#524 SHM Converge 2026–Recap

May 4, 2026 | By Monee Amin

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Transcript available via YouTube

We go so that you want to go next year!

Stay current with updates in hospital medicine from SHM Converge 2026 in Nashville, TN. 

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Show Segments

• Intro
• Picks of the Week
• Heart Failure Updates
• Things We Do For No Reason: Top 10
• Pneumonia updates
• Pharmacotherapy Updates
• Severe Acute Liver Injury
• Nephrology Updates
• MED-TED Competition Pearls
• Fevers in Oncology
• Addiction Updates for the Hospitalists
• Alternatives to Guardianship
• Infectious disease updates
• Updates in Transfusion Medicine
• Sodium overcorrection/demyelinating syndrome
• Total parenteral nutrition (TPN)
• Perioperative hip fracture management
• EKG Updates
• Dermatology Updates
• Home Antibiotics
• Sepsis Updates
• Updates in Hospital Medicine
• Diabetes Inpatient Management Updates
• Outro

Disclosures

Drs. Hunt, Kennedy, Maleque, Sata and White report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

#SHM Converge 2026 Recap

Heart Failure Updates

• Pleural effusions are a common finding in our patients with heart failure, TAP-IT looked at days alive outside of the hospital at 90 days for those patients who received thoracentesis versus those that did not. There was no difference in mortality across the two groups and no change in duration of index admission. There was a 1% risk of complication in the thoracentesis group (Glargaard, 2025). 
• A meta-analysis on prescribed inpatient sodium supplementation for decompensated heart failure demonstrated improvements in some biomarkers (creatinine, BNP) and decrease in length of hospital stay, with insufficient outcomes on mortality and readmission. Significant heterogeneity makes this challenging to routinely or definitively change practice (Mai, 2025).
• Sub-study analysis of STRONG-HF compared rapid uptitration of GDMT compared to usual care which showed improved 180-day all-cause death and 180-day readmission rates. This suggests that the ongoing decongestion is important for effective therapeutic responses (Biegus, 2024). Check out Episode #459 Inpatient Heart Failure for more.

Things We Do For No Reason: Top 10

• Number 4: De-escalate broad spectrum abx for non-purulent cellulitis (Gunderson, 2016)
  • Antibiotics should be directed at beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus (MSSA), with 1 of the suggested antibiotics by the IDSA (2014 IDSA guidelines) including penicillin, ceftriaxone, cefazolin, or clindamycin
  • If you still need more reassurance, a negative MRSA swab can help lower your concern for MRSA

• Number 3 (Pre-Print article presented at conference): De-escalate dual antithrombotic therapy in stable CAD after 6-12 months. This is based on data from the recent AQUATIC (Lemesle, 2025) and ADAPT AF (Lee, 2025)  trials.  
• Number 2: Do not withhold anticoagulation solely due to age or risk of falls (Wang, 2025)
  • Estimates suggest that an individual on apixaban would have to fall 458 times per year for the risk of bleeding to outweigh the stroke benefit.
• Number 1: There is no benefit and likely harm from acutely lowering asymptomatic hypertensive urgency (Breu, 2018)
  • Adverse events from severe asymptomatic hypertension are rare and accumulate over weeks to months, not hours to days.

Pneumonia Updates

• Steroids in community acquired pneumonia (CAP) are still controversial: The CAPE-COD trial (Dequin, 2023) showed a mortality benefit in patients with severe CAP in the ICU after receiving IV hydrocortisone, but the REMAP-CAP trial (Angus, 2025) showed that hydrocortisone appears unlikely to yield a large reduction in mortality.
• For patients (outpatient with CAP or inpatient with non-severe CAP) who reach clinical stability, ATS suggests using <5 days antibiotics with a minimum of 3 days (Dinh, 2021).
• IDSA (Hojat, 2025) removed support for the new ATS guidelines on CAP (Jones, 2026) due to their difference of recommendations regarding antibiotics in viral infections. It remains clinically challenging to know if you are suspicious of a bacterial co-infection. 

Pharmacotherapy Updates

• Finerenone was studied in FINEARTS-HF trial which was a double blind, randomized trial with a primary outcome of event of worsening heart failure and cardiovascular death. It demonstrated enhanced efficacy in reducing primary outcomes when initiated within 3 months after initial worsening heart failure event (Desai, 2025).
• New Lipid Guidelines state that the LDL goal is < 55 for very high risk patients, and recommends early stacking of therapies to meet goals. High-intensity statin as first line, and then if not at goal add ezetimibe and/or PCSK9 inhibitor, and then if not at goal, add inclisiran and if not at goal add bempedoic acid with the latter two really being true second line agents when first line has been exhausted (Blumenthal, 2026)

Severe Acute Liver Injury

• Pearls about labs during the workup: Don’t forget CK as part of work up, as it is important  to check for rhabdomyolysis in a patient with elevation of AST and ALT (although not a common cause of acute liver injury). Additionally, iron studies can be misleading in the acute phase, as they are often elevated as a consequence to the liver injury itself. Hemochromatosis, alpha-1antitrypsin, and PBC are not most common and likely unnecessary for the initial phase of work up. Check out Episodes #293, #380, #452 with Dr. Elliot Tapper for more liver and LFT lessons.
• The AST half-life is half of the ALT half-life, so the ALT is going to remain elevated longer than the AST, but isn’t necessarily indicative of ongoing liver injury
• The degree of transaminase elevation can be helpful in discerning the etiology: > 10,000 IU/l almost always ischemic, or DILI from acetaminophen, whereas > 400 IU/l often rules out alcohol-induced injury (Kwo, 2017)

Nephrology Updates

• About 25% of patients with AKI develop “acute kidney disease” and don’t return to baseline renal function within 90 days, so all patients with AKI don’t need to be back at baseline to discharge, just trending/close (Neyra, 2021)
• Furosemide stress test (FST) can help identify patients who will require renal replacement therapy (Chen, 2020). Critically ill patients with AKI are given 1 mg/kg furosemide if naïve (and 1.5 mg /kg if exposed). Urine output >200 ml over the first 2 hours after FST had a sensitivity and specificity of 87% and 84%, respectively, for the progression to stage 3 AKI and potentially needing dialysis
• Allergy to sulfonamide-cased antibiotics (SCAs) does not preclude the administration of sulfonamide-based diuretics like furosemide, and shouldn’t preclude their use. Allergy to SCA had a higher risk of having an allergy to penicillin than a sulfa diuretic. This suggests a predisposition to allergies overall (Strom, 2003)
• Only extremely large changes in TSH can have a significant impact on sodium levels. In cases where TSH is minimally elevated, search for other causes of hyponatremia. (Croal, 1997)
• A meta-analysis demonstrated very-slow or slow correction of hyponatremia is associated with higher mortality (Ayus, 2025). However, recommendation for rate of correction in severe hyponatremia remains the same. While newer data suggests that we have been overly cautious (Seethapathy, 2023; Kinoshita, 2023) , the current consensus from the guideline authors is to stay the course and still correct hyponatremia slowly. Speakers echoed holding off on practice change until further data (Sterns, 2024).

MED-TED Competition Pearls

• CAR-T and bispecific T-cell engager (BiTE) therapy therapy can cause cytokine release syndrome, which will present with a sepsis-like illness 6-12 hours after infusion with symptoms including fever, tachycardia, and can progress to shock. The temptation is to treat like sepsis, but appropriate treatment needed is instead tocilizumab or steroids. This is an oncologic emergency – wake up your local hematologist/oncologist for this! (Shimabukuro-Vornhagen, 2018)

Fevers in Oncology (expert opinion)

• To create a framework to approach oncology patients who present with fever:
  • Think about your patient’s host factors: What is their immune system doing? What is their reserve or functional status? What are their exposures (eg, hospitalizations, MDROs, recent antibiotics)
  • Think about their anatomy: barrier integrity, obstruction, implanted devices?
  • Think about their cancer treatment: are they on checkpoint inhibitors or immune effector therapies?

Addiction Updates for the Hospitalists

• Avoid stigmatizing language, including in the electronic medical language, as they cloud our judgement and impact our management
• Medications for opioid use disorder like methadone and buprenorphine in the fentanyl era: uptitrate methadone rapidly over a few days, whereas with buprenorphine consider using short-acting opioid in conjunction with buprenorphine to ease the receptors into the transition (Calcaterra, 2022; Englander, 2024).
• Adulterants (eg xylazine, medetomidine) in the opioid supply can cause autonomic instability as side effect, and patients may need ICU-level supportive care (eg, dexmedetomidine) while these adulterants are coming out of their system 
• Stimulant use disorder: while there are not medication-based therapies that are FDA approved, there is promising research on reward-based pathways for negative urine drug screens (Logan, 2025).

Infectious disease updates

• Complicated UTI Updates
  • 2025 IDSA complicated UTI updates (IDSA, 2025) now recommend transitioning IV to oral antibiotics for most patients who are clinically improving, able to take oral medication, and for whom an effective oral option is available. 
  • The guidelines identify fluoroquinolones, trimethoprim-sulfamethoxazole (TMP-SMX), and third-generation oral cephalosporins, but earlier generation cephalosporins (e.g., cephalexin), amoxicillin, amoxicillin-clavulanate, and cephalosporins may have low bioavailability (e.g., cefdinir) and less effective
  • Contrasts directly with oral stepdown therapy for CAP: Current practice has evolved to preferentially recommend β-lactam/macrolide combination therapy over fluoroquinolone monotherapy for hospitalized patients with nonsevere CAP, noting potential harms from fluoroquinolone therapy
  • These are two conditions where hospitalists are often managing oral stepdown without infectious disease colleagues, compared to oral stepdown therapy for osteomyelitis, staph bacteremia, etc.
• Organisms that have inducible ampC production (ECK): No more SPACE and SPICE acronyms for organisms: the newest iteration is ECK. When Enterobacter cloacae, Klebsiella aerogenes (formerly Enterobacter aerogenes), and Citrobacter freundii are recovered in clinical cultures (other than urine cultures in uncomplicated cystitis), the IDSA suggests avoiding treatment with ceftriaxone or ceftazidime, even if an isolate initially tests susceptible to these agents. Instead, opt for cefepime. In contrast, organisms historically presumed to be at high risk—including Serratia marcescens, Morganella morganii, and Providencia spp.—are unlikely to overexpress ampC based on both in vitro analysis and clinical reports (Tamma, 2023).
• Gram negative rod (GNR) bacteremia: Seven days of treatment is non-inferior to 14 days (Yahav, 2019).
• Strep bacteremia: Comparing IV therapy vs a PO stepdown, patients with uncomplicated strep bacteremia had similar clinical success; those transitioning to PO had shorter hospitalizations and less line complications (Lew, 2024)
• S. aureus bacteremia: Dalbavancin (off-label) and ceftobiprole are suitable alternatives to standard of care (Turner, 2025 ; Holland, 2023).
• Duration of treatment for bacteremia: 7 days of antibiotics is sufficient for most bacteremia that is not S. aureus or S. lungedensis (BALANCE, 2024)
• Dalbavancin for SSTI:
  • Only FDA approved use is in acute bacterial SSTI. However, the DOTS trial (Turner, 2025) had promising data for complicated Staph aureus bacteremia including MRSA. Met noninferiority criteria for clinical efficacy, but not yet FDA approved for this use
  • Dalbavancin is commonly $3,000-6,000 but can often save many days of hospitalization – weigh the benefits of these options

Updates in Transfusion Medicine

• Transfusions in myocardial infarction (MI): A liberal transfusion strategy is suggested for all acute MIs (NSTEMI, STEMI, Types 1-4) when hemoglobin <10 g/dL. Additionally, be mindful of the patient and their volume status along the way for this transfusion goal. (Pagano, 2025) 
• Platelets in procedures: AABM recommends a platelet cutoff of 20,000 for lumbar punctures, a less conservative recommendation from a more commonly cited platelet cutoff of 50,000 (Metcalf, 2025)

Total parenteral nutrition (TPN)

• Use a framework for when to decide feeds: what is baseline nutrition status? If a well-nourished person, you can wait 7 days without parenteral nutrition. If nutritional at-risk, they recommend only 3-5 days without parenteral nutrition. If the patient has malnutrition, then you should start nutrition right away. A good physical exam will help determine their nutritional status: muscle wasting, grip strength, and fat loss. This assessment doesn’t include the albumin or prealbumin. (Worthington, 2017)
• To start TPN while awaiting formal nutrition recs, consider estimating with the “Rule of 25”: 25 kcal/kg/day, 25 milliliters of fluid/kg/day, 1 g protein/kg/day
• Per speakers, this is pre-print information–emerging literature shows that central line associated bloodstream infection (CLABSI) risk may be overstated as long as abiding by bundle care for the line. 
• Interestingly, TPN does not affect a patient’s hunger drive (expert opinion). Based on limited data, this may be based on lipids in the parenteral nutrition (McCutcheon, 1989). 

Perioperative hip fracture management

• Hip fracture is not an elective surgery, so the hospitalist’s pre-op goal is to mitigate risk, even if the patient is not optimized
• Per the AAOS Clinical Practice Guideline, hemoglobin transfusion goal is 8 g/dl in patients with acute hip fracture.
• Bleeding starts at time of fracture and will continue 2-4 days post-op until it reaches the nadir. Therefore, think of a hip fracture as an acute bleed that may need ongoing transfusion support and IV iron may not be appropriate unless concerns about a chronic condition contributing. 
• Only about 10% of patients receive bisphosphonate therapy after their fracture (Kim, 2016). They shouldn’t necessarily have them prescribed during acute hospital stay, but should be getting after post-op therapy, so recommend this in their transition back to primary care (Lyles, 2007). 
• If patients are on SGLT-2 inhibitors, do not delay surgery for the optimization and holding of the medication alone.
• Major surgery is an opportunity to have a goals-of-care conversation and counsel patients in pre-operative period. Discussion points include the downstream effects from surgery such as cognitive impairments, increased frailty, and mortality. One such study showed that by 6 months after surgery, 16.5% of patients had significant new disability and death, and this further increased to 20.7% by 1 year (Wijeysundera, 2025). Additionally, when looking at 
• Anxiety pre-operatively is aided by playing mellow music; classical music was used most commonly and many studies allowed patient selection of music. (Yang, 2025).

EKG Updates 

• The risk of Torsades de Pointes occurs during cardiac repolarization, so the JT interval is more specific risk instead of the QT interval, which includes both the depolarization and repolarization (Bogossian, 2014; Othong, 2019). Can correct for QT using: MDCalc.
• Not all plaque ruptures result in ST elevation, i.e. STEMI (Betul Umit, 2026). For example, a patient can have ST depressions or early R wave peaking in a posterior MI. Occlusive and non-occlusive MI may be better representative terms for these phenomena. 

Dermatology Updates

• Trimethoprim/sulfamethoxazole is most common cause of SJS/TENS (Kridin, 2021)
• Distinguishing between SJS/TENS and DRESS is timing in relation to medication administration, so creating a drug chart with when rash starts can help distinguish the diagnosis. 

Home Antibiotics

• One dose of gentamicin has moderate certainty of microbiologic cure in the patients with a previous history of resistant organisms growing in urine cultures (Goodlet, 2018), and adverse events are very rare. 
• Previously, dogma was that bone and joint infections needed prolonged IV antibiotics. The OVIVA trial in 2019 (Li, 2019) and a 2025 meta-analysis confirm that PO therapy for bone and joint infections is non-inferior if they have had surgical source control, you know what organisms you are treating, and the patient can take and adhere to the oral antibiotics (Lima, 2025). 

Sepsis Updates

• Sepsis-2 defines sepsis as systemic inflammatory response syndrome (SIRS) plus an infectious source (Levy, 2001). According to the more updated definition in Sepsis-3, sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer, 2016). However, Centers for Medicaid Services (CMS) reimburses hospitals on the older Sepsis-2 definitions, which is a controversial policy (Rhee, 2024).

• In this era of ambiguity and mixed incentives with charting requirements and a commitment to evidence, ensure you are charting end-organ damage, while still meeting your institution’s charting requirements (which are often Sepsis-2 criteria)
• Learn more about inpatient sepsis management on Episode #419 Rapid Response Series: Sepsis with Dr. Mohleen Kang

Updates in Hospital Medicine

• The CARVE-AS trial was a prospective RCT for initiating carvedilol in patients with cirrhosis who had their first episode of ascites, but had no high-risk varices. Use of carvedilol reduced ascites-related complications including refractory ascites, AKI, etc. Start the carvedilol dose at 3.125 mg twice a day and increase to 6.25 mg twice a day as heart rate and blood pressure allow (Khajuria, 2025).
• The ADOPT trial was a RCT that compared oral versus extended-release injectable naltrexone for hospitalized patients with alcohol use disorder. This study showed that oral and extended-release injection naltrexone are both effective for treating alcohol use disorder in heavy drinking days. The injection improves adherence, as it removes the need for daily medication, but is significantly more expensive than daily oral pills (Magane, 2025).
• A CRP >204 mg/L predicts responsiveness to adjuvant therapy with corticosteroids in CAP (Smit, 2025).
• Chat GPT-4 can enhance clinical decision making (Goh, 2025).
• Suzetrigine is the first non-opioid pain medication released in over 20 years. A trial found it is efficacious for acute post-operative moderate-to-severe pain compared to hydrocodone/acetaminophen (Butroch, 2025). 
• An observational cohort study out of the VA analyzed inpatient metformin utilization and post-hospitalization clinical outcomes. This study found that a very wide range of 6-77% of hospitals held metformin at admission, suggesting that this decision is driven by institutional culture instead of patient factors. Use of inpatient metformin was correlated with less post-discharge hypoglycemia, lower 90-day mortality and readmissions, and fewer insulin prescriptions at discharge. A major limitation of this study is the lack of addressing inpatient safety concerns such as lactic acidosis (Gallo, 2025). 

Diabetes Inpatient Management Updates

• Continuous glucose monitors (CGMs) and automated insulin delivery systems are not clearly recommended in the inpatient setting and are not FDA approved for this use, but as there is an increase in use in the outpatient setting, there will need to be considerations in the future how to manage these technological updates (expert opinion). 
• Hold SGLT2 inhibitors during an acute UTI, but can resume their use after acute UTI as the benefits outweigh the risks. Can reconsider their use if the patient is having recurrent UTIs (expert opinion). 
• The GFR threshold for SGLT2 inhibitors has been lowered, and they can be used down to an eGFR of 20 mL/min/1.73m2 to reduce CKD progression and cardiovascular events (Bajaj, 2026).
• GLP-1 use is not associated with an increased risk of acute pancreatitis (Ayoub, 2025).
• In mild DKA, can consider subcutaneous insulin (Griffey, 2025). If your institution has a protocol, can utilize own protocol. If your institution does not have a protocol, can consider long acting 0.3 units mg/kg if fasting blood glucose is > 250 or the patient’s home dose of long acting and short acting is 0.1 units/kg every hour, or 0.2 units/kg every two hours (expert opinion).

Links

1. Nerds Juicy Gummy Clusters
2. RCA Studio B Tour
3. Ugly Bagel
4. Kiss All The Time. Disco, Occasionally by Harry Styles

Goal

Listeners will be served delicious knowledge food from SHM’s #Converge26

Learning objectives

After listening to this episode listeners will…  

1. Review key practice-changing pearls

Citation

Amin M, Coleman C, Trubitt M, Hunt D, Kennedy K, Maleque N, Sata S, White R, Williams PN, Watto MF. “#524 SHM Converge 2026–Recap”. The Curbsiders Internal Medicine Podcast. thecurbsiders.com/category/curbsiders-podcast May 4, 2026.