Importance:Empiric extended-spectrum antibiotics are routinely prescribed for over a million patients hospitalized annually with abdominal infection despite low likelihoods of infection with multidrug-resistant organisms (MDROs). Objective:To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates can reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with abdominal infection. Design, Setting, and Participants:This 92-hospital cluster randomized clinical trial assessed the effect of an antibiotic stewardship bundle with CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults hospitalized with abdominal infection. The trial population included adults (≥18 years) treated with empiric antibiotics for abdominal infection in non-intensive care units (ICUs). The trial periods included a 12-month baseline from January to December 2019 and an intervention period from January to December 2023. Intervention:CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period if the patient's estimated absolute risk of MDRO abdominal infection was less than 10%, coupled with feedback and education. Main Outcomes and Measures:The primary outcome was empiric extended-spectrum antibiotic days of therapy. Safety outcomes: days to ICU transfer and hospital length of stay. Analyses compared differences between baseline and intervention periods across strategies. Results:Among 92 hospitals with 198 480 patients, mean (SD) age was 60 (19) years and 118 723 (59.8%) were female. The trial included 93 476 and 105 004 patients hospitalized with abdominal infection during the baseline and intervention periods, respectively. Receipt of any empiric extended-spectrum antibiotics for the routine care group was 48.2% (22 519 of 46 725) during baseline and 50.5% (27 452 of 54 384) during intervention vs 47.8% (22 367 of 46 751) and 37.6% (19 010 of 50 620) for the CPOE bundle group. The group receiving CPOE prompts had a 35% relative reduction (rate ratio, 0.65; 95% CI, 0.60-0.71; P < .001) in empiric extended-spectrum antibiotic days of therapy vs routine care (raw absolute reduction between baseline and intervention periods was -169 for the CPOE bundle vs -20 for routine care). Hospital length of stay was noninferior to routine care (0.1 days longer during intervention; mean [SD], baseline, 5.4 [3.4] days vs intervention, 5.5 [3.5] days; hazard ratio [HR], 1.02; 90% CI, 0.99-1.06), and mean days to ICU transfer in the CPOE group was indeterminate (both groups 0.2 days longer during intervention; HR, 1.10; 90% CI, 0.99-1.23). Conclusions and Relevance:CPOE prompts recommending empiric standard-spectrum antibiotics (coupled with education and feedback) for patients admitted with abdominal infection who have low risk for MDRO infection significantly reduced extended-spectrum antibiotics without increasing ICU transfers or length of stay. Trial Registration:ClinicalTrials.gov Identifier: NCT05423743.

Empiric extended-spectrum antibiotics are routinely prescribed for over a million patients hospitalized annually with abdominal infection despite low likelihoods of infection with multidrug-resistant organisms (MDROs). To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates can reduce empiric extended-spectrum antibiotics for non–critically ill patients admitted with abdominal infection. This 92-hospital cluster randomized clinical trial assessed the effect of an antibiotic stewardship bundle with CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in non–critically ill adults hospitalized with abdominal infection. The trial population included adults (≥18 years) treated with empiric antibiotics for abdominal infection in non–intensive care units (ICUs). The trial periods included a 12-month baseline from January to December 2019 and an intervention period from January to December 2023. CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period if the patient’s estimated absolute risk of MDRO abdominal infection was less than 10%, coupled with feedback and education. The primary outcome was empiric extended-spectrum antibiotic days of therapy. Safety outcomes: days to ICU transfer and hospital length of stay. Analyses compared differences between baseline and intervention periods across strategies. Among 92 hospitals with 198 480 patients, mean (SD) age was 60 (19) years and 118 723 (59.8%) were female. The trial included 93 476 and 105 004 patients hospitalized with abdominal infection during the baseline and intervention periods, respectively. Receipt of any empiric extended-spectrum antibiotics for the routine care group was 48.2% (22 519 of 46 725) during baseline and 50.5% (27 452 of 54 384) during intervention vs 47.8% (22 367 of 46 751) and 37.6% (19 010 of 50 620) for the CPOE bundle group. The group receiving CPOE prompts had a 35% relative reduction (rate ratio, 0.65; 95% CI, 0.60-0.71; P < .001) in empiric extended-spectrum antibiotic days of therapy vs routine care (raw absolute reduction between baseline and intervention periods was −169 for the CPOE bundle vs −20 for routine care). Hospital length of stay was noninferior to routine care (0.1 days longer during intervention; mean [SD], baseline, 5.4 [3.4] days vs intervention, 5.5 [3.5] days; hazard ratio [HR], 1.02; 90% CI, 0.99-1.06), and mean days to ICU transfer in the CPOE group was indeterminate (both groups 0.2 days longer during intervention; HR, 1.10; 90% CI, 0.99-1.23). CPOE prompts recommending empiric standard-spectrum antibiotics (coupled with education and feedback) for patients admitted with abdominal infection who have low risk for MDRO infection significantly reduced extended-spectrum antibiotics without increasing ICU transfers or length of stay. ClinicalTrials.gov Identifier: NCT05423743

Abstract Background Up to 40% of hospitalized patients receive extended-spectrum (ES) antibiotics despite low risk of multidrug-resistant organism (MDRO) infection, increasing the risk for adverse effects and future resistance. We evaluated whether computerized physician order entry (CPOE) prompts providing patient-specific MDRO risk estimates could reduce ES antibiotic use compared to routine stewardship practices in patients hospitalized with skin and soft tissue (SST) infections. Methods This 92-hospital cluster-randomized trial compared CPOE prompts providing patient-specific absolute risk estimates for MDRO SST infection and recommending standard-spectrum antibiotics for risk < 10% vs. routine stewardship. Trial population: adults treated with antibiotics for SST infection in non-ICUs in the first 3 days of admission (empiric period). Prompts were triggered if ES antibiotics were ordered. Trial periods: 12-month Baseline (Jan 2019-Dec 2019); 5-month Phase-in (Aug 2022–Dec 2022); 12-month Intervention (Jan 2023-Dec 2023). Primary outcome: ES antibiotic days of therapy (ES-DOT) per patient per empiric day; secondary outcome was anti-pseudomonal DOT per empiric day. Unadjusted, as-randomized analyses used (1) generalized linear mixed effects models to assess differences in ES-DOT rates across intervention and baseline periods between groups, clustering by patient, hospital, and period and (2) proportional hazards models to assess safety outcomes: days to ICU transfer and hospital LOS. Results We randomized 92 hospitals in 15 states. Across the baseline and intervention periods there were 60,654 and 57,655 non-ICU patients with skin and soft tissue infection in the routine and CPOE prompt groups, respectively. The CPOE prompt group had a 28% reduction in ES-DOT compared to routine care (rate ratio 0.72 [95% CI 0.67-0.79], p< 0.001). Anti-pseudomonal DOT was reduced by 28% (Table, Figure 1) without significant differences in LOS or ICU transfers. Conclusion INSPIRE CPOE prompts providing patient-specific MDRO risk estimates recommending standard spectrum antibiotics in low risk patients significantly reduced empiric ES prescribing in adults admitted with skin and soft tissue infection. Disclosures Ken Kleinman, ScD, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work Richard Platt, MD, MSc, GlaxoSmithKline: Contract to academic department|Janssen: Contract to academic department|Pfizer: Contract to academic department Susan Huang, MD, MPH, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work

Importance:Empiric extended-spectrum antibiotics are routinely prescribed for patients hospitalized with skin and soft tissue infections (SSTIs) despite low likelihoods of infection with multidrug-resistant organisms (MDROs). Objective:To evaluate whether computerized provider order entry (CPOE) prompts presenting patient-specific and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for noncritically ill patients admitted with SSTI. Design, Setting, and Participants:This cluster randomized clinical trial included 92 hospitals and assessed the effect of an antibiotic stewardship bundle that included CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults hospitalized with SSTI. The trial population included adults 18 years and older treated with empiric antibiotics for SSTI in non-intensive care unit (ICU) settings. Data were collected from January 2019 to December 2023. Interventions:CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period when absolute risk of MDRO SSTI was estimated to be less than 10%, coupled with feedback and education. Main Outcomes and Measures:The primary outcome was empiric extended-spectrum antibiotic days of therapy (summed number of different extended-spectrum antibiotics targeting Pseudomonas and/or MDR gram-negative bacteria received per patient each calendar day). The secondary outcome was antipseudomonal days of therapy. Safety outcomes included days to ICU transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. Results:Among 118 562 patients admitted with SSTI at 92 hospitals, 67 033 (56.7%) were male and the mean (SD) age was 58.0 (17.5) years. A total of 57 837 patients were included in the baseline period and 60 725 in the intervention period. Receipt of any empiric extended-spectrum antibiotic during the baseline and intervention periods was 57.0% (16 855 of 29 595) and 56.0% (17 534 of 31 337), respectively, for the routine stewardship group compared with 55.4% (15 650 of 28 242) and 43.0% (12 647 of 29 388), respectively, for the CPOE group. Empiric extended-spectrum days of therapy per 1000 empiric days targeting Pseudomonas and/or MDR gram-negative pathogens was 511.5 during the baseline period and 488.7 during the intervention period in the routine stewardship group and was 496.2 and 359.1, respectively, in the CPOE bundle group (rate ratio, 0.72; 95% CI, 0.67-0.79; P < .001). There was no evidence of inferiority in the CPOE bundle group for mean (SD) hospital length of stay (routine stewardship, 6.5 [3.8] days; CPOE bundle, 6.4 [3.8] days) and days to ICU transfer (routine stewardship, 6.3 [3.2] days; CPOE bundle, 6.3 [3.1] days). Conclusions and Relevance:In this randomized clinical trial, CPOE prompts recommending standard-spectrum empiric antibiotics for low-risk patients hospitalized with SSTI coupled with education and feedback significantly reduced use of extended-spectrum antibiotics without increasing admissions to ICUs or hospital length of stay. Trial Registration:ClinicalTrials.gov Identifier: NCT05423756.

Abstract Background Up to 40% of hospitalized patients receive empiric extended-spectrum (ES) antibiotics despite low risk of multidrug-resistant organism (MDRO) infection, increasing the risk for adverse effects and future resistance. We evaluated whether computerized physician order entry (CPOE) prompts providing patient-specific MDRO risk estimates could reduce ES antibiotic use compared to routine stewardship in patients hospitalized with abdominal infections. Methods This 92-hospital cluster-randomized trial compared CPOE prompts providing patient-specific absolute risk estimates for MDRO abdominal infection and recommending standard-spectrum antibiotics for risk < 10% vs. routine stewardship. Trial population: adults treated with antibiotics for abdominal infection in non-ICUs in the first 3 days of admission (empiric period). Prompts were triggered if ES antibiotics were ordered. Trial periods: 12-month Baseline (Jan 2019-Dec 2019); 5-month Phase-in (Aug 2022–Dec 2022); 12-month Intervention (Jan 2023-Dec 2023). Primary outcome: ES antibiotic days of therapy (ES-DOT) per patient per empiric day; secondary outcomes were a) vancomycin and b) anti-pseudomonal DOT per empiric day. Unadjusted, as-randomized analyses used (1) generalized linear mixed effects models to assess differences in ES-DOT rates across intervention and baseline periods between groups clustering by patient, hospital, and period and (2) proportional hazards models to assess safety outcomes: days to ICU transfer and hospital LOS. Results We randomized 92 hospitals in 15 states. Across baseline and intervention periods there were 100,890 and 97,680 non-ICU patients with abdominal infection in the routine and CPOE prompt groups, respectively. The CPOE prompt group had a 35% reduction in ES-DOT compared to routine care (rate ratio 0.65 [95% CI 0.60-0.71], p< 0.001). Vancomycin and anti-pseudomonal DOT were reduced by 20% and 39%, respectively (Table, Figure 1) without significant differences in LOS or ICU transfers. Conclusion INSPIRE CPOE prompts providing patient-specific MDRO risk estimates recommending standard spectrum antibiotics in low risk patients significantly reduced empiric ES prescribing in adults admitted with abdominal infection. Disclosures Ken Kleinman, ScD, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work Richard Platt, MD, MSc, GlaxoSmithKline: Contract to academic department|Janssen: Contract to academic department|Pfizer: Contract to academic department Susan Huang, MD, MPH, Xttrium Laboratories: Conducting studies in which participating hospital patients received contributed antiseptic products outside the submitted work

Importance:Urinary tract infection (UTI) is the second most common infection leading to hospitalization and is often associated with gram-negative multidrug-resistant organisms (MDROs). Clinicians overuse extended-spectrum antibiotics although most patients are at low risk for MDRO infection. Safe strategies to limit overuse of empiric antibiotics are needed. Objective:To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO risk estimates could reduce use of empiric extended-spectrum antibiotics for treatment of UTI. Design, Setting, and Participants:Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time and risk-based CPOE prompts; 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults (≥18 years) hospitalized with UTI with an 18-month baseline (April 1, 2017-September 30, 2018) and 15-month intervention period (April 1, 2019-June 30, 2020). Interventions:CPOE prompts recommending empiric standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics who have low estimated absolute risk (<10%) of MDRO UTI, coupled with feedback and education. Main Outcomes and Measures:The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy. Safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes were assessed using generalized linear mixed-effect models to assess differences between the baseline and intervention periods. Results:Among 127 403 adult patients (71 991 baseline and 55 412 intervention period) admitted with UTI in 59 hospitals, the mean (SD) age was 69.4 (17.9) years, 30.5% were male, and the median Elixhauser Comorbidity Index count was 4 (IQR, 2-5). Compared with routine stewardship, the group using CPOE prompts had a 17.4% (95% CI, 11.2%-23.2%) reduction in empiric extended-spectrum days of therapy (rate ratio, 0.83 [95% CI, 0.77-0.89]; P < .001). The safety outcomes of mean days to ICU transfer (6.6 vs 7.0 days) and hospital length of stay (6.3 vs 6.5 days) did not differ significantly between the routine and intervention groups, respectively. Conclusions and Relevance:Compared with routine stewardship, CPOE prompts providing real-time recommendations for standard-spectrum antibiotics for patients with low MDRO risk coupled with feedback and education significantly reduced empiric extended-spectrum antibiotic use among noncritically ill adults admitted with UTI without changing hospital length of stay or days to ICU transfers. Trial Registration:ClinicalTrials.gov Identifier: NCT03697096.

Importance Pneumonia is the most common infection requiring hospitalization and is a major reason for overuse of extended-spectrum antibiotics. Despite low risk of multidrug-resistant organism (MDRO) infection, clinical uncertainty often drives initial antibiotic selection. Strategies to limit empiric antibiotic overuse for patients with pneumonia are needed. Objective To evaluate whether computerized provider order entry (CPOE) prompts providing patient- and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for non-critically ill patients admitted with pneumonia. Design, Setting, and Participants Cluster-randomized trial in 59 US community hospitals comparing the effect of a CPOE stewardship bundle (education, feedback, and real-time MDRO risk-based CPOE prompts; n = 29 hospitals) vs routine stewardship (n = 30 hospitals) on antibiotic selection during the first 3 hospital days (empiric period) in non-critically ill adults (>= 18 years) hospitalized with pneumonia. There was an 18-month baseline period from April 1, 2017, to September 30, 2018, and a 15-month intervention period from April 1, 2019, to June 30, 2020. Intervention CPOE prompts recommending standard-spectrum antibiotics in patients ordered to receive extended-spectrum antibiotics during the empiric period who have low estimated absolute risk (<10%) of MDRO pneumonia, coupled with feedback and education. Main Outcomes and Measures The primary outcome was empiric (first 3 days of hospitalization) extended-spectrum antibiotic days of therapy. Secondary outcomes included empiric vancomycin and antipseudomonal days of therapy and safety outcomes included days to intensive care unit (ICU) transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies. Results Among 59 hospitals with 96 451 (51 671 in the baseline period and 44 780 in the intervention period) adult patients admitted with pneumonia, the mean (SD) age of patients was 68.1 (17.0) years, 48.1% were men, and the median (IQR) Elixhauser comorbidity count was 4 (2-6). Compared with routine stewardship, the group using CPOE prompts had a 28.4% reduction in empiric extended-spectrum days of therapy (rate ratio, 0.72 [95% CI, 0.66-0.78]; P < .001). Safety outcomes of mean days to ICU transfer (6.5 vs 7.1 days) and hospital length of stay (6.8 vs 7.1 days) did not differ significantly between the routine and CPOE intervention groups. Conclusions and Relevance Empiric extended-spectrum antibiotic use was significantly lower among adults admitted with pneumonia to non-ICU settings in hospitals using education, feedback, and CPOE prompts recommending standard-spectrum antibiotics for patients at low risk of MDRO infection, compared with routine stewardship practices. Hospital length of stay and days to ICU transfer were unchanged. Trial Registration ClinicalTrials.gov Identifier: NCT03697070

BACKGROUND:Detection and containment of hospital outbreaks currently depend on variable and personnel-intensive surveillance methods. Whether automated statistical surveillance for outbreaks of health care-associated pathogens allows earlier containment efforts that would reduce the size of outbreaks is unknown. METHODS:We conducted a cluster-randomized trial in 82 community hospitals within a larger health care system. All hospitals followed an outbreak response protocol when outbreaks were detected by their infection prevention programs. Half of the hospitals additionally used statistical surveillance of microbiology data, which alerted infection prevention programs to outbreaks. Statistical surveillance was also applied to microbiology data from control hospitals without alerting their infection prevention programs. The primary outcome was the number of additional cases occurring after outbreak detection. Analyses assessed differences between the intervention period (July 2019 to January 2022) versus baseline period (February 2017 to January 2019) between randomized groups. A post hoc analysis separately assessed pre-coronavirus disease 2019 (Covid-19) and Covid-19 pandemic intervention periods. RESULTS:Real-time alerts did not significantly reduce the number of additional outbreak cases (intervention period versus baseline: statistical surveillance relative rate [RR]=1.41, control RR=1.81; difference-in-differences, 0.78; 95% confidence interval [CI], 0.40 to 1.52; P=0.46). Comparing only the prepandemic intervention with baseline periods, the statistical outbreak surveillance group was associated with a 64.1% reduction in additional cases (statistical surveillance RR=0.78, control RR=2.19; difference-in-differences, 0.36; 95% CI, 0.13 to 0.99). There was no similarly observed association between the pandemic versus baseline periods (statistical surveillance RR=1.56, control RR=1.66; difference-in-differences, 0.94; 95% CI, 0.46 to 1.92). CONCLUSIONS:Automated detection of hospital outbreaks using statistical surveillance did not reduce overall outbreak size in the context of an ongoing pandemic. (Funded by the Centers for Disease Control and Prevention; ClinicalTrials.gov number, NCT04053075. Support for HCA Healthcare's participation in the study was provided in kind by HCA.).

Drawing from real-life scenarios and insights shared at the RAISE (Responsible AI for Social and Ethical Healthcare) conference, we highlight the critical need for AI in health care (AIH) to primarily benefit patients and address current shortcomings in health care systems such as medical errors and access disparities.

Population Health ManagementVol. 26, No. 2 CommentariesHealth Systems Need to Transform Data Collection to Advance Health EquityJonathan Perlin and Alonzo PloughJonathan PerlinAddress correspondence to: Jonathan Perlin, MD, PhD, The Joint Commission, One Renaissance Boulevard, Oakbrook Terrace, IL 60181-4294, USA E-mail Address: jperlin@jointcommission.orgThe Joint Commission, Oakbrook Terrace, Illinois, USA.Search for more papers by this author and Alonzo PloughRobert Wood Johnson Foundation, Princeton, New Jersey, USA.Search for more papers by this authorPublished Online:14 Apr 2023https://doi.org/10.1089/pop.2023.0005AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 26Issue 2Apr 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Jonathan Perlin and Alonzo Plough.Health Systems Need to Transform Data Collection to Advance Health Equity.Population Health Management.Apr 2023.128-131.http://doi.org/10.1089/pop.2023.0005Published in Volume: 26 Issue 2: April 14, 2023Online Ahead of Print:March 22, 2023PDF download

We described care received by hospitalized children with COVID-19 or multi-system inflammatory syndrome (MIS-C) prior to the 2021 COVID-19 Omicron variant surge in the US. We identified hospitalized children <18 years of age with a COVID-19 or MIS-C diagnosis (COVID-19 not required), separately, from February 2020-September 2021 (n = 126 hospitals). We described high-risk conditions, inpatient treatments, and complications among these groups. Among 383,083 pediatric hospitalizations, 2,186 had COVID-19 and 395 had MIS-C diagnosis. Less than 1% had both COVID-19 and MIS-C diagnosis (n = 154). Over half were >6 years old (54% COVID-19, 70% MIS-C). High-risk conditions included asthma (14% COVID-19, 11% MIS-C), and obesity (9% COVID-19, 10% MIS-C). Pulmonary complications in children with COVID-19 included viral pneumonia (24%) and acute respiratory failure (11%). In reference to children with COVID-19, those with MIS-C had more hematological disorders (62% vs 34%), sepsis (16% vs 6%), pericarditis (13% vs 2%), myocarditis (8% vs 1%). Few were ventilated or died, but some required oxygen support (38% COVID-19, 45% MIS-C) or intensive care (42% COVID-19, 69% MIS-C). Treatments included: methylprednisolone (34% COVID-19, 75% MIS-C), dexamethasone (25% COVID-19, 15% MIS-C), remdesivir (13% COVID-19, 5% MIS-C). Antibiotics (50% COVID-19, 68% MIS-C) and low-molecular weight heparin (17% COVID-19, 34% MIS-C) were frequently administered. Markers of illness severity among hospitalized children with COVID-19 prior to the 2021 Omicron surge are consistent with previous studies. We report important trends on treatments in hospitalized children with COVID-19 to improve the understanding of real-world treatment patterns in this population.

In a survey of infection prevention programs, leaders reported frequent clinical and infection prevention practice modifications to avoid coronavirus disease 2019 (COVID-19) exposure that exceeded national guidance. Future pandemic responses should emphasize balanced approaches to precautions, prioritize educational campaigns to manage safety concerns, and generate an evidence-base that can guide appropriate infection prevention practices.

ImportanceUniversal nasal mupirocin plus chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) prevents methicillin-resistant Staphylococcus aureus (MRSA) infections and all-cause bloodstream infections. Antibiotic resistance to mupirocin has raised questions about whether an antiseptic could be advantageous for ICU decolonization. ObjectiveTo compare the effectiveness of iodophor vs mupirocin for universal ICU nasal decolonization in combination with CHG bathing. Design, Setting, and ParticipantsTwo-group noninferiority, pragmatic, cluster-randomized trial conducted in US community hospitals, all of which used mupirocin-CHG for universal decolonization in ICUs at baseline. Adult ICU patients in 137 randomized hospitals during baseline (May 1, 2015-April 30, 2017) and intervention (November 1, 2017-April 30, 2019) were included. InterventionUniversal decolonization involving switching to iodophor-CHG (intervention) or continuing mupirocin-CHG (baseline). Main Outcomes and MeasuresICU-attributable S aureus clinical cultures (primary outcome), MRSA clinical cultures, and all-cause bloodstream infections were evaluated using proportional hazard models to assess differences from baseline to intervention periods between the strategies. Results were also compared with a 2009-2011 trial of mupirocin-CHG vs no decolonization in the same hospital network. The prespecified noninferiority margin for the primary outcome was 10%. ResultsAmong the 801 668 admissions in 233 ICUs, the participants' mean (SD) age was 63.4 (17.2) years, 46.3% were female, and the mean (SD) ICU length of stay was 4.8 (4.7) days. Hazard ratios (HRs) for S aureus clinical isolates in the intervention vs baseline periods were 1.17 for iodophor-CHG (raw rate: 5.0 vs 4.3/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 4.1 vs 4.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 18.4% [95% CI, 10.7%-26.6%] for mupirocin-CHG, P < .001). For MRSA clinical cultures, HRs were 1.13 for iodophor-CHG (raw rate: 2.3 vs 2.1/1000 ICU-attributable days) and 0.99 for mupirocin-CHG (raw rate: 2.0 vs 2.0/1000 ICU-attributable days) (HR difference in differences significantly lower by 14.1% [95% CI, 3.7%-25.5%] for mupirocin-CHG, P = .007). For all-pathogen bloodstream infections, HRs were 1.00 (2.7 vs 2.7/1000) for iodophor-CHG and 1.01 (2.6 vs 2.6/1000) for mupirocin-CHG (nonsignificant HR difference in differences, -0.9% [95% CI, -9.0% to 8.0%]; P = .84). Compared with the 2009-2011 trial, the 30-day relative reduction in hazards in the mupirocin-CHG group relative to no decolonization (2009-2011 trial) were as follows: S aureus clinical cultures (current trial: 48.1% [95% CI, 35.6%-60.1%]; 2009-2011 trial: 58.8% [95% CI, 47.5%-70.7%]) and bloodstream infection rates (current trial: 70.4% [95% CI, 62.9%-77.8%]; 2009-2011 trial: 60.1% [95% CI, 49.1%-70.7%]). Conclusions and RelevanceNasal iodophor antiseptic did not meet criteria to be considered noninferior to nasal mupirocin antibiotic for the outcome of S aureus clinical cultures in adult ICU patients in the context of daily CHG bathing. In addition, the results were consistent with nasal iodophor being inferior to nasal mupirocin. Trial RegistrationClinicalTrials.gov Identifier: NCT03140423

What should a health system do when in possession of the largest and most coherent data set that could help accelerate the understanding of COVID-19 and its treatment?For HCA Healthcare, a large health care organization comprised of 185 hospitals and more than 2000 sites of care in 20 US states and the UK, the answer to this question was a matter of social responsibility: harness the potential of this asset through data sharing and research collaborations with public-sector and academic institutions.Although straightforward in concept, this goal was technically and ethically complex.By building on a legacy of multi-institution research partnerships and in conjunction with the

Background Statins are a commonly used class of drugs, and reports have suggested that their use may affect COVID-19 disease severity and mortality risk. Objective The purpose of this analysis was to determine the effect of discontinuation of previous atorvastatin therapy in patients hospitalized for COVID-19 on the risk of mortality and ventilation. Methods Data from 146,413 hospitalized COVID-19 patients were classified according to statin therapy. Home?+?in hospital atorvastatin use (continuation of therapy);home?+?no in hospital atorvastatin use (discontinuation of therapy);no home?+?no in hospital atorvastatin use (no statins). Logistic regression was performed to assess the association between atorvastatin administration and either mortality or use of mechanical ventilation during the encounter. Results Continuous use of atorvastatin (home and in hospital) was associated with a 35% reduction in the odds of mortality compared to patients who received atorvastatin at home but not in hospital (odds ratio [OR]: 0.65, 95% confidence interval [CI]: 0.59?0.72, p?<?.001). Similarly, the odds of ventilation were lower with continuous atorvastatin therapy (OR: 0.70, 95% CI: 0.64?0.77, p?<?.001). Conclusions Discontinuation of previous atorvastatin therapy is associated with worse outcomes for COVID-19 patients. Providers should consider maintaining existing statin therapy for patients with known or suspected previous use.

BACKGROUND: Devastating cases of sepsis in previously healthy patients have received widespread attention and have helped to catalyze state and national mandates to improve sepsis detection and care. However, it is unclear what proportion of patients hospitalized with sepsis previously were healthy and how their outcomes compare with those of patients with comorbidities. RESEARCH QUESTION: Among adults hospitalized with community-onset sepsis, how many previously were healthy and how do their outcomes compare with those of patients with comorbidities? STUDY DESIGN AND METHODS: We retrospectively identified all adults with community-onset sepsis hospitalized in 373 US hospitals from 2009 through 2015 using clinical indicators of presumed infection and organ dysfunction (Centers for Disease Control and Prevention's Adult Sepsis Event criteria). Comorbidities were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. We applied generalized linear mixed models to measure the associations between the presence or absence of comorbidities and short-term mortality (in-hospital death or discharge to hospice), adjusting for severity of illness on admission. RESULTS: Of 6,715,286 hospitalized patients, 337,983 (5.0%) were hospitalized with community-onset sepsis. Most patients with sepsis (329,052 [97.4%]) had received a diagnosis of at least one comorbidity; only 2.6% previously were healthy. Patients with sepsis who previously were healthy were younger than those with comorbidities (mean age, 58.0 +/- 19.8 years vs 67.0 +/- 16.5 years), were less likely to require ICU care on admission (37.9% vs 50.5%), and were more likely to be discharged home (57.9% vs 45.6%), rather than to subacute facilities (16.3% vs 30.8%), but showed higher short-term mortality rates (22.8% vs 20.8%; P < .001 for all). The association between previously healthy status and higher short-term mortality persisted after risk adjustment (adjusted OR, 1.99; 95% CI, 1.87-2.13). INTERPRETATION: The vast majority of patients hospitalized with community-onset sepsis harbor pre-existing comorbidities. However, previously healthy patients may be more likely to die when they seek treatment at the hospital with sepsis compared with patients with comorbidities. These findings underscore the importance of early sepsis recognition and treatment for all patients.

Digital Health in the 21st Century Over the past several decades, the development and accelerated advancement of digital technology has prompted change across virtually all aspects of human endeavor. […]

Abstract Background The CLUSTER trial assessed the impact of prospective identification of clusters coupled with a response protocol on the containment of hospital clusters. Methods This 82-hospital CRT in 16 states compared clusters of bacterial and fungal healthcare pathogens using a statistical outbreak detection tool (WHONET-SaTScan) coupled with a standardized response protocol (automated cluster detection arm) compared to routine surveillance with the response protocol (control arm). Trial periods: 24 mo Baseline (2/17–1/19); 5 mo Phase-in (2/19–6/19); 30 mo Intervention (7/19–1/22). The primary outcome was the number of additional cases occurring after initial cluster detection. Analyses used generalized linear mixed models to assess differences in additional cases between the intervention vs baseline periods across arms, clustering by hospital. Results were assessed overall and, to account for the effect of COVID-19 on hospital operations, stratified into pre-COVID-19 (7/19–6/20) and during COVID-19 (7/20–1/22) intervention periods. We also assessed the probability that a patient was in a cluster. Results In the baseline period, the automated cluster detection and control arms had 0.09 and 0.07 additional cluster cases/1000 admissions, respectively. The automated cluster detection arm had a 22% greater relative reduction in additional cluster cases in the intervention vs baseline period compared to control (P=0.5). Within the intervention period, the automated cluster detection arm had a significant 64% relative reduction pre-COVID-19 (P< 0.05) and a non-significant 6% relative reduction during COVID-19 (P=0.9) compared to control (Figure). When evaluating patient risk of being part of a cluster across the entire intervention period, the automated cluster detection arm had a significant 35% relative reduction vs control (P< 0.01). Conclusion A statistical automated tool coupled with a response protocol improved cluster containment by 64% pre-COVID-19 but not during COVID-19; there were no significant differences between the arms when using the entire intervention period. Automated cluster detection may substantially improve outbreak containment in non-pandemic periods when infection prevention programs are able to optimize containment protocols. Disclosures Susan S. Huang, MD, MPH, Medline: Conducted studies in which hospitals and nursing homes received contributed antiseptic and/or environmental cleaning products|Molnlyke: Conducted clinical studies in which hospitals received contributed antiseptic product|Stryker: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic products|Xttrium Laboratories: Conducted clinical studies in which hospitals and nursing homes received contributed antiseptic product.