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Background: Previous studies demonstrated a 'weekend effect' and a 'night effect' of increased mortality among patients admitted during weekends or night shifts, presumably due to understaffing. Aims: To examine whether death during hospitalisation follows a similar effect regardless of admission time. Methods: A retrospective cohort study among deceased patients hospitalised in the internal medicine wing of a tertiary medical centre in Israel, between 2019 and 2020. Demographic and medical data were retrieved from electronic medical charts. Causes of death were specifically categorised. We applied statistical models to test for differences in mortality using incidence rate ratio (IRR) according to the day, time and cause of death. Results: One thousand, two hundred and seventy‐eight deceased patients were included. All‐cause mortality was similar between weekends and weekdays. When sepsis was the cause of death, higher IRR were demonstrated on Fridays in comparison with weekdays (IRR 1.4; 95% confidence interval (CI) 1.1–1.9; P < 0.05). Other causes of death were not consistent with a 'weekend effect'. Mortality during night shifts was higher in comparison with the afternoon (IRR 1.5; 95% CI 1.3–4.7) and similar to the morning (IRR 1; 95% CI 0.9–1.2). Conclusion: Our study did not find a pattern of 'weekend effect' or 'night effect' on all‐cause mortality among hospitalised patients in internal medicine wards. Our findings suggest that perhaps specifically death from sepsis, and not all‐cause mortality, can be used as a surrogate for the measurement of understaffing or quality of care in the internal ward. [ABSTRACT FROM AUTHOR]

Summary: There is no consensus regarding the optimal duration of antibiotic therapy for urinary tract infection (UTI) following kidney transplantation (KT). We performed a retrospective study comparing short (6–10 days) versus prolonged (11–21 days) antibiotic therapy for complicated UTI among KT recipients. Univariate and inverse probability treatment weighted (IPTW) adjusted multivariate analysis for composite primary outcome of all‐cause mortality or readmissions within 30 days and relapsed UTI 180 days were performed. Overall, 214 KT recipients with complicated UTI were included; 115 short‐course treatment (median 8, interquartile range [IQR] 6–9 days), 99 prolonged course (median 14, IQR 12–21 days). The composite outcome occurred in 33 (28.6%) in the short‐course group and 30 (30%) in the prolonged‐course group; relapsed UTI occurred in 19 (16.5%) vs. 21 (21%), respectively. Duration of antibiotic treatment was not associated with any of these outcomes. The only risk factor for mortality/readmissions in multivariate analysis was deceased donor. No differences between groups were demonstrated for length of hospital stay, rates of bacteraemia, resistance development, and serum creatinine at 30 and 90 days. In conclusion, we found no difference in clinical outcomes between KT recipients treated for complicated UTI with short‐course antibiotic (6–10 days) versus longer course (11–21 days). [ABSTRACT FROM AUTHOR]

Little evidence exists addressing the clinical value of adding gentamicin to ampicillin for invasive listeriosis. A multicenter retrospective observational study of nonpregnant adult patients with invasive listeriosis (primary bacteremia, central nervous system (CNS) disease, and others) in 11 hospitals in Israel between the years 2008 and 2014 was conducted. We evaluated the effect of penicillin-based monotherapy compared with early combination therapy with gentamicin, defined as treatment started within 48 h of culture results and continued for a minimum of 7 days. Patients who died within 48 h of the index culture were excluded. The primary outcome was 30-day all-cause mortality. A total of 190 patients with invasive listeriosis were included. Fifty-nine (30.6%) patients were treated with early combination therapy, 90 (46.6%) received monotherapy, and 44 (22.8%) received other treatments. Overall 30-day mortality was 20.5% (39/190). Factors associated with mortality included lower baseline functional status, congestive heart failure, and higher sequential organ failure assessment score. Source of infection, treatment type, and time from culture taken date to initiation of effective therapy were not associated with mortality. In multivariable analysis, monotherapy was not significantly associated with increased 30-day mortality compared with early combination therapy (OR 1.947, 95% CI 0.691–5.487). Results were similar in patients with CNS disease (OR 3.037, 95% CI 0.574–16.057) and primary bacteremia (OR 2.983, 95% CI 0.575–15.492). In our retrospective cohort, there was no statistically significant association between early combination therapy and 30-day mortality. A randomized controlled trial may be necessary to assess optimal treatment. [ABSTRACT FROM AUTHOR]

Carbapenem resistant Acinetobacter baumannii (CRAB) is a significant cause of hospital acquired bloodstream infections in patients with hematological malignancies. Data regarding outcomes in this group of patients are limited. We retrospectively analyzed mortality risk factors of hospitalized hematological patients with CRAB bacteremia in our center. Among 46 included patients, overall 7-day mortality was 72% (33/46). Risk factors for 7-day mortality in multivariate analysis were higher infection severity score (SOFA score) at presentation (OR 1.481, 95% CI 1.091–2.012, p =.012) while appropriate antibiotic therapy within 48 h was protective (OR 0.052, 95% CI 0.005–0.590, p =.017). Inappropriate antibiotic therapy within 24 h was not significantly associated with 7-day mortality nor was absolute neutrophil count. Thirty-day mortality was 96% (44/46). CRAB bacteremia in hematological patients is associated with extremely high mortality, regardless of therapy. Infection control measures and antimicrobial stewardship aiming to prevent this infection of dismal prognosis are of major importance. [ABSTRACT FROM AUTHOR]

Background: Ceftazidime/avibactam is approved for complicated intra-abdominal and urinary tract infections (UTIs) based on results from randomized controlled trials (RCTs). Data regarding its effectiveness in treating hospital-acquired infections or resistant pathogens have not been systematically compiled.Methods: A systematic review and meta-analysis including RCTs evaluating ceftazidime/avibactam versus comparator for the treatment of any infection. Primary outcome was 30 day all-cause mortality. Subgroups of hospital-acquired infections and specific resistance phenotypes were planned.Results: Seven publications (eight trials, 4093 patients) were included, reporting a baseline ∼25% of ESBL-carrying Enterobacteriaceae. No significant difference between ceftazidime/avibactam and comparator (mostly carbapenem) was demonstrated for 30 day all-cause mortality, late follow-up mortality and clinical response [relative risk (RR) 1.10, 95% CI 0.70-1.72, P = 0.69; RR 1.23, 95% CI 0.87-1.76, P = 0.25; RR 0.98, 95% CI 0.96-1.01, P = 0.21, respectively, without significant heterogeneity]. Higher microbiological response rate was demonstrated with ceftazidime/avibactam in patients with UTI (RR 1.14, 1.0-1.29, P = 0.05, I2 = 51%). No significant difference in clinical response was demonstrated for patients with ceftazidime-resistant pathogens (RR 1.02, 95% CI 0.94-1.10, P = 0.66, I2 = 0%). Results for other subgroups of resistant pathogens or hospital-acquired infection were not available. Serious adverse events (SAEs) were significantly more common with ceftazidime/avibactam (RR 1.24, 95% CI 1.00-1.54, P = 0.05, I2 = 0%).Conclusions: Ceftazidime/avibactam is clinically and microbiologically as effective as carbapenems for treatment of infections in a setting of ∼25% ESBL-carrying Enterobacteriaceae. Safety of the drug should be further evaluated owing to a higher rate of SAEs compared with carbapenems. Further studies should assess the drug's effectiveness in the treatment of carbapenemase-producing Enterobacteriaceae. [ABSTRACT FROM AUTHOR]

Polymerase chain reaction (PCR) for the diagnosis of Clostridium difficile infection (CDI) might result in overdiagnosis. The clinical outcomes of symptomatic CDI patients diagnosed by PCR remain uncertain. We aimed to determine whether patients whose diagnosis of CDI was based on PCR had different characteristics and clinical outcomes than those diagnosed by toxin immunoassay. Consecutive CDI patients, hospitalized at Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, between January 2013 and January 2016, were identified retrospectively and included in the study. Diagnosis of CDI was based on PCR or diagnosis by immunoassay for C. difficile toxin. The main outcome was 30- and 90-day all-cause mortality. The PCR group included 165 patients and the immunoassay group included 157 patients. In comparison to the immunoassay group, patients in the PCR group were more likely to be younger, to be independent, to undergo previous abdominal surgery, and to use laxatives. The 30-day mortality rate in the PCR group was significantly lower than that in the immunoassay group, 29/165 (18%) vs 49/157 (31%), respectively; p = 0.028. On multivariate analysis, PCR diagnosis was associated with reduced mortality, OR 0.48 (95% CI 0.26-0.88). PCR-based diagnosis of CDI is associated with reduced all-cause mortality rates. Further studies are needed to determine the management of patients with discrepant immunoassay and PCR diagnosis of CDI. [ABSTRACT FROM AUTHOR]

Abstract: Time to first antibiotic dose (TFAD) of 4h or 8h has been suggested as a quality measure for adult patients hospitalised with community-acquired pneumonia (CAP). Clinical evidence leading to implementation of this quality measure came from two large, retrospective studies. Following these studies, several prospective studies were conducted, with variable results. In a compilation of all observational studies to date, no significant benefit for short TFAD in terms of all-cause mortality was observed [unadjusted odds ratio (OR)=1.01, 95% confidence interval (CI) 0.79–1.29, 13 studies; adjusted OR=0.95, 95% CI 0.73–1.23, 14 studies]. Implementation of a requirement for short TFAD for CAP in the emergency department or other acute medical care setting may lead to unnecessary antibiotic treatment. We believe that attention should be shifted to early appropriate empirical antibiotic treatment for severe sepsis in hospital regardless of the source of infection, rather than focusing on CAP. [Copyright &y& Elsevier]

Background Tigecycline is a novel glycylcycline that exhibits broad-spectrum antibacterial activity. Recently, the US FDA issued a warning concerning increased mortality with tigecycline in randomized controlled trials (RCTs). Methods We conducted a systematic review and meta-analysis of RCTs that compared tigecycline with any other antibiotic regimen for the treatment of any infection. A comprehensive search, without publication status or other restrictions, was conducted. The primary outcome was overall 30 day mortality. The secondary outcome included clinical and microbiological failure, superinfections and adverse events (AEs). The trials’ risks of bias and their effects on results were assessed. Two reviewers independently extracted the data. Individual trials’ relative risks (RRs) were pooled using a fixed effect meta-analysis. Results Fifteen trials (7654 patients) were included. Overall mortality was higher with tigecycline compared with other regimens [RR 1.29, 95% confidence interval (CI) 1.02–1.64, without heterogeneity]. The type of infection assessed and the trials’ reported risks of bias did not affect this result. Clinical failure was significantly higher with tigecycline (RR 1.16, 95% CI 1.06–1.27) and non-statistically significant higher rates of microbiological failure were demonstrated (RR 1.13, 95% CI 0.99–1.30). Development of septic shock was significantly more frequent with tigecycline (RR 7.01, 95% CI 1.27–38.66). Superinfections were significantly more common with tigecycline and so were AEs, including all AEs and AEs requiring discontinuation. Conclusions In the light of the increased mortality, probably explained by decreased clinical and microbiological efficacy, clinicians should avoid tigecycline monotherapy in the treatment of severe infections and reserve it as a last-resort drug. [ABSTRACT FROM PUBLISHER]

Aim Most cases of Clostridium difficile infections (CDI) occur in patients aged 65 years and older. Older age is associated with increased mortality. Risk factors for mortality in patients aged 80 years and older are not well recognized. Methods We analyzed retrospective data including 184 patients aged 80 years and older hospitalized with CDI during 2009-2014. We aimed to delineate risk factors for short- and long-term mortality. Results The 30-day mortality was 33.2%; 1-year mortality was 64.7%. Median survival was 110 days (interquartile range 24-655 days). All four patients who underwent colectomy died. Risk factors for 30-day mortality in multivariate analysis were diabetes mellitus, low albumin and therapy other than metronidazole monotherapy, the latter probably reflecting higher severity of disease rather than a true predictor of mortality. Risk factors for long-term mortality analyzed in Cox regression were albumin ≤2.5 g/dL (HR 0.58, 95% CI 0.395-0.850), presentation with sepsis (HR 0.597, 95% CI 0.408-0.873), a non-independent activities of daily living baseline status (HR 0.460, 95% CI 0.236--0.897) and Charlson score (HR 0.867, 95% CI 0.801-0.938). None of the traditional severity indices for CDI (such as leukocytosis or creatinine increase) proved to be predictors of mortality over the age of 80 years. Conclusions The prognosis of old patients with CDI is dismal. Considering the high mortality, efforts to prevent CDI should be first priority in patients aged 80 years and older. Assessment of albumin levels should be part of the evaluation at presentation and considered when choosing treatment, rather than standard severity indexes for CDI. Geriatr Gerontol Int 2017; 17: 1378-1383. [ABSTRACT FROM AUTHOR]

The article discusses a randomized clinical trial which compared the efficacy of trimethoprim-sulfamethoxazo versus ancomycin for the treatment of severe infections due to meticillin resistant Staphylococcus aureus (MRSA). Topics covered include the study's design, participants and setting. The primary outcomes of the research are also described which include treatment failure and all cause mortality at day 30.

• Respiratory syncytial virus (RSV) is considered a major pathogen that causes acute influenza-like illness. • Pneumonia was more common in RSV patients than in influenza patients. • RSV was found to be a predictor of respiratory illness and complications. Respiratory syncytial virus (RSV) is considered a major pathogen that causes acute influenza-like illness. The objective of this study was to compare the clinical outcomes of patients with laboratory-confirmed RSV and patients with influenza infection. Adults hospitalized in Beilinson Hospital (October 2017–April 2018) with laboratory-confirmed RSV or influenza were included. The primary outcome was the composite of RSV/influenza complications: 30-day mortality, pneumonia, mechanical ventilation, vasopressor support, intensive care unit admission, and myocarditis/encephalitis. Secondary outcomes were individual components of the primary outcome, 90-day mortality, 90-day readmission, and length of hospital stay. A total of 639 patients with RSV (n = 113) and influenza (n = 526) were included. The composite primary outcome was 21.4% (136/633), and was higher in RSV patients (30% (34/113) vs 19% (102/526), p = 0.002). Pneumonia was more common in RSV patients (21.2% (24/113) vs 9.1% (48/526), p = 0.001). On multivariable analysis, hypoalbuminemia (odds ratio (OR) 3.3, 95% confidence interval (CI) 2.1–5.3, p < 0.001), reduced room-air saturation (OR 1.1, 95% CI 1.02–1.1, p = 0.001), and infection with RSV (OR 1.67, 95% CI 1.01–2.76, p = 0.046) were predictors of complications. RSV infection in hospitalized adults resulted in serious respiratory illness with complications that are comparable to those caused by influenza. [ABSTRACT FROM AUTHOR]