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Background: Obesity, race/ethnicity, and other correlated characteristics have emerged as high-profile risk factors for adverse coronavirus disease 2019 (COVID-19)-associated outcomes, yet studies have not adequately disentangled their effects., Objective: To determine the adjusted effect of body mass index (BMI), associated comorbidities, time, neighborhood-level sociodemographic factors, and other factors on risk for death due to COVID-19., Design: Retrospective cohort study., Setting: Kaiser Permanente Southern California, a large integrated health care organization., Patients: Kaiser Permanente Southern California members diagnosed with COVID-19 from 13 February to 2 May 2020., Measurements: Multivariable Poisson regression estimated the adjusted effect of BMI and other factors on risk for death at 21 days; models were also stratified by age and sex., Results: Among 6916 patients with COVID-19, there was a J-shaped association between BMI and risk for death, even after adjustment for obesity-related comorbidities. Compared with patients with a BMI of 18.5 to 24 kg/m 2 , those with BMIs of 40 to 44 kg/m 2 and greater than 45 kg/m 2 had relative risks of 2.68 (95% CI, 1.43 to 5.04) and 4.18 (CI, 2.12 to 8.26), respectively. This risk was most striking among those aged 60 years or younger and men. Increased risk for death associated with Black or Latino race/ethnicity or other sociodemographic characteristics was not detected., Limitation: Deaths occurring outside a health care setting and not captured in membership files may have been missed., Conclusion: Obesity plays a profound role in risk for death from COVID-19, particularly in male patients and younger populations. Our capitated system with more equalized health care access may explain the absence of effect of racial/ethnic and socioeconomic disparities on death. Our data highlight the leading role of severe obesity over correlated risk factors, providing a target for early intervention., Primary Funding Source: Roche-Genentech.

Objectives: To use a standardized tool for a multicenter assessment of antibiotic appropriateness in ICUs and identify local antibiotic stewardship improvement opportunities., Design: Pilot point prevalence conducted on October 5, 2016; point prevalence survey conducted on March 1, 2017., Setting: ICUs in 12 U.S. acute care hospitals with median bed size 563., Patients: Receiving antibiotics on participating units on March 1, 2017., Interventions: The Centers for Disease Control and Prevention tool for the Assessment of Appropriateness of Inpatient Antibiotics was made actionable by an expert antibiotic stewardship panel and implemented across hospitals. Data were collected by antibiotic stewardship program personnel at each hospital, deidentified and submitted in aggregate for benchmarking. hospital personnel identified most salient reasons for inappropriate use by category and agent., Measurements and Main Results: Forty-seven ICUs participated. Most hospitals (83%) identified as teaching with median licensed ICU beds of 70. On March 1, 2017, 362 (54%) of 667 ICU patients were on antibiotics (range, 8-81 patients); of these, 112 (31%) were identified as inappropriate and administered greater than 72 hours among all 12 hospitals (range, 9-82%). Prophylactic antibiotic regimens and PICU patients demonstrated a statistically significant risk ratio of 1.76 and 1.90 for inappropriate treatment, respectively. Reasons for inappropriate use included unnecessarily broad spectrum (29%), no infection or nonbacterial syndrome (22%), and duration longer than necessary (21%). Of patients on inappropriate antibiotic therapy in surgical ICUs, a statistically significant risk ratio of 2.59 was calculated for noninfectious or nonbacterial reasons for inappropriate therapy., Conclusions: In this multicenter point prevalence study, 31% of ICU antibiotic regimens were inappropriate; prophylactic regimens were often inappropriate across different ICU types, particularly in surgical ICUs. Engaging intensivists in antibiotic stewardship program efforts is crucial to sustain the efficacy of antibiotics and quality of infectious diseases care in critical care settings. This study underscores the value of standardized assessment tools and benchmarking to be shared with local leaders for targeted antibiotic stewardship program interventions.

We conducted a cohort study to identify characteristics associated with testing for, and testing positive for, coccidioidomycosis among patients with community-acquired pneumonia in southern California, USA. Limited and delayed testing probably leads to underdiagnosis among non-Hispanic black, Filipino, or Hispanic patients and among high-risk groups, including persons in whom antimicrobial drug therapy has failed.

Background: Despite recommendations to vaccinate surgical inpatients against influenza, vaccination rates remain low in this population, due in part to concerns about potential negative effects on postsurgical care., Objective: To evaluate whether influenza vaccination in the perioperative period increases health care utilization and evaluations for postsurgical infection after discharge., Design: Retrospective cohort study., Setting: Members of Kaiser Permanente Southern California., Participants: Patients aged 6 months or older who had inpatient surgery with admission and discharge between 1 September and 31 March from 2010 to 2013., Measurements: All influenza vaccinations administered between 1 August and 30 April in the 2010-2011, 2011-2012, and 2012-2013 influenza seasons. Outcomes included rates of outpatient visits, readmission, emergency department (ED) visits, fever (temperature ≥38.0 °C), and clinical laboratory evaluations for infection (urine culture, complete blood count, blood culture, and wound culture) in the 7 days after discharge., Results: Of the 42 777 surgeries included in adjusted analyses, vaccine was administered during hospitalization in 6420. No differences were detected between the vaccinated and unvaccinated groups in risk for inpatient visits (rate ratio [RR], 1.12 [95% CI, 0.96 to 1.32]), ED visits (RR, 1.07 [CI, 0.96 to 1.20]), postdischarge fever (RR, 1.00 [CI, 0.76 to 1.31]), or clinical evaluations for infection (RR, 1.06 [CI, 0.99 to 1.13]). A marginal increase in risk for outpatient visits (RR, 1.05 [CI, 1.00 to 1.10]; P = 0.032) was found., Limitation: The study did not distinguish between planned and unplanned readmissions or outpatient visits., Conclusion: No strong evidence of increased risk for adverse outcomes was found in comparisons of patients who received influenza vaccine during a surgical hospitalization and those who did not. The data support the recommendation to vaccinate surgical inpatients against influenza., Primary Funding Source: Centers for Disease Control and Prevention.

Background: Limitations in sample size, overly inclusive antibiotic classes, lack of adjustment of key risk variables, and inadequate assessment of cases contribute to widely ranging estimates of risk factors for Clostridium difficile infection (CDI)., Objective: To incorporate all key CDI risk factors in addition to 27 antibiotic classes into a single comprehensive model., Design: Retrospective cohort study., Setting: Kaiser Permanente Southern California., Patients: Members of Kaiser Permanente Southern California at least 18 years old admitted to any of its 14 hospitals from January 1, 2011, through December 31, 2012., Methods: Hospital-acquired CDI cases were identified by polymerase chain reaction assay. Exposure to major outpatient antibiotics (10 classes) and those administered during inpatient stays (27 classes) was assessed. Age, sex, self-identified race/ethnicity, Charlson Comorbidity Score, previous hospitalization, transfer from a skilled nursing facility, number of different antibiotic classes, statin use, and proton pump inhibitor use were also assessed. Poisson regression estimated adjusted risk of CDI., Results: A total of 401,234 patients with 2,638 cases of incident CDI (0.7%) were detected. The final model demonstrated highest CDI risk associated with increasing age, exposure to multiple antibiotic classes, and skilled nursing facility transfer. Factors conferring the most reduced CDI risk were inpatient exposure to tetracyclines and first-generation cephalosporins, and outpatient macrolides. CONCLUSIONS Although type and aggregate antibiotic exposure are important, the factors that increase the likelihood of environmental spore acquisition should not be underestimated. Operationally, our findings have implications for antibiotic stewardship efforts and can inform empirical and culture-driven treatment approaches.

Objective: To describe incidence rates (IRs) of polymerase chain reaction (PCR)-diagnosed Clostridium difficile infection (CDI) in a large high-risk cohort., Patients and Methods: Members of Kaiser Permanente Southern California 1 year or older who were admitted to any of 14 Kaiser Permanente hospitals from January 1, 2011, through December 31, 2012, were included in the study. The CDI cases were identified by PCR in the inpatient and outpatient settings. The CDI IRs per 10,000 inpatient-days are estimated by year, surveillance category, age, sex, race/ethnicity, and Charlson comorbidity index. Recurrence rates are presented by age, sex, and race/ethnicity. Death and colectomy in the 30 days after CDI diagnosis, white blood cell count, and serum creatinine level are assessed., Results: Among 268,655 patients, 4286 (1.6%) had CDI. Among these patients, 671 (15.7%) had recurrent infections. The IR was highest among community-onset, health care facility-associated infections (11.1 per 10,000 inpatient-days). The CDI IRs differed by age, sex, and race/ethnicity. Overall, 528 patients (12.3%) died within 30 days of a positive CDI test result. The CDI IRs increased 34% with implementation of PCR testing., Conclusion: Increasingly, PCR is being used because of its higher diagnostic sensitivity. Reassessing the epidemic using PCR updates our understanding of CDI risk. Our capacity to identify patients presenting in the outpatient setting after discharge provides a more accurate picture of health care-associated CDI rates, particularly because the community appears to assume an increasing role in CDI onset and possibly transmission. The CDI burden differs by race, comorbidity, sex, and previous health care use. The detected increase in CDI incidence after transitioning to PCR diagnosis was modest compared with previous studies., (Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)