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Background:Clinicians and laboratories routinely use urinalysis (UA) parameters to determine whether antimicrobial treatment and/or urine cultures are needed. Yet the performance of individual UA parameters and common thresholds for action are not well defined and may vary across different patient populations.Methods:In this retrospective cohort study, we included all encounters with UAs ordered 24 hours prior to a urine culture between 2015 and 2020 at 3 North Carolina hospitals. We evaluated the performance of relevant UA parameters as potential outcome predictors, including sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). We also combined 18 different UA criteria and used receiver operating curves to identify the 5 best-performing models for predicting significant bacteriuria (≥100,000 colony-forming units of bacteria/mL).Results:In 221,933 encounters during the 6-year study period, no single UA parameter had both high sensitivity and high specificity in predicting bacteriuria. Absence of leukocyte esterase and pyuria had a high NPV for significant bacteriuria. Combined UA parameters did not perform better than pyuria alone with regard to NPV. The high NPV ≥0.90 of pyuria was maintained among most patient subgroups except females aged ≥65 years and patients with indwelling catheters.Conclusion:When used as a part of a diagnostic workup, UA parameters should be leveraged for their NPV instead of sensitivity. Because many laboratories and hospitals use reflex urine culture algorithms, their workflow should include clinical decision support and or education to target symptomatic patients and focus on populations where absence of pyuria has high NPV.

Of 100 patients discharged from short-stay units (SSUs) with antibiotics, 47 had a skin and soft-tissue infection, 22 had pneumonia, and 21 had a urinary tract infection. Among all discharge antibiotic prescriptions, 78% involved antibiotic overuse, most commonly excess duration (54 of 100) and guideline discordant selection (44 of 100).

Background:We sought to determine the incidence of community-onset and hospital-acquired coinfection in patients hospitalized with coronavirus disease 2019 (COVID-19) and to evaluate associated predictors and outcomes.Methods:In this multicenter retrospective cohort study of patients hospitalized for COVID-19 from March 2020 to August 2020 across 38 Michigan hospitals, we assessed prevalence, predictors, and outcomes of community-onset and hospital-acquired coinfections. In-hospital and 60-day mortality, readmission, discharge to long-term care facility (LTCF), and mechanical ventilation duration were assessed for patients with versus without coinfection.Results:Of 2,205 patients with COVID-19, 141 (6.4%) had a coinfection: 3.0% community onset and 3.4% hospital acquired. Of patients without coinfection, 64.9% received antibiotics. Community-onset coinfection predictors included admission from an LTCF (OR, 3.98; 95% CI, 2.34–6.76; P < .001) and admission to intensive care (OR, 4.34; 95% CI, 2.87–6.55; P < .001). Hospital-acquired coinfection predictors included fever (OR, 2.46; 95% CI, 1.15–5.27; P = .02) and advanced respiratory support (OR, 40.72; 95% CI, 13.49–122.93; P < .001). Patients with (vs without) community-onset coinfection had longer mechanical ventilation (OR, 3.31; 95% CI, 1.67–6.56; P = .001) and higher in-hospital mortality (OR, 1.90; 95% CI, 1.06–3.40; P = .03) and 60-day mortality (OR, 1.86; 95% CI, 1.05–3.29; P = .03). Patients with (vs without) hospital-acquired coinfection had higher discharge to LTCF (OR, 8.48; 95% CI, 3.30–21.76; P < .001), in-hospital mortality (OR, 4.17; 95% CI, 2.37–7.33; P ≤ .001), and 60-day mortality (OR, 3.66; 95% CI, 2.11–6.33; P ≤ .001).Conclusion:Despite community-onset and hospital-acquired coinfection being uncommon, most patients hospitalized with COVID-19 received antibiotics. Admission from LTCF and to ICU were associated with increased risk of community-onset coinfection. Future studies should prospectively validate predictors of COVID-19 coinfection to facilitate the reduction of antibiotic use.

This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.

Objective: Clostridioides difficile infection (CDI) can be prevented through infection prevention practices and antibiotic stewardship. Diagnostic stewardship (ie, strategies to improve use of microbiological testing) can also improve antibiotic use. However, little is known about the use of such practices in US hospitals, especially after multidisciplinary stewardship programs became a requirement for US hospital accreditation in 2017. Thus, we surveyed US hospitals to assess antibiotic stewardship program composition, practices related to CDI, and diagnostic stewardship. Methods: Surveys were mailed to infection preventionists at 900 randomly sampled US hospitals between May and October 2017. Hospitals were surveyed on antibiotic stewardship programs; CDI prevention, treatment, and testing practices; and diagnostic stewardship strategies. Responses were compared by hospital bed size using weighted logistic regression. Results: Overall, 528 surveys were completed (59% response rate). Almost all (95%) responding hospitals had an antibiotic stewardship program. Smaller hospitals were less likely to have stewardship team members with infectious diseases (ID) training, and only 41% of hospitals met The Joint Commission accreditation standards for multidisciplinary teams. Guideline-recommended CDI prevention practices were common. Smaller hospitals were less likely to use high-tech disinfection devices, fecal microbiota transplantation, or diagnostic stewardship strategies. Conclusions: Following changes in accreditation standards, nearly all US hospitals now have an antibiotic stewardship program. However, many hospitals, especially smaller hospitals, appear to struggle with access to ID expertise and with deploying diagnostic stewardship strategies. CDI prevention could be enhanced through diagnostic stewardship and by emphasizing the role of non–ID-trained pharmacists and clinicians in antibiotic stewardship.

Background:Peripherally inserted central catheters (PICCs) are frequently used to deliver intravenous (IV) antibiotic therapy after discharge from the hospital. Infectious disease (ID) physicians are often consulted prior to PICC placement, but whether their approval influences PICC appropriateness and complications is not known. Methods: Using data from the Michigan Hospital Medicine Safety Consortium (HMS) on PICCs placed in critically ill and hospitalized medical patients between January 1, 2015, and July 26, 2019, we examined the association between ID physician approval of PICC insertion for IV antibiotics and device appropriateness and outcomes. Appropriateness was defined according to the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) as a composite measure of (1) avoiding PICC use for durations ≤5 days; (2) using single-lumen instead of multilumen catheters; and (3) avoiding PICC use in patients with chronic kidney disease (eGFR>45 mL/min). The associations between ID approval of PICC use and odds of PICC-related complications (eg, deep vein thrombosis, central-line–associated bloodstream infection, and catheter occlusion) were also assessed. Multivariable models adjusting for patient severity of illness and hospital-level clustering were fit to both outcomes. Results were expressed as odds ratios (ORs) with corresponding 95% CIs. Results: Data from 36,594 patients who underwent PICC placement across 42 Michigan hospitals were included in the analysis. In total, 21,653 (55%) PICCs were placed for the indication of IV antibiotics; 14,935 (69%) of these had a documented ID consultation prior to placement, whereas 6,718 (31%) did not. Of the 14,935 PICCs with an ID consultation, 10,238 (69%) had ID approval documented prior to device placement (Fig. 1). Compared to no approval, PICCs approved by ID prior to insertion were more likely to be appropriate (OR, 3.51; 95% CI, 3.28–3.77; P < .001). Specifically, approval was associated with higher single-lumen use (OR, 5.13; 95% CI, 4.72–5.58; P < .001), less placement of PICCs with dwell times ≤ 5 days (OR, 0.29; 95% CI, 0.25–0.32; P < .001), and less frequent use in patients with chronic kidney disease (OR, 0.80; 95% CI, 0.73–0.87; P < .001). ID approval of PICCs prior to insertion was associated with a significantly lower odds of PICC-related complications (OR, 0.57; 95% CI, 0.51–0.64) (Table 1). Conclusions: ID approval of PICC use for IV antibiotic therapy in hospitalized patients was associated with greater appropriateness and fewer complications. Policies aimed at ensuring ID review prior to PICC use may help improve patient and device safety.Funding: NoneDisclosures:Valerie M. Vaughn reports contract research for Blue Cross and Blue Shield of Michigan, the Department of Veterans’ Affairs, the NIH, the SHEA, and the APIC. She also reports fees from the Gordon and Betty Moore Foundation Speaker’s Bureau, the CDC, the Pew Research Trust, Sepsis Alliance, and The Hospital and Health System Association of Pennsylvania.

Background: Nearly half of hospitalized patients with bacteriuria or treated for pneumonia receive unnecessary antibiotics (noninfectious or nonbacterial syndrome such as asymptomatic bacteriuria), excess duration (antibiotics prescribed for longer than necessary), or avoidable fluoroquinolones (safer alternative available) at hospital discharge.1–3 However, whether antibiotic overuse at discharge varies between hospitals or is associated with patient outcomes remains unknown. Methods: From July 2017 to December 2018, trained abstractors at 46 Michigan hospitals collected detailed data on a sample of adult, non–intensive care, hospitalized patients with bacteriuria (positive urine culture with or without symptoms) or treated for community-acquired pneumonia (CAP; includes those with the disease formerly known as healthcare-associated pneumonia [HCAP]). Antibiotic prescriptions at discharge were assessed for antibiotic overuse using a previously described, guideline-based hierarchical algorithm.3 Here, we report the proportion of patients discharged with antibiotic overuse by the hospital. We also assessed hospital-level correlation (using Pearson’s correlation coefficient) between antibiotic overuse at discharge for patients with bacteriuria and patients treated for CAP. Finally, we assessed the association of antibiotic overuse at discharge with patient outcomes (mortality, readmission, emergency department visit, and antibiotic-associated adverse events) at 30 days using logit generalized estimating equations adjusted for patient characteristics and probability of treatment. Results: Of 17,081 patients (7,207 with bacteriuria; 9,874 treated for pneumonia), nearly half (42.2%) had antibiotic overuse at discharge (36.3% bacteriuria and 51.1% pneumonia). The percentage of patients discharged with antibiotic overuse varied 5-fold among hospitals from 14.7% (95% CI, 8.0%–25.3%) to 74.3% (95% CI, 64.2%–83.8%). Hospital rates of antibiotic overuse at discharge were strongly correlated between bacteriuria and CAP (Pearson’s correlation coefficient, 0.76; P ≤ .001) (Fig. 1). In adjusted analyses, antibiotic overuse at discharge was not associated with death, readmission, emergency department visit, or Clostridioides difficile infection. However, each day of overuse was associated with a 5% increase in the odds of patient-reported antibiotic-associated adverse events after discharge (Fig. 2). Conclusions: Antibiotic overuse at discharge was common, varied widely between hospitals, and was associated with patient harm. Furthermore, antibiotic overuse at discharge was strongly correlated between 2 disparate diseases, suggesting that prescribing culture or discharge processes—rather than disease-specific factors—contribute to overprescribing at discharge. Thus, discharge stewardship may be needed to target multiple diseases.Funding: This study was supported by the Society for Healthcare Epidemiology of America and by Blue Cross Blue Shield of Michigan and Blue Care Network.Disclosures: Valerie M. Vaughn reports contracted research for Blue Cross and Blue Shield of Michigan, the Department of VA, the NIH, the SHEA, and the APIC. She also reports receipt of funds from the Gordon and Betty Moore Foundation Speaker’s Bureau, the CDC, the Pew Research Trust, Sepsis Alliance, and the Hospital and Health System Association of Pennsylvania.

Background: Clinicians often diagnose bacterial infections such as urinary tract infection (UTI) and pneumonia in patients who are asymptomatic or have nonbacterial causes of their symptoms. Misdiagnosis of infection leads to unnecessary antibiotic use and potentially delays correct diagnoses. Interventions to improve diagnosis often focus on infections separately. However, if misdiagnosis is linked, broader interventions to improve diagnosis may be more effective. Thus, we assessed whether misdiagnosis of UTI and community-acquired pneumonia (CAP) was correlated. Methods: From July 2017 to July 2019, abstractors at 46 Michigan hospitals collected data on a sample of adult, non–intensive care, hospitalized patients with bacteriuria (positive urine culture) or who were treated for presumed CAP (discharge diagnosis plus antibiotics). Patients with concomitant bacterial infections were excluded. Using a previously described method,1,2 patients were assessed for UTI or CAP based on symptoms, signs, and laboratory or radiology findings. Misdiagnosis of UTI was defined as patients with asymptomatic bacteriuria (ASB) treated with antibiotics number of patients with bacteriuria Misdiagnosis of CAP was defined as patients treated for presumed CAP who did not have CAP number of patients treated for presumed CAP. Hospital-level correlation was assessed using Pearson’s correlation coefficient between misdiagnosis of UTI and CAP. For patients with prescriber data (N = 3,293), we also assessed emergency department (ED)-level correlation. Results: Of 11,914 patients with bacteriuria, 31.9% (N = 3,796) had ASB. Of those, 2,973 of 3,796 (78.3%) received antibiotics. Of 14,085 patients treated for CAP, 1,602 (11.4%) did not have CAP. Incidence of misdiagnosis varied by hospital: those with high rates of misdiagnosis of UTI were more likely to have high rates of misdiagnosis of CAP (Pearson’s correlation coefficient, 0.58; P ≤ .001) (Fig. 1). Of 2,137 patients misdiagnosed with UTI, 1,159 (54.2%) had antibiotic treatment started in the ED; of those, 942 (81.3%) remained on antibiotics on day 3 of hospitalization. Of 1,156 patients misdiagnosed with CAP, 871 (75.3%) had antibiotic therapy started in the ED, and 789 of these 871 patients (90.6%) were still on antibiotics on day 3 of hospitalization. Hospitals with high rates of UTI misdiagnosis in the ED were more likely to have high rates of CAP misdiagnosis in the ED (Pearson’s correlation coefficient, 0.33; P ≤ .001). Conclusions: Misdiagnosis of 2 unrelated infections was moderately correlated by hospital and weakly correlated by hospital ED. Potential causes include differences in organizational culture (eg, low tolerance for diagnostic uncertainty, emergency department culture), organizational initiatives (eg, sepsis, stewardship), or coordination between emergency and hospital medicine. Additionally, antibiotics initiated in the ED were typically continued following admission, potentially reflecting diagnosis momentum.Funding: This work was supported by Blue Cross Blue Shield of Michigan and Blue Care Network.Disclosures: Valerie M. Vaughn reports contract research for Blue Cross and Blue Shield of Michigan, the Department of Veterans’ Affairs, the NIH, the SHEA, and the APIC. She also reports fees from the Gordon and Betty Moore Foundation Speaker’s Bureau, the CDC, the Pew Research Trust, Sepsis Alliance, and The Hospital and Health System Association of Pennsylvania.