An infection prevention bundle that consisted of the development of a response team, public-academic partnership, daily assessment, regular testing, isolation, and environmental controls was implemented in 26 skilled nursing facilities in Detroit, Michigan (March 2020-April 2021). This intervention was associated with sustained control of severe acute respiratory coronavirus virus 2 infection among residents and staff.

Abstract Background Nursing home residents, a vulnerable population, experienced an extraordinary surge of COVID-19 cases and deaths at the beginning of the pandemic. Multidisciplinary collaboration from the Detroit Health Department (DHD), academic centers, along with interim guidance from the CDC provided a structured approach to control SARS-CoV-2 in Detroit skilled nursing facilities (SNF). We aim to describe this model. Methods There were 26 SNF prioritized by the DHD over a 13-month period from 3/2020 - 4/2021. Testing for SARS-CoV-2 occurred biweekly, on average, at each facility for staff and residents. Any staff or resident cases were investigated by a specialized investigations team to determine outbreak status. Any resident that was identified as positive for SARS-CoV-2 was moved to a designated in-house quarantine unit or specific COVID-19 designated nursing homes within the City of Detroit, and cohorting guidance was provided. Facilities were evaluated for environmental controls, PPE provided as needed and infection prevention guidance was provided. COVID-19 vaccination was conducted by pharmaceutical chains or the DHD and vaccine education sessions were conducted for nursing home staff and residents. Results On average, SNF facilities served a total of 2,262 residents (2031-2367 range) and employed a total of 2,965 staff (1034-3124 range) during the period from 7/2020 - 4/2021. SARS-CoV-2 cases overall for Michigan and Detroit are shown in Figure 1. In SNF facilities, cases ranged from zero to 279 cases in residents and zero to 115 cases per week in staff (Figure 1). Beginning 3/2020, the majority of cases were residents, whereas after 10/2020, staff cases exceeded resident cases. Immunization rates were 63% (partial) and 58% (complete) for residents, and 26% and 23% for staff, respectively. Measures to reduce vaccine hesitancy included organized education sessions, messaging from trusted leaders and organized mass vaccination schedules. Conclusion We describe the effectiveness of multidisciplinary interventions to control dissemination, morbidity and mortality of SARS-CoV-2 amongst SNF residents in Detroit. We emphasize the continued need to address vaccine hesitancy and importance of this model as successful interventions to decrease infection rates. Disclosures Paul E. Kilgore, M.D., M.P.H., Johnson and Johnson (Janssen) (Grant/Research Support, Scientific Research Study Investigator)Moderna (Grant/Research Support, Scientific Research Study Investigator) Marcus Zervos, MD, contrafect (Advisor or Review Panel member)janssen (Grant/Research Support)merck (Grant/Research Support)moderna (Grant/Research Support)pfizer (Grant/Research Support)serono (Grant/Research Support)

Abstract Background During the coronavirus disease 2019 (COVID-19) surge, there was a sharp increase of blood cultures (BC) performed at Henry Ford Health System (HFHS). However, the epidemiology and outcomes of bloodstream infections (BSI) in COVID-19 patients (pts) remains undefined. We report the utilization of blood cultures, risk factors and mortality associated with BSI in a large cohort of COVID-19 pts. Methods A retrospective analysis was performed of all COVID-19 pts that had BC performed during hospitalization at HFHS, a 5-hospital system in southeast Michigan. BSI was defined using NHSN criteria. Demographics, comorbidities, severity of illness, and outcome of pts with and without BSI were compared. Results From 3/10/2020 to 4/28/2020, 2541 pts were hospitalized with lab-confirmed COVID-19. 1393 (55%) of these pts had BC performed and 80 (5.74%) met criteria for BSI. Of the 84 pathogens identified, Staphylococcus aureus was most common (Figure 1). As compared to 1313 COVID-19 pts without BSI, those with BSI were older (70.1 vs 64.5 years, P = 0.0024). Other factors significantly associated with BSI included chronic kidney disease, higher mSOFA score, ICU stay and mechanical ventilation (all P < 0.0001) (Table 1). Multivariate analysis revealed age (OR, 1.07 CI [1.06–1.08]), ICU stay (OR, 7.91 [CI: 5.75–10.87]) and mSOFA score (OR, 1.29 [CI: 1.13–1.47]) were independent risk factors associated with mortality. BSI was not associated with increased mortality (Table 3). Conclusion Although more than half of hospitalized COVID-19 pts had BC done, the number of BSI were low suggesting overutilization of BC. BSI was associated with older age and disease severity. Mortality was not affected by BSI but was primarily driven by age and severity of illness. Disclosures Indira Brar, MD, Gilead (Speaker’s Bureau)janssen (Speaker’s Bureau)ViiV (Speaker’s Bureau) Marcus Zervos, MD, Melinta Therapeutics (Grant/Research Support)

Abstract Background The clinical spectrum of the novel corona virus disease 2019 (COVID-19) ranges from mild to severe disease and death. We aim to construct a simple and novel scoring model that will predict mortality events in hospitalized COVID-19 patients. Methods We established a retrospective cohort of 2541 patients admitted with COVID-19 from February 19, 2020 to April 28, 2020 to Henry Ford Health System, MI. Sociodemographic data, comorbidities, and clinical data were collected. Our novel SAS score was constructed using 3 easily available parameters, namely Sex, Age, and Oxygen Saturation at presentation (Table 1 and 2). Primary endpoint was mortality. Multivariate analysis with logistic regression was done and the model was assessed using receiver operating characteristic (ROC) with area under ROC (AUROC) to determine the optimal cutoff for sensitivity, specificity, and positive and negative predictive values. Results The mean age of survivors was 61 compared to 75 years for non-survivors (standard deviation 16 vs 13.8, p< 0.0001), and 1298 (51.1%) were men. Multivariate analysis of the SAS score adjusted for modified SOFA [Sequential organ failure assessment] score (mSOFA) showed that age (odds ratio [OR] 2.4, 95% confidence interval {CI} 2.04–2.72, p< 0.0001) and oxygen saturation (OR 1.6, 95% CI 1.27–1.98) were the most significant predictors of mortality in the model. The SAS score had an AUROC of 0.78 (95% CI 0.77–0.81) (Figure 1). A cutoff score of 3 offered the most sensitivity for predicting mortality while maintaining a negative predictive value of 95% (Table 3). Comparison of AUROC shows that SAS score adjusted to mSOFA has better diagnostic information compared to either SAS score or mSOFA alone (Figure 2). Conclusion The easy to use SAS score at time of presentation identified hospitalized COVID-19 patients at high risk for mortality. Application of the SAS score in the emergency department may help triage patients to inpatient versus outpatient care. Disclosures Marcus Zervos, MD, Melinta Therapeutics (Grant/Research Support)

SignificanceThe United States is in an acceleration phase of the COVID-19 pandemic. Currently there is no known effective therapy or vaccine for treatment of SARS-CoV-2, highlighting urgency around identifying effective therapies.ObjectiveThe purpose of this study was to evaluate the role of hydroxychloroquine therapy alone and in combination with azithromycin in hospitalized patients positive for COVID-19.DesignMulti-center retrospective observational study.SettingThe Henry Ford Health System (HFHS) in Southeast Michigan: large six hospital integrated health system; the largest of hospitals is an 802-bed quaternary academic teaching hospital in urban Detroit, Michigan.ParticipantsConsecutive patients hospitalized with a COVID-related admission in the health system from March 10, 2020 to May 2, 2020 were included. Only the first admission was included for patients with multiple admissions. All patients evaluated were 18 years of age and older and were treated as inpatients for at least 48 h unless expired within 24 h.ExposureReceipt of hydroxychloroquine alone, hydroxychloroquine in combination with azithromycin, azithromycin alone, or neither.Main outcomeThe primary outcome was in-hospital mortality.ResultsOf 2,541 patients, with a median total hospitalization time of 6 days (IQR: 4–10 days), median age was 64 years (IQR:53–76 years), 51% male, 56% African American, with median time to follow-up of 28.5 days (IQR:3–53). Overall in-hospital mortality was 18.1% (95% CI:16.6%–19.7%); by treatment: hydroxychloroquine + azithromycin, 157/783 (20.1% [95% CI: 17.3%–23.0%]), hydroxychloroquine alone, 162/1202 (13.5% [95% CI: 11.6%–15.5%]), azithromycin alone, 33/147 (22.4% [95% CI: 16.0%–30.1%]), and neither drug, 108/409 (26.4% [95% CI: 22.2%–31.0%]). Primary cause of mortality was respiratory failure (88%); no patient had documented torsades de pointes. From Cox regression modeling, predictors of mortality were age>65 years (HR:2.6 [95% CI:1.9–3.3]), white race (HR:1.7 [95% CI:1.4–2.1]), CKD (HR:1.7 [95%CI:1.4–2.1]), reduced O2 saturation level on admission (HR:1.5 [95%CI:1.1–2.1]), and ventilator use during admission (HR: 2.2 [95%CI:1.4–3.3]). Hydroxychloroquine provided a 66% hazard ratio reduction, and hydroxychloroquine + azithromycin 71% compared to neither treatment (p < 0.001).Conclusions and relevanceIn this multi-hospital assessment, when controlling for COVID-19 risk factors, treatment with hydroxychloroquine alone and in combination with azithromycin was associated with reduction in COVID-19 associated mortality. Prospective trials are needed to examine this impact.

Background: The surge of COVID-19 cases overwhelms hospital systems necessitating rapid learning of the disease process and management During the course of a novel pandemic, multiple interventions are rapidly implemented to improve patient outcomes When evaluating efficacy of individual interventions, one should account for the simultaneous improvements in knowledge and experience of healthcare providers (HCP), known as the maturation effect We hypothesized that multiple processes rapidly implemented, along with the maturation effect would result in improved survival of COVID-19 patients hospitalized over the course of the pandemic Methods: This retrospective study was done at Henry Ford Hospital (HFH), a 900-bed tertiary care facility in Detroit, Michigan The first COVID-19 patient was hospitalized on March 10, 2020 followed by a rapid surge of cases We evaluated the trends of in-hospital case fatality rate of COVID-19 PCR positive patients through April 28, 2020 Time-points of sequential implementation of key measures for the management of COVID-19 patients were recorded Results: A total of 1023 COVID-19 patients were hospitalized during the study period with 165 deaths (16 %) Case fatality rate during week one was 42% and down trended over time (Figure 1) Key measures were sequentially implemented over the course of the study period as shown in Figure 1 These included development and implementation of in-house PCR testing, dedicated infectious diseases COVID-19 rounding teams, treatment guidelines and algorithms, and early steroid use in hypoxic patients Figure 2 demonstrates that despite the surge of COVID-19 admissions, mortality continued to improve over time Conclusion: Maturation effect takes into consideration that regardless of individual interventions, HCP improve their knowledge of the disease process and treatment over time leading to better outcomes Our study shows the possibility of the maturation effect leading to improved survival in hospitalized COVID-19 patients The maturation effect should be accounted for when evaluating the effect of specific interventions for COVID-19 (Table Presented)

In response: We thank those submitting letters. It is important to critically review COVID-19 experience in a peer-reviewed, non-politicized process, and we fully support appropriately powered double-blind, randomized trials to address questions on COVID-19 clinical management. Many letters discussed several similar points, which we will address jointly. Corticosteroids (MPD) were controlled for in the multivariate and propensity analyses as were age and comorbidities, including cardiac disease and severity of illness. Age was an independent risk factor associated with mortality. We do feel that steroids have a role in reducing mortality for COVID-19 and were first to publish this (Fadel et al., 2020Fadel R. Morrison A.R. Vahia A. Smith Z.R. Chaudhry Z. Bhargavaet P. et al.Early short course corticosteroids in hospitalized patients with COVID-19.Clin Infect Dis cia. 2020; ([published online ahead of print, 2020 May 19]): a601https://doi.org/10.1093/cid/ciaa60Crossref Google Scholar), however in this study, HCQ was independently associated with decreased mortality, a distinct benefit from the steroid effect. We agree with Wiseman that prospective evaluation of a stage-and-age-nuanced approach to COVID-19 that exploits the multiple mechanisms of HCQ and synergy with MPD is needed. In response to Malviya, we reported 91% of all patients began treatment within two days of admission. We agree that early therapy is of most benefit; however, we do not have information on the duration of symptoms prior to hospitalization. The mSOFA has been validated in other studies (de Grooth et al., 2017de Grooth H.-J. Geenen I.L. Girbes A.R. Vincent J.-L. Parienti J.-J. Heleen M. Oudemans-van Straaten SOFA and mortality endpoints in randomized controlled trials: a systematic review and meta-regression analysis.Crit Care. 2017; 21: 38https://doi.org/10.1186/s 13054-017-1609-1Crossref PubMed Scopus (0) Google Scholar, Grissom et al., 2010Grissom C.K. Brown S.M. Kuttler K.G. Boltax J.P. Jones J. Jephson A.R. et al.A modified sequential organ failure assessment (MSOFA) Score for Critical Care Triage Disaster.Med Public Health Prep. 2010; 4https://doi.org/10.1001/dmp.2010.40 paperCrossref Google Scholar); moreover, we also used hypoxia as an independent marker of disease severity. In response to Thornton, HCQ was used throughout the study period, limiting time bias. We used dosages that followed FDA guidelines, with monitoring for cardiac arrhythmias. All centers used the same treatment guideline minimizing treatment bias. The protocol we used was previously published (Fadel et al., 2020Fadel R. Morrison A.R. Vahia A. Smith Z.R. Chaudhry Z. Bhargavaet P. et al.Early short course corticosteroids in hospitalized patients with COVID-19.Clin Infect Dis cia. 2020; ([published online ahead of print, 2020 May 19]): a601https://doi.org/10.1093/cid/ciaa60Crossref Google Scholar). In response to Atkinson, patients assigned to the HCQ group had a moderate and severe illness at presentation, which would favor worse outcomes with HCQ. The exclusion of patients with premorbid risk for cardiac toxicity is similar to clinical trials of many other drugs such as remdesivir, where individuals with severe liver or kidney disease were excluded (Clinical Trial, 2020https://clinicaltrials.gov/ct2/show/NCT04280705Google Scholar). Importantly, in response to Rosenberg, our study differed from other studies, including randomized controlled trials (RCTs), in a variety of ways, including the number of patients, comorbidities, the severity of illness and dosage and timing of administration of HCQ (WHO, 2020https://www.who.int/publications/m/item/informal-consultation-on-the-dose-of-chloroquine-and-hydroxychloroquine-for-the-solidarity-clinical-trial---8-april-2020Google Scholar, New Indian Express, 2020https://www.newindianexpress.com/nation/2020/may/29/icmr-writes-to-who-disagreeing-with-hcq-assessment-officials-say-international-trial-dosage-four-ti-2149702.htmlGoogle Scholar, Mikami et al., 2020Mikami T. Miyashita H. Yamada T. Harrington M. Steinberg D. Dunn A. et al.Risk factors for mortality in patients with COVID-19 in New York City.J Gen Intern Med. 2020; Crossref PubMed Scopus (144) Google Scholar). Prior studies have major limitations with timing, dosing, cardiac AE monitoring, and therapeutic windows. To date, there has been no properly designed and powered RCT that evaluates HCQ treatment for COVID-19. Concerning our comments about the Rosenberg paper, a variety of serious limitations in that paper should be corrected on the record. The critical limitation, among many others, is that patients receiving HCQ with or without azithromycin (AZM) were overall sicker on presentation and had multiple other risk factors; Black or Hispanic patients were likely to receive HCQ or AZM (mortality is significantly higher in these groups). Patients receiving HCQ were more likely to be obese, diabetic, have chronic lung disease, and cardiovascular conditions, yet these sicker patients had approximately the same mortality rates compared to patients with a milder course of the disease and fewer risk factors. However, the authors incorrectly conclude that “there are no significant benefits.” It is noteworthy that HCQ was associated with a significant survival benefit in a larger cohort of patients from New York City, as reported by Mikami et al., 2020Mikami T. Miyashita H. Yamada T. Harrington M. Steinberg D. Dunn A. et al.Risk factors for mortality in patients with COVID-19 in New York City.J Gen Intern Med. 2020; Crossref PubMed Scopus (144) Google Scholar. In these unprecedented times, the role, cost-benefit, and availability of repurposed agents such as HCQ and newer drugs such as remdesivir should be urgently evaluated in an impartial manner. Remdesivir is a novel drug with a novel approach and has a place in the COVID-19 treatment formulary; however, it is expensive, and there is limited availability outside of the United States (Forbes, 2020https://www.forbes.com/sites/iainmartin/2020/07/01/us-buys-the-world-supply-of-breakthrough-coronavirus-drug-remdesivir/#7556f0cf547Google Scholar, Finley, 2020Finley, A. The Politics of Hydroxychloroquine: Trump touted it, so Biden denounces it. The FDA has suspended a permit for its use. Let doctors decide.Google Scholar). Our paper's overarching theme is that a safe dosage and early utilization of hydroxychloroquine reduced mortality in hospitalized patients. Similar published large cohort studies support our findings from New York City and France (Mikami et al., 2020Mikami T. Miyashita H. Yamada T. Harrington M. Steinberg D. Dunn A. et al.Risk factors for mortality in patients with COVID-19 in New York City.J Gen Intern Med. 2020; Crossref PubMed Scopus (144) Google Scholar, Lagier et al., 2020Lagier J.C. Million M. Gautret P. Colson P. Cortaredona S. Giraud-Gatineau A. et al.Outcomes of 3,737 COVID-19 patients treated with hydroxychloroquine/azithromycin and other regimens in Marseille, France: a retrospective analysis.Travel Med Infect Dis. 2020; 1017: 91Google Scholar) As stated in our paper, further prospective studies are needed. No conflict of interest to declare. Approval was not required. Treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with COVID-19International Journal of Infectious DiseasesVol. 97PreviewAs of May 27, 2020, there were over 1,678,843 confirmed cases of COVID-19 claiming more than 100,000 lives in the Unites States (CDC, 2020). Currently there is no known effective therapy or vaccine. The urgent need for therapeutic agents has resulted in repurposing and redeployment of experimental agents (McCreary and Pogue, 2020; Sanders et al., 2020). Full-Text PDF Open AccessHydroxychloroquine in COVID-19: Taking care of statistics to take care of patientsInternational Journal of Infectious DiseasesVol. 99PreviewI read with great interest the article published by Arshad and the Henry Ford COVID-19 Task Force. They evaluated the role of hydroxychloroquine (HCQ) therapy alone and in combination with azithromycin in hospitalized COVID-19 patients. They included a total of 2.541 patients divided into four groups: HCQ alone, HCQ + azithromycin, azithromycin alone, and neither drug. The authors performed propensity score matching to control for confounding factors, using the parameters included in the Cox regression model. Full-Text PDF Open AccessProblems with the analysis in “Treatment with Hydroxychloroquine, Azithromycin, and Combination in Patients Hospitalized with COVID-19”International Journal of Infectious DiseasesVol. 99PreviewI am writing to comment on the article “Treatment with Hydroxychloroquine, Azithromycin, and Combination in Patients Hospitalized with COVID-19” by Samia Arshad et al. (Arshad et al., 2020). In this observational study, the patients were deliberately assigned to the treatment protocols based on their underlying medical conditions. This introduces a bias into the study, and as with all observational studies, there is the hope that the subsequent adjustments, based on a regression model in this instance, will compensate for this bias. Full-Text PDF Open AccessEffectiveness of hydroxychloroquine in COVID-19 disease: A done and dusted deal?International Journal of Infectious DiseasesVol. 99PreviewArshad et al. show evidence for reduced mortality in COVID-19 patients taking hydroxychloroquine alone or with azithromycin in an observational study in the USA (Arshad et al., 2020). Data on the effectiveness and toxicity of hydroxychloroquine are controversial (Liu et al., 2020; Devaux et al., 2020; Gautret et al., 2020; Tang et al., 2020; Geleris et al., 2020). Full-Text PDF Open AccessPossible synergistic effects of hydroxychloroquine and steroids in COVID-19, time for a nuanced approach. Comment on Arshad et al.International Journal of Infectious DiseasesVol. 99PreviewAs its accompanying editorial (Lee et al., 2020) perceives, Arshad’s report (Arshad et al., 2020) indeed fuels the fire of the hydroxychloroquine (HCQ) controversy. It also fans the steroid controversy (Salton et al., 2020). Full-Text PDF Open AccessComment on Arshad et al.: Treatment with Hydroxychloroquine, Azithromycin, and Combination in Patients Hospitalized with COVID-19International Journal of Infectious DiseasesVol. 99PreviewWe read, with great interest, the results published by Arshad and colleagues concerning the potential association between treatment with hydroxychloroquine with or without azithromycin and in-hospital mortality in patients with COVID-19 (Arshad et al., 2020). The reported treatment benefit contradicts that reported elsewhere, including a recent study at US Veterans Affairs Hospitals that showed an almost perfectly inverse risk of mortality (HR = 2.61; 95% CI, 1.10–6.10) (Magagnoli et al., 2020). Full-Text PDF Open AccessThe continued dilemma about the usage of hydroxychloroquine: Respite is in randomized control trialsInternational Journal of Infectious DiseasesVol. 99PreviewI read with interest the retrospective cohort study published in the International Journal of Infectious Diseases by Arshad et al., who report that treatment with Hydroxychloroquine (HCQ) alone and in combination with Azithromycin was associated with a reduction in COVID-19 associated mortality. I congratulate the authors, but I have noted a few limitations in the study, which may constrain the application of the study's results in routine clinical practice. Full-Text PDF Open AccessClarifying the record on hydroxychloroquine for the treatment of patients hospitalized with COVID-19International Journal of Infectious DiseasesVol. 99PreviewThe study from Arshad et al. on the use of hydroxychloroquine, with and without azithromycin, for the treatment of inpatients with COVID-19 in one healthcare system (Henry Ford Health System), is a new entrant into the rapidly expanding literature on the treatment of this disease (Arshad et al., 2020; Sattui et al., 2020). The study's findings of a significant beneficial effect of hydroxychloroquine in the reduction of in-hospital mortality are not consistent with several recent studies, and as authors of one of those studies, we wish to share a few observations (Sattui et al., 2020; Geleris et al., 2020; Rosenberg et al., 2020). Full-Text PDF Open Access

OBJECTIVES:Vancomycin is the treatment of choice for methicillin-resistant Staphylococcus aureus (MRSA) bacteremia; however, its use has been subject to scrutiny due to failure in severe infections. Ceftaroline fosamil (CPT-F) is approved for MRSA acute bacterial skin and skin structure infections, but not for bloodstream infections. The clinical outcomes of treatment with CPT-F in patients with MRSA bacteremia were evaluated.METHODS:Patients diagnosed with MRSA bacteremia at Henry Ford Hospital in Detroit, Michigan, USA, involving isolates with a vancomycin minimum inhibitory concentration ≥1.0mg/l and susceptible in vitro to CPT-F, were systematically reviewed retrospectively. Ceftaroline fosamil-treated patients were matched with at least two vancomycin- and/or one daptomycin-treated control patient based on age-patients age 65 years or greater or less than 65 years of age. Outcomes evaluated included the duration of hospitalization, duration of therapy, adverse events, relapse, hospital readmission, and death.RESULTS:Thirty consecutive cases of MRSA bacteremia treated with CPT-F during the period May 2011 to June 2013 were identified; these patients were matched to 56 MRSA bacteremia patients treated with vancomycin and 46 MRSA bacteremia patients treated with daptomycin. The primary source of MRSA bacteremia in the cohort treated with CPT-F was endocarditis (n=7, 23%), skin/wound (n=9, 30%), and bone/joint (n=8, 27%). The MRSA bacteremia in those treated with CPT-F was community-acquired in 43% of cases, healthcare-associated in 43%, and hospital-acquired in 13%. The mean length of hospital stay for these patients was 22 days. The overall 30-day mortality rate was 13% (n=4) in CPT-F patients versus 24% (n=11) in daptomycin patients and 11% (n=6) in vancomycin patients (p=0.188).CONCLUSIONS:CPT-F demonstrated comparable clinical outcomes in MRSA bacteremia patients compared with the other agents, especially as salvage therapy.

Obesity was identified as a risk factor for severe influenza during the 2009 influenza A(H1N1)pandemic, but evidence of this association has been mixed since. Post‐pandemic antiviral treatment guidelines may have increased antiviral treatment among obese individuals. A prospective study of adults hospitalized with laboratory‐confirmed influenza in Detroit, Michigan in 2011‐2012 and 2012‐2013 was conducted. Patient information was collected from interviews and medical chart abstraction. Obese (BMI ≥ 30) and non‐obese (BMI < 30) participants were compared. Late antiviral treatment (>2 days from symptom onset), obesity (30 ≤ BMI < 40), and morbid obesity (BMI ≥ 40) were evaluated as predictors of lower respiratory tract disease (LRD), ICU admission, and length of stay (LOS) using logistic regression and inverse probability weighted models. Forty‐eight participants were included in the study after exclusions and all patients received antiviral treatment. Participants who were obese were significantly more likely to have a cough and to take steroids than non‐obese participants, and had a shorter time from hospital admission to antiviral treatment (median time from admission to treatment of 0 days for obese patients and 1 day for non‐obese patients [P = 0.001]). In all models, late antiviral treatment was associated with increased odds of LRD (OR: 3.9 [1.1,15.9] in fully adjusted model). After adjustment for treatment timing, the odds of ICU admission (OR: 6.4 [0.8,58.2] to 7.9 [0.9, 87.1]) and LRD (OR: 3.3 [0.5, 23.5] to 4.0 [0.6, 35.0]) associated with morbid obesity increased. Obese individuals were treated with antivirals earlier than others. Late antiviral treatment was associated with severe influenza in the hospital.

In the United States, influenza and pneumonia account significantly to emergency room use and hospitalization of adults >65 y. The Centers for Disease Control and Prevention recommends use of the annual influenza vaccine and 2 pneumococcal vaccines for older adults to decrease risks of morbidity and mortality. However, actual vaccine up-take is estimated at 61.3% for pneumococcal vaccines and 65% for influenza vaccine in the 2013-2014 season. Vaccine up-take is affected by multiple socio-cultural and economic factors including general healthcare access and utilization, social networks and norms, communication with health providers and health information sources, as well as perceptions related to vaccines and targeted diseases. In this study, 8 focus group discussions (total N = 48) were conducted with adults 65+ years living in urban and suburban communities in the Detroit Metropolitan Area. The research objective was to increase understanding of barriers and facilitators to vaccine up-take in this age cohort within the context of general healthcare availability and accessibility, social networks, information sources, and personal perceptions of diseases and vaccines. The data suggest the need to integrate broader health care service experiences, concepts of knowledge of one's own well-being and vulnerabilities, and self-advocacy as factors associated with older adults' vaccine-use decisions. These data also support recognition of multiple levels of vaccine acceptance which can be disease specific. Implications include potential for increasing vaccine up-take through general improvement in health care delivery and services, as well as specific vaccine-focused patient and provider education programs.

Purpose: Methicillin-resistant Staphylococcus aureus (MRSA) pneumonia patients treated with current antibiotic therapies have exhibited poor outcomes, increased hospital length of stay, and higher costs of care. Twenty-eight-day mortality rate of 32% was reported with vancomycin therapy for MRSA hospital-acquired pneumonia (HAP) and MRSA health care-associated pneumonia (HCAP) from the same institution. The purpose of this study was to compare the epidemiology and effectiveness of ceftaroline versus alternative antibiotic therapies: linezolid, vancomycin, and/or cefepime, in hospitalized patients with MRSA HAP or HCAP based on clinical outcomes.Methods: Through retrospective matched case-control study design, the Infectious Diseases Society of America- and Centers for Disease Control and Prevention-defined MRSA HCAP or HAP consecutive hospitalized subjects treated with either ceftaroline fosamil (CPT-F) or alternative antibiotics were compared. Primary outcomes were 28-day mortality and 14-day clinical evaluation. Secondary outcomes included duration of hospitalization, complications with treatment, and clinical response to therapy switches.Results: Overall, 40 cases of MRSA HAP or HCAP treated with CPT-F were matched to 109 control subjects treated with either vancomycin or linezolid based on age, intensive care unit status, and type of pneumonia infection. The CPT-F cohort had a 10% (n = 4) 28-day mortality rate, and 91% (n = 32) had 14-day clinical success/cure (1 day) from diagnosis of pneumonia for the 35 evaluable cases. Of the 4 patients who died, 3 had debilitating comorbid conditions and an overall APACHE (Acute Physiology and Chronic Health Evaluation) II score greater than 20. Of those failing on standard antibiotic therapy, 50% (n = 20) were switched to CPT-F; subsequently, all (n = 20) switched patients cleared pneumonia. The overall success rate with CPT-F was 90% versus 75% for comparators.Conclusions: Treatment of MRSA pneumonia with CPT-F is associated with overall lower 28-day mortality than earlier studies with other agents. These data suggest a possible benefit in the use of CPT-F for therapy of MRSA hospital-acquired and health care-associated pneumonia.

The aim of this study was to identify patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia with low risk of infective endocarditis (IE) who might not require routine trans-esophageal echocardiography (TEE). We retrospectively evaluated 398 patients presenting with MRSA bacteremia for the presence of the following clinical criteria: intravenous drug abuse (IVDA), long-term catheter, prolonged bacteremia, intra-cardiac device, prosthetic valve, hemodialysis dependency, vertebral/nonvertebral osteomyelitis, cardio-structural abnormality. IE was diagnosed using the modified Duke criteria. Of 398 patients with MRSA bacteremia, 26.4 % of cases were community-acquired, 56.3 % were health-care-associated, and 17.3 % were hospital-acquired. Of the group, 44 patients had definite IE, 119 had possible IE, and 235 had a rejected diagnosis. Out of 398 patients, 231 were evaluated with transthoracic echocardiography (TTE) or TEE. All 44 patients with definite IE fulfilled at least one criterion (sensitivity 100 %). Finally, a receiver operator characteristic (ROC) curve was obtained to evaluate the total risk score of our proposed criteria as a predictor of the presence of IE, and this was compared to the ROC curve of a previously proposed criteria. The area under the ROC curve for our criteria was 0.710, while the area under the ROC curve for the criteria previously proposed was 0.537 (p < 0.001). The p-value for comparing those 2 areas was less than 0.001, indicating statistical significance. Patients with MRSA bacteremia without any of our proposed clinical criteria have very low risk of developing IE and may not require routine TEE.

In total, 718 consecutive clinical meticillin-resistant Staphylococcus aureus (MRSA) isolates from 2006 to 2010 and 417 clinical meticillin-susceptible S. aureus (MSSA) isolates from mid-2007 to 2010 were evaluated. Isolates were from blood cultures obtained from separate patients in Detroit, MI, and were tested for in vitro susceptibility trends to vancomycin and daptomycin by molecular strain type. The MRSA pulsed-field gel electrophoresis (PFGE) results showed that 290 (40.4%) were USA100, 296 (41.2%) were USA300 and the remaining isolates were non-USA100/300. Vancomycin minimum inhibitory concentrations (MICs) by Etest [mean±standard deviation (S.D.) 1.55±0.26mg/L] in MRSA isolates showed no significant change over the 5-year period within all strain types, whilst daptomycin MICs by Etest (mean±S.D. 0.51±0.25mg/L) showed a significant downward trend across time (r=-0.243; P<0.001), with this trend occurring among all PFGE groups. For MSSA, a significant decrease in MICs to vancomycin was found by Etest (r=-0.160; P=0.001) and conversely a significant increase in daptomycin MICs by Etest was found (r=0.146; P=0.028). The results of this study showed that changes in MIC were not specific to strain molecular type. For vancomycin, there was no change in MRSA MICs and a decrease in MSSA MICs for blood isolates. For daptomycin, MICs decreased in MRSA and increased in MSSA blood isolates over the study period.

Methicillin-resistant Staphylococcus aureus (MRSA) hospital-acquired pneumonia (HAP) and healthcare-associated pneumonia (HCAP) patients treated with current antibiotic therapies have exhibited poor outcomes, increased hospital length of stay, and higher costs of care. The optimal management of these infections is undetermined; thus, it is critical to look at ways to improve outcomes in these patients. There is insufficient data on clinical efficacy in patients with MRSA HAP or HCAP infection treated with ceftaroline-fosamil. In a recent pilot study, nearly 90% of patients treated with ceftaroline-fosamil survived, despite the difficulties associated with administrating bactericidal antimicrobial therapy for this increasingly resistant pathogen. These data suggest a possible benefit in the use of ceftaroline-fosamil for MRSA pneumonia. Presently, we have identified cases over a two-year period treated with ceftaroline-fosamil, and will conduct a comparative analysis to controls (those treated with vancomycin and/or cefepime, and linezolid) to determine optimal therapeutic agents; these findings will have important implications for control of further spread of infection, recurrence, readmission, and mortality attributable to MRSA HAP and HCAP.

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Background Methicillin-resistant Staphylococcus aureus (MRSA) infections are associated with severe necrotizing syndromes and high mortality, accounting for 20% to 40% of all hospital-acquired pneumonia and ventilator-associated pneumonia. There is insufficient data on comparative outcomes by specific strain characteristics in MRSA isolates in patients with pneumonia. Methods Clinical outcomes of patients with USA600 (ST45) MRSA strain were compared with other sequence types in MRSA pneumonia from 5 different hospitals in a retrospective case-control study. Patients were identified through review of microbiology laboratory records and through the Improving Medicine through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia database. Pulsed-field gel electrophoresis of SmaI-digested genomic DNA was performed on all isolates using a CHEF-DR III (BioRad). Pulsed-field gel electrophoresis patterns were compared using BioNumerics software (Applied Maths). Results Two hundred fifty-one consecutive patients with MRSA pneumonia were evaluable for an all-cause 28-day mortality and 14-day failure outcome. Prevalence of USA600 was 8% (21). Laboratory characteristics of USA600 isolates were 100% (21) Panton-Valentine leukocidin toxin negative, agr I type, 67% (14) heteroresistant to vancomycin, and higher rates of SCCmec type II versus SCCmec type IVa, 95% versus 5%. Twenty-eight–day mortality rates were USA600 (52.4%), USA100 (ST5; 29%), and USA300 (ST8; 32%); and 14-day failure rates were USA600 (50%), USA100 (37%), and USA300 (27%), respectively. Conclusions This is the first comparative observational study of its kind, with evidence of a much higher failure rate (>50%) within patients with USA600 MRSA pneumonia. The high mortality rate in this subset warrants further investigation of factors of this emerging strain that may predict mortality and failure outcomes.

– A retrospective review of medical records was performed from 2010-2013 of all VRE faecium bloodstream infections from individual patients at a single 900 bed teaching hospital in Detroit – 166 VRE faecium isolates, collected from 2010-2013, were evaluated – Identification and susceptibility of isolates was performed in the microbiology laboratory using Vitek 2 (bioMerieux, Durham, NC) – Baseline demographics and characteristics, risk factors, and therapeutic antibiotic regimens used were evaluated to assess 90-day all-cause mortality

We assessed for vancomycin-resistant Staphylococcus aureus (VRSA) precursor organisms in southeastern Michigan, an area known to have VRSA. The prevalence was 2.5% (pSK41-positive methicillin-resistant S. aureus, 2009–2011) and 1.5% (Inc18-positive vancomycin-resistant Enterococcus, 2006–2013); Inc18 prevalence significantly decreased after 2009 (3.7% to 0.82%). Risk factors for pSK41 included intravenous vancomycin exposure.Infect Control Hosp Epidemiol 2014;35(12):1531–1534