ImportanceRecent evolutions in clinical care and remote monitoring suggest that some acute illnesses no longer require intravenous therapy and inpatient hospitalization.ObjectiveTo describe outcomes of patients receiving care in a new, outpatient, virtual, home-based acute care model called Safer@Home.Design, Setting, and ParticipantsThis retrospective cohort analysis, conducted from September 1, 2022, through August 31, 2023, included 2466 patients treated at a safety net hospital in Los Angeles County for 10 core illnesses and 24 other acute illnesses for which patients are commonly hospitalized.ExposureOutpatient, home-based, acute care with virtual monitoring and clinic visits in lieu of inpatient or in-home care.Main Outcomes and MeasuresThe primary measure was hospital length of stay. Secondary measures included all-cause mortality, 30-day readmission, return urgent care visit rates, and return emergency department (ED) visit rates.ResultsSafer@Home provided care to 876 patients (mean [SD] age, 54.0 [14.5] years; 541 men [61.8%]) during the study period, compared with a cohort of 1590 patients (mean [SD] age, 52.3 [19.6] years; 901 men [56.7%]) with matching diagnoses who received standard, hospital-based care. Safer@Home patients had significantly shorter mean (SD) lengths of inpatient stay than the comparison cohort (1.3 [2.0] vs 5.3 [10.4] days; P < .001), totaling 3505 bed-days avoided (mean [SD], 4.0 [10.6] bed-days saved per patient), with no significant difference in all-cause mortality at last follow-up (2.6% [23 of 876] vs 4.0% [64 of 1590]; P = .07). Safer@Home patients and control patients also had no significant difference in the proportion experiencing 30-day hospital readmission (19.9% [174 of 876] vs 16.7% [266 of 1590]; P = .06). As intended, more Safer@Home than control patients had at least one 30-day return urgent care visit (37.3% [327 of 876] vs 5.2% [82 of 1590]; P < .001). In contrast, the Safer@Home and control cohorts did not significantly differ in experiencing at least one 30-day return ED visit (15.2% [133 of 876] vs 12.5% [199 of 1590]; P = .06). Safer@Home patients had significantly fewer mean (SD) total 30-day return ED visits per patient than control patients (0.19 [0.50] vs 0.21 [0.85]; P < .001).Conclusions and RelevanceIn this cohort study, patients receiving acute, virtual, home care with remote monitoring and as-needed return urgent care visits had markedly shorter hospital stays than patients receiving standard inpatient hospital care, with no significant increase in mortality, ED revisits, or return hospitalizations. This new care model is promising for systems that cannot staff Medicare-compliant hospital-at-home visits.

Background: Based on multiple randomized-controlled clinical trials, shorter antibiotic courses are equally effective as traditional longer courses for many types of infections. However, longer courses are still being used widely in the clinical practice.Objectives: To describe four components involved in the successful implementation of shorter antibiotic courses in our health care institutions, including an academic, public hospital and a community hospital staffed primarily by private practitioners.Sources: Clinical trials and peer-reviewed publications.Content: We provide practical advice on how to support the change in clinical practice to shorten antibiotic duration. Specifically, we list the steps that we have successfully used to develop and implement an institutional practice change regarding the duration of antibiotic therapy: (a) establishing consensus documents outlining a data-driven expected practice for using antibiotics, (b) antibiotic stewardship programme support, (c) provider education, and (d) reinforcing behaviour through psychological and other tools. The implementation of these processes has successfully led to shorter antibiotic courses and decreased antibiotic use in our diverse practice settings.Implications: Intentional improvement in decreasing the duration of antibiotic therapy can be achieved by a specific antibiotic stewardship programme strategy and tactics. The implementation of shorter antibiotic courses has effects at individual and societal levels in an era of increasing antibacterial resistance and health care costs. Fernando Dominguez, Clin Microbiol Infect 2023;29:1402 (c) 2022 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Background We sought to compare the outcomes of patients treated with intravenous (IV)-only vs oral transitional antimicrobial therapy for infective endocarditis (IE) after implementing a new expected practice within the Los Angeles County Department of Health Services (LAC DHS). Methods We conducted a multicentered, retrospective cohort study of adults with definite or possible IE treated with IV-only vs oral therapy at the 3 acute care public hospitals in the LAC DHS system between December 2018 and June 2022. The primary outcome was clinical success at 90 days, defined as being alive and without recurrence of bacteremia or treatment-emergent infectious complications. Results We identified 257 patients with IE treated with IV-only (n = 211) or oral transitional (n = 46) therapy who met study inclusion criteria. Study arms were similar for many demographics; however, the IV cohort was older, had more aortic valve involvement, were hemodialysis patients, and had central venous catheters present. In contrast, the oral cohort had a higher percentage of IE caused by methicillin-resistant Staphylococcus aureus. There was no significant difference between the groups in clinical success at 90 days or last follow-up. There was no difference in recurrence of bacteremia or readmission rates. However, patients treated with oral therapy had significantly fewer adverse events. Multivariable regression adjustments did not find significant associations between any selected variables and clinical success across treatment groups. Conclusions These results demonstrate similar outcomes of real-world use of oral vs IV-only therapy for IE, in accord with prior randomized, controlled trials and meta-analyses. In this retrospective, multicenter cohort study of 257 patients with endocarditis, patients who received oral transition therapy had similar clinical success, readmissions, complications, and recurrences of bacteremia, with fewer adverse drug effects, compared with IV-only therapy.

Abstract Background The Omicron variant of SARS-CoV-2 saw the highest incidence of cases during the COVID-19 pandemic, yet these cases had less severe outcomes compared to earlier variants. This could be due to increased immunity from vaccination, infection of healthier patients, increased identification of less severe cases, and decreased viral pathogenicity. We examine the relative contribution of these factors to outcomes among hospitalized COVID-19 patients by comparing a cohort from the early pandemic to a cohort from the Omicron wave, subdivided by baseline immunity. Methods We retrospectively reviewed electronic medical records of 456 patients hospitalized for COVID during the early pandemic (03/2020 - 05/2020) and 453 patients hospitalized for COVID during the Omicron wave (12/2021 - 01/2022) at a public safety net hospital in Los Angeles, CA. We recorded demographics, clinical data, infection and vaccination history, and hospital outcomes including severe disease, defined as need for supplemental oxygen. Results Patients hospitalized during the early pandemic were more likely to have severe disease than those during the Omicron wave (75.9% vs 35.1%, p < 0.001). Within the Omicron cohort, “non-immune” patients without vaccination or prior infection had more severe disease than “immune” patients with prior vaccination or infection (37.8% vs 33.3%, p < 0.001). Patients hospitalized during the early pandemic were older with more medical comorbidities than during the Omicron wave; within the Omicron cohort, immune patients were older with more medical comorbidities than non-immune patients. After controlling for age and medical comorbidities via logistic regression, non-immune Omicron patients were less likely to have severe disease than early pandemic patients (OR = 0.25 [0.17-0.38]); immune Omicron patients had even lower rates of severe disease compared to early pandemic patients (OR = 0.15 [0.10-0.23]). Characteristics of Patient Cohorts divided by Pandemic Period and Immunity Status Risk Factors associated with Severe Disease by Logistic Regression Conclusion We conclude that the Omicron variant of SARS-CoV-2 produced milder disease than earlier variants irrespective of baseline risk factors and immunity, but vaccination or prior infection further reduced disease severity in the Omicron cohort. The likely presence of undetected prior infection in the Omicron cohort would weaken the first but strengthen the second conclusion. Disclosures All Authors: No reported disclosures

BACKGROUND:The belief that antibiotics must be administered intravenously (IV) to treat bacteraemia and endocarditis has its origins 70 years ago and has engrained itself in the psyche of the medical community and the public at large. This has led to hesitancy in adopting evidence-based strategies utilizing oral transitional therapy for the treatment of these infections. We aim to reframe the narrative around this debate, focusing on patient safety over vestigial psychology. OBJECTIVES:This narrative review summarizes the current state of the literature regarding the use of oral transitional therapy for the treatment of bacteraemia and infective endocarditis, focusing on studies comparing it to the traditional, IV-only approach. SOURCES:Relevant studies and abstracts from PubMed reviewed in April 2023. CONTENT:Treating bacteraemia with oral transitional therapy has been studied in 9 randomized controlled trials (RCTs), totalling 625 patients, as well as numerous large, retrospective cohorts, including 3 published in the last 5 years alone, totalling 4763 patients. We identified 3 large, retrospective cohort studies; one quasi-experimental, pre-post study, and 3 RCTs of patients with endocarditis, totalling 748 patients in the retrospective cohorts and 815 patients in prospective, controlled studies. In all these studies, no worse outcomes were observed in the oral transitional therapy arm as compared with IV-only therapy. The main difference has consistently been longer durations of inpatient hospitalization and increased risk of catheter-related adverse events like venous thrombosis and line-associated blood stream infections in the IV-only groups. IMPLICATIONS:There are ample data showing that choosing oral therapy reduces hospital stay and has fewer adverse events for patients than IV-only therapy, all with similar or better outcomes. In selected patients, choosing IV-only therapy may serve more as an anxiolytic "placebo" for the patient and provider rather than a necessity for treating the actual infection.

An Mpox-Related Death in the United States A death due to mpox in an immunocompromised patient in the United States is described. Evaluation revealed disseminated viral infection.

When hospitals first encountered coronavirus disease 2019 (COVID-19), there was a dearth of therapeutic options and nearly 1 in 3 patients died from the disease. By the summer of 2020, as deaths from the disease declined nationally, multiple single-center studies began to report declining mortality of patients with COVID-19. To evaluate the effect of COVID-19 on hospital-based mortality, we searched the Vizient Clinical Data Base for outcomes data from approximately 600 participating hospitals, including 130 academic medical centers, from January 2017 through December 2020. More than 32 million hospital admissions were included in the analysis. After an initial spike, mortality from COVID-19 declined in all regions of the country to under 10% by June 2020 and remained constant for the remainder of the year. Despite this, inpatient, all-cause mortality has increased since the beginning of the pandemic, even those without respiratory failure. Inpatient mortality has particularly increased in elderly patients and in those requiring intubation for respiratory failure. Since June 2020, COVID-19 kills one in every 10 patients admitted to the hospital with this diagnosis. The addition of this new disease has raised overall hospital mortality especially those who require intubation for respiratory failure.

TO THE EDITOR—While preventing infection was the initial focus of the coronavirus disease 2019 (COVID-19) pandemic response, with increasing population immunity and variant transmissibility, the current focus has shifted to reducing hospitalization and deaths, particularly in vulnerable communities [1]. During the recent surge in disease activity driven by the Omicron variant, an increased proportion of “COVID-19 hospitalizations” were incidentally discovered infections in patients newly hospitalized for other reasons [2–6], resulting in decreased measurements of in-hospital disease severity and mortality compared to prior disease surges [6–9]. However, estimates of the proportion of total COVID-19 hospitalizations accounted for by these incidental infections range widely from 15% to 68% [2–6], due to heterogeneity in case definitions for these incidental infections and variability across populations with respect to vaccination status and other risk factors for severe COVID-19. We propose utilizing the Centers for Disease Control and Prevention (CDC) criteria for severe COVID-19, based on need for supplemental oxygen or oxygen saturation <92%, to define COVID-19 hospitalization [10]. To study the impact of this case definition, we reviewed medical records of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR)–positive patients admitted to LAC + USC Medical Center, a safety net hospital serving predominantly Latino and low-income patients in Los Angeles, California, during the local Omicron variant surge between 10 December 2021 and 19 January 2022. We abstracted data on age, vaccination and prior infection history, disease severity assessed by oxygen requirement, hospital length of stay, and mortality via retrospective medical record review. Using this case definition based on the CDC criteria for severe disease, 67.5% of SARS-CoV-2 PCR-positive hospitalized patients would not have met criteria for a COVID-19 hospitalization. These patients had significantly lower median age (44 years vs 57 years), median hospital length of stay (2 days vs 3 days), and inhospital mortality (3.5% vs 14%) (Table 1). While unadjusted analysis did not show significant association between exposure to vaccine or prior infection and non-severe disease (odds ratio [OR], 0.79 [95% confidence interval {CI}, .53– 1.17]; P= .24), exposure to vaccine or prior infection was associated with non-severe disese upon adjustment for age using logistic regression (OR, 0.58 [95% CI, .38–.89]; P= .01). The high frequency of incidental COVID-19 infection among hospitalized patients detected using the case definition based on lack of oxygen requirement exceeds the rates reported in previous studies that used more stringent case definition based on complete absence of COVID-19 symptoms [2] or were performed during periods of the pandemic prior to the Omicron variant surge [3]. However, the high frequency of incidental COVID-19 is very similar to measurements based on the case definition of severe COVID-19 [6] or correlates, such as administration of steroid treatment [5] during the Omicron surge. Given that nonsevere COVID-19 infections not requiring supplemental oxygen can generally be treated on an outpatient basis, we propose that the number of hospitalized COVID-19 patients requiring supplemental oxygen be reported alongside the total number of hospitalized COVID-19 patients in public health statistics used to inform the public or make policy decisions. One caveat is that patients with nonsevere COVID-19 are hospitalized at a higher rate than patients without COVID-19 [4], which may reflect nonrespiratory complications of COVID-19 including thrombosis or multisystem inflammation or exacerbation of underlying chronic diseases, although these complications are often difficult to attribute directly to

Background. We sought to determine the comparative efficacy of fosfomycin vs ertapenem for outpatient treatment of complicated urinary tract infections (cUTIs). Methods. We conducted a multicenter, retrospective cohort study involving patients with cUTI treated with outpatient oral fosfomycin vs intravenous ertapenem at 3 public hospitals in Los Angeles County between January 2018 and September 2020. The primary outcome was resolution of clinical symptoms 30 days after diagnosis. Results. We identified 322 patients with cUTI treated with fosfomycin (n = 110) or ertapenem (n = 212) meeting study criteria. The study arms had similar demographics, although patients treated with ertapenem more frequently had pyelonephritis or bacteremia while fosfomycin-treated patients had more retained catheters, nephrolithiasis, or urinary obstruction. Most infections were due to extended-spectrum beta-lactamase-producing E. coli and Klebsiella pneumoniae, 80%-90% of which were resistant to other oral options. Adjusted odds ratios for clinical success at 30 days, clinical success at last follow-up, and relapse were 1.21 (95% CI, 0.68-2.16), 0.84 (95% Cl, 0.46-1.52), and 0.94 (95% CI, 0.52-1.70) for fosfomycin vs ertapenem, respectively. Patients treated with fosfomycin had significant reductions in length of hospital stay and length of antimicrobial therapy and fewer adverse events (1 vs 10). Fosfomycin outcomes were similar irrespective of duration of lead-in intravenous (IV) therapy or fosfomycin dosing interval (daily, every other day, every third day). Conclusions. These results would support the conduct of a randomized controlled trial to verify efficacy. In the meantime, they suggest that fosfomycin may be a reasonable stepdown from IV antibiotics for cUTI.

Aim: Anticipating local surges in COVID-19 cases has predominantly been based on observation of increasing cases. We sought to determine if temporal trends in SARS-CoV-2 Cycle threshold (Ct) values from clinical testing were predictive of future cases. Methods: Data were collected from a large, safety-net hospital in Los Angeles, California. Ct values for all SARSCoV-2 detections by the GeneXpert system (Cepheid) between October 2020 to March 2021 were analyzed. Results: A total of 2,114 SARS-CoV-2-positive samples were included. Cases increased dramatically in December 2020, peaking the first week of January, before returning to pre-surge numbers by mid-February. Ct values fell during this same period, with values in December and January (25.6 ?? 7.8 and 27-7.9, respectively) significantly lower than those of the other months (30-9.3 to 37.7 - 6.3). Average weekly Ct values for all patients negatively correlated with the number of tests run two weeks in the future (r=-0.74, p<0.0001), whereas Ct values for asymptomatic patients negatively correlated most strongly with total number of tests performed one month later (r=-0.88, p<0.0001). Predictive modeling using these Ct values correctly predicted whether cases would increase or decrease 65% of the time for a subsequent surge (May-July 2021). Conclusions: During the largest COVID-19 surge in Los Angeles to date, we observed significantly lower Ct values (representing higher levels of viral RNA) suggesting that increased transmission of COVID-19 was temporarily associated with higher viral loads. Decreasing Ct values appear to be a leading indicator for predicting future COVID-19 cases, which can facilitate improved hospital-level surge planning.

We conducted a quality improvement project at our large, public, tertiary-care, academic hospital to reduce the standardized infection ratio (SIR) of hospital-acquired catheter-associated urinary tract infections (CAUTIs). Our diagnostic stewardship program, based on education and audit and feedback, significantly reduced inpatient urine culture orders and CAUTI SIR.

Importance To optimize patient outcomes and preserve critical acute care access during the COVID-19 pandemic, the Los Angeles County Department of Health Services developed the SAFE @ HOME O2Expected Practice (expected practice), enabling ambulatory oxygen management for COVID-19. Objective To assess outcomes of patients with COVID-19 pneumonia discharged via the expected practice approach to home or quarantine housing with supplemental home oxygen. Design, Setting, and Participants This retrospective cohort study included 621 adult patients with COVID-19 pneumonia who were discharged from 2 large urban public hospitals caring primarily for patients receiving Medicaid from March 20 to August 19, 2020. Patients were included in the analysis cohort if they received emergency or inpatient care for COVID-19 and were discharged with home oxygen. Interventions Patients receiving at least 3 L per minute of oxygen, stable without other indication for inpatient care, were discharged from either emergency or inpatient encounters with home oxygen equipment, educational resources, and nursing telephone follow-up within 12 to 18 hours of discharge. Nurses provided continued telephone follow up as indicated, always with physician back-up. Main Outcomes and Measures All-cause mortality and all-cause 30-day return admission. Results A total of 621 patients with COVID-19 pneumonia (404 male [65.1%] and 217 female [34.9%]) were discharged with home oxygen. Median age of these patients was 51 years (interquartile range, 45-61 years), with 149 (24.0%) discharged from the emergency department and 472 (76%) discharged from inpatient encounters. The all-cause mortality rate was 1.3% (95% CI, 0.6%-2.5%) and the 30-day return hospital admission rate was 8.5% (95% CI, 6.2%-10.7%) with a median follow-up time of 26 days (interquartile range, 15-55 days). No deaths occurred in the ambulatory setting. Conclusions and Relevance In this cohort study, patients with COVID-19 pneumonia discharged on home oxygen had low rates of mortality and return admission within 30 days of discharge. Ambulatory management of COVID-19 with home oxygen has an acceptable safety profile, and the expected practice approach may help optimize outcomes, by ensuring right care in the right place at the right time and preserving access to acute care during the COVID-19 pandemic.

Prostate abscesses in developed countries are becoming increasingly less common. Left untreated these abscesses can lead to numerous complications, including some which are very rare.

Background We sought to determine if controlled, prospective clinical data validate the long-standing belief that intravenous (IV) antibiotic therapy is required for the full duration of treatment for 3 invasive bacterial infections: osteomyelitis, bacteremia, and infective endocarditis. Methods We performed a systematic review of published, prospective, controlled trials that compared IV-only to oral stepdown regimens in the treatment of these diseases. Using the PubMed database, we identified 7 relevant randomized controlled trials (RCTs) of osteomyelitis, 9 of bacteremia, 1 including both osteomyelitis and bacteremia, and 3 of endocarditis, as well as one quasi-experimental endocarditis study. Study results were synthesized via forest plots and funnel charts (for risk of study bias), using RevMan 5.4.1 and Meta-Essentials freeware, respectively. Results The 21 studies demonstrated either no difference in clinical efficacy, or superiority of oral versus IV-only antimicrobial therapy, including for mortality; in no study was IV-only treatment superior in efficacy. The frequency of catheter-related adverse events and duration of inpatient hospitalization were both greater in IV-only groups. Discussion Numerous prospective, controlled investigations demonstrate that oral antibiotics are at least as effective, safer, and lead to shorter hospitalizations than IV-only therapy; no contrary data were identified. Treatment guidelines should be modified to indicate that oral therapy is appropriate for reasonably selected patients with osteomyelitis, bacteremia, and endocarditis.

There is increasing recognition that not all severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription-PCR (RT-PCR) assays are created equal with respect to test performance (1). A recently published study found that 7.1% of COVID-19 patients with initially negative RT-PCR results had SARS-CoV-2 detected upon repeat testing (2). Infectious Disease Society of America (IDSA) guidelines advocate for repeating testing in patients with intermediate or high clinical suspicion of COVID-19 infection when the initial test is negative (https://www.idsociety.org/practice-guideline/covid-19-guideline-diagnostics/).

The clinical significance of high crossing threshold (Ct) detection of SARS-CoV-2 by RT-PCR is inadequately defined. In the course of universal admission screening with the Cepheid Xpert Xpress SARS-CoV-2 assay at our institution, we observed that 3.9 % (44/1123) of SARS-CoV-2 positive results were negative for the envelope (E) gene target but positive for the nucleocapsid (N2) target. The overall SARS-CoV-2 positivity rate during the three-month study period was 15.4 % (1123/7285), spanning April-June 2020. The majority of patients with E-negative, N2-positive results were asymptomatic, with 29.5 % of patients symptomatic for COVID-19 at the time of presentation. Asymptomatic patients with E-negative, N2-positive results were significantly younger than symptomatic patients with the same results (average 37.6 vs. 58.4, p = 0.003). Similar proportions of prior SARS-CoV-2 positivity were noted among symptomatic and asymptomatic individuals (38.5 % vs. 33.3 %, p = 0.82). Among the 16 asymptomatic patients with radiographic imaging performed, four (25 %) had chest radiographic findings concerning for viral pneumonia. Interestingly, we observed an E-negative, N2-positive result in one patient with a previous SARS-CoV-2 by the Xpert Xpress that occurred 71 days prior. Critically, E-negative, N2-positive results were observed in 8 symptomatic patients with a new diagnosis of COVID-19. Thus, though concerns remain about extended SARS-CoV-2 RT-PCR positivity in some patients, the ability of clinical laboratories to detect patients with high Ct values (including E-negative, N2-positive results) is vital for retaining maximal sensitivity for diagnostic purposes. Our data show that a finding of E-positive, N2-negative SARS-CoV-2 should not be used to rule out the presence of subclinical infection.

Yan Bai, MD; Lingsheng Yao, MD; Tao Wei, MD; Fei Tian, MD; Dong-Yan Jin, PhD; Lijuan Chen, PhD; Meiyun Wang, MD, PhD

The treatment of osteomyelitis in patients with stage IV sacral pressure ulcers is controversial. We conducted a systematic literature review and did not find evidence of benefit of antibacterial therapy in this setting without concomitant surgical debridement and wound coverage. Furthermore, many patients with chronically exposed bone do not have evidence of osteomyelitis when biopsied, and magnetic resonance imaging may not accurately distinguish osteomyelitis from bone remodeling. The goal of therapy should be local wound care and assessment for the potential of wound closure. If the wound can be closed and osteomyelitis is present on bone biopsy, appropriate antibiotic therapy is reasonable. We find no data to support antibiotic durations of >6 weeks in this setting, and some authors recommend 2 weeks of therapy if the osteomyelitis is limited to cortical bone. If the wound will not be closed, we find no clear evidence supporting a role for antibiotic therapy.