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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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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.