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OBJECTIVES: Compare the clinical practice and outcomes in severe community-acquired pneumonia (sCAP) patients to those in non-sCAP patients using guideline-defined criteria for sCAP. DESIGN: Retrospective observational cohort study. SETTING: One hundred seventy-seven U.S. hospitals within the Premier Healthcare Database. PATIENTS: Hospitalized adult (≥ 18 yr old) patients with pneumonia. MEASUREMENTS AND MAIN RESULTS: Adult patients (≥ 18 yr old) with a principal diagnosis of pneumonia or a secondary diagnosis of pneumonia paired with a principal diagnosis of sepsis or respiratory failure were included. Patients with at least one guideline-defined major criterion for severe pneumonia were compared with patients with nonsevere disease. Among 154,799 patients with pneumonia, 21,805 (14.1%) met criteria for sCAP. They had higher organ failure scores (1.9 vs 0.63; p < 0.001) and inpatient mortality (22.0 vs 5.0%; p < 0.001), longer lengths of stay (8 vs 5 d; p < 0.001), and higher costs ($20,046 vs $7,543; p < 0.001) than those with nonsevere disease. Patients with sCAP had twice the rate of positive blood cultures (10.0% vs 4.5%; p < 0.001) and respiratory cultures (34.2 vs 21.1%; p < 0.001) and more often had isolates resistant to first-line community-acquired pneumonia antibiotics (10% of severe vs 3.1% of nonsevere; p < 0.001). Regardless of disease severity, Streptococcus pneumoniae was the most common pathogen recovered from blood cultures and Staphylococcus aureus and Pseudomonas species were the most common pathogens recovered from the respiratory tract. Although few patients with sCAP had cultures positive for a resistant organism, 65% received vancomycin and 42.8% received piperacillin-tazobactam. CONCLUSIONS: sCAP patients had worse outcomes and twice the rate of culture positivity. S. aureus and S. pneumoniae were the most common organisms in respiratory and blood specimens, respectively. Although only recommended for sCAP patients, nearly all pneumonia patients received blood cultures, a quarter of nonsevere patients received sputum cultures, and treatment with broad-spectrum agents was widespread, indicating fertile ground for antimicrobial and diagnostic stewardship programs.

Influenza is a leading cause of community-acquired pneumonia (CAP), and results of influenza tests can direct therapy. However, among adults hospitalized with CAP, little is known about the frequency and timing of influenza testing, treatment, and their associations with outcomes.In patients with CAP, is testing for influenza associated with antiviral treatment and shorter antibiotic courses, and is early treatment associated with better clinical outcomes?This study included adults admitted with pneumonia in 2010 to 2015 to 179 US hospitals contributing to the Premier database. We assessed influenza testing and compared antimicrobial utilization and the outcomes of test-positive, test-negative, and untested patients. Associations of early antiviral treatment (oseltamivir) with 14-day in-hospital mortality, hospital length of stay, and cost were studied.Among 166,268 patients with CAP, 38,703 (23.3%) were tested for influenza, of whom 11.5% tested positive. Testing increased from 15.4% to 35.6% from 2010 to 2015 and was 28.9% during flu season (October-May) vs 8.2% in June to September. Patients testing positive for influenza received antiviral agents more often and antibacterial agents less often and for shorter courses than patients testing negative (5.3 vs 6.4 days; P .001). Influenza-positive patients receiving oseltamivir on hospital day 1 (n = 2,585) experienced lower 14-day in-hospital mortality (adjusted OR, 0.75; 95% CI, 0.59-0.96), lower costs (adjusted ratio of means, 0.88; 95% CI, 0.81-0.95), and shorter length of stay (adjusted ratio of means, 0.88; 95% CI, 0.84-0.93) vs patients receiving oseltamivir later or not at all (n = 1,742).Even during flu season, most patients with CAP in this study went untested for influenza. A positive influenza test result was associated with antiviral treatment, and early treatment was associated with lower mortality, suggesting that more widespread testing might improve patient outcomes.

Background Community-acquired pneumonia (CAP) is a leading cause of hospital admissions and antimicrobial use. Clinical practice guidelines recommend switching from intravenous (IV) to oral antibiotics once patients are clinically stable. Methods We conducted a retrospective cohort study of adults admitted with CAP and initially treated with IV antibiotics at 642 US hospitals from 2010 through 2015. Switching was defined as discontinuation of IV and initiation of oral antibiotics without interrupting therapy. Patients switched by hospital day 3 were considered early switchers. We compared length of stay (LOS), in-hospital 14-day mortality, late deterioration (intensive care unit [ICU] transfer), and hospital costs between early switchers and others, controlling for hospital characteristics, patient demographics, comorbidities, initial treatments, and predicted mortality. Results Of 378 041 CAP patients, 21 784 (6%) were switched early, most frequently to fluoroquinolones. Patients switched early had fewer days on IV antibiotics, shorter duration of inpatient antibiotic treatment, shorter LOS, and lower hospitalization costs, but no significant excesses in 14-day in-hospital mortality or late ICU admission. Patients at a higher mortality risk were less likely to be switched. However, even in hospitals with relatively high switch rates, Conclusions Although early switching was not associated with worse outcomes and was associated with shorter LOS and fewer days on antibiotics, it occurred infrequently. Even in hospitals with high switch rates

Objective:Clostridioides difficile infection (CDI) is the most common cause of gastroenteritis, and community-acquired pneumonia (CAP) is the most common infection treated in hospitals. American Thoracic Society (ATS)/Infectious Diseases Society of America (IDSA) CAP guidelines recommend empiric therapy with a respiratory fluoroquinolone or cephalosporin plus macrolide combination, but the CDI risk of these regimens is unknown. We examined the association between each antibiotic regimen and the development of hospital-onset CDI.Methods:We conducted a retrospective cohort study using data from 638 US hospitals contributing administrative including 177 also contributing microbiologic data to Premier, Inc. We included adults admitted with pneumonia and discharged from July 2010 through June 2015 with a pneumonia diagnosis code who received ≥3 days of either empiric regimen. Hospital-onset CDI was defined by a diagnosis code not present on admission and positive laboratory test on day 4 or later or readmission for CDI. Mixed propensity-weighted multiple logistic regression was used to estimate the associations of CDI with antibiotic regimens.Results:Our sample included 58,060 patients treated with either cephalosporin plus macrolide (36,796 patients) or a fluoroquinolone alone (21,264 patients) and with microbiological data; 127 (0.35%) patients who received cephalosporin plus macrolide and 65 (0.31%) who received a fluoroquinolone developed CDI. After adjustment for patient demographics, comorbidities, risk factors for antimicrobial resistance, and hospital characteristics, CDI risks were similar for fluoroquinolones versus cephalosporin plus macrolide (odds ratio [OR], 0.98; 95% confidence interval [CI], 0.70–1.38).Conclusion:Among patients with CAP at US hospitals, CDI was uncommon, occurring in ∼0.33% of patients. We did not detect a significant association between the choice of empiric guideline recommended antibiotic therapy and the development of CDI.

Background:Evidence from pandemics suggests that influenza is often associated with bacterial coinfection. Among patients hospitalized for influenza pneumonia, we report the rate of coinfection and distribution of pathogens, and we compare outcomes of patients with and without bacterial coinfection.Methods:We included adults admitted with community-acquired pneumonia (CAP) and tested for influenza from 2010 to 2015 at 179 US hospitals participating in the Premier database. Pneumonia was identified using an International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) algorithm. We used multiple logistic and gamma-generalized linear mixed models to assess the relationships between coinfection and inpatient mortality, intensive care unit (ICU) admission, length of stay, and cost.Results:Among 38,665 patients hospitalized with CAP and tested for influenza, 4,313 (11.2%) were positive. In the first 3 hospital days, patients with influenza were less likely than those without to have a positive culture (10.3% vs 16.2%; P < .001), and cultures were more likely to contain Staphylococcus aureus (34.2% vs 28.2%; P = .007) and less likely to contain Streptococcus pneumoniae (24.9% vs 31.0%; P = .008). Of S. aureus isolates, 42.8% were methicillin resistant among influenza patients versus 53.2% among those without influenza (P = .01). After hospital day 3, pathogens for both groups were similar. Bacterial coinfection was associated with increased odds of in-hospital mortality (aOR, 3.00; 95% CI, 2.17–4.16), late ICU transfer (aOR, 2.83; 95% CI, 1.98–4.04), and higher cost (risk-adjusted mean multiplier, 1.77; 95% CI, 1.59–1.96).Conclusions:In a large US inpatient sample hospitalized with influenza and CAP, S. aureus was the most frequent cause of bacterial coinfection. Coinfection was associated with worse outcomes and higher costs.

Despite recent guidance from the Centers for Disease Control and Prevention (CDC) allowing institutions to relax in-facility masking strategies and due to our evolving understanding of respiratory pathogen transmission during the coronavirus disease 2019 (COVID-19) pandemic, we propose an updated standard for universal precautions in healthcare settings: permanently including universal masking in routine patient-care interactions. Such a practice prioritizes safety for patients, healthcare providers (HCPs), and visitors.

Objective: To derive and validate a model for risk of resistance to first-line community-acquired pneumonia (CAP) therapy. Design: We developed a logistic regression prediction model from a large multihospital discharge database and validated it versus the Drug Resistance in Pneumonia (DRIP) score in a holdout sample and another hospital system outside that database. Resistance to first-line CAP therapy (quinolone or third generation cephalosporin plus macrolide) was based on blood or respiratory cultures. Setting: This study was conducted using data from 177 Premier Healthcare database hospitals and 11 Cleveland Clinic hospitals. Participants: Adults hospitalized for CAP. Exposure: Risk factors for resistant infection. Results: Among 138,762 eligible patients in the Premier database, 12,181 (8.8%) had positive cultures and 5,200 (3.8%) had organisms resistant to CAP therapy. Infection with a resistant organism in the previous year was the strongest predictor of resistance; markers of acute illness (eg, receipt of mechanical ventilation or vasopressors) and chronic illness (eg, pressure ulcer, paralysis) were also associated with resistant infections. Our model outperformed the DRIP score with a C-statistic of 0.71 versus 0.63 for the DRIP score (P < .001) in the Premier holdout sample, and 0.65 versus 0.58 (P < .001) in Cleveland Clinic hospitals. Clinicians at Premier facilities used broad-spectrum antibiotics for 20%–30% of patients. In discriminating between patients with and without resistant infections, physician judgment slightly outperformed the DRIP instrument but not our model. Conclusions: Our model predicting infection with a resistant pathogen outperformed both the DRIP score and physician practice in an external validation set. Its integration into practice could reduce unnecessary use of broad-spectrum antibiotics.

Background Choice of empiric therapy for pneumonia depends on risk for antimicrobial resistance. Models to predict resistance are derived from blood and respiratory culture results. We compared these results to understand if organisms and resistance patterns differed by site. We also compared characteristics and outcomes of patients with positive cultures by site. Methods We studied adult patients discharged from 177 US hospitals from July 2010 through June 2015, with principal diagnoses of pneumonia, or principal diagnoses of respiratory failure, acute respiratory distress syndrome, respiratory arrest, or sepsis with a secondary diagnosis of pneumonia, and who had blood or respiratory cultures performed. Demographics, treatment, microbiologic results, and outcomes were examined. Results Among 138 561 hospitalizations of patients with pneumonia who had blood or respiratory cultures obtained at admission, 12 888 (9.3%) yielded positive cultures: 6438 respiratory cultures, 5992 blood cultures, and 458 both respiratory and blood cultures. Forty-two percent had isolates resistant to first-line therapy for community-acquired pneumonia. Isolates from respiratory samples were more often resistant than were isolates from blood (54.2% vs 26.6%; P < .001). Patients with both culture sites positive had higher case-fatality, longer lengths of stay, and higher costs than patients who had only blood or respiratory cultures positive. Among respiratory cultures, the most common pathogens were Staphylococcus aureus (34%) and Pseudomonas aeruginosa (17%), whereas blood cultures most commonly grew Streptococcus pneumoniae (33%), followed by S. aureus (22%). Conclusions Patients with positive respiratory tract cultures are clinically different from those with positive blood cultures, and resistance patterns differ by source. Models of antibiotic resistance should account for culture source.

Background The Infectious Diseases Society of America recommends pneumococcal urinary antigen testing (UAT) when identifying pneumococcal infection would allow for antibiotic de-escalation. However, the frequencies of UAT and subsequent antibiotic de-escalation are unknown. Methods We conducted a retrospective cohort study of adult patients admitted with community-acquired or healthcare-associated pneumonia to 170 US hospitals in the Premier database from 2010 to 2015, to describe variation in UAT use, associations of UAT results with antibiotic de-escalation, and associations of de-escalation with outcomes. Results Among 159 894 eligible admissions, 24 757 (15.5%) included UAT performed (18.4% of intensive care unit [ICU] and 15.3% of non-ICU patients). Among hospitals with ≥100 eligible patients, UAT proportions ranged from 0% to 69%. Compared to patients with negative UAT, 7.2% with positive UAT more often had a positive Streptococcus pneumoniae culture (25.4% vs 1.9%, P < .001) and less often had resistant bacteria (5.2% vs 6.8%, P < .05). Of patients initially treated with broad-spectrum antibiotics, most were still receiving broad-spectrum therapy 3 days later, but UAT-positive patients more often had coverage narrowed (38.4% vs 17.0% UAT-negative and 14.6% untested patients, P < .001). Hospital rate of UAT was strongly correlated with de-escalation following a positive test. Only 3 patients de-escalated after a positive UAT result were subsequently admitted to ICU. Conclusions UAT is not ordered routinely in pneumonia, even in ICU. A positive UAT result was associated with less frequent resistant organisms, but usually did not lead to antibiotic de-escalation. Increasing UAT and narrowing therapy after a positive UAT result are opportunities for improved antimicrobial stewardship.

BackgroundFor patients at risk for multidrug-resistant organisms, IDSA/ATS guidelines recommend empiric therapy against methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas. Following negative cultures, the guidelines recommend antimicrobial de-escalation. We assessed antibiotic de-escalation practices across hospitals and their associations with outcomes in hospitalized patients with pneumonia with negative cultures.MethodsWe included adults admitted with pneumonia in 2010–2015 to 164 US hospitals if they had negative blood and/or respiratory cultures and received both anti-MRSA and antipseudomonal agents other than quinolones. De-escalation was defined as stopping both empiric drugs on day 4 while continuing another antibiotic. Patients were propensity adjusted for de-escalation and compared on in-hospital 14-day mortality, late deterioration (ICU transfer), length-of-stay (LOS), and costs. We also compared adjusted outcomes across hospital de-escalation rate quartiles.ResultsOf 14 170 patients, 1924 (13%) had both initial empiric drugs stopped by hospital day 4. Hospital de-escalation rates ranged from 2–35% and hospital de-escalation rate quartile was not significantly associated with outcomes. At hospitals in the top quartile of de-escalation, even among patients at lowest risk for mortality, the de-escalation rates were ConclusionsA minority of eligible patients with pneumonia had antibiotics de-escalated by hospital day 4 following negative cultures and de-escalation rates varied widely between hospitals. To adhere to recent guidelines will require substantial changes in practice.

Objective:Viruses are more common than bacteria in patients hospitalized with community-acquired pneumonia. Little is known, however, about the frequency of respiratory viral testing and its associations with antimicrobial utilization.Design:Retrospective cohort study.Setting:The study included 179 US hospitals.Patients:Adults admitted with pneumonia between July 2010 and June 2015.Methods:We assessed the frequency of respiratory virus testing and compared antimicrobial utilization, mortality, length of stay, and costs between tested versus untested patients, and between virus-positive versus virus-negative patients.Results:Among 166,273 patients with pneumonia on admission, 40,787 patients (24.5%) were tested for respiratory viruses, 94.8% were tested for influenza, and 20.7% were tested for other viruses. Viral assays were positive in 5,133 of 40,787 tested patients (12.6%), typically for influenza and rhinovirus. Tested patients were younger and had fewer comorbidities than untested patients, but patients with positive viral assays were older and had more comorbidities than those with negative assays. Blood cultures were positive for bacterial pathogens in 2.7% of patients with positive viral assays versus 5.3% of patients with negative viral tests (P < .001). Antibacterial courses were shorter for virus-positive versus -negative patients overall (mean 5.5 vs 6.4 days; P < .001) but varied by bacterial testing: 8.1 versus 8.0 days (P = .60) if bacterial tests were positive; 5.3 versus 6.1 days (P < .001) if bacterial tests were negative; and 3.3 versus 5.2 days (P < .001) if bacterial tests were not obtained (interaction P < .001).Conclusions:A minority of patients hospitalized with pneumonia were tested for respiratory viruses; only a fraction of potential viral pathogens were assayed; and patients with positive viral tests often received long antibacterial courses.

Background American Thoracic Society/Infectious Diseases Society of America guidelines recommend against routine Legionella pneumophila testing, but recommend that hospitalized patients with community-acquired pneumonia receive empiric treatment covering Legionella. Testing, empiric treatment, and outcomes for patients with Legionella have not been well described. Research Question Is testing for Legionella pneumophila appropriate, and could it impact treatment? Study Design and Methods We conducted a large retrospective cohort analysis using Premier Healthcare Database data from 2010 to 2015. We included adults with a principal diagnosis code for pneumonia (or a principal diagnosis of respiratory failure or sepsis with secondary diagnosis of pneumonia) if they also received treatment for pneumonia on hospital days 1-3. We categorized Legionella-tested patients by test result, identified patient characteristics associated with testing and test result, and examined seasonal and regional patterns of Legionella pneumonia (LP) diagnoses. Empiric therapy for LP was defined as a macrolide, quinolone, or doxycycline, administered on each of the first two hospital days. Results Of 166,689 eligible patients, 43,070 (26%) were tested for Legionella, and 642 (1.5%) tested positive. Although only 36% of tests were ordered from June to October, 70% of positive test results occurred during this time. Only 30% of patients with hyponatremia, 32% with diarrhea, and 27% in the ICU were tested. Of patients with positive test results, 495 of 642 (77%) had received empiric Legionella therapy. Patients with LP did not have more severe presentation. They had more frequent late decompensation, but similar mortality to patients without LP. Interpretation Legionella is an uncommon cause of community-acquired pneumonia, occurring primarily from late spring through early autumn. Testing is uncommon, even among patients with risk factors, and many patients with positive test results failed to receive empiric coverage for LP.

Purpose of Review We reviewed the benefit of influenza vaccination in healthcare personnel (HCP), rates of vaccine coverage, and practices used to try to boost vaccine coverage among HCP. Recent Findings Influenza vaccination in HCP provides benefits to both HCP and patients, including reductions in patient morbidity and mortality and decreases in HCP absenteeism. Despite these benefits, influenza vaccine coverage among HCP still falls short of the Healthy People 2020 goal of 90%. As a result, healthcare institutions have used various practices to boost vaccination, including mandatory vaccine policies and requiring non-immunized HCP to wear masks during the influenza season. All of these efforts have been successful at increasing vaccination rates, and employer vaccination requirements have led to rates that meet the Healthy People 2020 goal. Rates of mandatory vaccine policies have increased over time, and several states now have influenza vaccine requirements. However, additional study into how these policies improve patient outcomes is needed. Summary Continued effort is needed to boost influenza vaccination rates among HCP, and mandatory vaccine policies may be used if other methods have not been effective in adequately raising vaccination rates. Future research should focus on how mandatory vaccine policies can improve patient outcomes.

Background Contact precautions (CP) are a widely adopted strategy to prevent cross-transmission of organisms, commonly methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE). Some hospitals have discontinued CP for patients with MRSA or VRE; however, the impact on hospital-acquired infection rates (HAI) has not been assessed systematically. Methods Retrospective multicenter interrupted time series between 2002 and 2017 at three academic hospitals. Participating hospitals discontinued CP for patients with contained body fluids who were colonized or infected with MRSA or VRE. The primary intervention was stopping the use of CP. Secondary interventions were horizontal infection prevention strategies. The primary outcomes were rates of central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia due to MRSA, VRE, or any organism using Centers for Disease Control and Prevention National Healthcare Safety Network surveillance definitions. Results Central line-associated bloodstream infections, catheter-associated urinary tract infections, mediastinal surgical site infection, and ventilator-associated pneumonia rates trended down at each institution. There were no statistically significant increases in these infections associated with discontinuing CP. Individual horizontal infection prevention strategies variably impacted HAI outcomes. Conclusions Stopping the routine use of CP for patients with contained body fluids who are colonized or infected with MRSA or VRE did not result in increased HAIs. Bundled horizontal infection prevention strategies resulted in sustained HAI reductions.

BACKGROUND The American Thoracic Society and Infectious Diseases Society of America guidelines for management of healthcare-associated pneumonia (HCAP), first published in 2005, have been controversial regarding the selection of empiric broad-spectrum antibiotics, whether the criteria for HCAP predicts the likelihood of infection with multidrug resistant organisms, and whether HCAP patients have improved outcomes when treated with empiric broad-spectrum antibiotics. METHODS A retrospective cohort study at 488 US hospitals from July 2007 to November 2011. Patients who met criteria for HCAP were included. Guideline-concordant antibiotics were assessed based on guideline recommendations. We assessed changes in hospital rates of concordant antibiotic use over time and their correlation with outcomes. RESULTS Among 149,963 patients with HCAP, 19.6% received fully guideline-concordant antibiotics, 21.7% received partially concordant antibiotics, and 58.9% received discordant antibiotics. Guideline concordance increased over time. Rates of fully or partially concordant antibiotics varied across hospitals (median 36.4%; interquartile range 25.8%-49.1%). Among patients who received discordant antibiotics, 81.5% were treated according to community-acquired pneumonia (CAP) guidelines. On average, the rate of guideline concordance increased by 2.2% per 6-month interval, while hospital level rates of mortality, excess length of stay, and progression to respiratory failure did not change. CONCLUSIONS In this large, nationally representative cohort, only 1 in 5 patients with risk factors for HCAP received treatment that was fully in accordance with guidelines, and many received CAP therapy instead. At the hospital level, increases in the use of concordant antibiotics were not associated with declines in mortality, excess length of stay, or progression to respiratory failure.

Randomized trials suggest that assessment of serum procalcitonin (PCT) levels can be used to safely limit antibiotic use among patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD).To determine the impact of PCT testing on antibiotic treatment of patients hospitalized for exacerbations of COPD in routine practice.We conducted a series of cross-sectional and longitudinal multivariable analyses using data from 2009 to 2011 and 2013 to 2014 from a sample of 505 U.S. hospitals.Of 203,177 patients hospitalized for COPD exacerbation in 2013 to 2014, nearly 9 out of 10 were treated with antibiotics. Hospital PCT testing rates ranged from 0 to 83%. In cross-sectional analysis, there was a weak negative association between the rate of PCT testing and risk-adjusted rates of antibiotic initiation (Spearman correlation, -0.12; P = 0.005); each 10-point increase in the percentage of patients undergoing PCT testing was associated with a 0.7% decline in risk-adjusted antibiotic use (P = 0.001). There was no association between hospital rates of PCT testing and duration of antibiotic treatment. In a longitudinal analysis, comparing treatment patterns in 2009 to 2011 and 2013 to 2014, we did not observe a significant difference in the change in antibiotic treatment rates or duration of therapy between hospitals that had adopted PCT testing compared with those that had not.As currently implemented, PCT testing appears to have had little impact on decisions to initiate antibiotic therapy or on duration of treatment for COPD exacerbations. Implementation research is necessary to translate the promising outcomes from PCT testing observed in randomized trials into clinical practice.

Background.Healthcare-associated pneumonia (HCAP) is an entity distinct from community-acquired pneumonia (CAP). HCAP has a higher case-fatality rate, due either to HCAP organisms or to the health status of HCAP patients. The contribution of HCAP criteria to case-fatality rate is unknown.Methods.We conducted a retrospective review of adult patients admitted with a diagnosis of pneumonia from July 2007 through November 2011 to 491 US hospitals. HCAP was defined as having at least 1 of the following: prior hospitalization within 90 days, hemodialysis, admission from a skilled nursing facility, or immune suppression. We compared characteristics of patients with CAP and patients with HCAP and explored the contribution of HCAP criteria to case-fatality rate in a hierarchical generalized linear model.Results.Of 436,483 patients hospitalized with pneumonia, 149,963 (34.4%) had HCAP. Compared to CAP patients, HCAP patients were older, had more comorbidities, and were more likely to require intensive care unit (ICU) care. In-hospital case-fatality rate was higher among patients with HCAP, compared to those with CAP (11.1% vs 5.1%, P < .001). After adjustment for demographics, comorbidities, presence of other infections, early ICU admission, chronic and acute medications, early tests and therapies, and length of stay, HCAP remained associated with increased case-fatality rate (odds ratio [OR], 1.35 [95% confidence interval (CI), 1.32-1.39]); odds of death increased for each additional HCAP criterion (OR [95% CI]: 1 criterion, 1.27 [1.23-1.31], 2 criteria, 1.55 [1.49-1.62], and 3 or more criteria, 1.88 [1.72-2.06]).Conclusions.After adjustment for differences in patient characteristics, HCAP was associated with greater case-fatality rate than CAP. This difference may be due to HCAP organisms or to HCAP criteria themselves.

OBJECTIVE To examine the impact of hospital-onset Clostridium difficile infection (HOCDI) on the outcomes of patients with sepsis. BACKGROUND 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. DESIGN Retrospective cohort study. SETTING AND PATIENTS 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. MEASUREMENTS We used propensity matching and date of diagnosis to match cases to patients without Clostridium difficile infections and compared outcomes between the 2 groups. MAIN RESULTS 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

Background Community-acquired pneumonia (CAP) continues to be the leading cause of infection-related mortality in the United States. Epidemiological studies of CAP are usually based on single-center studies and there is a need for large population based studies. We evaluated the microbial etiology of CAP among patients requiring hospitalization using a large US database. Methods We included adult patients admitted with pneumonia from 2010 to 2015 to 175 US hospitals participating in Premier and providing administrative and microbacteriological data. Patients were identified as having CAP if they had a radiographic evidence of pneumonia (X-ray) on the first day and if they were on antimicrobials on the first day for 3 consecutive days. For studying the microbial etiology, patients were included if they had a positive culture or test collected by hospital Day 0 or 1. Patients with identical Gram negative organisms in blood and urine were excluded. We also excluded patients with a present on admission secondary diagnosis of cholecystitis, appendicitis, peritonitis or abdominal infections. Results A total of 95,169 patients had a diagnosis of CAP with a culture or other test performed on the first day. A pathogen was detected in 15.4% of the patients. Among the pathogen positive patients, the mean age was 67 ± 16 years (range 18–89) and 52% were male. Thirty-four percent required ICU care and 8.4% died in the hospital. Almost all patients (99%) had at least one culture drawn, including blood (96%) and respiratory (51%) specimens. Bacteria were the most commonly detected pathogens. Among the Gram-positive bacteria, Streptococcus pneumoniae accounted for 22.2% followed by methicillin sensitive Staphylococcus aureus (MSSA) (14.8%) and methicillin-resistant S. aureus (7.9%). Among the Gram-negative bacteria, the most common organisms reported were Pseudomonas aeruginosa (5.9%), Escherichia coli (5.2%) and Hemophilus influenzae (5.3%). Mycoplasma pneumoniae was identified in 2.2%. Among viral pathogens, the most common were influenza virus (2.6%) and human rhinovirus (0.71%). Conclusion In a large US inpatient sample, a majority of patients with CAP had no microbial etiology identified by laboratory testing. Among the test positive patients, S. pneumoniae was the most common bacteria reported followed by MSSA and MRSA. Disclosures A. Deshpande, 3M: Investigator, Research support; Clorox: Investigator and Speaker’s Bureau, Research grant and Speaker honorarium; Merck: Investigator and Speaker’s Bureau, Research support. S. S. Richter, bioMerieux: Grant Investigator, Research grant; BD Diagnostics: Grant Investigator, Research grant; Roche: Grant Investigator, Research grant; Hologic: Grant Investigator, Research grant; Diasorin: Grant Investigator, Research grant; Accelerate: Grant Investigator, Research grant; Biofire: Grant Investigator, Research grant.

Background Influenza is a leading cause of community-acquired pneumonia (CAP). Little is known about the effect of influenza testing on antimicrobial treatment among adult patients hospitalized with CAP. We quantified prevalence of testing and impact of positivity on treatment with antibacterials, antivirals, and outcomes. Methods We included adults admitted with pneumonia in 2010–2015 to 179 US hospitals contributing to the Premier database. Patients had CAP if radiographic evidence of pneumonia and antimicrobial treatment were present on day 1. We assessed influenza testing and compared antimicrobial utilization and outcomes of patients who tested positive vs negative vs not tested. Using mixed logistic regression and gamma generalized linear mixed models, we assessed the impact of influenza testing on inpatient mortality, length of stay (LOS) and cost. Results Among 166,273 patients with CAP, 38,665 (23.2%) were tested for influenza; 11.5% of these tested positive. The influenza testing rate increased from 15.4% in 2010/7–2011/6 to 35.6% in 2014/7–2015/6, ranging from 28.8% during flu season (October–May) to 8.2% in other months. Positive tests were more common during flu season (12.2% vs. 2.8%, P < 0.001). Patients tested for influenza were younger (66.6 vs. 70.3 years), less likely admitted from SNF (5.4% vs. 7.9%), with fewer comorbidities (2.9 vs. 3.3). Of patients tested for influenza, positive patients were younger (66.3 vs. 68.8 years), less likely admitted from SNF (5.2% vs. 6.8%), with more comorbidities (2.9 vs. 2.7) (all comparisons P < 0.001). Patients testing positive more likely received antivirals, were slightly less likely to receive antibacterials (Figure 1), but received shorter antibacterial courses than negative patients (5.3 vs 6.4 days, P < 0.001). Influenza tests were associated with reduced odds of in-hospital mortality compared with no testing (adjusted OR 0.71, 95% CI 0.63–0.81) and positive vs. negative tests with reduced costs (0.95, 0.92–0.99) and LOS (0.97, 0.94–0.99) (Figure 2). Conclusion In a large US inpatient sample hospitalized for pneumonia, only 23.2% of the patients were tested for influenza, but testing varied widely by hospital. A positive influenza test was associated with antiviral treatment but had minimal impact on antibiotic prescribing. Disclosures All authors: No reported disclosures.

Background Limited evidence suggests that influenza leads not only to bacterial colonization and greater risk of bacterial pneumonia, but to poor outcomes and increased mortality. We compared bacterial culture results between patients positive (FLU+) and negative (FLU-) for influenza in the setting of community-acquired pneumonia (CAP). Among FLU+ patients we compared bacterial etiology, characteristics, treatment and outcomes between patients with and without bacterial coinfection. Methods We included adults admitted with pneumonia 2010–2015 to 179 US hospitals participating in the Premier database. Pneumonia was identified using an ICD-9-CM algorithm. Among patients tested for FLU, we limited the microbiology results to the first 14 hospital days. We assessed inpatient mortality, ICU admission, use of vasopressors, mechanical ventilation (MV), cost, and LOS using mixed multiple logistic regression and gamma generalized linear mixed models. Results Among 166,273 patients hospitalized with CAP, 38,665 (23.3%) were tested for influenza and 4,313 (11.15%) were positive. In FLU+ patients the most common bacterial co-infection was Staphylococcus aureus (37.6%) followed by Streptococcus pneumoniae (25.9%) and Pseudomonas aeruginosa (10.9%), varying based on the day of coinfection (days 1–3 vs. days 4–14) (Figure 1). In FLU- patients, S. pneumoniae (30.5%) and S. aureus (30.3%) were similarly common, followed by P. aeruginosa (10.0%). FLU+ patients with bacterial co-infection were younger (66.3 vs. 69.1 years), with more comorbidities (3.2 vs. 2.7) than influenza patients with no bacterial co-infection (all comparisons P < 0.001). Bacterial co-infection was also associated with increased odds of in-hospital mortality (OR 1.86, 95% CI,1.31–2.65), ICU admission (OR 3.46, 2.44–4.9), use of vasopressors (OR 3.74, 2.61–5.36), and MV (OR 3.51, 2.49–5.36), increased cost (risk-adjusted ratio of geometric means, 1.6, (1.47–1.73) and LOS (risk-adjusted ratio of geometric means 1.42, (1.33–1.52). Conclusion In a large US inpatient sample hospitalized for CAP, 11% of patients with influenza had or acquired a bacterial co-infection. Bacterial co-infection was associated with significantly worse outcomes and higher cost. Disclosures All authors: No reported disclosures.

Key Points Question What is the etiology of pneumonia among patients with alcohol use disorder, and is alcohol use disorder associated with poorer outcomes? Findings In this cohort study of 137 496 patients with pneumonia, the most common cause of pneumonia among patients with alcohol use disorder was Streptococcus pneumoniae; resistant gram-negative infections were rare. In comorbidity-adjusted models, alcohol use disorder was not significantly associated with inpatient mortality, but patients with alcohol use disorder undergoing alcohol withdrawal more frequently required late mechanical ventilation, vasopressors, and intensive care unit admissions and had increased lengths of stay and hospital costs. Meaning This study suggests that alcohol use disorder alone is not an independent risk factor for resistant infection or mortality, but alcohol withdrawal is associated with clinical deterioration and higher use of health care resources., Importance Patients with alcohol use disorder (AUD) are at elevated risk of developing pneumonia, but few studies have assessed the outcomes of pneumonia in patients with AUD. Objectives To compare the causes, treatment, and outcomes of pneumonia in patients with and without AUD and to understand the associations of comorbid illnesses, alcohol withdrawal, and any residual effects due to alcohol itself with patient outcomes. Design, Setting, and Participants A retrospective cohort study was conducted of 137 496 patients 18 years or older with pneumonia who were admitted to 177 US hospitals participating in the Premier Healthcare Database from July 1, 2010, to June 30, 2015. Statistical analysis was conducted from October 27, 2017, to August 20, 2018. Exposure Alcohol use disorders identified from International Classification of Diseases, Ninth Revision, Clinical Modification codes. Main Outcomes and Measures Pneumonia cause, antibiotic treatment, inpatient mortality, clinical deterioration, length of stay, and cost. Associations of AUD with these variables were studied using generalized linear mixed models. Results Of 137 496 patients with community-acquired pneumonia (70 358 women and 67 138 men; mean [SD] age, 69.5 [16.2] years), 3.5% had an AUD. Patients with an AUD were younger than those without an AUD (median age, 58.0 vs 73.0 years; P, This cohort study uses data from the Premier Healthcare Database to compare the causes, treatment, and outcomes in patients hopitalized with community-acquired pneumonia with and without alcohol use disorder.

BACKGROUND Fluoroquinolones have equivalent oral and intravenous bioavailability, but hospitalized patients with community-acquired pneumonia (CAP) generally are treated intravenously. Our objectives were to compare outcomes of hospitalized CAP patients initially receiving intravenous vs oral respiratory fluoroquinolones. METHODS This was a retrospective cohort study utilizing data from 340 hospitals involving CAP patients admitted to a non-intensive care unit (ICU) setting from 2007 to 2010, who received intravenous or oral levofloxacin or moxifloxacin. The primary outcome was in-hospital mortality. Secondary outcomes included clinical deterioration (transfer to ICU, initiation of vasopressors, or invasive mechanical ventilation [IMV] initiated after the second hospital day), antibiotic escalation, length of stay (LOS), and cost. RESULTS Of 36 405 patients who met inclusion criteria, 34 200 (94%) initially received intravenous treatment and 2205 (6%) received oral treatment. Patients who received oral fluoroquinolones had lower unadjusted mortality (1.4% vs 2.5%; P = .002), and shorter mean LOS (5.0 vs 5.3; P < .001). Multivariable models using stabilized inverse propensity treatment weighting revealed lower rates of antibiotic escalation for oral vs intravenous therapy (odds ratio [OR], 0.84; 95% confidence interval [CI], .74-.96) but no differences in hospital mortality (OR, 0.82; 95% CI, .58-1.15), LOS (difference in days 0.03; 95% CI, -.09-.15), cost (difference in $-7.7; 95% CI, -197.4-182.0), late ICU admission (OR, 1.04; 95% CI, .80-1.36), late IMV (OR, 1.17; 95% CI, .87-1.56), or late vasopressor use (OR, 0.94; 95% CI, .68-1.30). CONCLUSIONS Among hospitalized patients who received fluoroquinolones for CAP, there was no association between initial route of administration and outcomes. More patients may be treated orally without worsening outcomes.

Background Escherichia coli has been thought to be an uncommon cause of community-acquired pneumonia (CAP). Large epidemiological data on E. coli CAP (E-CAP) and its comparison to pneumococcal CAP (P-CAP) are lacking. Methods A multi-center retrospective cohort study of adult patients (aged ≥ 18 years) admitted to 140 US hospitals with pneumonia and/or sepsis from 2010–2015, included in the Premier Research database. Patients with community-onset infection, antibiotic treatment beginning within the first 2 hospital days, and continued for at least 3 consecutive days were included. Patients were excluded if they had been transferred from another acute care facility, had cystic fibrosis, had a hospital length of stay of 1 day or less, co-existent urinary tract infection, gastrointestinal/ intra-abdominal infection, or simultaneous presence of other CAP pathogens. Pneumonia and sepsis were identified by ICD-9 codes. Results A total of 13,165 patients met the inclusion criteria, of which 1,247 had E. coli CAP. Majority of patients with E-CAP were nonnursing home residents (90.2%, 1,125/1,247). 69.3% (864/1,247) patients with E-CAP presented with”sepsis syndrome’ compared with only 48.1% in other Gram-negative CAP and 62.5% in P-CAP. Aspiration pneumonia was diagnosed in 5.9% (73/1,247) with E-CAP. Blood cultures were positive in 59.9% (748/1,247) of patients with E-CAP with 84.8% positivity in patients with sepsis syndrome. Patients with E-CAP compared with P-CAP were more likely to require ICU-level care (42.6% vs. 38.2%), mechanical ventilation (19.3% vs. 15.7%), and require vasopressors (21% vs. 13.8%). In-hospital mortality was 14.8% in E-CAP compared with 7.4% in P-CAP. The median cost of hospitalization was great in E-CAP than P-CAP ($12,420.1 vs. $9,857.5) Re-admission within 30 days was greater among patients with E-CAP than P-CAP (5.4% vs. 4%). 36.8% of isolates were resistant to fluoroquinolones, 10.4% to ceftriaxone and 18.1% to aminoglycosides. Only 10/1,247(0.8%) were multi-drug-resistant. Conclusion E. coli is an important cause of severe CAP, with higher mortality, greater need for ICU-level care, and higher re-admission rates than patients with pneumococcal pneumonia. The rate of fluoroquinolone resistance was high and empiric quinolones should be used with caution for patients who are critically ill due to E-CAP Disclosures A. Deshpande, 3M: Investigator, Research support; Clorox: Investigator and Speaker’s Bureau, Research grant and Speaker honorarium; Merck: Investigator and Speaker’s Bureau, Research support.

Background The institution of a process used to successfully execute a perioperative antibiotic administration system is but 1 component of preventing postoperative infections. Continued surveillance of infections is an important part of the process of decreasing postoperative infections. We recently experienced an increase in the number of postoperative infections in our patients. Using standard infection control methods of outbreak investigation, we tracked multiple variables to search for a common cause. We describe herein the process by which Quality Improvement methodology was used to investigate and manage this surgical site infection (SSI) cluster. Methods As part of routine surveillance for SSI, the infection control division seeks out evidence of postoperative infections. Patients were defined as having an SSI according to National Healthcare Safety Network SSI criteria. SSI data are reviewed monthly and aggregated on a quarterly basis. The SSI rate was above our usual level for 3 consecutive quarters of 2007. This increase in the infection rate led to an internal outbreak investigation, termed a "cluster investigation." This investigation comprised multiple concurrent methods including manual chart review of all cases; review of microbiological data; and inspection of operating rooms, instrument processing facilities, and storage areas. Results During 3 quarters, a trend emerged in our general surgical population that demonstrated that 4 surgical types had a sustained increase in SSI. The institutional antibiotic protocol was appropriate for prevention of the majority of these SSIs. As part of the investigation, direct observation of hand hygiene and surgical hand antisepsis technique was undertaken. At this time, there were 2 types of surgical hand preparation being used, at the discretion of the clinician: either a "standard" scrub with an antimicrobial soap or the application of a chlorhexidine gluconate and alcohol-based surgical hand antisepsis product. Observers noted improper use of this alcohol-based surgical hand antiseptic. This product was withdrawn from our operating rooms, and the SSI rate markedly decreased in the following 2 quarters. Discussion In conclusion, we report the results of a quality improvement process that investigated a 3-quarter increase in our SSI rate. An investigation was undertaken, and it was thought that the (mis)use of an alcohol-based hand antiseptic product was associated with the increased infection rate. Removing this product, along with reemphasizing the importance of infection control, was associated with a decrease in the infection rate to a level at or below our historical rate.

Viral influenza is a seasonal infection associated with significant morbidity and mortality. In the United States more than 35,000 deaths and 200,000 hospitalizations due to influenza occur annually, and the number is increasing. Children aged less than 1 year and adults aged more than 65 years, pregnant woman, and people of any age with comorbid illnesses are at highest risk. Annual vaccination is the cornerstone of prevention, but some older patients may derive less benefit from immunization than otherwise fit individuals. If started promptly, antiviral medications may reduce complications of acute influenza, but increasing resistance to amantadine and perhaps neuraminidase inhibitors underscores the need for novel prevention and treatment strategies. Pulmonary complications of influenza are most common and include primary influenza and secondary bacterial infection. Either may cause pneumonia, and each has a unique clinical presentation and pathologic basis. Staphylococcus aureus, including methicillin-resistant strains, is an important cause of secondary bacterial pneumonia with high mortality. During influenza season, treatment of pneumonia should include empiric coverage for this pathogen. Neuromuscular and cardiac complications are unusual but may manifest in persons of any age.

Objectives Guidelines for treatment of healthcare-associated pneumonia (HCAP) recommend empirical therapy with broad-spectrum antimicrobials. Our objective was to examine the association between guideline-based therapy (GBT) and outcomes for patients with HCAP. Patients and methods We conducted a pharmacoepidemiological cohort study at 346 US hospitals. We included adults hospitalized between July 2007 and June 2010 for HCAP, defined as patients admitted from a nursing home, with end-stage renal disease or immunosuppression, or discharged from a hospital in the previous 90 days. Outcome measures included in-hospital mortality, length of stay and costs. Results Of 85 097 patients at 346 hospitals, 31 949 (37.5%) received GBT (one agent against MRSA and at least one against Pseudomonas). Compared with patients who received non-GBT, those who received GBT had a heavier burden of chronic disease and more severe pneumonia. GBT was associated with higher mortality (17.1% versus 7.7%, P Conclusions Among patients who met HCAP criteria, GBT was not associated with lower adjusted mortality, length of stay or costs in any analyses. Better criteria are needed to identify patients at risk for MDR infections who might benefit from broad-spectrum antimicrobial coverage.