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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With Special Guest Dr. Emily Reams

In this special episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Emily Reams to break down the most practice-changing takeaways from SHM Converge 2026.

No fluff — just what you can start doing on rounds tomorrow.

Topics include:

•  Flu shots in heart failure — real mortality benefit 
•  Stopping aspirin in patients on DOACs 
•  Anticoagulation in AFib despite fall risk 
•  Naltrexone for alcohol use disorder — start inpatient 
•  Phenobarbital for withdrawal — coming soon 
•  Metformin in the hospital — dogma challenged 
•  Transfusion thresholds in MI 
•  “Things We Do for No Reason” highlights 

Practical take-homes and what to actually change this week.

Practice-Changing Highlights

💉 Flu shots in heart failure
NNT ≈ 17 for death/readmission
→ Vaccinate before discharge during flu season

💊 Stop aspirin with DOACs
↑ bleeding and mortality without benefit
→ Stop aspirin ~6–12 months post-stent (most patients)

🧠 AFib + fall risk
Benefit >> risk (would need >450 falls/year to offset)
→ Don’t withhold anticoagulation for falls alone

🍺 Alcohol use disorder

• Naltrexone: start before discharge → ↓ cravings, ↓ readmissions 
• Phenobarbital: increasing use, likely future standard 

💊 Metformin inpatient
May be safe in select patients
→ Consider if GFR ≥30 and no lactic acidosis

🩸 Transfusion in MI
Target Hgb ~10 may reduce mortality
→ Evolving — keep on radar

💊 Anticoagulation updates

•  Apixaban preferred over rivaroxaban 
•  Reduce dose after 3–6 months for VTE
   → Reassess dosing routinely

Big Picture

•  Biggest wins = simple changes
•  Often: stop meds or use basics better
•  Hospitalists have high-impact touchpoints 

If You Change Nothing Else This Week

•  Give flu shots in heart failure 
•  Stop aspirin in DOAC patients (when appropriate) 
•  Anticoagulate AFib despite fall risk 
•  Start naltrexone before discharge 

Small changes. Massive reach. Real impact.

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Episode 5: De-escalating Sepsis Antibiotics & When to Pull the IV w/ Nicholas Linde, PA

With Special Guest Nicholas Linde, PA

In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist PA Nick Linde to tackle two everyday decisions that impact nearly every inpatient service:

• De-escalating broad-spectrum antibiotics in sepsis — is it safe to stop vancomycin and zosyn earlier than we think? 
• Routine peripheral IV use — are we leaving IVs in too long and causing harm? 

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

Articles & PubMed Links

Antibiotic De-escalation in Adults Hospitalized With Community-Onset Sepsis

JAMA Internal Medicine (2026)

Compared:

• Continue broad-spectrum antibiotics beyond day 4
  vs 
• De-escalate at day 4 

Key Findings

• No difference in 90-day mortality (OR ≈ 1.0) 
• Shorter hospital length of stay 
   
  • ~1 day shorter (MRSA de-escalation) 
  • ~2 days shorter (pseudomonal de-escalation) 
  • No clear harm signal with de-escalation 

Takeaway

In clinically improving patients with negative or non-MDR cultures, early de-escalation at day 4 is safe and reduces hospital stay.

Pubmed: https://pubmed.ncbi.nlm.nih.gov/41428290/ 

Things We Do for No Reason™: Routinely Maintaining Intravenous Access in Hospitalized Patients

Journal of Hospital Medicine (2026)

Key Points

• ~25% of inpatient IVs are idle (not in use) 
• Peripheral IVs contribute to morbidity: 
  • ~20% of MSSA bacteremia 

When to Remove

• No IV medications or fluids needed 
• Clinically stable patient 
• Oral alternatives available 

When to Keep

• High risk of decompensation 
• Anticipated procedures or IV contrast 
• Ongoing electrolyte replacement or IV therapy 

Takeaway

Peripheral IVs are not benign — if you’re not using it, seriously consider removing it.

Pubmed: https://pmc.ncbi.nlm.nih.gov/articles/PMC12865233/ 

Practice-Changing Takeaways

• Sepsis: At day 4, reassess. If cultures are negative and patient improving, de-escalate broad-spectrum antibiotics. 
• IVs: “Use it or lose it.” Idle IVs carry real risk — don’t leave them in by default. 
• These are high-frequency decisions → small changes = big impact.

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Episode 4: Faster Hypernatremia Correction & Long-Acting Antibiotics for Staph Bacteremia

With Special Guest Dr. Kevin Baker

In this episode of Inpatient Update, Dr. Mason Turner is joined by hospitalist Dr. Kevin Baker to discuss two studies that challenge long-held dogma in inpatient medicine:

• Faster correction of hypernatremia — is the traditional “go slow” rule actually harming patients?
• Dalbavancin for Staph aureus bacteremia (DOTS Trial) — can two long-acting antibiotic injections replace weeks of IV therapy and PICC lines?

Practical take-homes, real-world discussion, and what to change on rounds tomorrow (with a couple of bourbons).

Articles & PubMed Links

Clinical outcomes of early fast compared to slow sodium correction rate in adults with severe hypernatremia: A comparative effectiveness study

Journal of Critical Care (2025)

Key Findings

• Faster correction associated with lower 30-day mortality
• Shorter ICU length of stay
• Shorter hospital length of stay
• No signal for neurologic complications from rapid correction

Supporting data from prior studies:

• 2023 JAMA observational cohort
  Faster correction associated with lower mortality
  No neurologic complications reported
• 2025 Journal of Critical Care meta-analysis
  Faster correction not associated with worse outcomes

Takeaway

For adult hypernatremia, especially in critically ill patients, more aggressive correction appears safe and may improve outcomes.

Pubmed: https://pubmed.ncbi.nlm.nih.gov/41240509/

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

JAMA 2025

Compared:

Standard Therapy

• 4–8 weeks IV antibiotics
• Cefazolin / anti-staphylococcal penicillin (MSSA)
• Vancomycin or daptomycin (MRSA)

vs

Dalbavancin Strategy

• 1500 mg IV day 1
• 1500 mg IV day 8

Long-acting lipoglycopeptide with ~14-day half-life, allowing completion of therapy without PICC lines.

Population

• Complicated Staph aureus bacteremia

Key Results

Clinical efficacy:

• Dalbavancin: 73%
• Standard therapy: 72%

Microbiologic success:

• Dalbavancin: 98.8%
• Standard therapy: 96.3%

Met criteria for non-inferiority.

Takeaway

For selected patients with cleared Staph aureus bacteremia, two doses of dalbavancin may replace weeks of IV antibiotics and PICC lines.

Potential advantages:

• Avoids central line complications
• Simplifies discharge planning
• Useful in patients with difficult social situations or IV access concerns

Pubmed: https://pubmed.ncbi.nlm.nih.gov/40802264/

Practice-Changing Takeaways

• Hypernatremia: Faster correction appears safe in adults and IMPROVES mortality.
• Staph bacteremia: Long-acting dalbavancin offers a PICC-free alternative for completing therapy in selected patients.
• Hospital medicine continues to move toward shorter and simpler antibiotic strategies.

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In this episode of Inpatient Update, Dr. Mason Turner is joined by Dr. Andres Ospina, fellow hospitalist, to discuss two recent trials with immediate impact on hospital practice:

• Aspirin plus anticoagulation in chronic coronary disease (AQUATIC Trial) — does keeping aspirin help or harm when long-term anticoagulation is started?
• Seven vs fourteen days of antibiotics for bloodstream infection (BALANCE Trial) — can we safely cut bacteremia treatment in half?

Practical take-homes, clear links to the evidence, and what to change on rounds tomorrow.

Articles & PubMed Links

Aspirin in Patients with Chronic Coronary Syndrome Receiving Oral Anticoagulation (AQUATIC Trial)

New England Journal of Medicine (October 2025)

Key Findings:

• Higher morbidity and mortality with dual therapy (HR 1.53)

Bottom Line:
In stable CAD >6 months from revascularization, if anticoagulation is started, stop the aspirin.

Pubmed: https://pubmed.ncbi.nlm.nih.gov/40888725/

Antibiotic Treatment for Bloodstream Infection (BALANCE Trial)

New England Journal of Medicine (November 2024)

Multicenter, randomized, non-inferiority trial (n≈3,600)

Bottom Line:
In uncomplicated bacteremia with source control and no severe immunocompromise, 7 days is non-inferior to 14.

Pubmed: https://pubmed.ncbi.nlm.nih.gov/39565030/

Practice-Changing Takeaways

• Stable CAD + new anticoagulation? Stop aspirin if >6 months from PCI/CABG.
• Uncomplicated bacteremia? Seven days of antibiotics is sufficient in most cases (excluding Staph aureus and deep-seated infection).

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In Episode 2 of Inpatient Update, your host, Dr. Mason Turner, breaks down three studies that could change what you do on rounds tomorrow:

• Phenobarbital for alcohol withdrawal — fewer admissions and shorter ED stays during the IV lorazepam shortage natural experiment.
• Conservative dialysis in AKI requiring RRT (LIBERATE-D) — less routine dialysis, more kidney recovery?
• Postoperative transfusion thresholds in high–cardiac-risk patients (TOP Trial) — is 7 still enough?

Articles & PubMed Links

1. Fewer Admissions, Shorter Stays: Phenobarbital Use for Alcohol Withdrawal in the Emergency Department
   Academic Emergency Medicine (2025)
   PubMed: https://pubmed.ncbi.nlm.nih.gov/41147831/
2. A Conservative Dialysis Strategy and Kidney Function Recovery in Dialysis-Requiring Acute Kidney Injury (LIBERATE-D Trial)
   JAMA ( 2026)
   PubMed: https://pubmed.ncbi.nlm.nih.gov/41201895/
3. Liberal or Restrictive Postoperative Transfusion in Patients at High Cardiac Risk: The TOP Randomized Clinical Trial
   JAMA (2025)
   PubMed: https://pubmed.ncbi.nlm.nih.gov/41205227/

REACH OUT:

Have insight into inpatient medicine?
 Article suggestion?
 Interested in being a guest?

Email or DM me. 

Follow and subscribe wherever you listen so you never miss the next update.

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In this pilot episode of Inpatient Update, your host, Dr. Mason Turner, breaks down three clinically relevant studies that could change how you practice tomorrow on the wards:

1. Pre-ERCP antibiotic prophylaxis — does it reduce post-procedure infections in biliary obstruction?
2. Reduced-dose apixaban after 6 months in cancer-associated VTE — noninferior and potentially safer?
3. Early initiation of beta-blockers in cirrhosis with uncomplicated ascites — early signals of benefit.

Practical take-homes, clear links to evidence, and what to tell your team on rounds.

Articles & PubMed Links

1. Is Antibiotic Prophylaxis Warranted in All Patients With Biliary Obstruction Undergoing Endoscopic Retrograde Cholangiopancreatography?: A Systematic Review and Meta-Analysis
   PubMed: https://pubmed.ncbi.nlm.nih.gov/40961256/ 
2. Extended Reduced-Dose Apixaban for Cancer-Associated VTE (API-CAT)
   PubMed: https://pubmed.ncbi.nlm.nih.gov/40162636/ 
3. Efficacy and Safety of Carvedilol in Cirrhosis Patients With New-Onset Uncomplicated Ascites Without High-Risk Esophageal Varices (CARVE-AS Trial)
   PubMed: https://pubmed.ncbi.nlm.nih.gov/40689908/ 

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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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