To assess whether antibiotic duration (AD) and one-year antibiotic-free days (AFD) are associated with key in-hospital and post-discharge outcomes among critically ill adults.

Prospective observational study.

611-bed, quaternary care academic medical center in the United States.

126 critically ill adults (mean age 68.1 ± 15.6 yr, 51.6% male, median APACHE II score 20.5 [IQR 15–25]); 71.4% met sepsis criteria.

Secondary infection was defined as ≥3 consecutive antibiotic days within a year after the index sepsis admission. Multivariate analyses adjusted for age, APACHE II score, BMI, and glucocorticosteroid dose. Time-to-event analysis employed Cox proportional hazards modeling; cumulative infection burden was assessed via nonparametric tests using normalized antibiotic exposure (AD as a proportion of days alive).

Within 30 days, longer AD correlated with increased hospital stay; each additional antibiotic day added ∼0.93 hospital days (P < 0.001) in adjusted linear regression. AD did not predict one-year mortality (OR 1.01, P = 0.739) or readmission (OR 1.01, P = 0.771). Normalized antibiotic exposure significantly differed by cumulative secondary infection episodes (P = 0.0033), with higher exposure among patients experiencing two or more secondary infections (P = 0.026 and P = 0.036, respectively). Cox regression showed a significant association between AD and time to first secondary infection (HR 1.10, 95% CI: 1.04–1.15, P = 0.001), indicating that longer AD predisposed to secondary infection or recurrent antibiotic use.

Extended AD, in critically ill patients, prolongs hospitalization without reducing mortality or readmission rates. These findings highlight the importance of robust antibiotic stewardship practices, where shorter, targeted regimens may minimize unintended complications.

To quantify the impact of a changing cohort strategy on COVID-19 transmission in an acute inpatient behavioral health facility.

Cohort study.

Behavioral health inpatients exposed to COVID-19.

This cohort project compared COVID-19 conversion rates during two periods. In the first period (July 2020–April 2022), exposed patients (regardless of vaccination status) were cohorted separately from unexposed individuals. In the second period (May 2022–September 2022), exposed vaccinated patients remained with unexposed patients. COVID-19 conversion was identified through post-exposure asymptomatic testing or test-confirmed symptom development, with rates quantified per all admissions, per 10,000 patient days at risk, and per patient-specific exposure.

The 27-month project included 11,761 admissions and 164,762 patient days of care. The proportion of patients up-to-date on COVID-19 vaccination at admission and discharge ranged from 11%–19%. The second period showed an increased risk of SARS-CoV-2 conversion per admission (1.87% vs 0.36%, P < 0.001) and per 1,000 patient-days at risk (1.44 vs 0.27 conversions per 1,000 patient days, P < 0.001), but not per exposure (3.44% vs 3.13%, P = 0.68).

Reducing the population of patients cohorted after a SARS-COV-2 exposure is associated with increased risk of SARS-COV-2 transmission in inpatient psychiatric settings.

Antibiotic stewardship programs (ASPs) are crucial to prevent the emergence of antibiotic resistance and to improve outcomes for patients. A validated instrument rooted in a theoretically derived implementation science framework will increase our understanding of ASP implementation and enable comparisons across implementation sites.

Antibiotic stewards (infectious disease pharmacists and physicians) were recruited from Veterans Affairs (VA) hospitals to complete a survey on stewardship implementation. We used the Consolidated Framework for Implementation Research (CFIR) to guide development of an ASP implementation survey assessing 22 potential determinants of implementation across five domains of CFIR. We conducted confirmatory factor analyses (CFA) to assess construct validity of 8 construct measures and evaluated internal consistency.

A total of 150 stewards completed the survey from 110 VA hospitals. CFA for most CFIR constructs exhibited good fit. Internal consistency for CFIR construct subscales (Cronbach’s alpha) ranged from 0.54–0.96, indicating modest to strong internal consistency. Determinants that were rated highly present at the sites (across site means ≥ 4.0 or above) included Self-Efficacy, Engaging, Evidence Strength and Quality and Relative Advantage, indicating stewards found ASP evidence compelling and felt their personal involvement was effective in engendering positive results for the ASP.

Psychometric properties indicate validity of the first CFIR-based survey of determinants for ASP implementation outcomes. Clinical, quality improvement, and research teams can use this survey to identify contextual determinants of ASP implementation and use this information to guide selection of strategies and compare results across multiple sites.

Approximately 95% of patients with a beta-lactam allergy noted in their medical record are not truly allergic when tested. These patients may unnecessarily avoid first-line antibiotics, resulting in increased treatment failure, higher costs, and antibiotic resistance. Bone marrow transplant (BMT) patients may be at higher risk for these adverse outcomes due to weakened immune systems and high risk for severe infections. Our objective was to evaluate beta-lactam allergy labels and their influence on BMT patient outcomes.

We conducted a retrospective cohort study of adult inpatients undergoing BMT during April 2018-March 2020. Eligibility for penicillin allergy testing/de-labeling was evaluated. Multivariable logistic regression was performed to measure independent effects of beta-lactam allergy labels on 100-day outcomes: mortality, ICU admission, rehospitalization, and intravenous antibiotic use.

Among 358 BMT patients, 75 (21%) had a beta-lactam allergy label at baseline. Mortality was higher in patients with an allergy label (14.7% vs 7.8%, P = 0.067). In multivariable analysis, patients with allergy labels were not at a significantly greater risk of mortality (OR = 1.60; 95% CI = 0.68 – 3.78) but were significantly more likely to receive carbapenems (OR = 6.27; 95% CI = 2.81–13.98). All patients with penicillin-class allergy labels were eligible for allergy testing/de-labeling.

We did not observe a significant increased risk of mortality in BMT patients with beta-lactam allergy labels; however, increased carbapenem use was observed. Penicillin allergy de-labeling programs may help optimize antibiotic prescribing in BMT patients. Larger studies are needed to quantify the impact of beta-lactam allergy labels on BMT patient outcomes.

To illustrate how a partnership between an academic medical center and a public health department successfully responded to a large tuberculosis (TB) exposure at a community daycare center.

A multidisciplinary team rapidly established a dedicated TB Exposure Clinic to evaluate and screen exposed children requiring window prophylaxis.

The exposure affected 592 individuals, including 359 children under five—those at highest risk for severe disease.

Given the vulnerability of young children to TB infection, timely evaluation and initiation of window prophylaxis were prioritized.

Over two days, 162 children were assessed for TB window prophylaxis, and 110 additional children underwent TB screening.

By leveraging clinical expertise, interdisciplinary collaboration, and informatics infrastructure, the TB Exposure Clinic delivered rapid, comprehensive care while minimizing disruption to local healthcare systems. This model underscores the essential role of academic medical centers in supporting public health responses.

To investigate a cluster of surgical site infections (SSIs) in patients who underwent coronary artery bypass graft (CABG) procedures, identify risk factors for infection, and implement measures to prevent new cases.

The investigation comprised a retrospective case–control study and an observational review of infection control practices between the fall of 2018 and 2019 (study period).

Tertiary care medical center in Florida, USA.

Patients who acquired an SSI following CABG during the study period were defined as case-patients. Control-patients were randomly selected patients who did not acquire a post-CABG SSI.

We recorded clinical and epidemiologic details on a standardized form and analyzed data with SAS statistical software. Odds ratios and 95% confidence intervals were calculated.

Seven patients met the case definition and 21 control-patients were identified. While multiple variables were significant on univariate analysis, after controlling for confounding using multivariate analysis/logistic regression, only lower age (P < 0.0001) and meeting the requirements for appropriate perioperative temperature management (SCIP measure 10) (P = 0.01) were identified as independent risk factors for SSI. Per observational review, measures to reduce operating room traffic and limit door opening/closing were implemented and wound vacuum-assisted closure (VAC) use was phased out. Our institutional SSI rate returned to baseline and no additional clusters were seen in the following three years.

Multiple potential risk factors exist for SSI after coronary artery bypass grafting. At our institution, minimizing operating room traffic and reducing wound VAC use may have successfully addressed these healthcare-associated infections.

To assess the safety of penicillin allergy evaluation and testing in obstetric patients utilizing oral drug challenges with or without prior penicillin skin testing (PST) depending on characteristics of the patient’s medication reaction, and to determine whether removal of the drug allergy label led to an increased use of guideline-recommended antibiotic prophylaxis for group B Streptococcus (GBS).

This retrospective cohort study evaluated obstetric patients cared for at the University of Iowa Health Care who were identified as having a penicillin allergy label between June 1, 2021 and July 1, 2023.

A total of 728 patients were identified to have a penicillin allergy and 299 patients were seen in the drug allergy clinic (DAC) for allergy evaluation.

Of patients seen in the DAC for allergy evaluation, 270 (90.3%) had their allergy de-labeled after undergoing an oral drug challenge with or without PST. No patients experienced an IgE-mediated anaphylactic reaction to an oral drug challenge. Patients received penicillin G more often for GBS prophylaxis during labor when they had their drug allergy removed in the DAC compared to those who were not seen for allergy evaluation (87.5% vs 24.5%, P < 0.001).

This study supports the safety of drug allergy testing in obstetric patients. Most patients are appropriate candidates for a direct oral challenge only or PST followed by an oral challenge. Identifying and testing penicillin allergic obstetric patients prior to delivery resulted in an increase in use of first-line guideline-recommended antibiotic prophylaxis for GBS during labor.

To determine if the initial procalcitonin level and the serial trend of procalcitonin levels in blood were predictive of clinical outcomes in children with sepsis.

A retrospective cohort study

One primary-to-quaternary care pediatric healthcare system from May 2020 to May 2022

Encounters for children 1 to 18 years old with a sepsis ICD-10 diagnosis code and clinical sepsis were included.

Procalcitonin clearance at 48 hours (CL-PCT48) was defined as the difference in procalcitonin values drawn on admission and at 48 hours divided by initial procalcitonin value. The primary outcome was early clinical stability. Receiver operating characteristic analysis was performed to measure the correlation of CL-PCT48 and initial procalcitonin value (PCT0) with the outcomes.

320 unique encounters met the clinical criteria of sepsis with at least two procalcitonin values. 187 encounters had procalcitonin collected at eligible times. The mean age of the participants was 9 years and 8 months, 103 (55%) were male, and 74 (40%) were Hispanic. 78 (41.7%) individuals had good early clinical response, and 177 (94.7%) survived. There was no correlation identified between CL–-PCT48 and early clinical stability (area under ROC curve [AUC] = 0.57, 95% CI 0.48–0.65) or mortality (AUC = 0.60, 95% CI 0.43–0.76). There was also no correlation between PCT0 and early clinical stability (AUC = 0.47, 95% CI 0.39–0.56) or mortality (AUC = 0.50, 95% CI 0.29–0.72).

Procalcitonin clearance at 48 hours after admission did not predict early clinical stability in children with sepsis.

Antibiotics are essential to combating infections; however, misuse and overuse has contributed to antimicrobial resistance (AMR). Antimicrobial stewardship programs (ASPs) are a strategy to combat AMR and are mandatory in Canadian hospitals for accreditation. The Canadian Nosocomial Infection Surveillance Program (CNISP) sought to capture a snapshot of ASP practices within the network of Canadian acute care hospitals. Objectives of the survey were to describe the status, practices, and process indicators of ASPs across acute care hospitals participating in CNISP.

The survey explored the following items related to ASP programs: 1) program structure and leadership, 2) human, technical and financial resources allocated, 3) inventory of interventions carried and implemented, 4) tracking antimicrobial use; and 5) educational and promotional components.

CNISP developed a 34-item survey in both English and French. The survey was administered to 109 participating CNISP hospitals from June to August 2024, responses were analyzed descriptively.

Ninety-seven percent (106/109) of CNISP hospitals responded to the survey. Eighty-four percent (89/106) reported having a formal ASP in place at the time of the study. Ninety percent (80/89) of acute care hospitals with an ASP performed prospective audit and feedback for antibiotic agents and 85% (76/89) had formal surveillance of quantitative antimicrobial use. Additionally, just over 80% (74/89) provided education to their prescribers and other healthcare staff.

CNISP acute care hospitals employ multiple key aspects of ASP including implementing interventions and monitoring/tracking antimicrobial use. There were acute care hospitals without an ASP, highlighting areas for investigation and improvement.

It is unknown how providers are utilizing procalcitonin in the real world to make antibiotic prescribing decisions, and whether procalcitonin can limit harms related to antibiotic misuse. We examined how the probability of receiving antibiotics changed just below and above the pre-specified procalcitonin cut-points. We sought to understand whether providers interpret procalcitonin as a dichotomous or continuous diagnostic test.

Retrospective cohort study.

We included adult inpatients who had procalcitonin collected as part of routine care. Patients with procalcitonin collected more than 48 hours after the first antibiotic dose, those discharged from the emergency department, or those on an obstetrics service were excluded.

We used administrative data from the Health Data Compass database (2018-2019) at the University of Colorado Hospital to examine the correlation of pre-specified procalcitonin cut-points (0.1, 0.25, and 0.5 ng/mL) with the antibiotic treatment decisions using a regression discontinuity analysis (RDA), stratified by level of care. We constructed receiver operating characteristic (ROC) curves depicting the relationship between procalcitonin level and antibiotic prescribing. We performed sensitivity analyses by varying bandwidth for RDA.

The study included 4383 patients. A total of 68.9% received a full antibiotic course. RDA did not demonstrate any discontinuity at the pre-specified cut-points. However, sensitivity analyses showed a potential discontinuity at the 0.25 ng/mL cut-point in the ICU subgroup. The ROC curves were consistent with the RDA findings.

This study suggests that most clinicians in real-world settings interpret procalcitonin as a continuous diagnostic test when prescribing antibiotics.

Overtreatment of asymptomatic bacteriuria (ASB) is a major cause of antibiotic overuse. We facilitated a nationwide implementation of an ASB antimicrobial stewardship intervention in 41 Veterans Affairs facilities. Twenty-one sites participated in a Virtual Learning Collaborative (VLC) with monthly webinars. We assess what VLC teams learned from one another in these webinars.

The bi-monthly VLC webinars featured expert presentations and spotlighted 1–2 site teams, asking them to discuss their barriers and facilitators for the intervention. Data come from analyses of descriptive field notes from the webinars and chat transcripts. Field notes were analyzed using the “sort and sift, think and shift” method. We sorted and labeled common strategies thematically, sifted through illustrative quotes, and iteratively discussed the results to reach consensus.

Across 22 webinars (August 2023–April 2024), sites discussed different resources, team membership, and organizational structures. Sites had to “tailor swiftly” to their site needs and target audiences by adapting educational materials for timing, length, audience, and outreach location. Sites used five tailoring strategies to implement the antimicrobial stewardship program: Organizational and Structural Strategies, Recruitment Strategies, Data- and Information-Based Strategies, Interpersonal Strategies, and Resource Provision.

VLC webinars allowed sites to share tips and strategies for the implementation of a nationwide antimicrobial stewardship program wherein rapid tailoring and local adaptations were effective. Our supportive approach to tailoring allowed implementation sites to adapt antimicrobial stewardship materials and intervention delivery to their different resources and organizational contexts.

To compare clinical failure of intravenous vs intravenous with oral step-down antibiotic treatment for Streptococcus and Enterococcus bloodstream infection.

Multicenter, retrospective, cohort study at one academic medical center and eight community hospitals.

Hospitalized adult patients with blood cultures positive for Streptococcus or Enterococcus were included. Patients were excluded if they had complicated infection, had polymicrobial bacteremia, received less than 5 days of therapy, or died before completing therapy.

Patients who completed intravenous therapy were compared with patients who transitioned to oral therapy after 3 to 7 days. The primary endpoint was clinical failure, defined as 90-day all-cause mortality or recurrent bacteremia. The primary analysis excluded patients with unknown outcomes, and the sensitivity analysis treated them as failures.

429 patients were included (intravenous group: n = 225; oral step-down group; n = 204). The intravenous group had more comorbidities and vasopressor use. The intravenous group had a higher risk of clinical failure in the primary analysis (17.5% vs. 8.8%; adjusted OR 2.14 [95% CI, 1.09–4.2]; p = 0.03) while the sensitivity analysis found no difference in clinical failure (adjusted OR 1.1 [95% CI, 0.69–1.74], p = 0.69). The oral step-down group had a mean length of stay of 9.2 days shorter than the intravenous group ([95% CI, 7.5–11.0]; p<0.001).

Oral step-down therapy was not associated with an increased risk of clinical failure compared to a full course of intravenous therapy for uncomplicated Streptococcus and Enterococcus bloodstream infections. Patients with more comorbidities or who required vasopressors were less likely to be switched to oral therapy.