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Background Community-acquired pneumonia (CAP) is a common cause for hospitalization and antibiotic overuse. We aimed to improve antibiotic duration for CAP across 41 hospitals participating in the Michigan Hospital Medicine Safety Consortium (HMS). Methods This prospective collaborative quality initiative included patients hospitalized with uncomplicated CAP who qualified for a 5-day antibiotic duration. Between 23 February 2017 and 5 February 2020, HMS targeted appropriate 5-day antibiotic treatment through benchmarking, sharing best practices, and pay-for-performance incentives. Changes in outcomes, including appropriate receipt of 5 ± 1–day antibiotic treatment and 30-day postdischarge composite adverse events (ie, deaths, readmissions, urgent visits, and antibiotic-associated adverse events), were assessed over time (per 3-month quarter), using logistic regression and controlling for hospital clustering. Results A total of 41 hospitals and 6553 patients were included. The percentage of patients treated with an appropriate 5 ± 1–day duration increased from 22.1% (predicted probability, 20.9% [95% confidence interval: 17.2%–25.0%]) to 45.9% (predicted probability, 43.9% [36.8%–51.2%]; adjusted odds ratio [aOR] per quarter, 1.10 [1.07–1.14]). Thirty-day composite adverse events occurred in 18.5% of patients (1166 of 6319) and decreased over time (aOR per quarter, 0.98 [95% confidence interval: .96–.99]) owing to a decrease in antibiotic-associated adverse events (aOR per quarter, 0.91 [.87–.95]). Conclusions Across diverse hospitals, HMS participation was associated with more appropriate use of short-course therapy and fewer adverse events in hospitalized patients with uncomplicated CAP. Establishment of national or regional collaborative quality initiatives with data collection and benchmarking, sharing of best practices, and pay-for-performance incentives may improve antibiotic use and outcomes for patients hospitalized with uncomplicated CAP.

Though opportunities exist to improve antibiotic prescribing across the care spectrum, discharge from acute hospitalization is an increasingly recognized source of antibiotic overuse. Antimicrobials are prescribed to more than 1 in 8 patients at hospital discharge; approximately half of which could be improved. Key targets for antibiotic stewardship at discharge include unnecessary antibiotics, excess duration, avoidable fluoroquinolones, and improving (or avoiding) intravenous antibiotic therapy. Barriers to discharge antibiotic stewardship include the perceived “high stakes” of care transitions during which patients move from intense to infrequent observation, difficulties in antibiotic measurement to guide improvement at discharge, and poor communication across silos, particularly with skilled nursing facilities. In this review, we discuss what is currently known about antibiotic overuse at hospital discharge, key barriers, and targets for improving antibiotic prescribing at discharge and we introduce an evidence-based framework, the Reducing Overuse of Antibiotics at Discharge Home Framework, for conducting discharge antibiotic stewardship.

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: Gender inequity is pervasive in academic medicine. Factors contributing to these gender disparities must be examined. A significant body of literature indicates men and women are assessed differently in teaching evaluations. However, limited data exist on how faculty gender affects resident evaluation of faculty performance based on the skill being assessed or the clinical practice settings in which the trainee-faculty interaction occurs. OBJECTIVE: Evaluate for gender-based differences in the assessment of general internal medicine (GIM) faculty physicians by trainees in inpatient and outpatient settings. DESIGN: Retrospective cohort study SUBJECTS: Inpatient and outpatient GIM faculty physicians in an Internal Medicine residency training program from July 1, 2015, to December 31, 2018. MAIN MEASURES: Faculty scores on trainee teaching evaluations including overall teaching ability and Accreditation Council for Graduate Medical Education (ACGME) competencies (medical knowledge [MK], patient care [PC], professionalism [PROF], interpersonal and communication skills [ICS], practice-based learning and improvement [PBLI], and systems-based practice [SBP]) based on the institutional faculty assessment form. KEY RESULTS: In total, 3581 evaluations by 445 trainees (55.1% men, 44.9% women) assessing 161 GIM faculty physicians (50.3% men, 49.7% women) were included. Male faculty were rated higher in overall teaching ability (male=4.69 vs. female=4.63, p=0.003) and in four of the six ACGME competencies (MK, PROF, PBLI, and SBP) based on our institutional evaluation form. In the inpatient setting, male faculty were rated more favorably for overall teaching (male = 4.70, female = 4.53, p=

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.

As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines., Highlights • COVID-19 protocols agreed on heparin-based venous thromboembolism prophylaxis. • Disagreement on thrombosis risk and diagnosis, D-dimer, empiric anticoagulation • Cumulative incidence of COVID-19 did not correlate with specific recommendations. • Framework for frontline providers and hospitals to evaluate practices and outcomes

Background Antibiotics are commonly prescribed to patients as they leave the hospital. We aimed to create a comprehensive metric to characterize antibiotic overuse after discharge among hospitalized patients treated for pneumonia or urinary tract infection (UTI), and to determine whether overuse varied across hospitals and conditions. Methods In a retrospective cohort study of hospitalized patients treated for pneumonia or UTI in 46 hospitals between 1 July 2017–30 July 2019, we quantified the proportion of patients discharged with antibiotic overuse, defined as unnecessary antibiotic use, excess antibiotic duration, or suboptimal fluoroquinolone use. Using linear regression, we assessed hospital-level associations between antibiotic overuse after discharge in patients treated for pneumonia versus a UTI. Results Of 21 825 patients treated for infection (12 445 with pneumonia; 9380 with a UTI), nearly half (49.1%) had antibiotic overuse after discharge (56.9% with pneumonia; 38.7% with a UTI). For pneumonia, 63.1% of overuse days after discharge were due to excess duration; for UTIs, 43.9% were due to treatment of asymptomatic bacteriuria. The percentage of patients discharged with antibiotic overuse varied 5-fold among hospitals (from 15.9% [95% confidence interval, 8.7%–24.6%] to 80.6% [95% confidence interval, 69.4%–88.1%]) and was strongly correlated between conditions (regression coefficient = 0.85; P < .001). Conclusions Antibiotic overuse after discharge was common and varied widely between hospitals. Antibiotic overuse after discharge was associated between conditions, suggesting that the prescribing culture, physician behavior, or organizational processes contribute to overprescribing at discharge. Multifaceted efforts focusing on all 3 types of overuse and multiple conditions should be considered to improve antibiotic prescribing at discharge., Of 21 825 hospitalized patients with pneumonia or urinary tract infection in 46 hospitals, half (49.1%) had antibiotic overuse after discharge. Overuse varied 5-fold among hospitals (15.9%–80.6%) and was correlated between conditions. To improve prescribing, stewardship should include care transitions.

Background Amid growing antimicrobial resistance, there is an increasing focus on antibiotic stewardship efforts to reduce inappropriate antibiotic prescribing. In this context, novel approaches for treating infections without antibiotics are being explored. One such strategy is the use of non-steroidal anti-inflammatory drugs (NSAIDs) for uncomplicated urinary tract infections (UTIs). Therefore, we conducted a systematic review of randomized controlled trials to evaluate the rates of symptom resolution and infectious complications in adult women with uncomplicated UTIs treated with antibiotics versus NSAIDs. Methods We systematically searched PubMed, CINHAL, Scopus, Web of Science Core Collection, EMBASE, and ClinicalTrials.gov from inception until January 13, 2020, for randomized controlled trials comparing NSAIDs with antibiotics for treatment of uncomplicated UTIs in adult women. Studies comparing symptom resolution between groups were eligible. Two authors screened all studies independently and in duplicate; data were abstracted using a standardized template. Risk of bias was assessed using the Cochrane Collaboration tool. Results Five randomized trials that included 1309 women with uncomplicated UTI met inclusion criteria. Three studies (1130 patients) favored antibiotic therapy in terms of symptom resolution. Two studies (179 patients) found no difference between NSAIDs and antibiotics in terms of symptom resolution. Three studies reported rates of pyelonephritis, two of which found higher rates in patients treated with NSAIDs versus antibiotics. Between two studies that reported this outcome (747 patients), patients randomized to NSAIDs received fewer antibiotic prescriptions compared with those in the antibiotics group. Three studies were at low risk of bias, one had an unclear risk of bias, and one was at high risk of bias. Discussion For the outcomes of symptom resolution and complications in adult women with UTI, evidence favors antibiotics over NSAIDs. Prospero CRD42018114133

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.

PURPOSE OF REVIEW: The goal of this article is to highlight how and why urinalyses and urine cultures are misused, review quality improvement interventions to optimize urine culture utilization, and highlight how to implement successful, sustainable interventions to improve urine culture practices in the acute care setting. RECENT FINDINGS: Quality improvement initiatives aimed at reducing inappropriate treatment of asymptomatic bacteriuria often focus on optimizing urine test utilization (i.e., urine culture stewardship). Urine culture stewardship interventions in acute care hospitals span the spectrum of quality improvement initiatives, ranging from strong systems-based interventions like suppression of urine culture results to weaker interventions that focus on clinician education alone. While most urine culture stewardship interventions have met with some success, overall results are mixed, and implementation strategies to improve sustainability are not well understood. SUMMARY: Successful diagnostic stewardship interventions are based on an assessment of underlying key drivers and focus on multifaceted and complementary approaches. Individual intervention components have varying impacts on effectiveness, provider autonomy, and sustainability. The best urine culture stewardship strategies ultimately include both technical and socio-adaptive components with long-term, iterative feedback required for sustainability.

Background Antibiotic overuse at hospital discharge is common and harmful; however, methods to improve prescribing during care transitions have been understudied. We aimed to pilot a pharmacist-facilitated antibiotic timeout prior to discharge. Methods From May 2019 to October 2019, we conducted a single-center, controlled pilot study of a pharmacist-facilitated antibiotic timeout prior to discharge. The timeout addressed key elements of stewardship (e.g., duration) and was designed and implemented using iterative cycles with rapid feedback. We evaluated implementation outcomes related to feasibility, including usability, adherence, and acceptability, using mixed methods. Pre vs. post intervention antibiotic use at discharge in intervention vs. control groups was assessed using logistic regression models controlling for patient characteristics. Results Pharmacists conducted 288 antibiotic timeouts. Timeouts were feasible (mean 2.5 minutes per timeout) and acceptable (85% [40/48] of hospitalists believed timeouts improved prescribing). Pharmacists recommended an antibiotic change in 25% (73/288) of timeouts with 70% (51/73) of recommended changes accepted by hospitalists. Barriers to adherence included unanticipated and weekend discharges. Compared to control services, there were no differences in antibiotic use after discharge during the intervention. Conclusions A pharmacist-facilitated antibiotic timeout at discharge was feasible and holds promise as a method to improve antibiotic use at discharge.

ObjectiveTo describe patient characteristics, symptoms, patterns of care and outcomes for patients hospitalised with COVID-19 in Michigan.DesignMulticentre retrospective cohort study.Setting32 acute care hospitals in the state of Michigan.ParticipantsPatients discharged (16 March–11 May 2020) with suspected or confirmed COVID-19 were identified. Trained abstractors collected demographic information on all patients and detailed clinical data on a subset of COVID-19-positive patients.Primary outcome measurementsPatient characteristics, treatment and outcomes including cardiopulmonary resuscitation, mortality and venous thromboembolism within and across hospitals.ResultsDemographic-only data from 1593 COVID-19-positive and 1259 persons under investigation discharges were collected. Among 1024 cases with detailed data, the median age was 63 years; median body mass index was 30.6; and 51.4% were black. Cough, fever and shortness of breath were the top symptoms. 37.2% reported a known COVID-19 contact; 7.0% were healthcare workers; and 16.1% presented from congregated living facilities.During hospitalisation, 232 (22.7%) patients were treated in an intensive care unit (ICU); 558 (54.9%) in a ‘cohorted’ unit; 161 (15.7%) received mechanical ventilation; and 90 (8.8%) received high-flow nasal cannula. ICU patients more often received hydroxychloroquine (66% vs 46%), corticosteroids (34% vs 18%) and antibiotic therapy (92% vs 71%) than general ward patients (pAcross 14 hospitals, the proportion of patients admitted directly to an ICU ranged from 0% to 43.8%; mechanical ventilation on admission from 0% to 12.8%; mortality from 7.9% to 45.7%. Use of at least one COVID-19-specific therapy varied from 32% to 96.3% across sites.ConclusionsDuring the early days of the Michigan outbreak of COVID-19, patient characteristics, treatment and outcomes varied widely within and across hospitals.

Key Points Question What is the frequency with which patients hospitalized with COVID-19 are treated with venous thromboembolism (VTE) prophylactic- and treatment-dose anticoagulation, and what is the association of anticoagulation with in-hospital and 60-day mortality? Findings In this cohort study of 1351 patients hospitalized with COVID-19 in which 1127 patients received anticoagulation, 34.8% missed 2 or more days of VTE prophylaxis. Use of only prophylactic-dose or treatment-dose anticoagulation was associated with lower in-hospital mortality vs no anticoagulation; however, only prophylactic-dose anticoagulation remained associated with lower mortality at 60 days. Meaning These findings suggest that prophylactic-dose VTE anticoagulation may be optimal therapy for patients hospitalized with COVID-19., This cohort study of patients hospitalized with COVID-19 examines the association of anticoagulation treatment with mortality rates, and assesses differences between prophylactic- and treatment-doses in in-hospital and 60-day mortality., Importance Venous thromboembolism (VTE) is a common complication of COVID-19. It is not well understood how hospitals have managed VTE prevention and the effect of prevention strategies on mortality. Objective To characterize frequency, variation across hospitals, and change over time in VTE prophylaxis and treatment-dose anticoagulation in patients hospitalized for COVID-19, as well as the association of anticoagulation strategies with in-hospital and 60-day mortality. Design, Setting, and Participants This cohort study of adults hospitalized with COVID-19 used a pseudorandom sample from 30 US hospitals in the state of Michigan participating in a collaborative quality initiative. Data analyzed were from patients hospitalized between March 7, 2020, and June 17, 2020. Data were analyzed through March 2021. Exposures Nonadherence to VTE prophylaxis (defined as missing ≥2 days of VTE prophylaxis) and receipt of treatment-dose or prophylactic-dose anticoagulants vs no anticoagulation during hospitalization. Main Outcomes and Measures The effect of nonadherence and anticoagulation strategies on in-hospital and 60-day mortality was assessed using multinomial logit models with inverse probability of treatment weighting. Results Of a total 1351 patients with COVID-19 included (median [IQR] age, 64 [52-75] years; 47.7% women, 48.9% Black patients), only 18 (1.3%) had a confirmed VTE, and 219 (16.2%) received treatment-dose anticoagulation. Use of treatment-dose anticoagulation without imaging ranged from 0% to 29% across hospitals and increased over time (adjusted odds ratio [aOR], 1.46; 95% CI, 1.31-1.61 per week). Of 1127 patients who ever received anticoagulation, 392 (34.8%) missed 2 or more days of prophylaxis. Missed prophylaxis varied from 11% to 61% across hospitals and decreased markedly over time (aOR, 0.89; 95% CI, 0.82-0.97 per week). VTE nonadherence was associated with higher 60-day (adjusted hazard ratio [aHR], 1.31; 95% CI, 1.03-1.67) but not in-hospital mortality (aHR, 0.97; 95% CI, 0.91-1.03). Receiving any dose of anticoagulation (vs no anticoagulation) was associated with lower in-hospital mortality (only prophylactic dose: aHR, 0.36; 95% CI, 0.26-0.52; any treatment dose: aHR, 0.38; 95% CI, 0.25-0.58). However, only the prophylactic dose of anticoagulation remained associated with lower mortality at 60 days (prophylactic dose: aHR, 0.71; 95% CI, 0.51-0.90; treatment dose: aHR, 0.92; 95% CI, 0.63-1.35). Conclusions and Relevance This large, multicenter cohort of patients hospitalized with COVID-19, found evidence of rapid dissemination and implementation of anticoagulation strategies, including use of treatment-dose anticoagulation. As only prophylactic-dose anticoagulation was associated with lower 60-day mortality, prophylactic dosing strategies may be optimal for patients hospitalized with COVID-19.

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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 Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance. Hospitals often use pre-prescription approval or prospective audit and feedback to target fluoroquinolone prescribing. Whether these strategies impact aggregate fluoroquinolone use is unknown. Methods This study is a 48-hospital, retrospective cohort of general-care, medical patients hospitalized with pneumonia or positive urine culture between December 2015–September 2017. Hospitals were surveyed on their use of pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing during hospitalization (fluoroquinolone stewardship). After controlling for hospital clustering and patient factors, aggregate (inpatient and post-discharge) fluoroquinolone (ciprofloxacin, levofloxacin, moxifloxacin) exposure was compared between hospitals with and without fluoroquinolone stewardship. Results There were 11 748 patients (6820 pneumonia; 4928 positive urine culture) included at 48 hospitals. All hospitals responded to the survey: 29.2% (14/48) reported using pre-prescription approval and/or prospective audit and feedback to target fluoroquinolone prescribing. After adjustment, fluoroquinolone stewardship was associated with fewer patients receiving a fluoroquinolone (37.1% vs 48.2%; P = .01) and fewer fluoroquinolone treatment days per 1000 patients (2282 vs 3096 days/1000 patients; P = .01), driven by lower inpatient prescribing. However, most (66.6%) fluoroquinolone treatment days occurred after discharge, and hospitals with fluoroquinolone stewardship had twice as many new fluoroquinolone starts after discharge as hospitals without (15.6% vs 8.4%; P = .003). Conclusions Hospital-based stewardship interventions targeting fluoroquinolone prescribing were associated with less fluoroquinolone prescribing during hospitalization, but not at discharge. To limit aggregate fluoroquinolone exposure, stewardship programs should target both inpatient and discharge prescribing., In this 48-hospital cohort study of 11 748 patients hospitalized with pneumonia or positive urine cultures, hospital-based antibiotic stewardship interventions targeting fluoroquinolone prescribing were associated with less fluoroquinolone use during hospitalization, but appeared to partially increase fluoroquinolone prescribing at discharge.

Key Points Question Is approval by an infectious disease physician prior to placement of a peripherally inserted central catheter (PICC) for intravenous antimicrobials associated with appropriate device use or complications? Findings In this cohort study of 21 653 PICCs placed for intravenous antimicrobials in 42 hospitals, 47% of PICCs were placed with approval of an infectious disease physician. Compared with nonapproved PICCs, approved PICCs were more likely to be appropriately placed, and the patients less likely to experience complications. Meaning This cohort study suggests that infectious disease physician approval of PICCs prior to placement for intravenous antimicrobial therapy is associated with more appropriate device use and fewer complications., Importance Peripherally inserted central catheters (PICCs) are frequently used to deliver intravenous antimicrobial therapy. However, inappropriate PICC use may lead to patient harm. Objective To evaluate whether infectious disease physician approval prior to PICC placement for intravenous antimicrobials is associated with more appropriate device use and fewer complications. Design, Setting, and Participants This cohort study of 21 653 PICCs placed for a primary indication of intravenous antimicrobial therapy between January 1, 2015, and July 26, 2019, was conducted in 42 hospitals participating in a quality collaborative across Michigan among hospitalized medical patients. Main Outcomes and Measures Appropriateness of PICCs was defined according to the Michigan Appropriateness Guide for Intravenous Catheters as a composite measure of (1) single-lumen catheter use, (2) avoiding use of PICCs for 5 days or less, and (3) avoiding use of PICCs for patients with chronic kidney disease (defined as an estimated glomerular filtration rate, This cohort study evaluates whether infectious disease physician approval prior to placement of a peripherally inserted central catheter (PICC) for intravenous antimicrobials is associated with more appropriate device use and fewer complications.

Background Antibacterials may be initiated out of concern for bacterial coinfection in coronavirus disease 2019 (COVID-19). We determined prevalence and predictors of empiric antibacterial therapy and community-onset bacterial coinfections in hospitalized patients with COVID-19. Methods A randomly sampled cohort of 1705 patients hospitalized with COVID-19 in 38 Michigan hospitals between 3/13/2020 and 6/18/2020. Data were collected on early (within 2 days of hospitalization) empiric antibacterial therapy and community-onset bacterial coinfections (positive microbiologic test ≤3 days). Poisson generalized estimating equation models were used to assess predictors. Results Of 1705 patients with COVID-19, 56.6% were prescribed early empiric antibacterial therapy; 3.5% (59/1705) had a confirmed community-onset bacterial infection. Across hospitals, early empiric antibacterial use varied from 27% to 84%. Patients were more likely to receive early empiric antibacterial therapy if they were older (adjusted rate ratio [ARR]: 1.04 [1.00–1.08] per 10 years); had a lower body mass index (ARR: 0.99 [0.99–1.00] per kg/m2), more severe illness (eg, severe sepsis; ARR: 1.16 [1.07–1.27]), a lobar infiltrate (ARR: 1.21 [1.04–1.42]); or were admitted to a for-profit hospital (ARR: 1.30 [1.15–1.47]). Over time, COVID-19 test turnaround time (returned ≤1 day in March [54.2%, 461/850] vs April [85.2%, 628/737], P < .001) and empiric antibacterial use (ARR: 0.71 [0.63–0.81] April vs March) decreased. Conclusions The prevalence of confirmed community-onset bacterial coinfections was low. Despite this, half of patients received early empiric antibacterial therapy. Antibacterial use varied widely by hospital. Reducing COVID-19 test turnaround time and supporting stewardship could improve antibacterial use.

Health care-associated infection (HAI) is associated with substantial harm. To reduce HAI, the largest integrated health care system in the United States-the Veterans Health Administration-was an early adopter of infection prevention policies and initiatives. Whether these efforts translated into increased use of practices to prevent HAI in Veterans Affairs (VA) hospitals is unknown.To evaluate changes over time in infection prevention practices and the perception of the importance of infection prevention to hospital leadership.For this survey study, every 4 years between 2005 and 2017, infection preventionists were surveyed at all VA hospitals on use of practices associated with common HAIs, including central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP), and (beginning in 2013) Clostridioides difficile infection. Data analysis was performed from February 1, 2019, to July 1, 2019.Reported regular use of key infection prevention practices and perceived importance of infection prevention to hospital leadership.Between 2005 and 2017, 320 total surveys were completed with response rates ranging from 59% (73 of 124) in 2017 to 80% (95 of 119) in 2005. Use of 12 different infection prevention practices increased. Since 2013, 92% (69 of 75) to 100% of VA hospitals reported regular use of key infection prevention practices for C difficile infection and CLABSI. In contrast, adoption of many practices to prevent CAUTI, although increasing, have lagged. Despite reported increases in the use of some practices for VAP such as semirecumbent positioning (89% [79 of 89] in 2005 vs 97% [61 of 63] in 2017, P = .007 for trend) and subglottic secretion drainage (23% [19 of 84] in 2005 vs 65% [40 of 62] in 2017, P .001), use of other key practices such as daily interruptions of sedation (85% [55 of 65] in 2009 vs 87% [54 of 62] in 2017, P = .66) and early mobilization (81% [52 of 64] in 2013 vs 82% [51 of 62] in 2017, P = .88) has not increased. Antibiotic stewardship programs are now reported in nearly every VA hospital (97% [71 of 73]); however, some hospitals report practices for microbiologic testing for HAIs (eg, 22% [16 of 72] report routine urine culture testing in 2017) that could also contribute to antibiotic overuse.From 2005 to 2017, reported use of 12 different infection prevention practices increased in VA hospitals. Areas for continued improvement of infection prevention practices appear to include CAUTI, certain VAP practices, and diagnostic stewardship for HAI. The reported adoption of many infection prevention practices in VA hospitals was higher than in non-VA hospitals. As hospitals continue to merge and health systems become increasingly integrated, these successes could help inform patient safety broadly.

Background: Between 2007 and 2015, inpatient fluoroquinolone use declined in US Veterans’ Affairs (VA) hospitals. Whether fluoroquinolone use at discharge has also declined, in particular since antibiotic stewardship programs became mandated at VA hospitals in 2014, is unknown. Methods: In this retrospective cohort study of hospitalizations with infection between January 1, 2014, and December 31, 2017, at 125 VA hospitals, we assessed inpatient and discharge fluoroquinolone (ciprofloxacin, levofloxacin, and moxifloxacin) use as (1) proportion of hospitalizations with a fluoroquinolone prescribed and (2) fluoroquinolone days per 1,000 hospitalizations. After adjusting for illness severity, comorbidities, and age, we used multilevel logit and negative binomial models to assess for hospital-level variation and longitudinal prescribing trends. Results: Of 560,219 hospitalizations meeting inclusion criteria as hospitalizations with infection (Fig. 1), 209,602 of 560,219 (37.4%) had a fluoroquinolone prescribed either during hospitalization (182,337 of 560,219, 32.5%) or at discharge (110,003 of 560,219, 19.6%) (Fig. 1). Hospitals varied appreciably in inpatient, discharge, and total fluoroquinolone use, with 71% of hospitals in the highest prescribing quartile located in the southern United States. Nearly all measures of fluoroquinolone use decreased between 2014 and 2017, with the largest decreases found in inpatient fluoroquinolone and ciprofloxacin use (Fig. 2). In contrast, there was minimal decline in fluoroquinolone use at discharge (Fig. 2), which accounted for 1,433 of 2,339 (61.3%) of hospitalization-related fluoroquinolone days by 2017. Between 2014 and 2017, fluoroquinolone use decreased in VA hospitals, largely driven by a decrease in inpatient fluoroquinolone (especially ciprofloxacin) use. Fluoroquinolone prescribing at discharge, and levofloxacin prescribing overall, remain prime targets for stewardship.Funding: This work was funded by a locally initiated project grant from the Center for Clinical Management Research at the VA Ann Arbor Healthcare System.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.Disclaimer The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Background Data suggest hospitalists are less adherent to quality indicators for decompensated cirrhosis, and gastroenterology consultation may improve adherence. We sought to evaluate the impact of inpatient attending specialty and gastroenterology consultation on quality of care for decompensated cirrhosis. Methods This was a retrospective cohort study of patients with decompensated cirrhosis admitted to gastroenterology or hospitalist service at the University of Michigan between 2016-2020. The primary outcome was adherence to nationally recommended inpatient quality indicators for ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, and gastrointestinal bleeding. Performance was calculated per patient admission as the proportion of quality indicators met vs quality indicators for which the patient was eligible. Quality indicator scores were compared between services using t-tests. We also evaluated the effect of gastroenterology consultation on quality indicator scores for patients admitted to hospitalist service. Clinical outcomes were compared using multivariable models adjusted for patient characteristics. Results Two hundred eighty-eight admissions were included (155 to gastroenterology service; 133 to hospitalist service). Quality indicator score for all admissions was 69.9% (standard deviation [SD] ± 24.2%). Quality indicator scores were similar between gastroenterology (69.9%, SD ± 23.6%) and hospitalist (69.8%, SD ± 25.1%) services (P = .913). There was no difference in quality indicator subscores for each complication between services. Hospitalists placed a gastroenterology consultation in 53.4% of admissions, and it was associated with higher albumin administration for patients with spontaneous bacterial peritonitis (57.1% vs 25%, P = .044). Patients admitted to gastroenterology service had higher readmissions within 30 days (adjusted odds ratio = 1.95) and shorter length of hospitalization (adjusted rate ratio = 0.85). Conclusions Hospitalists provided comparable quality of care to gastroenterologists for inpatients with decompensated cirrhosis.

Background Antibiotic therapy has no known benefit against COVID-19, but is often initiated out of concern for concomitant bacterial infection. We sought to determine how common early empiric antibiotic therapy and community-onset bacterial co-infections are in hospitalized patients with COVID-19. Methods In this multi-center cohort study of hospitalized patients with COVID-19 discharged from 32 Michigan hospitals during the COVID-19 Michigan surge, we describe the use of early empiric antibiotic therapy (within the first two days) and prevalence of community-onset bacterial co-infection. Additionally, we assessed patient and hospital predictors of early empiric antibiotic using poison generalized estimating equation models. Results Between 3/10/2020 and 5/10/2020, data were collected on 951 COVID-19 PCR positive patients. Patient characteristics are described in Table 1. Nearly two thirds (62.4%, 593/951) of COVID-19 positive patients were prescribed early empiric antibiotic therapy, most of which (66.2%, 393/593) was directed at community-acquired pathogens. Across hospitals, the proportion of COVID-19 patients prescribed early empiric antibiotics varied from 40% to 90% (Figure 1). On multivariable analysis, patients were more likely to receive early empiric antibiotic therapy if they were older (adjusted rate ratio [ARR]: 1.01 [1.00–1.01] per year), required respiratory support (e.g., low flow oxygen, ARR: 1.16 [1.04–1.29]), had signs of a bacterial infection (e.g., lobar infiltrate, ARR: 1.17 [1.02–1.34]), or were admitted to a for-profit hospital (ARR: 1.27 [1.11–1.45]); patients admitted later were less likely to receive empiric antibiotics (April vs. March, ARR: 0.72 [0.62–0.84], Table 2). Community-onset bacterial co-infections were identified in 4.5% (43/951) of COVID-19 positive patients (2.4% [23/951] positive blood culture; 1.9% [18/951] positive respiratory culture). Conclusion Despite low prevalence of community-onset bacterial co-infections, patients hospitalized with COVID-19 often received early empiric antibiotic therapy. Given the potential harms from unnecessary antibiotic use, including additional personal protective equipment to administer antibiotics, judicious antibiotic use is key in hospitalized patients with COVID-19. Disclosures Tejal N. Gandhi, MD, Blue Cross Blue Shield of Michigan (Grant/Research Support) Scott A. Flanders, MD, Agency for Healthcare Research and Quality (Research Grant or Support)Blue Cross Blue Shield of Michigan (Research Grant or Support)

Central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infection (CAUTI) are costly and morbid. Despite evidence-based guidelines, Some intensive care units (ICUs) continue to have elevated infection rates. In October 2015, we performed a systematic search of the peer-reviewed literature within the PubMed and Cochrane databases for interventions to reduce CLABSI and/or CAUTI in adult ICUs and synthesized findings using a narrative review process. The interventions were categorized using a conceptual model, with stages applicable to both CAUTI and CLABSI prevention: (stage 0) avoid catheter if possible, (stage 1) ensure aseptic placement, (stage 2) maintain awareness and proper care of catheters in place, and (stage 3) promptly remove unnecessary catheters. We also looked for effective components that the 5 most successful (by reduction in infection rates) studies of each infection shared. Interventions that addressed multiple stages within the conceptual model were common in these successful studies. Assuring compliance with infection prevention efforts via auditing and timely feedback were also common. Hospitalists with patient safety interests may find this review informative for formulating quality improvement interventions to reduce these infections.

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.

OBJECTIVE: To evaluate the impact of changes to urine testing orderables in computerized physician order entry (CPOE) system on urine culturing practices. DESIGN: Retrospective before (January 2015 to April 2016) and after (May 2016 to August 2017) study. SETTING: A 1,250-bed academic tertiary referral center. PATIENTS: Hospitalized adults who had ≥1 urine culture performed during their stay. INTERVENTION: The intervention (implemented in April 2017) consisted of notifications to providers, changes to order sets and inclusion of the new urine culture reflex tests in commonly used order sets. We compared the urine culture rates before and after intervention, adjusting for temporal trends. RESULTS: During the study period, 18,954 inpatients (median age 62 years, 68.8% white and 52.3% female) had 24,569 urine cultures ordered. Twenty-seven percent (n=6642) of the urine cultures were positive. Urine culturing rate decreased significantly in the post-intervention period for any specimen type (38.1 pre-vs. 20.9 per 1000 patient days post-intervention, p

Background Most patients hospitalized with community-acquired pneumonia (CAP) can be safely treated with 5 days of antibiotics, but many are not. We determined whether a hospitalist-collaborative can reduce excess antibiotic duration in patients with CAP through partnership with antibiotic stewardship teams (AST), data feedback, pay-for-performance, and sharing best practices. Methods From April 2017 to October 2018, abstractors collected data (medical record, phone calls 30-days post-discharge) on adult, non-ICU patients hospitalized with CAP at 43 hospitals in Michigan. We used a guideline-based algorithm1 to determine appropriate antibiotic duration based on patient factors (e.g., clinical stability). All hospitals received a) quarterly reports on appropriate 5-day treatment rates (2016—current), b) best practice recommendations (2017—current) including toolkit and webinar (3/2018), and c) pay-for-performance based on 5-day CAP metric (2018—current). Generalized linear mixed models were used to evaluate change over time in a) proportion of patients with CAP eligible for 5-day treatment who received 5 ± 1 days and, after adjusting for patient factors and weighting by inverse probability of treatment, b) patient outcomes 30-days post-discharge. Results Of 6,229 patients hospitalized with CAP, 4,769 (76.6%) were eligible for 5-days of antibiotic treatment; 283 (5.9%) were excluded due to inability to determine antibiotic duration. Between April 2017 and October 2018, the proportion of patients eligible for a 5-day duration of antibiotic treatment who received 5 ± 1 days increased from 19.8% (181/914) to 30.9% (207/670; P = 0.01), a relative improvement of 56.1% (Figure 1). During this time period, there were no changes in 30-day post-discharge death, readmission, emergency room visit, Clostridioides difficile infection, or provider-documented antibiotic-associated adverse-events (Table 1). However, there was a decrease (3.3% to 1.7%, P = 0.03 for change over time; relative reduction: 48.5%) in patient-reported antibiotic-associated adverse events (Figure 2). Conclusion A hospitalist collaborative partnering with AST can safely reduce excess antibiotic duration and antibiotic-associated adverse-events in hospitalized patients with CAP. Disclosures All Authors: No reported Disclosures.

Background Fluoroquinolones increase the risk of Clostridioides difficile infection and antibiotic resistance, but are frequently used for hospitalized patients with bacteriuria. We assessed patterns and predictors of inappropriate fluoroquinolone (FQ) use among hospitalized patients with asymptomatic bacteriuria (ASB) and cystitis. Methods This is a retrospective cohort study of non-ICU medicine patients with ASB or cystitis (complicated or uncomplicated) from January 2018 to March 2019 at 43 Michigan hospitals. Patients with concomitant infections, bacteremia, or pyelonephritis were excluded. Each day of FQ (ciprofloxacin, levofloxacin) use (inpatient and post discharge) was assessed for appropriateness. FQ use was inappropriate if: (A) ASB, (B) urine culture with an FQ-resistant bacteria, (C) a safer alternative empiric or definitive antibiotic (treatment ≥2 days after urine culture collection) based on disease severity, cultures, allergies, and renal function, or (D) excess duration (>7 days complicated cystitis; >3 days uncomplicated cystitis). Hospitals were also surveyed on existing stewardship (ASP) practices targeting FQ use. ASP practices associated with inappropriate FQ use were evaluated using logistic generalized estimated equation models adjusting for patient factors and hospital clustering. Results Of 4849 included patients with ASB (39.7%) or cystitis (60.3%), 21.9% (n = 1,061) received an FQ and 92.7% (n = 984) received a, FQ inappropriately (Figure 1). Of 5,465 FQ days of therapy (DOT), 90.7% (n = 4,959) were inappropriate. Definitive treatment of complicated cystitis led to the greatest proportion of inappropriate FQ DOTs (50.6%), followed by ASB (36.4%) (Table 1). Hospitals varied (Figure 2), but those with cascade reporting of antibiotic susceptibilities, urinary tract infection (UTI) treatment guideline or an ASP performing prospective audit and feedback on FQ use had lower inappropriate FQ treatment rates (Table 2). Conclusion Hospitalized patients with ASB and cystitis often receive an FQ. Most FQ use is inappropriate due to ASB treatment or FQ use for complicated cystitis despite the option of an alternative antibiotic. Prospective audit and feedback, UTI guidelines, and cascade reporting of antibiotic susceptibilities can be used by ASP to reduce inappropriate FQ use. Disclosures All authors: No reported disclosures.

Background Antibiotics prescribed at hospital discharge account for half of antibiotic use related to hospitalization for urinary tract infection or bacterial pneumonia. It is unclear how much antibiotic use at discharge represents overuse, and thus, could potentially be improved through antibiotic stewardship. Methods From July 2017 to December 2018, trained abstractors at 46 Michigan hospitals collected detailed data on a sample of adult, nonintensive care, hospitalized patients with bacteriuria or treated for community-acquired or healthcare-associated pneumonia (discharge diagnosis of pneumonia plus antibiotic treatment). Antibiotic prescriptions at discharge were assessed for overuse using a guideline-based hierarchical algorithm: evaluating first for unnecessary antibiotics (noninfectious/nonbacterial syndrome), then excess duration (antibiotics needed, but prescribed for longer than necessary), and finally avoidable fluoroquinolones (safer alternative antibiotic available) (Figure 1). For each disease state, descriptive results are shown with comparisons by t- or Fisher’s exact tests. Results Of 17,157 patients (7,283 with bacteriuria; 9,874 treated for pneumonia), 30.1% of patients with bacteriuria had asymptomatic bacteriuria and 11.4% of patients treated for pneumonia did not meet diagnostic criteria for pneumonia. The most common antibiotics prescribed at discharge were fluoroquinolones. Nearly half (43.6%) of patients had antibiotic overuse at discharge (33.8% bacteriuria, 50.9% pneumonia), with a median 4 days of overuse after discharge (Table 1). For bacteriuria, 45.0% of overuse days at discharge were due to unnecessary antibiotics; for pneumonia, 61.2% were due to excess antibiotic duration (Figure 2). Patients with community-acquired pneumonia and those with sepsis on admission had the highest rates of antibiotic overuse at discharge (Table 2). Conclusion In the largest assessment of antibiotics at discharge to-date, antibiotic overuse at discharge was extremely common. Specific targets for discharge stewardship vary by disease state. Notably, interventions may be more effective at reducing fluoroquinolone prescribing at discharge indirectly by stopping treatment for asymptomatic bacteriuria and reducing excess duration in pneumonia. Disclosures All Authors: No reported Disclosures.

The United States spends substantially more per capita for healthcare than any other nation. Defensive medicine is 1 source of such spending, but its extent is unclear. Using a national survey of approximately 1500 US hospitalists, we report the estimates the US hospitalists provided of the percent of resources spent on defensive medicine and correlates of their estimates. We also ascertained how many reported being sued. Sixty-eight percent of eligible recipients responded. Overall, respondents estimated that 37.5% of healthcare costs are due to defensive medicine. Just over 25% of our respondents, including 55% of those in practice for 20 years or more, reported being sued for medical malpractice. Veterans Affairs (VA) hospital affiliation, more years practicing as a physician, being male, and being a non-Hispanic white individual were all independently associated with decreased estimates of resources spent for defensive medicine.

BACKGROUNDClostridium difficileinfection (CDI) is the most common infectious cause of nosocomial diarrhea, and its prevention is an urgent public health priority. However, reduction of CDI is challenging because of its complex pathogenesis, large reservoirs of colonized patients, and the persistence of infectious spores. The literature lacks high-quality evidence for evaluating interventions, and many hospitals have implemented bundled interventions to reduce CDI with variable results. Thus, we conducted a systematic review to examine the components of CDI bundles, their implementation processes, and their impact on CDI rates.METHODSWe conducted a comprehensive literature search of multiple computerized databases from their date of inception through April 30, 2016. The protocol was registered in PROSPERO, an international prospective register of systematic reviews. Bundle effectiveness, adherence, and study quality were assessed for each study meeting our criteria for inclusion.RESULTSIn the 26 studies that met the inclusion criteria for this review, implementation and adherence factors to interventions were variably and incompletely reported, making study reproducibility and replicability challenging. Despite contextual differences and the variety of bundle components utilized, all 26 studies reported an improvement in CDI rates. However, given the lack of randomized controlled trials in the literature, assessing a causal relationship between bundled interventions and CDI rates is currently impossible.CONCLUSIONCluster randomized trials that include a rigorous assessment of the implementation of bundled interventions are urgently needed to causally test the effect of intervention bundles on CDI rates.Infect Control Hosp Epidemiol2017;38:639–650

Background Broad-spectrum (BS) antibiotics directed against Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) are commonly used for health-care associated pneumonia (HCAP) treatment. Many patients with HCAP do not have a microbiologically confirmed diagnosis. The goal of this study was to evaluate the impact of antibiotic de-escalation on clinical outcomes in patients with HCAP without a microbiological diagnosis. Methods This is a retrospective cohort study of adult, non-ICU, medical patients hospitalized with HCAP between January 2016 and February 2018 at 46 Michigan hospitals. Exclusions included extrapulmonary infection, severe immune suppression, or clinical instability on day 4. Included patients: (1) lacked any positive culture (blood/sputum); (2) started on empiric anti-P. aeruginosa and anti-MRSA therapy by hospital day 2; (3) switched to a narrow-spectrum (NS) regimen (no anti-P. aeruginosa or anti-MRSA coverage) or maintained on BS antibiotics (anti-P. aeruginosa ± anti-MRSA) by therapy day 4 (Figure 1). Mortality, readmission, Clostridium difficile infection, and adverse events from antibiotics were compared between the BS and NS groups. Data were analyzed using logistic generalized estimating equation models and inverse probability of treatment weighting. Results Of 363 patients with HCAP included, 73 (20%) were switched to an NS regimen. Of 290 patients maintained on anti-PSA BS regimens, 47.6% also continued anti-MRSA therapy. The median age was 72 (IQR, 61–81) and Charlson comorbidity index was 4 (IQR, 2–6) of the entire cohort. Baseline characteristics were similar between BS and NS groups, except more patients had chronic kidney disease in the BS group. On multivariable analysis, no other baseline factors were found to be associated with use of BS antibiotics on day 4. Both total and IV antibiotic duration were longer in the BS group (10 vs. 8 days, P = 0.002, and 4 vs. 3 days, P < 0.001, respectively). On adjusted analysis, there were no differences in patient outcomes (Figure 2). Conclusion Among patients with HCAP started on empiric MRSA and PSA coverage without microbiological diagnosis, clinical outcomes were similar in patients switched to an NS antibiotic and those maintained on BS antibiotics. Our findings suggest a potential role for antimicrobial stewardship in promoting antibiotic de-escalation in this population. Disclosures All authors: No reported disclosures.

Background Treatment of asymptomatic bacteriuria (ASB) is a major driver of inappropriate antibiotic use and an important target for antimicrobial stewardship. We identified patient- and hospital-level factors associated with treatment of ASB and its impact on patient outcomes. Methods In this retrospective cohort study, detailed data were abstracted from the medical record of adult non-ICU patients hospitalized with a positive urine culture (Ucx) between January 2016 and February 2018 at 46 Michigan hospitals. Exclusions included pregnancy, urologic surgery or abnormality, immune-compromise, or concomitant infection. ASB was defined as a positive Ucx without signs or symptoms attributable to a urinary tract infection (UTI). The treatment group received ≥1 antibiotic dose. Patient outcomes included mortality, readmissions, Clostridium difficile infection, and emergency room visits. Patient and hospital factors associated with ASB treatment were evaluated using logistic generalized estimating equation models; patient outcomes were inverse probability of treatment weighted. Results Of 2,733 included patients with ASB, 82.9% (n = 2,266) were treated with antibiotics for a median 7 days (IQR 4,9). Ceftriaxone (71.1%) was the most frequent initial therapy; fluoroquinolones (33.2%) were most common at discharge. In the multivariable model, patient variables associated with ASB treatment included: increased age, dementia, positive urinalysis, incontinence, indwelling urinary catheter, and nonambulatory status (Figure 1). Hospitals varied (Figure 2), but those that required a documented indication for antibiotics in the order or medical record had lower ASB treatment rates (OR = 0.5). There was no difference in patient outcomes for patients treated vs. not treated with antibiotics. Conclusion Antibiotic treatment of ASB, often broad-spectrum, is widespread. Certain patient characteristics (including advanced age, nonambulatory, dementia, and incontinence) and the misinterpretation of test results (including overemphasis of the urinalysis) drive clinicians to treat ASB. Requiring documentation of antibiotic indication may decrease inappropriate treatment. Future interventions may be more effective by incorporating these drivers of ASB treatment. Disclosures All authors: No reported Disclosures.

Importance Treatment of asymptomatic bacteriuria (ASB) with antibiotics is a common factor in inappropriate antibiotic use, but risk factors and outcomes associated with treatment of ASB in hospitalized patients are not well defined. Objective To evaluate factors associated with treatment of ASB among hospitalized patients and the possible association between treatment and clinical outcomes. Design, Setting, and Participants A retrospective cohort study was conducted from January 1, 2016, through February 1, 2018, at 46 hospitals participating in the Michigan Hospital Medicine Safety Consortium. A total of 2733 hospitalized medical patients with ASB, defined as a positive urine culture without any documented signs or symptoms attributable to urinary tract infection, were included in the analysis. Exposures One or more antibiotic dose for treatment of ASB. Main Outcomes and Measures Estimators of antibiotic treatment of ASB. Secondary outcomes included 30-day mortality, 30-day hospital readmission, 30-day emergency department visit, discharge to post–acute care settings,Clostridioides difficileinfection (formerly known asClostridium difficile) at 30 days, and duration of hospitalization after urine testing. Results Of 2733 patients with ASB, 2138 were women (78.2%); median age was 77 years (interquartile range [IQR], 66-86 years). A total of 2259 patients (82.7%) were treated with antibiotics for a median of 7 days (IQR, 4-9 days). Factors associated with ASB treatment included older age (odds ratio [OR], 1.10 per 10-year increase; 95% CI, 1.02-1.18), dementia (OR, 1.57; 95% CI, 1.15-2.13), acutely altered mental status (OR, 1.93; 95% CI, 1.23-3.04), urinary incontinence (OR, 1.81; 95% CI, 1.36-2.41), leukocytosis (white blood cell count >10 000/μL) (OR, 1.55; 95% CI, 1.21-2.00), positive urinalysis (presence of leukocyte esterase or nitrite, or >5 white blood cells per high-power field) (OR, 2.83; 95% CI, 2.05-3.93), and urine culture with a bacterial colony count greater than 100 000 colony-forming units per high-power field (OR, 2.30; 95% CI, 1.83-2.91). Treatment of ASB was associated with longer duration of hospitalization after urine testing (4 vs 3 days; relative risk, 1.37; 95% CI, 1.28-1.47). No other differences in secondary outcomes were identified after propensity weighting. Conclusions and Relevance Hospitalized patients with ASB commonly receive inappropriate antibiotic therapy. Antibiotic treatment did not appear to be associated with improved outcomes; rather, treatment may be associated with longer duration of hospitalization after urine testing. To possibly reduce inappropriate antibiotic use, stewardship efforts should focus on improving urine testing practices and management strategies for elderly patients with altered mental status.

Background Randomized trials demonstrate no benefit from antibiotic treatment exceeding the shortest effective duration. Objective To examine predictors and outcomes associated with excess duration of antibiotic treatment. Design Retrospective cohort study. Setting 43 hospitals in the Michigan Hospital Medicine Safety Consortium. Patients 6481 general care medical patients with pneumonia. Measurements The primary outcome was the rate of excess antibiotic treatment duration (excess days per 30-day period). Excess days were calculated by subtracting each patient's shortest effective (expected) treatment duration (based on time to clinical stability, pathogen, and pneumonia classification [community-acquired vs. health care-associated]) from the actual duration. Negative binomial generalized estimating equations (GEEs) were used to calculate rate ratios to assess predictors of 30-day rates of excess duration. Patient outcomes, assessed at 30 days via the medical record and telephone calls, were evaluated using logit GEEs that adjusted for patient characteristics and probability of treatment. Results Two thirds (67.8% [4391 of 6481]) of patients received excess antibiotic therapy. Antibiotics prescribed at discharge accounted for 93.2% of excess duration. Patients who had respiratory cultures or nonculture diagnostic testing, had a longer stay, received a high-risk antibiotic in the prior 90 days, had community-acquired pneumonia, or did not have a total antibiotic treatment duration documented at discharge were more likely to receive excess treatment. Excess treatment was not associated with lower rates of any adverse outcomes, including death, readmission, emergency department visit, or Clostridioides difficile infection. Each excess day of treatment was associated with a 5% increase in the odds of antibiotic-associated adverse events reported by patients after discharge. Limitation Retrospective design; not all patients could be contacted to report 30-day outcomes. Conclusion Patients hospitalized with pneumonia often receive excess antibiotic therapy. Excess antibiotic treatment was associated with patient-reported adverse events. Future interventions should focus on whether reducing excess treatment and improving documentation at discharge improves outcomes. Primary funding source Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program.

Background Community-acquired pneumonia (CAP) guidelines recommend transition to an oral (PO) β-lactam (BL) regimen or fluoroquinolone (FQ) when patients are clinically stable. Due to collateral damage associated with FQs, stewardship efforts often focus on reducing initial FQ use for CAP therapy. We hypothesized that FQ use remains prevalent in CAP treatment despite initial intravenous (IV) BL therapy, and examined factors associated with switching to a PO BL vs. an FQ and the impact on outcomes. Methods In this retrospective cohort study, data were collected from January 2016 through February 2018 on non-ICU medical patients admitted with CAP at 46 Michigan hospitals. Patients were included if they received IV BL (ceftriaxone or ampicillin-sulbactam) plus macrolide/doxycycline by hospital day 2 and switched to a PO respiratory FQ or BL by therapy day 4. Exclusions included positive culture, concomitant infection, HCAP, unstable on day 4, or severe immune deficiency. Data were analyzed using logistic generalized estimating equation models, accounting for hospital-level clustering; outcomes were adjusted using the inverse probability of treatment weighting by propensity scores. Results. Of 555 included patients, 54.4% were switched to a PO BL vs. 45.6% to an FQ by day 4 of therapy. The groups had similar durations of therapy (8 days), time to clinical stability, prior antibiotics, and COPD, but the BL group was older, with a higher Pneumonia Severity Index, CURB-65, and more cardiovascular (CV) disease (Figure 1). In multivariable analysis, CV disease and higher CURB-65 were more common and diabetes (DM) less common in the PO BL group (Figure 2). Sharing antibiotic use data with providers were associated with less FQ use (83.1% vs. 70.8%, OR 0.51, 95% CI 0.27, 0.97, P = 0.04). On adjusted analysis there were no differences in patient outcomes (Figure 3). Conclusion. Among CAP patients started on an IV BL regimen, nearly half were switched to a PO FQ by therapy day 4, including more patients with DM. Although there were sicker patients in the BL group, there were no differences in outcomes between cohorts. To reduce FQ use, stewardship programs should share antibiotic use data and provide guidance for step-down therapy in clinically stable CAP patients. Disclosures All authors: No reported disclosures.

Glycogen storage disease type Ia (GSD-Ia) profoundly impairs glucose release by the liver due to glucose-6-phosphatase (G6Pase) deficiency. An adeno-associated virus (AAV) containing a small human G6Pase transgene was pseudotyped with AAV8 (AAV2/8) to optimize liver tropism. Survival was prolonged in 2-week-old G6Pase (-/-) mice by 600-fold fewer AAV2/8 vector particles (vp), in comparison to previous experiments involving this model (2 x 10(9) vp; 3 x 10(11) vp/kg). When the vector was pseudotyped with AAV1, survival was prolonged only at a higher dose (3 x 10(13) vp/kg). The AAV2/8 vector uniquely prevented hypoglycemia during fasting and fully corrected liver G6Pase deficiency in GSD-Ia mice and dogs. The AAV2/8 vector has prolonged survival in three GSD-Ia dogs to11 months, which validated this strategy in the large animal model for GSD-Ia. Urinary biomarkers, including lactate and 3-hydroxybutyrate, were corrected by G6Pase expression solely in the liver. Glycogen accumulation in the liver was reduced almost to the normal level in vector-treated GSD-Ia mice and dogs, as was the hepatocyte growth factor (HGF) in GSD-Ia mice. These preclinical data demonstrated the efficacy of correcting hepatic G6Pase deficiency, and support the further preclinical development of AAV vector-mediated gene therapy for GSD-Ia.

Traditionally, generations of physicians have been taught that the evaluation of the febrile hospitalised patient consists of the ‘panculture;’ that is, microbiological culture of blood, urine, sputum or stool in search of an offending pathogen. Often, these laboratory tests are paired with complementary imaging such as chest or abdominal X-rays in order to elucidate sources of infection. Indeed, it is hard to find a ‘competent’ physician that has not developed this repertoire during the course of their practice. Although well established in clinical parlance, the term panculture was formally introduced in the medical literature in the 1990s in response to an article examining blood culture contamination in emergency department settings.1 Even at this juncture, the phrase introduced palpable anxiety. For example, some termed the practice a ‘knee-jerk’ response to fever. Others called for the term to be removed from medical discourse.2 Why the consternation regarding an ostensibly innocuous practice? As with most medical interventions, the practice of panculture to evaluate fever is associated with benefits and risks. For example, ordering pancultures in a febrile patient allows for retrieval of bacteria from multiple sites, thus informing decision-making with respect to source and severity of infection. In haemodynamically unstable patients or those at high risk of adverse events, the practice also allows for microbiological sampling prior to initiation of broad-spectrum antibiotics which may reduce subsequent yield. Finally, panculture data in association with imaging can inform management beyond diagnosis. For example, the presence of an anaerobic pathogen in blood in association with a right lower-lobe infiltrate helps clinch the diagnosis of aspiration pneumonia, and inform care beyond the management of fever. Despite these benefits, relying on pancultures in the setting of fever is also problematic for several reasons. First, culture of bodily fluids inherently assumes that all fever is infectious in …

UNLABELLED Among liver transplant recipients, development of post-transplant complications such as new-onset diabetes after transplantation (NODAT) is common and highly morbid. Current methods of predicting patient risk are inaccurate in the pre-transplant period, making implementation of targeted therapies difficult. We sought to determine whether analytic morphomics (using computed tomography scans) could be used to predict the incidence of NODAT. We analyzed peri-transplant scans from 216 patients with varying indications for liver transplantation, among whom 61 (28%) developed NODAT. Combinations of visceral fat, subcutaneous fat, and psoas area were considered in addition to traditional risk factors. On multivariate analysis adjusting for usual risk factors such as type of immunosuppression, subcutaneous fat thickness remained significantly associated with NODAT (OR = 1.43, 95% CI 1.00-1.88, p = 0.047). Subgroup analysis showed that patients with later-onset of NODAT had higher visceral fat, whereas subcutaneous fat thickness was more correlated with earlier-onset of NODAT (using 10 months post-transplant as the cut-off). CONCLUSION Analytic morphomics may be used to help assess NODAT risk in patients undergoing liver transplantation.

Background Acute pancreatitis is among the most common and costly reasons for hospitalization in the United States. Bowel rest, pain control, and intravenous fluids are the cornerstones of treatment, but early feeding might also be beneficial. Purpose To compare length of hospital stay, mortality, and readmission in adults hospitalized with pancreatitis who received early versus delayed feeding. Data sources MEDLINE via Ovid, EMBASE, the Cochrane Library, CINAHL, and Web of Science through January 2017. Study selection Two authors independently reviewed and selected studies if they were randomized clinical trials, included adults hospitalized with acute pancreatitis, and compared early versus delayed feeding (≤48 vs. >48 hours after hospitalization). Data extraction Two investigators independently extracted study data and rated risk of bias using the Cochrane Collaboration tool. Data synthesis Eleven randomized trials (8 peer-reviewed publications, 3 abstract-only presentations) that included 948 patients were eligible. Seven trials (3 with low risk of bias) enrolled patients with mild to moderate pancreatitis. Four trials (1 with low risk of bias) included patients with predicted severe pancreatitis. Routes used for early feeding included oral (4 studies), nasogastric (2 studies), nasojejunal (4 studies), and oral or nasoenteric (1 study). Among patients with mild to moderate pancreatitis, early feeding was associated with reduced length of stay in 4 of 7 studies (including 2 of 3 with low risk of bias). Other outcomes were heterogeneous and variably reported, but no study showed an increase in adverse events with early feeding. Among patients with severe pancreatitis, limited evidence revealed no statistically significant difference in outcomes between early and delayed feeding. Limitation Heterogeneity of feeding protocols and outcomes, scant data, and unclear or high risk of bias in several studies. Conclusion Limited data suggest that early feeding in patients with acute pancreatitis does not seem to increase adverse events and, for patients with mild to moderate pancreatitis, may reduce length of hospital stay. Primary funding source None. (PROSPERO: CRD42015016193).

Purpose To evaluate patterns and predictors of peripherally inserted central catheter (PICC)–related occlusion. Materials and Methods Data from a multihospital study were used to examine factors associated with PICC occlusion. Occlusion was defined if documented in the medical record or when tissue plasminogen activator was administered for occlusion-related concerns. Mixed-effects logistic regression was used to predict occlusion, controlling for patient-, provider-, device-, and hospital-level characteristics. Results A total of 14,278 PICCs placed in 13,408 patients were included. Of these, occlusion developed in 1,716 PICCs (12%) in 1,684 patients. The most common indications for PICC insertion were intravenous antibiotic therapy (32.7%), difficult intravenous access (21.5%), and central access (13.7%). PICCs placed in the right arm had decreased odds of occlusion compared with those in the left arm (odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.72–0.94). Verification of catheter tip position following insertion was associated with reduction in occlusion (OR = 0.75; 95% CI = 0.61–0.92). Although normal saline solution or heparin flushes did not reduce occlusion, PICCs flushed with normal saline solution and “locked” with heparin were less likely to become occluded (OR = 0.54; 95% CI = 0.33–0.88). Compared with single-lumen devices, double- and triple-lumen PICCs were associated with greater incidences of occlusion (double, OR = 3.07; 95% CI = 2.56–3.67; triple, OR = 3.72; 95% CI = 2.92–4.74). Catheter tip malposition was also associated with occlusion (OR = 1.46; 95% CI = 1.14–1.87). Conclusions Several patient, provider, and device characteristics appear associated with PICC occlusion. Interventions targeting these factors may prove valuable in reducing this complication.