Summaries and highlights

of the most important

new clinical guidelines to
inform your practice

Guideline
Watch
2021
 September 2021

nejm journal watch Dear Reader,

Cardiology
General Medicine Clinical guidelines are used increasingly to set practice standards
Hospital Medicine and quality measures. NEJM Journal Watch not only publishes
Infectious Diseases summaries of the latest clinical research, but also helps you to keep
Neurology up with the guidelines most important to general medical practice.
Oncology and Hematology
Our physician-editors regularly survey a broad range of medical
journals to identify practice guidelines from a variety of disciplines.
They choose recommendations with the most clinical impact and
highlight key points, pointing out what’s new and what remains
unchanged. This collection of Guideline Watches is of broad
relevance to clinical practice, spanning outpatient and inpatient
medicine and addressing both primary care and subspecialty
perspectives.
We hope you enjoy this compilation and find it useful for providing
the best and most responsible patient care.

Allan S. Brett, MD
NEJM Journal Watch Editor-in-Chief

800.843.6356 | f: 781.891.1995 | nejmgroup@mms.org

860 winter street, waltham, ma 02451-1413
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Guideline Watch 2021

Table of Contents

Appropriate Use of High-Flow Nasal Oxygen in Hospitalized Patients 4

Perioperative Management of Endocrine and Urologic Medications 5

Clostridioides difficile Infection: Updated Recommendations 7

Managing Acute Upper Gastrointestinal Bleeding from Ulcers 9

Practical Approach to Identifying and Managing Idiosyncratic Drug-Induced Liver Injury 11

Updated Recommendations for Colorectal Cancer Screening 12

Screening for Vitamin D Deficiency in Community-Dwelling, Nonpregnant Adults 14

A Consensus Decision Pathway for Optimizing Care for Heart Failure 15

ACP Recommends Short-Course Antibiotics for Many Common Infections 17

Managing Acute Diverticulitis 19

Providing Long-Term Oxygen Therapy for Patients with COPD and Interstitial Lung Disease 20

Contrast-Enhanced MRIs in Patients with Kidney Disease 21

2020 Asthma Guideline Update 22

NEJM Journal Watch is produced by NEJM Group, a division of the Massachusetts Medical Society.
©2021 Massachusetts Medical Society. All rights reserved.
Guideline Watch 2021 jwatch.org

Appropriate Use of High-Flow Nasal Oxygen in Hospitalized

Patients
High-flow nasal cannulae generally should be used in hypoxemic patients.

Patricia Kritek, MD, reviewing Ann Intern Med 2021 Apr 27.

Sponsoring Organization: American College of Physicians (ACP)

Background
This is the first guideline focused solely on use of high-flow nasal cannulae (HFNC). Recommendations
were based on best available evidence as well as patient values and preferences, potential risks and
benefits, and cost.
Key Points
• Patients with hypoxemic respiratory failure should be treated initially with HFNC as opposed to
noninvasive ventilation (NIV).
• Patients with postextubation hypoxemia should be treated with HFNC as opposed to conventional
oxygen therapy.

COMMENT
Use of HFNC to support hypoxemic patients has increased dramatically in the past decade, but
guidance on when it is the best option and when it should be avoided has been minimal. Although
the evidence of benefit is low quality, using HFNC as a first step in managing hypoxemic respiratory
failure makes sense: It is less expensive than NIV and generally is well tolerated. Data suggest lower
short-term mortality and less progression to intubation with HFNC than with NIV. The recom­
mendation for postextubation support is reasonable but is a conditional recommendation because
of the paucity of data.

Qaseem A et al. Appropriate use of high-flow nasal oxygen in hospitalized patients for initial or postextubation management of
acute respiratory failure: A clinical guideline from the American College of Physicians. Ann Intern Med 2021 Apr 27; [e-pub].
(https://doi.org/10.7326/M20-7533)

Baldomero AK et al. Effectiveness and harms of high-flow nasal oxygen for acute respiratory failure: An evidence
report for a clinical guideline by the American College of Physicians. Ann Intern Med 2021 Apr 27; [e-pub].
(https://doi.org/10.7326/M20-4675)

Dr. Kritek is Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of Washington,
Seattle.

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Perioperative Management of Endocrine and Urologic

Medications
A multidisciplinary group has published recommendations on which drugs to continue and which to hold before
surgery.

Allan S. Brett, MD, reviewing Mayo Clin Proc 2021 Jun.

Sponsoring Organization: Society for Perioperative Assessment and Quality Improvement (SPAQI)

Background
SPAQI is a multidisciplinary organization that recently has published several position papers on peri­
operative medication management. This statement — addressing endocrine and urologic medications —
was produced by a consensus process outlined by the authors.
Key Recommendations
Diabetes drugs:
• Basal (intermediate- or long-acting) insulins generally should be continued at 60% to 80% of the usual
dose on the morning of surgery or the evening before surgery, depending on the patient’s usual insulin
schedule.
• Metformin, sulfonylureas, pioglitazone, and dipeptidyl peptidase (DPP)-4 inhibitors should not be
given the morning of surgery.
• Sodium–glucose cotransporter (SGLT)-2 inhibitors should be stopped at least 3 days before surgery.
• Glucagon-like peptide (GLP)-1 agonists should be held the morning of surgery (for agents dosed daily)
or during the week before surgery (for agents dosed weekly).
Other endocrine drugs:
• Thyroid hormone and antithyroid drugs can be taken the morning of surgery.
• A patient’s usual dose of corticosteroid can be taken the morning of surgery (this document did not
address perioperative administration of additional, stress-dose steroids).
• Most other hormonal or endocrine-related drugs can be continued the morning of surgery. However,
bisphosphonates should be held (given risk for esophagitis when patients are supine after taking these
drugs).
Urologic drugs:
• α-blockers and 5-α-reductase inhibitors can be taken the morning of surgery.
• Anticholinergic bladder medications should be held the morning of surgery.
• Phosphodiesterase (PDE)-5 inhibitors, when prescribed for urologic indications, should be held for
3 days prior to surgery, due to concern about intraoperative hypotension.

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COMMENT
Most of these recommendations are based on common-sense inferences from these drugs’
mechanisms of action and side effects — not on direct perioperative studies. The authors
encourage clinical judgment in certain scenarios (e.g., holding certain prothrombotic hormonal
agents in patients at high risk for perioperative thrombosis). I would urge clinicians who perform
preoperative assessments to read this report.

Pfeifer KJ et al. Preoperative management of endocrine, hormonal, and urologic medications: Society for Perioperative Assessment
and Quality Improvement (SPAQI) consensus statement. Mayo Clin Proc 2021 Jun; 96:1655. (https://doi.org/10.1016/
j.mayocp.2020.10.002)

Dr. Brett is Clinical Professor of Medicine at the University of Colorado School of Medicine.

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Clostridioides difficile Infection: Updated Recommendations

Diagnosis and treatment are discussed, with substantial detail on fecal microbiota transplantation.

David J. Bjorkman, MD, MSPH (HSA), SM (Epid.), reviewing Am J Gastroenterol 2021 Jun.

Sponsoring Organization: American College of Gastroenterology

Background
This clinically oriented document is meant to complement the Infectious Diseases Society of America’s
2018 guideline on Clostridioides difficile infections (NEJM JW Infect Dis May 2018 and Clin Infect Dis
2018; 66:e1). The authors rate each recommendation as strong or conditional, and they grade the quality
of supporting evidence as high, moderate, or low.
Selected Recommendations
• A two-step diagnostic testing algorithm is favored: Start with a sensitive test for C. difficile infection
(CDI), and when results are positive, perform specific testing for toxin.
• Oral vancomycin or fidaxomicin generally is favored for treating patients with non­severe CDI, but
metronidazole is acceptable for low-risk patients — especially when cost is a factor.
• Patients with severe CDI should be treated with either oral vancomycin or fidaxomicin (but not
metronidazole). Severe disease is defined as having a leukocytosis >15,000 white blood cells/mm3
or a creatinine level of >1.5 mg/dL.
• Fulminant CDI (defined as severe CDI plus hypotension, shock, ileus, or megacolon) should be
managed with fluid resuscitation and high-dose oral vancomycin; addition of parenteral metronidazole
and vancomycin enemas (for patients with ileus) can be considered.
• Fecal microbiota transplantation (FMT) should be considered for refractory or severe CDI.
• A first recurrence should be treated with tapering/pulsed-dose vancomycin or fidaxomicin if it was not
the initial therapy. A patient experiencing a second or further recurrence of CDI should be treated with
FMT, delivered via a colonoscope or capsules, with enemas used when colonoscopy or capsules are not
available. Repeat FMT can be used to treat a recurrence within 8 weeks of initial FMT.
• Patients with recurrent CDI who are not FMT candidates or have relapsed after FMT can be given
long-term oral vancomycin prophylaxis to prevent recurrences. Oral vancomycin prophylaxis also can
be considered when patients with recurrent CDI are given systemic antibiotics.
• Additional recommendations are made for specific populations (those with inflam­ma­tory bowel
disease, pregnancy, lactation, or immunocompromise) and for surgical intervention.
• Probiotics should not be used for primary or secondary prevention of CDI.

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COMMENT
The narrative discussions for each recommendation are well written, with balanced assessments of the
strengths and limitations of supporting evidence. Overall, this document provides comprehensive
updated guidance on managing CDI. Note: The Infectious Diseases Society of America currently is
updating its guideline on C. difficile and will be recommending fidaxomicin as first-line treatment
for a patient with an initial episode of C. difficile infection. However, the recommendation is
“conditional” and acknowledges vancomycin as an acceptable alternative.

Kelly CR et al. Prevention, diagnosis, and treatment of Clostridioides difficile infections. Am J Gastroenterol 2021 Jun;
116:1124. (https://doi.org/10.14309/ajg.0000000000001278)

Dr. Bjorkman is Professor in the Division of Gastroenterology, Hepatology and Nutrition at the University of Utah School of
Medicine.

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Managing Acute Upper Gastrointestinal Bleeding from Ulcers

An American College of Gastroenterology guideline addresses risk stratification, endoscopic intervention,
proton-pump inhibitors, and transfusions.

David J. Bjorkman, MD, MSPH (HSA), SM (Epid.), reviewing Am J Gastroenterol 2021 May 1.

Sponsoring Organization: American College of Gastroenterology (ACG)

Background
Acute upper gastrointestinal bleeding is the most common gastrointestinal cause of hospitalization in the
U.S. To reconcile multiple recently published guidelines, ACG-sponsored reviewers assessed primary
studies and made recommendations according to the strength of the supporting evidence. They addressed
only bleeding from peptic ulcers.
Key Points
Strong recommendations, backed by moderate- or high-quality evidence:
• Endoscopic therapy should be performed for ulcers with active bleeding or a nonbleeding visible vessel.
• High-dose proton-pump inhibitor (PPI) therapy should be given continuously (intravenously) or
intermittently (intravenously or orally) for 3 days after successful endoscopic therapy.
Conditional recommendations, with low- or very low–quality evidence:
• Early risk stratification should be performed in the emergency department, and patients with low risk
(Glasgow-Blatchford score, 0–1) should be discharged for out­patient follow-up.
• Blood transfusions should be restrictive (i.e., only for patients with hemoglobin levels ≤7 g/dL).
• Erythromycin infusion should be given before endoscopy.
• Endoscopy should occur within 24 hours of hospitalization.
• Endoscopic treatment should be undertaken for high-risk ulcers.
• Epinephrine injection should not be used alone — only in combination with another hemostatic
modality.
• Twice-daily oral PPI therapy should be continued for 2 weeks after index endoscopy and parenteral PPI
treatment.
• Patients with recurrent bleeding should undergo another endoscopy procedure, rather than surgery or
embolization; however, patients in whom endoscopic therapy fails should proceed to embolization.

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COMMENT
The supporting literature review explains the nuances of the recommendations. Note that no
agreement could be reached on the need for endoscopic therapy for ulcers with adherent clots or
for use of PPIs prior to endoscopy. The literature supports neither of these actions, but therapy
often is individualized, based on perceived risk for rebleeding. The role of endoscopic therapy and
parenteral PPI therapy in patients with high-risk ulcers is strong, but the other recommendations
are conditional, based on low-quality evidence. Nonetheless, this guideline should be the current
standard of care for patients with ulcer-related acute upper gastrointestinal bleeding.

Laine L et al. ACG clinical guideline: Upper gastrointestinal and ulcer bleeding. Am J Gastroenterol 2021 May 1; 116:899.
(https://doi.org/10.14309/ajg.0000000000001245)

Dr. Bjorkman is Professor in the Division of Gastroenterology, Hepatology and Nutrition at the University of Utah School of
Medicine.

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Practical Approach to Identifying and Managing Idiosyncratic

Drug-Induced Liver Injury
The American College of Gastroenterology has updated its 2014 practice guideline.

Atif Zaman, MD, MPH, reviewing Am J Gastroenterol 2021 May 1.

Sponsoring Organization: American College of Gastroenterology

Background
Drug-induced liver injury (DILI) can be separated into two categories: Intrinsic type, where a drug can
cause injury in a predictable fashion (e.g., acetaminophen), and idiosyncratic type, where injury is less
predictable. The focus of this guideline is the idiosyncratic type, often associated with commonly used
antimicrobials, oncologic agents, dietary supplements, and herbal supplements.
Key Points
• Liver biopsy should be considered when immunosuppressive therapy is being con­templated, liver
enzymes rise despite discontinuing the suspected offending agent,
or delayed resolution of liver enzyme elevation is noted. Liver biopsy also should be considered when
autoimmune hepatitis is a possibility: DILI can present with features similar to those of autoimmune
hepatitis, and non–drug-related autoimmune hepatitis and DILI can present similarly.
• Prognostic models such as the Model for End-stage Liver Disease (MELD) and the Charlson
comorbidity index (CCI) can be useful to predict 6-month mortality.
Clinicians might find the web-based DILI mortality calculator useful.
• Although no good evidence supports or refutes use of corticosteroids, steroids might be appropriate for
patients in whom autoimmune hepatitis is highly suspected.
• N-acetylcysteine can be considered for DILI patients in whom progression to acute liver failure is likely.

COMMENT
As with the previous guidelines on DILI, the overall quality of evidence in this updated practice
guidance is of low quality. These guidelines should be viewed as preferred approaches and are
intended to be flexible enough to be adjusted to particular clinical situations. Patients with severe
DILI and concern for impending acute liver failure should be managed in a tertiary center.

Chalasani NP et al. ACG clinical guideline: Diagnosis and management of idiosyncratic drug-induced liver injury. Am J
Gastroenterol 2021 May 1; 116:878. (https://doi.org/10.14309/ajg.0000000000001259)

Dr. Zaman is Professor in the Department of Gastroenterology and Hepatology at Oregon Health & Science University.

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Updated Recommendations for Colorectal Cancer Screening

The U.S. Preventive Services Task Force concludes, with moderate certainty, that screening confers moderate
benefit to average-risk patients starting at age 45.

Thomas L. Schwenk, MD, reviewing JAMA 2021 May 18.

Sponsoring Organization: U.S. Preventive Services Task Force (USPSTF)

Background
The USPSTF last published colorectal cancer (CRC) screening guidelines for average-risk patients in 2016
(NEJM JW Gen Med Aug 1 2016 and JAMA 2016; 315:2564). They have now updated those recommenda­
tions and added a new recommendation for younger people (age range, 45–49). These guidelines apply to
adults (age, ≥45) at average risk for colorectal cancer (i.e., no prior CRC, adenomatous polyps, or inflam­
matory bowel disease; no prior diagnosis or family history of genetic predisposition to CRC, such as
Lynch syndrome).
Key Recommendations
• The Task Force concludes with high certainty that CRC screening for middle-aged people (age range,
50–75) confers substantial benefit (A Recommendation).
• The USPSTF concludes with moderate certainty that screening younger people (age range, 45–49)
confers moderate benefit (B Recommendation).
• The Task Force concludes with moderate certainty that screening older people (age range, 76–85) who
have been screened previously confers small benefit (C Recom­mendation). People in this age range
who have never been screened might benefit slightly more.
• Evidence for benefit in even older patients (age, ≥86) is lacking, but harms of screening likely outweigh
any long-term survival benefit.
What’s Changed
The main change in this recommendation is the lower age (45) for beginning screening. The Task Force
took a broad view of available tests and included both direct visualization (i.e., computed tomography
[CT] colonography, colonoscopy, and flexible sigmoidoscopy) and stool-based tests (i.e., high-sensitivity
guaiac fecal occult blood tests [gFOBT], fecal immunochemical tests [FIT], and stool DNA tests). The
only stool DNA test currently approved by the U.S. FDA includes a FIT component (sDNA-FIT). Based on
a sophisticated modeling exercise to balance harms and benefits that accompanied the Task Force’s
evidence assessment and recommendation, they recommend the following intervals for screening:
• gFOBT or FIT: every year
• sDNA-FIT: every 1 to 3 years
• CT colonography: every 5 years
• Flexible sigmoidoscopy: every 5 years, or every 10 years with FIT every year
• Colonoscopy: every 10 years
The Task Force did not recommend any particular test as most desirable or effective.

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COMMENT
The lower age to begin screening is a major change in CRC screening policy; note, however, that
the B recommendation is not as strong as the A recommendation for the 50-to-75 age range. This
distinction aligns with the American Cancer Society’s most recent guideline, which labels the
45-year-old threshold as a “qualified” recommendation and the 50-year-old threshold as a “strong”
recommendation (CA Cancer J Clin 2018; 68:250). Implementing this directive will require
substantial educational outreach to both patients and clinicians.

US Preventive Services Task Force. Screening for colorectal cancer: US Preventive Services Task Force recommendation statement.
JAMA 2021 May 18; 325:1965. (https://doi.org/10.1001/jama.2021.6238)

Lin JS et al. Screening for colorectal cancer: Updated evidence report and systematic review for the US Preventive Services Task
Force. JAMA 2021 May 18; 325:1978. (https://doi.org/10.1001/jama.2021.4417)

Knudsen AB et al. Colorectal cancer screening: An updated modeling study for the US Preventive Services Task Force. JAMA
2021 May 18; 325:1998. (https://doi.org/10.1001/jama.2021.5746)

Dr. Schwenk is Professor of Family and Community Medicine and Dean Emeritus, University of Nevada, Reno, School of
Medicine.

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Screening for Vitamin D Deficiency in Community-Dwelling,

Nonpregnant Adults
The U.S. Preventive Services Task Force reiterates its 2014 statement of insufficient evidence of either benefits or
harms.

Thomas L. Schwenk, MD, reviewing JAMA 2021 Apr 13.

Sponsoring Organization: U.S. Preventive Services Task Force (USPSTF)

Background
Many studies have shown an association of low vitamin D levels (defined by the National Academy of
Medicine as 25-hydroxyvitamin D [25(OH)D] levels <20 ng/mL [49.9 nmol/L]) with many disease states
and adverse clinical outcomes. Despite little evidence showing routine screening and supplementation
provide any benefit, the frequency of vitamin D screening has increased dramatically in the last 10 years.
In 2014, the USPSTF found insufficient evidence of either harms or benefits to make a definitive recom­
mendation for screening in community-dwelling, nonpregnant adults (NEJM JW Gen Med Jan 15 2015
and Ann Intern Med 2015; 162:133). The USPSTF now updates that recommendation.
Key Point
In community-dwelling, nonpregnant adults without signs or symptoms of vitamin D deficiency or
indications for supplementation, the USPSTF once again finds insufficient evidence of either benefits or
harms to make a definitive recommendation about screening (I statement).

COMMENT
Several factors influenced the USPSTF’s conclusion. The definition of deficiency is uncertain, and
that definition likely varies among individuals and patient populations. Measuring 25(OH)D levels
is difficult and can vary among laboratories. No studies directly measured either harms or benefits
of screening on actual clinical outcomes, and no studies showed benefit for supplementation,
except in a narrow range of bone diseases or conditions known to lead to deficiency, such as
chronic kidney disease. No evidence suggested harm from screening, so the Task Force did not
make a D recommendation (against screening).
However well-founded this conclusion is, the high frequency of screening con­tinues unabated,
with frequent requests from patients for screening and advice for supplementation. A reasonable re-
sponse to low-risk patients is that the National Academy of Medicine’s recommended daily allowance
for vitamin D is 600 to 800 IU.

Krist AH et al. Screening for vitamin D deficiency in adults: US Preventive Services Task Force recommendation statement.
JAMA 2021 Apr 13; 325:1436. (https://doi.org/10.1001/jama.2021.3069)

Kahwati LC et al. Screening for vitamin D deficiency in adults: Updated evidence report and systematic review for the US
Preventive Services Task Force. JAMA 2021 Apr 13; 325:1443. (https://doi.org/10.1001/jama.2020.26498)

Dr. Schwenk is Professor of Family and Community Medicine and Dean Emeritus, University of Nevada, Reno, School of
Medicine.

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A Consensus Decision Pathway for Optimizing Care for Heart

Failure
Guidance with respect to pivotal clinical questions in the care of patients with heart failure

Frederick A. Masoudi, MD, MSPH, FACC, FAHA, reviewing J Am Coll Cardiol 2021 Feb 16.

Sponsoring Organization: American College of Cardiology

Background and Objective

The evidence for treating heart failure, particularly with reduced ejection fraction (HFrEF), has evolved
substantially since the publication in 2017 of the most recent guideline from the American College of
Cardiology and American Heart Association (ACC/AHA) and the ACC Expert Consensus Decision
Pathway.
Key Points
The document addresses the following crucial issues:
• Initiating, adding, or switching evidence-based therapies for HFrEF, with a focus on initiating
angiotensin receptor/neprilysin inhibitors (ARNIs), incorporating sodium–glucose cotransporter-2
(SGLT-2) inhibitors, and considering transcatheter mitral-valve repair
• Achieving optimal guideline-directed therapy for HFrEF, with guidance around target medication
doses and clinical assessments to inform dose changes
• Criteria to use for referral of patients to HF specialists
• Approaches to enhancing medication adherence and managing medication costs
• Care strategies in specific patient populations, including old or frail individuals and Black patients
• Management of common coexisting conditions
• Ways to integrate palliative care into practice and to ease transitions to hospice care
What’s Changed
The document focuses particularly on therapies that have emerged since 2017, including ARNIs, SGLT-2
inhibitors, and percutaneous mitral-valve repair for functional mitral regurgitation.

COMMENT
This document, which bridges the gap between the most recent ACC/AHA guideline and an
update currently in development, is timely given the rapid evolution and increasing complexity of
HF management, particularly in patients with HFrEF. While the document does not include
traditional guideline recommendations, it is full of practical information, particularly with respect
to dosing and titration of the many guideline-recommended medications. Given that evidence-
based pharma­cotherapy for HFrEF requires complex and costly regimens, this document will
enable clinicians to feel more confident in delivering care for these individuals.

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Maddox TM et al. 2021 update to the 2017 ACC Expert Consensus Decision Pathway for optimization of heart failure treatment:
Answers to 10 pivotal issues about heart failure with reduced ejection fraction. J Am Coll Cardiol 2021 Feb 16; 77:772.
(https://doi.org/10.1016/j.jacc.2020.11.022)

Dr. Masoudi is a coauthor of this update and Chief Scientific Advisor to the American College of Cardiology’s NCDR
programs. He is Professor of Medicine in the Division of Cardiology at the University of Colorado Denver.

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ACP Recommends Short-Course Antibiotics for Many Common

Infections
The American College of Physicians says 5 days of therapy often is best practice.

Daniel D. Dressler, MD, MSc, MHM, FACP, reviewing Ann Intern Med 2021 Apr 6.

Sponsoring Organization: American College of Physicians (ACP)

Background
Nearly one third of prescribed antibiotic courses are longer than necessary, and antibiotic-associated
adverse events — allergic reactions, Clostridioides difficile infections, and antimicrobial resistance —
occur in ≈20% of patients who receive antimicrobials. ACP experts offer best evidence-based practice
advice on optimal duration of antibiotics for common outpatient and inpatient bacterial infections.
Key Recommendations
1. Acute uncomplicated exacerbation of chronic obstructive pulmonary disease characterized by purulent
sputum plus increased dyspnea, sputum volume, or both
• Common bacterial pathogens: Haemophilus influenzae, Streptococcus pneumoniae, Moraxella
catarrhalis
• Recommended antimicrobials: amoxicillin/clavulanic acid, azithromycin, or doxycycline
• Recommended duration: 5 days
2. Community-acquired pneumonia
• Common bacterial pathogens: S. pneumoniae, H. influenzae, Mycoplasma pneumoniae (and, less
commonly, Staphylococcus aureus or Legionella sp.)
• Recommended antimicrobials: amoxicillin, doxycycline, or azithromycin (for healthy patients); or
β-lactam with macrolide or respiratory fluoroquinolone (for patients with comorbidities)
• Recommended duration: 5 days (extend therapy beyond 5 days if vital signs or mentation remain
abnormal)
3. Urinary tract infections
• Uncomplicated cystitis in women: nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole
(TMP-SMZ) for 3 days, or fosfomycin for 1 day.
• Uncomplicated pyelonephritis in men or women: urinary fluoroquinolone (e.g., ciprofloxacin) for
5 days or TMP-SMZ for 14 days. Cultures and susceptibility data should be used to guide antibiotic
selection.
4. Nonpurulent cellulitis
• Common bacterial pathogens: Streptococcus sp. or S. aureus
• Recommended antimicrobials: cephalosporin (e.g., cephalexin), antistaphylococcal penicillin (e.g.,
dicloxacillin), or clindamycin (in patients without penetrating trauma or evidence of methicillin-
resistant S. aureus infection [e.g., colonization or prior MRSA])

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• Recommended duration: 5 days (particularly for patients able to self-monitor and with close
follow-up in primary care)

COMMENT
Shorter antimicrobial duration for common uncomplicated infections benefits our patients in the
long run and likely reduces adverse drug effects and costs. ACP’s guidance helps bring us all into
the 2020s in terms of offering more care by prescribing less.

Lee RA et al. Appropriate use of short-course antibiotics in common infections: Best practice advice from the American College of
Physicians. Ann Intern Med 2021 Apr 6; [e-pub]. (https://doi.org/10.7326/M20-7355)

Dr. Dressler is a Professor of Medicine and Chair of the Medical Student Societies Leadership Council at Emory University
School of Medicine in Atlanta. He is the Director of Internal Medicine Teaching Services at Emory University Hospital and the
Associate Program Director for the J. Willis Hurst Internal Medicine Residency Program.

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Managing Acute Diverticulitis

Recommendations from the American Gastroenterological Association are largely unchanged.

Molly S. Brett, MD, reviewing Gastroenterology 2021 Feb.

Sponsoring Organization: American Gastroenterological Association (AGA)

Background
The AGA last published a guideline on managing acute diverticulitis in 2015 (Gastroenterology 2015;
149:1944). Now, the AGA has provided an update that outlines 14 “best practices.”
Key Recommendations
• Computed tomography (CT) scans should be considered when diverticulitis is suspected, because
alternate diagnoses are identified in about half of cases.
• Antibiotics should be used “selectively rather than routinely” for mild cases of diverticulitis. Indica­
tions for antibiotic use in uncomplicated diverticulitis include presence of comorbidities or immuno­
suppres­sion, C-reactive protein level >140 mg/L, white blood cell count >15,000/mm3, presence of
fluid collection, or long segment of inflammation on imaging.
• When symptoms persist after an episode of acute diverticulitis, CT scan and colonoscopy are
recommended to exclude ongoing inflammation. (However, the authors acknowledge that most
chronic symptoms likely are related to visceral hypersensitivity.)
• Clinicians should not recommend segmental colectomy based solely on the number of diverticulitis
episodes a patient has experienced. Rather, decisions regarding colectomy should reflect the individual
patient’s disease severity, operative risks and benefits, and values and preferences.
• Measures to prevent recurrence include a high-quality diet (e.g., high-fiber, vegetarian), regular
physical activity, achieving normal body-mass index, smoking cessation, and avoiding nonsteroidal
anti-inflammatory drugs (except aspirin for secondary cardiovascular disease prevention). A “low-
roughage diet” does not lower risk for recurrence.
• No medications are proven to lower risk for recurrence.

COMMENT
This clinical practice update, which is similar to prior AGA guidelines, reflects a continued shift
towards individualized, patient-centered decision-making in managing acute diverticulitis. The
authors more forcefully question resection for patients with recurrent diverticulitis and provide
criteria for antibiotic use in mild diverticulitis. However, physicians often are slow to adopt new
recommendations: Rates of elective colectomy after acute diverticulitis continue to increase (NEJM
JW Gastroenterol Nov 2019 and Gastroenterology 2019; 157:1679), and antibiotics still are used
widely for mild cases.

Peery AF et al. AGA clinical practice update on medical management of colonic diverticulitis: Expert review. Gastroenterology
2021 Feb; 160:906. (https://doi.org/10.1053/j.gastro.2020.09.059)

Dr. Brett is an Instructor in Medicine at the University of Colorado.

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Providing Long-Term Oxygen Therapy for Patients with COPD

and Interstitial Lung Disease
Guideline recommendations from the American Thoracic Society for patients with chronic obstructive
pulmonary disease

Patricia Kritek, MD, reviewing Am J Respir Crit Care Med 2021 Nov.

Sponsoring Organization: American Thoracic Society (ATS)

Background
This guideline is focused on long-term oxygen therapy (LTOT) for patients with chronic obstructive
pulmonary disease (COPD) and interstitial lung disease. Recommendations are based on best available
evidence and patient-specific risks and benefits.
Key Points
• Patients with COPD and severe resting hypoxemia (partial pressure of oxygen [PaO2], ≤55 mm Hg or
oxygen saturation [SpO2], ≤88%) should be prescribed LTOT for at least 15 hours daily.
• Patients with COPD and severe exertional desaturation should be prescribed ambu­latory oxygen.
• Patients with interstitial lung disease should receive LTOT for severe resting hypoxemia and
ambulatory oxygen for severe exertional desaturation. These recommendations are based on
extrapolation from the COPD literature, as no studies have been done in patients with interstitial lung
disease.
• LTOT should not be prescribed for COPD patients with moderate hypoxemia (SpO2, 89%–93%).
• Portable liquid oxygen should be prescribed for use outside of the home if oxygen flow of >3 L/minute
are needed.
• Patients and caregivers should receive education on safe use of home oxygen.

COMMENT
Some evidence for the COPD population is of moderate quality, but evidence is lacking for the
interstitial lung disease recommendations. Trials of no oxygen for severely hypoxemic patients
with interstitial lung disease are unlikely to be performed, so the ATS expert panel’s approach
seems reasonable. The recommendation for portable liquid oxygen was based mostly on indirect
evidence and reflects prioritization of mobility outside of the home. Because using home oxygen is
challenging, prescription in any of these settings should be anchored in shared decision making.

Jacobs SS et al. Home oxygen therapy for adults with chronic lung disease. An official American Thoracic Society clinical practice
guideline. Am J Respir Crit Care Med 2020 Nov; 202:e121. (https://doi.org/10.1164/rccm.202009-3608ST)

Dr. Kritek is Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of Washington,
Seattle.

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Guideline Watch 2021 jwatch.org

Contrast-Enhanced MRIs in Patients with Kidney Disease

Currently used gadolinium-based contrast media appear to be safe for magnetic resonance imaging, even in
patients with advanced kidney disease.

Allan S. Brett, MD, reviewing Radiology 2021 Jan.

Sponsoring Organizations: American College of Radiology; National Kidney Foundation

Background
For certain clinical scenarios, enhancement with intravenous gadolinium-based contrast media (GBCM)
improves diagnostic yield of magnetic resonance imaging (MRI). However, in 2006, a syndrome called
nephrogenic systemic fibrosis (NSF) was associated with use of GBCM in patients with advanced kidney
disease. The U.S. FDA recommends assessing renal function before patients receive GBCM. However,
documented cases of NSF have become nearly nonexistent with use of newer gadolinium-based agents at
recommended doses — including in patients with end-stage renal disease. In this consensus statement,
radiologists and nephrologists provide a literature review and updated guidance on use of GBCM.
Key Points and Recommendations
• GBCM are classified into group I, II, and III agents.
– Nearly all convincing cases of NSF occurred with group I agents, which are no longer used in the
U.S. and most other countries.
– For group II agents*, kidney function screening is optional; screening is still recommended for the
one available group III agent (Eovist) because data are limited.
– Contrast-enhanced MRI with a group II agent should not be withheld, regardless of renal function,
if MRI is deemed clinically necessary.
• Hemodialysis removes GBCM; when patients on dialysis require contrast-enhanced MRI, scheduling
the MRI just prior to dialysis is reasonable if possible, but not mandatory.
• On-label dosing of GBCM is not thought to cause clinically relevant nephrotoxicity.

COMMENT
Radiology departments in the U.S. likely differ in their willingness to use gadolinium-based
contrast media in patients with known advanced kidney disease and in their policies on checking
serum creatinine before performing MRI with contrast. This consensus statement provides an
evidence-based blueprint that should minimize practice variation across the U.S.

*MultiHance, ProHance, Gadavist, Dotarem, Clariscan

Weinreb JC et al. Use of intravenous gadolinium-based contrast media in patients with kidney disease: Consensus
statements from the American College of Radiology and the National Kidney Foundation. Radiology 2021 Jan; 298:28.
(https://doi.org/10.1148/radiol.2020202903)

Dr. Brett is Clinical Professor of Medicine at the University of Colorado School of Medicine.

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Guideline Watch 2021 jwatch.org

2020 Asthma Guideline Update

New guidance from the National Asthma Education and Prevention Program

David J. Amrol, MD, reviewing JAMA 2020 Dec. 8.

Sponsoring Organization: U.S. National Asthma Education and Prevention Program (NAEPP)

Background
The NAEEP guidelines were last updated in 2007. This update addresses managing asthma in children,
adolescents, and adults.
Key Recommendations
• Using intermittent inhaled corticosteroids (ICS)
– Step 1 or mild intermittent asthma still is managed with as-needed short-acting β-agonists (SABAs).
– In adolescents (age, ≥12) and adults, step 2 therapy for mild persistent asthma is either daily ICS
plus rescue SABAs or as-needed ICS plus SABAs. A recommended regimen is 2 to 4 puffs of al-
buterol, followed by 80 to 250 µg of beclomethasone equivalent, every 4 hours as needed. (This
requires 2 separate inhalers.)
– Children (age, ≥4 years) and adults treated with, and adherent to, daily ICS should not temporarily
double, quadruple, or quintuple their ICS dose for managing acute exacerbations. Single mainte-
nance and reliever therapy (SMART) seems to be effective because extra ICS doses are given early
(with every dose of rescue bronchodilator during asthma worsening), whereas waiting to increase
the dose of maintenance ICS until an acute exacerbation occurs is too late.
– Children (age, ≥4 years) and adults with moderate-to-severe asthma (steps 3 and 4) should use
SMART with both daily and as-needed ICS/formoterol. During an exacerbation, the maximum rec-
ommended daily dose is 12 puffs for adolescents and adults (with currently available inhalers, this
would be 2 puffs twice daily as maintenance therapy, plus an additional 2 puffs as often as 4 times
daily as reliever therapy).
– In young children (age, <4 years) who have recurrent wheezing only with colds and who are not
treated with daily ICS, a 7-to-10 day course of ICS at the onset of a respiratory tract infection can be
used to prevent exacerbations.
• Adolescents and adults whose asthma is uncontrolled with ICS plus long-acting β-agonists (LABAs)
should add long-acting muscarinic antagonists (LAMAs) for step 5 therapy.
• In children (age, ≥5 years) and adults, use of fractional exhaled nitric oxide (FeNO) is recommended
for diagnosing and monitoring asthma in conjunction with history, clinical findings, and spirometry
results. FeNO is a simple in-office breath test that typically is performed by asthma specialists. It is
helpful when the diagnosis of asthma is in question, and it can help tailor therapy in patients with
frequent exacerbations. It should not be used in isolation to make clinical decisions.
• In patients who have symptoms and exposure to indoor allergens (based on history, skin prick testing,
or IgE testing,) allergen-specific mitigation should be used (including dust mite, mold, and pet dander
reduction and pest management for roaches and rodents). For well-controlled mild-to-moderate
allergic asthma, subcutaneous (but not sublingual) allergen immunotherapy is recommended in
conjunction with optimal pharmacotherapy.

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Guideline Watch 2021 jwatch.org

COMMENT
This long-awaited update does an excellent job of addressing the topics outlined above, using
published evidence available through October 2018; however, asthma care is addressed more
comprehensively in the annually updated Global Initiative for Asthma (GINA) guidelines. GINA
recommends using as-needed ICS/formoterol for both intermittent and mild persistent asthma and
discourages using a SABA without an ICS in any patient. I prefer using as-needed ICS/formoterol
in a single device (since we have two U.S. FDA-approved products, whereas no single ICS/SABA
device is available yet). As a final reminder, only formoterol, not salmeterol, is suitable for as-
needed use due to its quicker onset of action.

Cloutier MM et al. Managing asthma in adolescents and adults: 2020 asthma guideline update from the National Asthma
Education and Prevention Program. JAMA 2020 Dec 8; 324:2301. (https://doi.org/10.1001/jama.2020.21974)

Dr. Amrol is Associate Professor of Medicine and adjunct Assistant Professor of Pediatrics at the University of South Carolina
School of Medicine, where he serves as the Allergy and Clinical Immunology Division Director.

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