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.

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.

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).

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/

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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/