News Release 

Daily aspirin may benefit many patients without existing cardiovascular disease

American College of Physicians

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information.

1. Daily aspirin may benefit many patients without existing cardiovascular disease

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1132

Editorial: http://annals.org/aim/article/doi/10.7326/M19-2475

URLs go live when the embargo lifts

The benefits of aspirin may outweigh the risks for many patients without known cardiovascular disease (CVD). Such patients could be identified by using a personalized benefit-harm analysis, which could inform discussions between doctors and patients. The findings are published in Annals of Internal Medicine.

Aspirin reduces the risk for CVD in at-risk patients, but also increases the risk for bleeding. It is not clear if the benefits of aspirin outweigh the risks for patients without known CVD.

Researchers from the University of Auckland, New Zealand studied 245,028 persons (43.6 percent women) aged 30 to 79 years without established CVD to identify persons for whom aspirin would probably result in a net benefit. The net effect of aspirin was calculated for each participant by subtracting the number of CVD events likely to be prevented from the number of major bleeds likely to be caused over 5 years. The data were derived from PREDICT, a well-characterized web-based decision support program integrated with electronic primary care practice management systems in New Zealand. The researchers found that 2.5 percent of women and 12.1 percent of men without established CVD were likely to derive net benefit from aspirin treatment for 5 years if a hospitalization or death due to an acute CVD event was considered equivalent to a hospitalization or death due to an acute major bleed. These percentages increased to 21 percent of women and 41 percent of men when one CVD event was assumed to be equivalent to two major bleeds.

The author of an editorial from the Cardiovascular Institute, Rutgers Robert Wood Johnson Medical School cautions that the study findings may not apply to populations outside New Zealand. Also, participants over the age of 79 were not included in the analysis. The author points to the diversity of findings in several aspirin studies to conclude that making firm, evidence-based recommendations for aspirin use for primary prevention is difficult.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with author, Vanessa Selak, MBChB, PhD, please contact her directly at v.selak@auckland.ac.nz.

2. New study supports sepsis recommendations to take blood cultures first, administer antibiotics second

Abstract: http://annals.org/aim/article/doi/10.7326/M19-1696

Editorial: http://annals.org/aim/article/doi/10.7326/M19-2489

URLs go live when the embargo lifts

Administering antimicrobial therapy before taking a blood culture in patients with sepsis significantly diminishes test sensitivity. These finding support existing recommendations to withhold antibiotic treatment until blood cultures are drawn. Findings from a diagnostic study are published in Annals of Internal Medicine.

Clinical practice guidelines, such as the Surviving Sepsis Campaign, recommend obtaining blood cultures before giving antibiotics to maximize the likelihood of identifying a pathogen. However, administering antimicrobial agents before obtaining blood cultures could potentially decrease time to treatment and improve outcomes. This is important because the odds of mortality in sepsis increase by as much as 10 percent per hour when treatment is delayed. It is unclear how this strategy would affect diagnostic sensitivity.

Researchers from the University of British Columbia, McGill University, and Harvard Medical School obtained blood cultures from 325 patients with severe sepsis in whom antimicrobial therapy had just been initiated to determine the sensitivity of blood cultures obtained after antimicrobial therapy. They found that initiation of antimicrobial therapy significantly reduces the sensitivity of blood cultures drawn shortly after treatment initiation. According to the researchers, accurate microbiological data is important to the care of patients with sepsis, and there is now robust evidence to support current guidelines.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the corresponding author, Matthew P. Cheng, MD, please contact Elaine St. Peter at estpeter@bwh.harvard.edu.

3. Patient diagnosed with simultaneous and persistent bacteremia from 2 strains of S aureus

Abstract: http://annals.org/aim/article/doi/10.7326/L19-0369

URLs go live when the embargo lifts

A patient's persistent bacteremia (blood infection) was caused by two unrelated strains of Staphylococcus aureus with identical antibiotic susceptibilities. Physicians should be aware of this possible polyclonal infection, as standard microbiological practice may not be sufficient to identify it. A case report is published in Annals of Internal Medicine.

S aureus is a leading cause of bacteremia and endocarditis, in which incidence of true polyclonal bacteremia is unknown.

Clinicians from Westmead Institute for Medical Research and Westmead Hospital, Sydney, Australia, report the case of a 36-year-old woman hospitalized with chest pain and fever. Through a series of tests, the patient was diagnosed methicillin-susceptible S aureus bacteremia, a vegetation on the septal leaflet of her tricuspid valve, and pulmonary emboli with empyema in the right lower lobe. Her bacteremia and sepsis did not resolve after 6 days of intravenous antibiotic treatment, so investigators evaluated the patient for bacteriophage treatment which requires precise identification of the S aureus strain causing disease. The in vitro susceptibility to bacteriophages, which would not have been done otherwise, identified 2 different strains of S aureus. Both were susceptible to the same antibiotics and patient eventually responded well to combined, antibiotic-bacteriophage treatment.

Notes and media contacts: For an embargoed PDF please contact Lauren Evans at laevans@acponline.org. To speak with the lead author, Dr. Aleksandra Petrovic Fabijan, please contact Alison Grinyer at alison.grinyer@sydney.edu.au.

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