To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
To evaluate the role of procalcitonin (PCT) results in antibiotic decisions for COVID-19 patients at hospital presentation.
Design, setting, and participants:
Multicenter retrospective observational study of patients ≥18 years hospitalized due to COVID-19 at the Johns Hopkins Health system. Patients who were transferred from another facility with >24 hours stay and patients who died within 48 hours of hospitalization were excluded.
Elevated PCT values were determined based on each hospital’s definition. Antibiotic therapy and PCT results were evaluated for patients with no evidence of bacterial community-acquired pneumonia (bCAP) and patients with confirmed, probable, or possible bCAP. The added value of PCT testing to clinical criteria in detecting bCAP was evaluated using receiving operating curve characteristics (ROC).
Of 962 patients, 611 (64%) received a PCT test. ROC curves for clinical criteria and clinical criteria plus PCT test were similar (at 0.5 ng/mL and 0.25 ng/mL). By bCAP group, median initial PCT values were 0.58 ng/mL (interquartile range [IQR], 0.24–1.14), 0.23 ng/mL (IQR, 0.1–0.63), and 0.15 ng/mL (IQR, 0.09–0.35) for proven/probable, possible, and no bCAP groups, respectively. Among patients without bCAP, an elevated PCT level was associated with 1.8 additional days of CAP therapy (95% CI, 1.01–2.75; P < .01) compared to patients with a negative PCT result after adjusting for potential confounders. Duration of CAP therapy was similar between patients without a PCT test ordered and a low PCT level for no bCAP and possible bCAP groups.
PCT results may be abnormal in COVID-19 patients without bCAP and may result in receipt of unnecessary antibiotics.
In a multicenter cohort of 963 adults hospitalized due to coronavirus disease 2019 (COVID-19), 5% had a proven hospital-acquired infection (HAI) and 21% had a proven, probable, or possible HAI. Risk factors for proven or probable HAIs included intensive care unit admission, dexamethasone use, severe COVID-19, heart failure, and antibiotic exposure upon admission.
In a qualitative study of healthcare workers and patients discharged on oral antibiotics, we identified 5 barriers to antibiotic decision making at hospital discharge: clinician perceptions of patient expectations, diagnostic uncertainty, attending physician–led versus multidisciplinary team culture, not accounting for total antibiotic duration, and need for discharge prior to complete data.
Background: In 2018, the Maryland Department of Health, in collaboration with the University of Maryland and Johns Hopkins University, created the Statewide Prevention and Reduction of Clostridioides difficile (SPARC) collaborative to reduce C. difficile as specified in Healthy People 2020. Methods: The SPARC collaborative recruited hospitals contributing most cases to statewide C. difficile standardized infection ratio (SIR), according to data reported to the National Healthcare Safety Network (NHSN). SPARC developed intervention bundles around 4 domains: infection prevention, environmental cleaning, and diagnostic and antimicrobial stewardship. Each facility completed a self-assessment followed by an on-site, day-long, peer-to-peer (P2P) evaluation with 8–12 SPARC subject matter experts (SMEs) representing each domain. The SMEs met with hospital executive leadership and then led 4 domain-based group discussions with relevant hospital team leaders. To identify policy and practice gaps, SMEs visited hospital inpatient units for informal interviews with frontline staff. In a closing session, SPARC SMEs, hospital executives, and team leaders reconvened to discuss preliminary findings. This included review of covert observation data (hand hygiene, personal protective equipment compliance, environmental cleaning) obtained by SPARC team 1–2 weeks prior. Final SPARC P2P written recommendations guided development of customized interventions at each hospital. SPARC provided continuous support (follow up phone calls, educational webinars, technical support, didactic training for antimicrobial stewardship pharmacists) to enhance facility-specific implementation. For every quarter, we categorized C. difficile NHSN data for each Maryland hospital into “SPARC” or “non-SPARC” based on participation status. Using negative binomial mixed models, we analyzed difference-in-difference of pre- and postincidence rate ratios (IRRs) for SPARC and non-SPARC hospitals, which allowed estimation of change attributable to SPARC participation independent of other time-varying factors. Results: Overall, 13 of 48 (27%) hospitals in Maryland participated in the intervention. The baseline SIR for all Maryland hospitals was 0.92, and the post-SPARC SIR was 0.67. The SPARC hospitals had a greater reduction in hospital-onset C. difficile incidence; 8.6 and 4.3 events per 10,000 patient days for baseline and most recent quarter, respectively. For non-SPARC hospitals, these hospital-onset C. difficile incidences were 5.1 preintervention and 4.3 postintervention. We found a statistically significant difference-in-difference between SPARC and non-SPARC hospital C. difficile reduction rates (ratio of IRR, 0.63; 95% CI, 0.44−0.89; P = .01). Conclusions: The Maryland SPARC collaborative, a public health-academic partnership, was associated with a 25% reduction in the Maryland C. difficile SIR. Hospitals participating in SPARC demonstrated significantly reduced C. difficile incidences to match that of high-performing hospitals in Maryland.
Background: Inappropriate antibiotic prescription leads to increased Clostridiodes difficile infections, adverse effects including organ toxicity, and generation of antibiotic-resistant bacteria. Despite efforts to improve antibiotic use in acute-care settings, unnecessary and inappropriate prescription still occur in 30%–50% of patients. Objectives: We assessed factors associated with inappropriate antibiotic prescription at 2 time points: (1) initial, empiric therapy and (2) 3–5 days after therapy initiation. Methods: As part of a multicenter study investigating strategies to reduce antibiotic therapy after 3–5 days of use, antibiotic prescription data were collected from 11 adult and pediatric intensive care and general medical units at 6 hospitals in Maryland in 2014 and 2015. We performed a retrospective cohort study of all hospitalized patients who received any of 23 common antibiotics for at least 3 days. Each medical record was reviewed for demographics, admission and discharge dates, patient comorbidities, and antibiotic regimen by at least 1 infectious disease physician or pharmacist. Classification of antibiotic inappropriateness was based on each institution’s guidelines and standards. Bivariate analyses were performed using logistic regression for both initial therapy and therapy at days 3–5. Multivariable logistic regression was performed using covariates meeting the significance level of P < .05. Results: In total, 3,436 antibiotic courses were assessed at time of initial therapy, and 1541 regimens were continued and reviewed again at days 3–5 of therapy. For the initial therapy, 1,255 regimens (37%) were inappropriate; 45% of these were considered unnecessary and 41% were too broad in spectrum. In the multivariable regression, older age and antibiotic prescription during the summer were associated with the receipt of inappropriate antibiotics (Table 1). Having end-stage renal disease as a comorbid condition was protective against inappropriate use. At days 3–5 of therapy, 688 (45%) of the antibiotic courses were inappropriate. Reasons regimens were considered inappropriate included unnecessary antibiotic prescriptions (49%) and antibiotics being too broad (38%). Older age and receiving cefepime or piperacillin-tazobactam on day 3 of therapy were factors associated with inappropriate use (Table 2). Having undergone a transplant or a surgical procedure was protective of inappropriate antimicrobial use at days 3–5 of therapy. Conclusions: Older patients are more likely to receive inappropriate antibiotics at both initial regimen and 3–5 days later. Patients receiving cefepime or piperacillin-tazobactam are at greater risk of receiving inappropriate antibiotics at days 3–5 due to failure to de-escalate. Antibiotic stewardship strategies targeting these patient populations may limit inappropriate use.
Email your librarian or administrator to recommend adding this to your organisation's collection.