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Background The IDSA guideline for CAP recommends Pneumococcal urinary antigen testing (UAT) in addition to blood and sputum cultures for patients with severe CAP. In controlled settings, UAT is 50–80% sensitive and >90% specific; however, its utility and performance on a large-scale in real-world use has not been assessed. It is unclear whether UAT is clinically useful or whether the results impact prescribing behavior. Methods Retrospective cohort study of adult patients admitted with CAP or HCAP from 2010 to 2015 at 170 US hospitals that submit data to Premier. Date and time-stamped administrative and microbiologic data were assessed. Patients with a principal diagnosis of pneumonia, or sepsis with a secondary diagnosis of pneumonia plus a CXR and antibiotics within the first 24 hours, were included if they had a UAT plus either a blood or respiratory culture within the first 48 hours of admission. Results Of 159,894 eligible pneumonia patients, 24,757 (15.5%) had UAT plus either blood or respiratory cultures performed. Of 1,797 (7%) who had a positive UAT, 457 (25%) also grew S. pneumoniae (SP) from blood or respiratory cultures, 1,240 (69%) had negative cultures, and 100 (6%) an organism other than SP, with S. aureus, Pseudomonas spp., and E.coli being the most common pathogens, predominantly from respiratory cultures. Among 22,960 patients with a negative UAT, 429 (2%) had a positive blood or respiratory culture for SP and 2,653 (12%) had a culture positive for another organism. UAT was performed among 18.4% of patients admitted to the ICU, and 15.3% of those admitted to wards. Among patients empirically started on broad-spectrum antibiotics, 35% who had a positive UAT were de-escalated by Day 5, compared with 49% who grew SP in blood cultures and 24% in respiratory cultures. Conclusion In a large representative US inpatient database, there was poor concordance between UAT and cultures for SP. A positive UAT decreased the probability of having a non-SP pathogen. Antibiotic de-escalation occurred more often in association with a positive blood culture for SP than for UAT or positive respiratory culture, but occurred in less than half the patients with these markers of pneumococcal pneumonia. Overall, UAT is underutilized and does not appear to have a substantial impact on clinical care. Disclosures S. Haessler, AHRQ: Investigator, Research grant; P. C. Yu, AHRQ: Investigator, Research grant; M. Rothberg, AHRQ: Investigator, Research grant

Background For patients at risk for multidrug resistant organisms, IDSA/ATS guidelines recommend empiric therapy with 1 agent against methicillin-resistant Staphylococcus aureus (MRSA) and another against Pseudomonas. Following negative cultures, guidelines are unclear regarding antibiotic de-escalation. We assessed de-escalation and associated outcomes in a cohort of pneumonia patients with negative cultures. Methods We included adults admitted with pneumonia from 2010- 2015 to 168 US hospitals if they had blood/respiratory cultures and received vancomycin together with an antipseudomonal drug other than a quinolone by hospital day 1. We excluded patients with positive cultures, death or discharge by day 4. De-escalation was defined as stopping both drugs by day 4, but continuing another antibiotic. Patients were matched on propensity for de-escalation and compared on late deterioration, inpatient mortality, length of stay (LOS), cost and 30-day readmission. The propensity model included demographics, co-morbidities and treatments on day 4, which served as proxies for clinical severity. We also compared adjusted outcomes across hospital quartile of de-escalation. Results Of 22,400 patients included, 4121 (18.4 %) had both drugs stopped within 4 days. Median age was 72 years, 56% were female, and 39% were admitted to the intensive care unit (ICU). Compared with patients without de-escalation, those de-escalated had similar demographics, but fewer co-morbidities and less severe disease at days 1 and 4. After propensity-matching, there were no significant differences in 83 variables. In the matched sample, de-escalated patients had lower odds of inpatient mortality (OR 0.71, 95% CI 0.60 – 0.83), subsequent transfer to ICU (OR 0.31; 95% CI 0.19 – 0.52), LOS (OR 0.79, 95% CI 0.77 – 0.80) and lower costs (OR 0.79, 95% CI 0.77 – 0.80). Hospital rates of de-escalation ranged from 0–67%. Hospital de-escalation quartile was not significantly associated with any outcome. Conclusion In a sample of US hospitals

Influenza infection most commonly affects the upper and lower respiratory tracts, but can involve extrapulmonary sites, including the myocardium. We report on a case of myocarditis caused by documented 2009 pandemic H1N1 influenza in a previously healthy adult, and review the literature on influenza myocarditis.

The Hawthorne effect was first described in the 1950s, based on an analysis of experiments conducted three decades earlier at the Hawthorne works of the Western Electric Company in Illinois.1 These investigations of ways to improve productivity show that regardless of the intervention—changes in factory illumination, changes in the structure of breaks or even changes back to the original working conditions—worker productivity increased. While many have debated the meaning of these results,2 ,3 a common, basic interpretation has been that the attention received by participants in an experiment can itself alter the outcomes of the study. The concept that subjects behave differently in experimental settings has had an enduring impact in social sciences research.3 In medical research, the Hawthorne effect is seen as a type of bias, as patients seem to fare better by simply participating in a clinical trial, presumably due to the increased attention paid to participants, and the benefits of being watched.4 The effect has been most convincingly demonstrated in a study of intense versus minimal follow-up among patients with dementia receiving Gingko supplements, showing that the act of frequent follow-up visits rather than the administration of a medication led to improved patient outcomes.5 Unlike the placebo effect,6 where patients in a placebo arm experience a real change in symptoms while taking an inert substance, the Hawthorne effect represents a social phenomenon driven by a desire to please and meet the expectations of the researcher.7 In healthcare epidemiology, direct observation has long been the gold standard for monitoring hand hygiene compliance rates. Yet, many are worried that the Hawthorne effect inflates rates of hand hygiene compliance generated by direct observation. Healthcare workers will be more likely to perform hand hygiene when they know that a monitor is observing them. …

To examine the impact of hospital-onset Clostridium difficile infection (HOCDI) on the outcomes of patients with sepsis.Most prior studies that have addressed this issue lacked adequate matching to controls, suffered from small sample size, or failed to consider time to infection.Retrospective cohort study.We identified adults with a principal or secondary diagnosis of sepsis who received care at 1 of the institutions that participated in a large multihospital database between July 1, 2004 and December 31, 2010. Among eligible patients with sepsis, we identified patients who developed HOCDI during their hospital stay.We used propensity matching and date of diagnosis to match cases to patients without Clostridium difficile infections and compared outcomes between the 2 groups.Of 218,915 sepsis patients, 2368 (1.08%) developed HOCDI. Unadjusted in-hospital mortality was significantly higher in HOCDI patients than controls (25% vs 10%, P 0.001). After multivariate adjustment, in-hospital mortality rate was 24% in cases vs. 15% in controls. In an analysis limited to survivors, adjusted length of stay (LOS) among cases with Clostridium difficile infections was 5.1 days longer than controls (95% confidence interval: 4.4-5.8) and the median-adjusted cost increase was $4916 (P 0.001).After rigorous adjustment for time to diagnosis and presenting severity, hospital-acquired Clostridium difficile infection was associated with increased mortality, LOS, and cost. Our results can be used to assess the cost-effectiveness of prevention programs and suggest that efforts directed toward high-risk patient populations are needed.

Background Despite ample evidence that hand hygiene (HH) can reduce nosocomial infections, physician compliance remains low. The authors hypothesised that attending physician role modelling and peer pressure among internal medicine teams would impact HH adherence. Methods Nine teams were covertly observed. Team member entry and exit order, and adherence to HH were recorded secretly. The mean HH percentage across encounters was estimated by compliance of the first person entering and exiting an encounter, and by the attending physician's HH compliance. Results 718 HH opportunities prior to contact and 744 opportunities after contact were observed. If the first person entering a patient encounter performed HH, the mean compliance of other team members was 64%, but was only 45% if the first person failed to perform HH (p=0.002). When the attending physician performed HH upon entering the patient encounter, the mean HH compliance was 66%, but only 42% if the attending physician did not perform HH (p

The clinical findings of influenza overlap those of community-acquired bacterial pneumonia (CABP), and influenza infection can be complicated by bacterial infections. Reviewed here are the epidemiology, pathophysiology, diagnosis, and management of community-acquired pneumonia (CAP) with special emphasis on considerations during influenza season.

Background and objectives: Antibiotic locks in catheter-dependent chronic hemodialysis patients reduce the rate of catheter-related blood stream infections (CRIs), but there are no data regarding the long-term consequences of this practice. Design, setting, participants, & measurements: Over a 4-year period, from October 1, 2002, to September 30, 2006, we initiated a gentamicin and heparin lock (GHL) protocol in 1410 chronic hemodialysis patients receiving dialysis through a tunneled catheter in eight outpatient units. Results: Within the first year of the GHL protocol, our CRI rate decreased from 17 to 0.83 events per 1000 catheter-days. Beginning 6 months after initiation of the GHL protocol, febrile episodes occurred in 13 patients with coagulase-negative Staphylococcus bacteremia resistant to gentamicin. Over the 4 years of GHL use, an additional 10 patients developed 11 episodes of gentamicin-resistant CRI (including 7 with Enterococcus faecalis), in which there were 4 deaths, 2 cases of septic shock requiring intensive care unit admission, and 4 cases of endocarditis. Because of these events, the GHL protocol was discontinued at the end of 2006. Conclusions: Although the use of GHL effectively lowered the CRI rate in our dialysis population, gentamicin-resistant CRIs emerged within 6 months. Gentamicin-resistant infections are a serious complication of the long-term use of GHLs. Alternative nonantibiotic catheter locks may be preferable to decrease the incidence of CRIs without inducing resistant pathogens.

Influenza is a seasonal viral infection associated with significant morbidity and mortality. In 2009, a novel H1N1 influenza A virus emerged and has been classified as a pandemic. In contrast to seasonal influenza, severe disease from pandemic H1N1 seems concentrated in older children and young adults, with almost no cases reported in patients older than 60 yrs. Although patients with underlying cardiopulmonary disease remain at risk, most complications have occurred among previously healthy individuals, with obesity and respiratory disease as the strongest risk factors. Pulmonary complications are common. Primary influenza pneumonia occurs most commonly in adults and may progress rapidly to acute lung injury requiring mechanical ventilation. Secondary bacterial infection is more common in children. Staphylococcus aureus, including methicillin-resistant strains, is an important cause of secondary bacterial pneumonia with a high mortality rate. Treatment of pneumonia should include empirical coverage for this pathogen. Neuromuscular and cardiac complications are unusual but may occur.

Staphylococcus aureus (SA) is becoming increasingly resistant to antibiotics in hospitals and the community. Long-term outcomes following susceptible and resistant SA infection have not been studied. We performed a retrospective matched pair analysis of all patients with positive culture for meticillin-resistant SA (MRSA) or meticillin-susceptible SA (MSSA) from any site to assess the outcomes of infection. Data were collected for length of hospitalisation and in-hospital mortality, as well as longer-term outcomes including all-cause mortality, number of rehospitalisations and subsequent cultures for SA during the year following infection. Twelve months after their initial SA infection, 42% of patients were dead. There were no differences between the groups in short-term mortality, length of hospitalisation, number of subsequent hospitalisations and cultures for SA during the year following infection. Following discharge, however, MRSA infection was associated with higher mortality than MSSA at three months (32% vs 18% P=0.02), six months (42% vs 22% P=0.002) and 12 months (51% vs 32% P=0.005). In conclusion, SA infection is associated with a high one-year all-cause mortality. Most deaths occur after discharge. The likelihood of dying during the year following infection is higher for patients with MRSA infection than for those with MSSA infection.