. CDC contraindications and precautions.

Featured audio and further listening

From Inside Family Medicine, produced by the American Academy of Family Physicians:

• How we create vaccine guidance — September 14, 2026. Drs. Margot Savoy and Danielle Carter explain the AAFP’s current process for developing vaccine recommendations. Recommended listening in this episode.
• AAFP Fall Immunizations Recommendations — September 16, 2025. Includes the featured excerpt from Dr. Margot Savoy on evidence-based recommendations and shared decision-making.

Also featured:

• Inpatient Update: SHM 2026 Takeaways with Dr. Emily Reams—our original discussion of influenza vaccination in heart failure.
• CDC/ACIP public meeting excerpts: RSV, April 2025; pneumococcal vaccination, October 2024; vaccination during hospitalization, October 2014.

Take a vaccine history. Check eligibility. Offer indicated vaccines before discharge.

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In this episode of Inpatient Update, Dr. Mason Turner is joined by clinical pharmacist Lindsay Deloney for one big question and three pharmacy quick hits:

• Phenobarbital for alcohol withdrawal — can we safely use a structured IV pathway on the medical floor?
• Steroids + PPIs — does starting glucocorticoids really require gastroprotection?
• Extended anticoagulation — should apixaban 5 mg twice daily live on the medication list forever after a VTE?
• AmpC organisms — when should a ceftriaxone-susceptible result actually make you nervous?

Practical pharmacology, evidence, and a little pharmacist gentle guidance for your next day on service.

Hospital-Wide Implementation, Clinical Outcomes, and Safety of Phenobarbital for Alcohol Withdrawal

JAMA Network Open, 2025

https://doi.org/10.1001/jamanetworkopen.2025.28694

Hospital-wide implementation of a weight-based IV phenobarbital pathway was associated with:

• Faster improvement in withdrawal symptoms
• ~30 hours shorter treatment duration
• ~2.2 days shorter time to discharge
• No significant increase in intubation, mortality, or other measured safety outcomes

Takeaway

Phenobarbital does not have to be an ED- or ICU-only medication.

The evidence is observational, but a structured, protocolized approach appears feasible on the medical floor.

Steroids + PPI Prophylaxis

Prescribing of Medication to Prevent Glucocorticoid Harms in Patients With Polymyalgia Rheumatica

Arthritis & Rheumatology, 2026

https://doi.org/10.1002/art.70087

Gastroprotection with a PPI or H2 blocker was not associated with fewer serious GI events in patients receiving glucocorticoids.

Things We Do for No Reason™: Routine Use of Proton Pump Inhibitors for Peptic Ulcer Prophylaxis in Adults on High-Dose Corticosteroids

Journal of Hospital Medicine, 2023

https://doi.org/10.1002/jhm.13095

Takeaway

Steroids alone are not an automatic indication for a PPI.

Instead, look for actual GI risk factors: NSAIDs, anticoagulation, antiplatelets, previous GI bleeding, or another independent indication for acid suppression.

Extended Anticoagulation After VTE

Apixaban for Extended Treatment of Venous Thromboembolism — AMPLIFY-EXT

New England Journal of Medicine, 2013

https://doi.org/10.1056/nejmoa1207541

Extended Reduced-Dose Apixaban for Cancer-Associated VTE — API-CAT

New England Journal of Medicine, 2025

https://doi.org/10.1056/nejmoa2416112

Apixaban for Extended Treatment of Provoked Venous Thromboembolism — HI-PRO

New England Journal of Medicine, 2025

https://doi.org/10.1056/nejmoa2509426

RENOVE Trial

Lancet, 2025

https://doi.org/10.1016/s0140-6736(24)02842-3

Takeaway

Don’t let apixaban 5 mg twice daily remain on the medication list indefinitely without asking why.

After the acute VTE treatment period, reassess:

• Does this patient still need extended anticoagulation?
• If so, do they still need full-dose therapy?
• Could reduced-dose anticoagulation preserve benefit while reducing bleeding risk?

The answer depends on recurrence risk, but hospitalization is a great opportunity to revisit the plan.

IDSA 2024 Guidance on Antimicrobial-Resistant Gram-Negative Infections

https://doi.org/10.1093/cid/ciae403

For organisms at meaningful risk of inducible AmpC:

• Enterobacter cloacae complex
• Klebsiella aerogenes
• Citrobacter freundii

A susceptibility report showing “sensitive” to ceftriaxone does not necessarily mean you should use it for an invasive infection.

Takeaway

Remember the AmpC bugs.

For invasive infections with these organisms:

• Avoid reflexive ceftriaxone
• Piperacillin-tazobactam is also not preferred
• Cefepime is generally the preferred option when appropriate

Don’t just read the susceptibility result. Know the organism.

• Alcohol withdrawal: Phenobarbital can be used beyond the ICU when supported by a structured pathway.
• Steroids: Don’t automatically add a PPI.
• VTE: Reassess chronic full-dose apixaban once the acute treatment period is over.
• AmpC: Enterobacter cloacae, Klebsiella aerogenes, Citrobacter freundii — don’t let a ceftriaxone “S” fool you.

Question the medication list. Know the organism. Use your pharmacist.

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With Special Guests Dr. Catie Glatz & Dr. Joseph S. Thomas

In this special episode of Inpatient Update, Dr. Mason Turner is joined by Dr. Catie Glatz and Dr. Joseph S. Thomas of the Journal of Hospital Medicine Digital Media Team to dig into three practice-changing articles featured in #JHMWrapped 2025 — JHM’s annual roundup of some of the year’s most impactful hospital medicine literature:

• Gram-negative bacteremia — if Cipro and Bactrim aren’t options, does your patient really need continued IV antibiotics?
• Hypercapnia — do you actually need an ABG?
• Steroid leukocytosis — how much of that rising white count can you really blame on steroids?

Three common hospitalist reflexes—and evidence that may change what you do on rounds tomorrow.

Articles

Transition to Oral Beta-Lactam Therapy in Uncomplicated Gram-Negative Bacteremia

Journal of Hospital Medicine, 2025

Systematic review and meta-analysis of 8 studies and 7,500 patients comparing oral beta-lactams with fluoroquinolones or TMP-SMX.

Key Findings

• No significant difference in 30-day mortality
• No significant difference in antibiotic failure
• Oral beta-lactams offer another option for appropriately selected patients

Takeaway

Cipro or Bactrim resistance does not automatically mean a PICC line.

For uncomplicated gram-negative bacteremia with source control and clinical improvement, an appropriately dosed oral beta-lactam such as amoxicillin or cephalexin may be a reasonable step-down option.

Things We Do for No Reason™: Arterial Blood Gas Testing to Screen for Hypercarbic Respiratory Failure

Journal of Hospital Medicine, 2025

Across multiple prospective studies, a venous PCO₂ <45 mmHg reliably ruled out arterial hypercarbia.

Using VBGs as the initial screening test can:

• Avoid painful arterial sticks
• Reduce delays in care
• Reduce unnecessary ABGs

Takeaway

Worried about hypercapnia?

Start with a VBG.

If the venous PCO₂ is <45, significant hypercarbia is effectively ruled out. If elevated and greater precision would change management, then consider the ABG.

Elevation in White Blood Cell Count After Corticosteroid Use in Noninfected Hospitalized Patients

Journal of Hospital Medicine, 2025

Large cohort study of more than 28,000 hospitalized patients examining the expected leukocytosis after steroids.

Key Findings

• WBC rise was dose-dependent
• The effect peaked around 48 hours
• Mean increases ranged from approximately:
   
  • 0.3 with low-dose steroids 
  • 1.7 with medium-dose steroids 
  • 4.8 with high-dose steroids

Takeaway

Steroids raise the white count—but often less than we casually assume.

A substantial or unexpectedly early rise should not automatically be dismissed as “just the steroids.” Consider the dose, timing, magnitude, and the clinical picture.

Practice-Changing Takeaways

• Gram-negative bacteremia: Oral beta-lactams may help appropriate patients avoid prolonged IV therapy.
• Hypercapnia: Screen with a VBG before reaching for an ABG.
• Steroids: Don’t blame every rising white count on demargination.

Question the reflex. Check the evidence. Treat the patient.

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With Special Guest Dr. Scott Curry

In this Inpatient Update News Flash, Dr. Mason Turner is joined by infectious disease physician and hospital epidemiologist Dr. Scott Curry to examine the sharp rise in cyclosporiasis cases across the United States—and what it should change in clinical practice.

Thousands of confirmed cases have been reported across more than 40 states, with hundreds of hospitalizations and additional clusters still under investigation.

So what should hospitalists do differently?

Cyclospora is a foodborne parasite that infects the small intestine and commonly causes:

• Prolonged watery diarrhea
• Frequent or urgent bowel movements
• Bloating and gas
• Poor oral intake
• Hypovolemia, AKI, and electrolyte abnormalities

Unlike many other gastrointestinal infections, illness may relapse and persist for a month or longer without treatment.

Person-to-person transmission is not expected because the organism must mature in the environment before becoming infectious.

Think about cyclosporiasis when a patient has:

• Prolonged or relapsing diarrhea
• Recent consumption of uncooked produce
• Restaurant or grocery-store exposures
• Symptoms lasting longer than expected for viral gastroenteritis
• Hypovolemia, AKI, or hyponatremia associated with ongoing diarrhea

The incubation period may be 7–14 days, so the food history needs to extend well beyond the last meal.

Ask about:

• Fresh produce and salads
• Restaurants and shared meals
• Grocery stores and product brands
• Travel
• Well water
• Whether anyone else who shared the meal became ill

Document those details. They may become important during a public-health investigation.

For patients admitted with acute or prolonged gastrointestinal symptoms:

• Order and collect a GI multiplex PCR early, ideally at admission.
• Do not wait until the patient has been hospitalized for several days.
• Interpret results in the context of the clinical syndrome because false positives can occur.

Avoid reflexively ordering a traditional stool ova and parasite examination. It is labor-intensive, low yield, and may miss Cyclospora unless special testing is performed.

A positive result that does not fit the clinical picture should prompt discussion with microbiology or infectious disease rather than automatic treatment.

For an immunocompetent adult with clinically convincing cyclosporiasis:

Trimethoprim-sulfamethoxazole double strength twice daily for 7–10 days

Treatment usually shortens what can otherwise become a prolonged and miserable illness.

Consult infectious disease when the patient:

• Has a serious sulfa allergy
• Is significantly immunocompromised
• Has severe, relapsing, or complicated illness
• Has testing that conflicts with the clinical picture

There is currently no clearly proven, equally effective alternative for patients with a serious sulfa allergy.

Cyclospora does not require special isolation beyond standard precautions once the diagnosis is known.

However, patients presenting with undifferentiated vomiting or diarrhea should initially be approached with appropriate gown and glove precautions because norovirus and other highly contagious infections remain much more common.

Laboratories generally report confirmed cases to public-health authorities. Clinicians should also consider contacting their health department when a detailed food history suggests a specific restaurant, product, or shared exposure.

• Take a real food history—and go back up to two weeks.
• Order GI PCR early in the hospitalization when clinically appropriate.
• Stop reflexively ordering stool ova and parasite examinations.
• Treat convincing cyclosporiasis with TMP-SMX.
• Recognize that a positive multiplex PCR does not override a clinical picture that does not fit.
• Call microbiology or ID when the diagnosis or treatment is uncertain.

The Cyclospora outbreak does not require a completely new approach.

It should sharpen the approach hospitalists already use for gastrointestinal illness:

Ask earlier. Test earlier. Interpret thoughtfully. Treat the patient in front of you.

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In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Daniel Hardgrove to rethink two common fluid decisions:

• Acute pancreatitis — should aggressive IV fluids still be the default?
• LR vs normal saline — does balanced crystalloid actually improve outcomes?

Practical take-homes, real-world discussion, and what to change on rounds tomorrow.

Articles & PubMed Links

Aggressive or Moderate Fluid Resuscitation in Acute Pancreatitis

New England Journal of Medicine, 2022
WATERFALL Trial

Compared:

• Aggressive fluids: 20 mL/kg bolus + 3 mL/kg/hr
• Moderate fluids: bolus only if hypovolemic + 1.5 mL/kg/hr

Key Findings

• No improvement in moderately severe/severe pancreatitis
• More fluid overload with aggressive fluids
• Trial stopped early for harm
• Shorter length of stay with moderate fluids

Takeaway

For acute pancreatitis, stop reflexively flooding patients.

Give fluids if hypovolemic.
 Start moderate.
 Reassess early.
 Stop when no longer needed.

Pubmed: https://pubmed.ncbi.nlm.nih.gov/36103415/ 

A Crossover Trial of Hospital-Wide Lactated Ringer’s Solution vs Normal Saline

New England Journal of Medicine, 2025
FLUID Trial

Hospital-wide crossover trial comparing:

• Lactated Ringer’s
• Normal saline

Key Findings

No significant difference in:

• Death or readmission at 90 days
• Mortality
• Dialysis
• Length of stay
• ED visits

Takeaway

LR is reasonable.
 Normal saline is reasonable.

For most hospitalized patients, the choice probably matters less than we thought.

Pubmed: https://pubmed.ncbi.nlm.nih.gov/40503714/ 

Practice-Changing Takeaways

• Pancreatitis: moderate, reassessed fluids beat automatic aggressive hydration.
• Crystalloid choice: LR is not clearly superior to saline for broad hospital use.
• Fluids are treatment, not autopilot.

Bottom Line

If you change nothing else this week:

• Don’t automatically flood pancreatitis patients.
• Put a stop time or reassessment point on maintenance fluids.
• Use LR or saline thoughtfully based on the patient.

Treat the patient. Not the reflex.

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Semi-Annual Recap Episode

In this special episode of Inpatient Update, Dr. Mason Turner looks back at the first 10 episodes and distills the biggest practice-changing lessons from more than 25 recent studies.

If you're new to the show, this is the fastest way to understand what Inpatient Update is all about: practical evidence that changes what hospitalists do on rounds tomorrow.

From pneumonia treatment and antibiotic duration to anticoagulation, flu vaccination, and asymptomatic inpatient hypertension, these are the five changes most likely to improve patient care right now.

The theme: stop reflexive treatment decisions and individualize care.

Featured Article

Short Versus Longer Antibiotic Duration for Community-Acquired Pneumonia: A Multicenter Target Trial Emulation
Annals of Internal Medicine, 2026

Original Episode:
Shorter CAP Antibiotics + The Cipro QTc Myth — with Dr. Ernest Murray

Supporting Articles

Predicting Benefit from Adjuvant Therapy with Corticosteroids in Community-Acquired Pneumonia: A Data-Driven Analysis of Randomized Trials
Lancet Respiratory Medicine, 2025

Original Episode:
Apixaban vs Rivaroxaban + Steroids in Community-Acquired Pneumonia — with Dr. Adam Jaffe

Associations Between Antibiotic Use and Outcomes in Patients Hospitalized with Community-Acquired Pneumonia and Positive Respiratory Viral Assays
Clinical Infectious Diseases, 2026

Original Episode:
Asymptomatic Inpatient Hypertension + Viral Pneumonia Antibiotics — with Dr. Austin White

Takeaway

For carefully selected, clinically improving patients with community-acquired pneumonia:

• Three days of antibiotics may be enough
• CRP may help identify who benefits from steroids
• A positive viral panel should make us pause before reflexively prescribing antibiotics

The lesson is not "do less."

The lesson is to be more deliberate.

Featured Article

Influenza Vaccination to Improve Outcomes for Patients with Acute Heart Failure (PANDA II)
Lancet, 2025

Original Episode:
SHM Converge 2026 Recap — with Dr. Emily Reams

Takeaway

A one-time intervention that many hospitalized patients still miss.

For patients admitted with heart failure during flu season:

• Reduced mortality
• Reduced readmissions
• Number needed to treat ≈ 17

Hospitalization creates an opportunity that should not be missed.

If they're eligible and willing, vaccinate before discharge.

Featured Article

Aspirin in Patients with Chronic Coronary Syndrome Receiving Oral Anticoagulation (AQUATIC Trial)
New England Journal of Medicine, 2025

Original Episode:
Aspirin Plus Anticoagulation + 7 vs 14 Days for Bacteremia — with Dr. Andres Ospina

Supporting Articles

Extended Reduced-Dose Apixaban for Cancer-Associated Venous Thromboembolism (API-CAT Trial)
New England Journal of Medicine, 2025

Original Episode:
Pilot Episode — Solo

Bleeding Risk with Apixaban vs Rivaroxaban in Acute Venous Thromboembolism
New England Journal of Medicine, 2026

Original Episode:
Apixaban vs Rivaroxaban + Steroids in Community-Acquired Pneumonia — with Dr. Adam Jaffe

Takeaway

Several recent studies point in the same direction:

• Stop aspirin when stable CAD patients begin long-term anticoagulation
• Consider reduced-dose apixaban for extended VTE treatment in selected patients
• Apixaban appears safer than rivaroxaban for bleeding

Less anticoagulation is not always better.

But less unnecessary anticoagulation often is.

Featured Article

Antibiotic Treatment for 7 versus 14 Days in Patients with Bloodstream Infections (BALANCE Trial)
New England Journal of Medicine, 2025

Original Episode:
Aspirin Plus Anticoagulation + 7 vs 14 Days for Bacteremia — with Dr. Andres Ospina

Supporting Articles

Antibiotic De-escalation in Adults Hospitalized for Community-Onset Sepsis
JAMA Internal Medicine, 2026

Original Episode:
De-escalating Sepsis Antibiotics + When to Pull the IV — with Nicholas Linde, PA

Dalbavancin for Treatment of Staphylococcus aureus Bacteremia: The DOTS Randomized Clinical Trial
JAMA, 2025

Original Episode:
Faster Hypernatremia Correction + Long-Acting Antibiotics for Staph Bacteremia — with Dr. Kevin Baker

Takeaway

Across multiple infections, the trend is consistent:

• Seven days often beats fourteen
• Earlier de-escalation appears safe
• Long-acting antibiotics may help some patients avoid prolonged IV therapy and hospitalization

The question is no longer:

"Can we shorten antibiotics?"

The question is:

"Why are we still giving so many patients long courses?"

Featured Article

As-Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals
JAMA Internal Medicine, 2025

Original Episode:
Asymptomatic Inpatient Hypertension + Viral Pneumonia Antibiotics — with Dr. Austin White

Takeaway

This was the most practice-changing study discussed on the show so far.

For hospitalized patients with:

• Elevated blood pressure
• No symptoms
• No evidence of end-organ damage

The reflexive response should not be:

"What PRN should I give?"

Instead ask:

• Why is the blood pressure elevated?
• Is the patient in pain?
• Anxious?
• Post-operative?
• Does this patient actually need acute treatment?

Acute treatment of asymptomatic inpatient hypertension was associated with:

• More AKI
• More large blood pressure drops
• Worse clinical outcomes

Treat the patient.

Not the number.

If you change nothing else from the first six months of Inpatient Update:

1. Stop treating asymptomatic inpatient hypertension.
2. Shorten antibiotics when the evidence supports it.
3. Reconsider aspirin when starting anticoagulation.
4. Give eligible heart failure patients a flu shot before discharge.
5. Be more deliberate in your pneumonia management.

Small changes.

Huge reach.

Real impact.

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With Special Guest Dr. Bianca Farley

In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Bianca Farley to examine two practices driven largely by fear of rare but devastating complications:

• Are we correcting severe hyponatremia too cautiously? 
• Does pharmacologic DVT prophylaxis improve outcomes that actually matter to patients? 

Two common hospitalist decisions. Two deeply ingrained habits. Two areas where the evidence may be more nuanced than many of us were taught. 

Articles & PubMed Links

Sodium Correction Rates and Outcomes Among Patients With Severe Hyponatremia

Annals of Internal Medicine (2026)

Retrospective cohort study of nearly 14,000 hospitalized patients with severe hyponatremia (Na ≤120 mEq/L). 

Compared:

• Slow correction: <8 mEq/L per 24 hours 
• Moderate correction: 8–12 mEq/L per 24 hours 
• Fast correction: >12 mEq/L per 24 hours 

Primary Outcome

• Composite of: 
   
  • 90-day mortality 
• 
  
  • Delayed neurologic complications 
• 
  

Key Findings

• Slow correction had the worst outcomes 
• Moderate correction reduced adverse outcomes 
• Fast correction reduced adverse outcomes even further 
• Primary outcome occurred in 21% of patients overall 
• Faster correction was associated with significantly lower risk of death or delayed neurologic events compared with slow correction. 

What About Osmotic Demyelination Syndrome?

The traditional fear of overcorrection continues to matter, particularly in high-risk populations, but this study suggests that aggressively avoiding correction may also cause harm. 

Takeaway

→ Avoiding overcorrection remains important.
 → But correcting severe hyponatremia too slowly may also worsen outcomes.
→ A reasonable target may be 8–10 mEq/L/day rather than reflexively aiming for the lowest possible correction rate.

Pubmed: https://pubmed.ncbi.nlm.nih.gov/41587479/

Pharmacologic Thromboprophylaxis in Medical Inpatients

JAMA Network Open (2026)

Systematic review and network meta-analysis of 22 randomized trials involving 43,840 medical inpatients. 

Compared:

• Low-molecular-weight heparin (LMWH) 
• Unfractionated heparin (UFH) 
• Direct oral anticoagulants (DOACs) 
• No pharmacologic prophylaxis 

Key Findings

Symptomatic VTE

Baseline risk without prophylaxis:

• 1.7% at 90 days 

LMWH:

• Reduced symptomatic VTE 
• RR 0.68 (95% CI 0.49–0.94) 

Clinically Relevant VTE

• LMWH RR 0.57 
• DOAC RR 0.58 
• UFH RR 0.66 

Mortality

• No mortality benefit with any regimen. 

Major Bleeding

• DOACs increased major bleeding 
• UFH increased major bleeding 
• LMWH showed no statistically significant increase in major bleeding. 

Interpretation

Pharmacologic prophylaxis reduces VTE events, but:

• Absolute VTE risk is relatively low 
• Mortality is unchanged 
• Bleeding risk must be considered 
• Patient selection matters 

Takeaway

→ DVT prophylaxis works, but mostly by preventing relatively uncommon events.
 → Benefits are greatest in appropriately selected high-risk patients.
 → LMWH appears to offer the best balance of efficacy and safety.

Pubmed: https://pubmed.ncbi.nlm.nih.gov/42138924/

Practice-Changing Takeaways

Severe Hyponatremia

• Fear of osmotic demyelination has likely pushed many clinicians toward overly conservative correction. 
• Emerging evidence suggests slow correction may itself be harmful. 
• Consider targeting meaningful correction rather than simply avoiding overcorrection. 

DVT Prophylaxis

• Prevents VTE. 
• Does not appear to reduce mortality. 
• Absolute benefit is smaller than many clinicians assume. 
• Risk-benefit assessment remains essential. 

Clinical Pearls

• The most feared complication is not always the most common complication. 
• Many hospital practices persist because of rare catastrophic outcomes rather than aggregate patient outcomes. 
• The best question is often not "Can this happen?" but "What happens most often?" 

Bottom Line

If you change nothing else this week:

• Reconsider whether your severe hyponatremia patients are being corrected too slowly. 
• Remember that DVT prophylaxis prevents clots, but has never clearly been shown to save lives in general medical inpatients. 

Sometimes the greater danger isn't doing too much—it's doing too little.

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With Special Guest Dr. Ernest Murray

In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Ernest Murray to challenge two common antibiotic reflexes in hospital medicine:

• Do hospitalized patients with community-acquired pneumonia really need 5–7 days of antibiotics?
• Do we need to panic about QT prolongation every time we prescribe ciprofloxacin?

Two everyday prescribing decisions. Two long-standing assumptions. Two areas where the evidence may support a more precise approach. 

3–4 Days vs ≥5 Days of Antibiotics for Community-Acquired Pneumonia

Annals of Internal Medicine (2026)

Target trial emulation using >55,000 CAP hospitalizations across 60+ hospitals.

Compared:

• 3–4 days antibiotics
  vs 
• ≥5 days antibiotics

After strict inclusion/exclusion criteria, ~5,600 clinically stable patients were analyzed.

Excluded:

•  Immunocompromised patients 
•  Severe chronic lung disease 
•  Drug-resistant organisms 
•  ICU-level illness 
•  COVID-19 

Primary Outcomes

•  30-day mortality 
•  Readmissions / urgent visits 
•  Antibiotic-associated C. difficile 

Key Findings

•  No significant difference in: 
  •  Mortality 
  •  Readmissions 
  •  Urgent visits 
  •  C. difficile infection 

Interpretation

In carefully selected, clinically stable CAP patients:
 → 3 days may be enough

pubmed: https://pubmed.ncbi.nlm.nih.gov/41974005/

Ciprofloxacin and QTc Prolongation

Journal of Antimicrobial Chemotherapy (2026)

Prospective study evaluating QTc before and after standard-dose ciprofloxacin.

•  Baseline ECG obtained 
•  Repeat ECG after reaching steady-state ciprofloxacin levels 

Key Findings

•  No statistically significant change in QTc 
•  Mean QTc remained essentially unchanged (~415 ms) 
•  Patients with significant QT prolongation had: 
  •  Multiple competing risk factors 
  •  Concurrent QT-prolonging medications 
  •  Electrolyte abnormalities 

Interpretation

For most stable patients:
 → Ciprofloxacin alone does not meaningfully prolong QTc

The real danger appears to be:

•  Polypharmacy 
•  Electrolyte derangements 
•  Critical illness 
•  Multiple simultaneous QT-prolonging factors 

pubmed: https://pubmed.ncbi.nlm.nih.gov/41628197/

• Community-acquired pneumonia:
  •  Stable patients may only need 3 days of antibiotics 
  •  “Minimum 5 days” is no longer absolute dogma 
• Ciprofloxacin:
  •  QT concern should be contextual, not reflexive 
  •  Don’t deny patients effective oral therapy solely out of generalized QT fear 

•  Antibiotics may not need to “eradicate” infection completely — just shift the balance enough for the immune system to finish the job 
•  Lung microbiome preservation may become increasingly important in future stewardship strategies 
•  Most dangerous QT events are multifactorial, not caused by a single medication in isolation 
•  Ciprofloxacin remains an extremely valuable oral option for: 
  •  Gram-negative bacteremia 
  •  Pseudomonas coverage 
  •  Avoiding PICC lines and prolonged IV therapy 

If you change nothing else this week:

•  Consider stopping CAP antibiotics after 3 days in carefully selected stable patients 
•  Use ciprofloxacin thoughtfully — but don’t reflexively fear the QTc

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With Special Guest Dr. Adam Jaffe

In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Adam Jaffe to tackle two high-impact clinical questions:

• Is there a clear winner among DOACs? 
• Who actually benefits from steroids in community-acquired pneumonia? 

Two common decisions. New data. Practice-changing implications. 

Articles & PubMed Links

Apixaban vs Rivaroxaban for VTE (Head-to-Head RCT)

New England Journal of Medicine (2026)

Randomized trial (n=2,760) comparing:

• Apixaban
  vs 
• Rivaroxaban 

Population:

• Acute VTE 
• Excluded: active cancer, extreme obesity, other anticoagulation indications 

Key Findings

• ↓ Clinically significant bleeding with apixaban 
  • ~54% relative risk reduction 
  • NNT ≈ 27 
• ↓ Major bleeding (0.4% vs 2.4%) 
• No difference in: 
  • Recurrent VTE 
  • Mortality 

Interpretation

• Same efficacy 
• Less bleeding with apixaban 

Takeaway

→ For new starts: Apixaban is the preferred DOAC

pubmed: https://pubmed.ncbi.nlm.nih.gov/41812192/

Corticosteroids in Community-Acquired Pneumonia (IPD Meta-analysis)

Lancet

Large meta-analysis (n=3,224 across 8 RCTs)

Compared:

• Steroids
  vs 
• Placebo 

Primary Outcome: 30-day mortality

• Absolute risk reduction: 2.2% 
• NNT = 46 

🔑 The Key Insight: CRP Matters

When stratified by inflammation:

CRP >200

• Mortality: 13% → 6% 
• Absolute risk reduction ≈ 7% 
• NNT ≈ 14 

CRP <200

• No mortality benefit 

Other Findings

• ↑ Hyperglycemia (expected) 
• ↑ Readmissions (7% vs 3.7%) 
• No clear signal that severity scores (PSI) identify benefit 

Interpretation

• Steroids are not for everyone 
• Benefit appears driven by high inflammatory states 

Takeaway

→ Consider steroids in CAP only if CRP is markedly elevated (~>200)
→ Routine use in all pneumonia is not supported

pubmed: https://pubmed.ncbi.nlm.nih.gov/39892408/

Practice-Changing Takeaways

• DOACs: 
  • Apixaban > rivaroxaban for bleeding 
  • Same clot prevention → choose apixaban for new starts 
• Pneumonia: 
  • Steroids may reduce mortality — but only in the right patient 
  • CRP can help identify who benefits 

Clinical Pearls

• The difference between DOACs is no longer “vibes” — we now have head-to-head data 
• Most steroid benefit in pneumonia appears inflammatory-driven, not severity-driven 
• CRP — often ignored — may actually guide meaningful decisions here 

Bottom Line

If you change nothing else this week:

• Start apixaban for new VTE patients 
• In pneumonia, check a CRP — and consider steroids if >200 

Fewer bleeds. Smarter steroids. Better outcomes.

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With Special Guest Dr. Austin White

In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Austin White to tackle two everyday controversies that affect nearly every admission:

• Asymptomatic inpatient hypertension — are PRN antihypertensives helping… or harming? 
• Antibiotics for pneumonia with a positive viral panel — do these patients actually benefit? 

Practical take-homes, real-world night shift scenarios, and what to change on rounds tomorrow. 

As-Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals

JAMA Internal Medicine (2025)

Retrospective cohort of hospitalized patients comparing:

• Received PRN antihypertensives
  vs 
• No PRN treatment

Key Findings

•  ↑ Acute kidney injury (HR ~1.23) 
•  ↑ Rapid BP drops >25% (HR ~1.5) 
•  ↑ Composite outcome (MI, stroke, death) (HR ~1.6) 
• IV meds worse than oral 

Interpretation

•  Treating asymptomatic inpatient hypertension is associated with harm, not benefit 
•  Likely mechanism: overcorrection → hypoperfusion

Takeaway

For asymptomatic hypertension, especially overnight:
→ Don’t reflexively treat the number
→ Focus on symptoms and underlying cause

Pubmed: https://pubmed.ncbi.nlm.nih.gov/39585709/ 

Antibiotics for Pneumonia with Positive Viral Testing

Multicenter Retrospective Study (2015–2024)

Compared:

• Minimal antibiotics (0–1 day)
  vs 
• Standard CAP treatment (5–7 days)

In patients with:

•  Positive viral assay 
•  Clinical pneumonia (hypoxia, tachypnea, imaging) 

Key Findings

• No difference in: 
  •  Mortality 
  •  ICU admission 
  •  Length of stay 
•  No clear harm signal either 

Interpretation

•  Many patients with “pneumonia” + viral panel likely have pure viral illness
•  Routine antibiotics do not improve outcomes

Takeaway

→ If viral etiology fits the clinical picture,
 don’t routinely continue antibiotics

Pubmed: https://pubmed.ncbi.nlm.nih.gov/41378862/ 

• Hypertension:
  •  Treat the patient, not the number 
  •  PRN antihypertensives for asymptomatic BP may cause harm 
• Viral pneumonia:
  •  Positive viral panel + consistent story → hold antibiotics
  •  Reassess if clinical course worsens 
• Both topics highlight:
  → We often overtreat out of habit, not evidence

•  The body tolerates transient high BP better than rapid drops 
•  Overcorrection → ↓ cerebral perfusion → bad outcomes 
•  Viral infections (even “mild” ones like rhino/adenovirus) can cause severe illness
•  Antibiotic stewardship = patient safety, not just resistance 

If you change nothing else this week:

•  Stop reflexively treating asymptomatic inpatient hypertension 
•  Stop reflexively continuing antibiotics for viral pneumonia 

Less intervention. Better outcomes.

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