To evaluate the role of procalcitonin (PCT) results in antibiotic decisions for COVID-19 patients at hospital presentation.

Multicenter retrospective observational study of patients ≥18 years hospitalized due to COVID-19 at the Johns Hopkins Health system. Patients who were transferred from another facility with >24 hours stay and patients who died within 48 hours of hospitalization were excluded.

Elevated PCT values were determined based on each hospital’s definition. Antibiotic therapy and PCT results were evaluated for patients with no evidence of bacterial community-acquired pneumonia (bCAP) and patients with confirmed, probable, or possible bCAP. The added value of PCT testing to clinical criteria in detecting bCAP was evaluated using receiving operating curve characteristics (ROC).

Of 962 patients, 611 (64%) received a PCT test. ROC curves for clinical criteria and clinical criteria plus PCT test were similar (at 0.5 ng/mL and 0.25 ng/mL). By bCAP group, median initial PCT values were 0.58 ng/mL (interquartile range [IQR], 0.24–1.14), 0.23 ng/mL (IQR, 0.1–0.63), and 0.15 ng/mL (IQR, 0.09–0.35) for proven/probable, possible, and no bCAP groups, respectively. Among patients without bCAP, an elevated PCT level was associated with 1.8 additional days of CAP therapy (95% CI, 1.01–2.75; P < .01) compared to patients with a negative PCT result after adjusting for potential confounders. Duration of CAP therapy was similar between patients without a PCT test ordered and a low PCT level for no bCAP and possible bCAP groups.

PCT results may be abnormal in COVID-19 patients without bCAP and may result in receipt of unnecessary antibiotics.

Hospitals are required to have antibiotic stewardship programs (ASPs), but there are few models for implementing ASPs without the support of an infectious disease (ID) specialist, defined as an ID physician and/or ID pharmacist.

In this study, we sought to understand ASP implementation at hospitals that lack on-site ID support within the Veterans’ Health Administration (VHA).

Using a mandatory VHA survey, we identified acute-care hospitals that lacked an on-site ID specialist. We conducted semistructured interviews with personnel involved in ASP activities.

The study was conducted across 7 VHA hospitals.

In total, 42 hospital personnel were enrolled in the study.

The primary responsibility for ASPs fell on the pharmacist champions, who were typically assigned multiple other non-ASP responsibilities. The pharmacist champions were more successful at gaining buy-in when they had established rapport with clinicians, but at some sites, the use of contract physicians and frequent staff turnover were potential barriers. Some sites felt that having access to an off-site ID specialist was important for overcoming institutional barriers and improving the acceptance of their stewardship recommendations. In general, stewardship champions struggled to mobilize institutional resources, which made it difficult to advance their programmatic goals.

In this study of 7 hospitals without on-site ID support, we found that ASPs are largely a pharmacy-driven process. Remote ID support, if available, was seen as helpful for implementing stewardship interventions. These findings may inform the future implementation of ASPs in settings lacking local ID expertise.

To describe risk factors associated with inappropriate antibiotic prescribing to children.

Cross-sectional, retrospective analysis of antibiotic prescribing to children, using Kentucky Medicaid medical and pharmacy claims data, 2017.

Population-based sample of pediatric Medicaid patients and providers.

Antibiotic prescriptions were identified from pharmacy claims and used to describe patient and provider characteristics. Associated medical claims were identified and linked to assign diagnoses. An existing classification scheme was applied to determine appropriateness of antibiotic prescriptions.

Overall, 10,787 providers wrote 779,813 antibiotic prescriptions for 328,515 children insured by Kentucky Medicaid in 2017. Moreover, 154,546 (19.8%) of these antibiotic prescriptions were appropriate, 358,026 (45.9%) were potentially appropriate, 163,654 (21.0%) were inappropriate, and 103,587 (13.3%) were not associated with a diagnosis. Half of all providers wrote 12 prescriptions or less to Medicaid children. The following child characteristics were associated with inappropriate antibiotic prescribing: residence in a rural area (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.07–1.1), having a visit with an inappropriate prescriber (OR, 4.15; 95% CI, 4.1–4.2), age 0–2 years (OR, 1.39; 95% CI, 1.37–1.41), and presence of a chronic condition (OR, 1.31; 95% CI, 1.28–1.33).

Inappropriate antibiotic prescribing to Kentucky Medicaid children is common. Provider and patient characteristics associated with inappropriate prescribing differ from those associated with higher volume. Claims data are useful to describe inappropriate use and could be a valuable metric for provider feedback reports. Policies are needed to support analysis and dissemination of antibiotic prescribing reports and should include all provider types and geographic areas.

We examined the impact of microbiological results from respiratory samples on choice of antibiotic therapy in patients treated for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP).

Four-year retrospective study.

Veterans’ Health Administration (VHA).

VHA patients hospitalized with HAP or VAP and with respiratory cultures between October 1, 2014, and September 30, 2018.

We compared patients with positive and negative respiratory culture results, assessing changes in antibiotic class and Antibiotic Spectrum Index (ASI) from the day of sample collection (day 0) through day 7.

Between October 1, 2014, and September 30, 2018, we identified 5,086 patients with HAP/VAP: 2,952 with positive culture results and 2,134 with negative culture results. All-cause 30-day mortality was 21% for both groups. The mean time from respiratory sample receipt in the laboratory to final respiratory culture result was longer for those with positive (2.9 ± 1.3 days) compared to negative results (2.5 ± 1.3 days; P < .001). The most common pathogens were Staphylococcus aureus and Pseudomonas aeruginosa. Vancomycin and β-lactam/β-lactamase inhibitors were the most commonly prescribed agents. The decrease in the median ASI from 13 to 8 between days 0 and 6 was similar among patients with positive and negative respiratory cultures. Patients with negative cultures were more likely to be off antibiotics from day 3 onward.

The results of respiratory cultures had only a small influence on antibiotics used during the treatment of HAP/VAP. The decrease in ASI for both groups suggests the integration of antibiotic stewardship principles, including de-escalation, into the care of patients with HAP/VAP.

The association between blood transfusion and ventilator-associated events (VAEs) has not been fully understood. We sought to determine whether blood transfusion increases the risk of a VAE.

Nested case-control study.

This study was based on a registry of healthcare-associated infections in intensive care units at West China Hospital system.

1,657 VAE cases and 3,293 matched controls were identified.

For each case, 2 controls were randomly selected using incidence density sampling. We defined blood transfusion as a time-dependent variable, and we used weighted Cox models to calculate hazard ratios (HRs) for all 3 tiers of VAEs.

Blood transfusion was associated with increased risk of ventilator-associated complication-plus (VAC-plus; HR, 1.47; 95% CI, 1.22–1.77; P <.001), VAC-only (HR, 1.29; 95% CI, 1.01–1.65; P = .038), infection-related VAC-plus (IVAC-plus; HR, 1.78; 95% CI, 1.33–2.39; P < .001), and possible ventilator-associated pneumonia (PVAP; HR, 2.10; 95% CI, 1.10–3.99; P = .024). Red blood cell (RBC) transfusion was also associated with increased risk of VAC-plus (HR, 1.34; 95% CI, 1.08–1.65; P = .007), IVAC-plus (HR, 1.70; 95% CI, 1.22–2.36; P = .002), and PVAP (HR, 2.49; 95% CI, 1.17–5.28; P = .018). Compared to patients without transfusion, the risk of VAE was significantly higher in patients with RBC transfusions of >3 units (HR, 1.73; 95% CI, 1.25–2.40; P = .001) but not in those with RBC transfusions of 0–3 units.

Blood transfusions were associated with increased risk of all tiers of VAE. The risk was significantly higher among patients who were transfused with >3 units of RBCs.

To evaluate the impact of a vancomycin-resistant Enterococcus (VRE) screening policy change on the incidence of healthcare-associated (HA)-VRE bacteremia in an endemic hospital setting.

A quasi-experimental before-and-after study.

A 1,989-bed tertiary-care referral center in Seoul, Republic of Korea.

Since May 2010, our hospital has diminished VRE screening for admitted patients transferred from other healthcare facilities. We assessed the impact of this policy change on the incidence of HA-VRE bacteremia using segmented autoregression analysis of interrupted time series from January 2006 to December 2014 at the hospital and unit levels. In addition, we compared the molecular characteristics of VRE blood isolates collected before and after the screening policy change using multilocus sequence typing and pulsed-field gel electrophoresis.

After the VRE screening policy change, the incidence of hospital-wide HA-VRE bacteremia increased, although no significant changes of level or slope were observed. In addition, a significant slope change in the incidence of HA-VRE bacteremia (change in slope, 0.007; 95% CI, 0.001–0.013; P = .02) was observed in the hemato-oncology department. Molecular analysis revealed that various VRE sequence types appeared after the policy change and that clonally related strains became more predominant (increasing from 26.1% to 59.3%).

The incidence of HA-VRE bacteremia increased significantly after VRE screening policy change, and this increase was mainly driven by high-risk patient populations. When planning VRE control programs in hospitals, different approaches that consider risk for severe VRE infection in patients may be required.

To examine the associations between factors based on the social cognitive theory (SCT) and behavioral intention among doctors and nurses in China toward free and self-paid (600 RMB or US$91) severe acute respiratory coronavirus virus 2 (SARS-CoV-2) vaccination given 80% effectiveness and rare mild side effects.

Cross-sectional study.

Public hospitals.

The study included 362 doctors and 1,702 nurses in major departments of 5 hospitals of 3 Chinese provinces.

An anonymous online survey was conducted from October to November 2020, facilitated by hospital administrators through online WeChat/QQ working groups. Data on outcome expectations, self-efficacy, norms, and COVID-19–related work experiences were collected. Multivariate logistic regression models were used for data analyses.

The logistic regression analysis showed that physical (eg, protective effect of vaccination) and self-evaluative outcome expectations (eg, anticipated regret), self-efficacy, norms (eg, descriptive norm, subjective norm, professional norm, and moral norm), and job satisfaction were significantly and positively associated with the free and self-paid SARS-CoV-2 vaccination intention outcomes among doctors and nurses, adjusted for background variables. Doctors who had engaged in COVID-19–related work reported higher self-paid vaccination intention.

Health promotion is needed to improve the uptake of SARS-CoV-2 vaccination among healthcare workers. Such interventions may consider modifying the identified factors of vaccination intention, including strengthening perceived efficacy, positive feelings about vaccination, the need to avoid future regret, self-efficacy, and social norms. Future studies should examine the actual behavior patterns of SARS-CoV-2 vaccination, and the efficacy of promotion intervention should be tested in randomized controlled studies.

Prior studies of universal masking have not measured face-mask compliance. We performed a quality improvement study to monitor and improve face-mask compliance among healthcare personnel (HCP) during the coronavirus disease 2019 (COVID-19) pandemic.

Mixed-methods study.

Tertiary-care center in West Haven, Connecticut.

HCP including physicians, nurses, and ancillary staff.

Face-mask compliance was measured through direct observations during a 4-week baseline period after universal masking was mandated. Frontline and management HCP completed semistructured interviews from which a multimodal intervention was developed. Direct observations were repeated during a 14-week period following implementation of the multimodal intervention. Differences between units were evaluated with χ2 testing using the Bonferroni correction. Face-mask compliance between baseline and intervention periods was compared using time-series regression.

Among 1,561 observations during the baseline period, median weekly face-mask compliance was 82.2% (range, 80.8%–84.4%). Semistructured interviews were performed with 16 HCP. Qualitative analysis informed the development of a multimodal intervention consisting of audit and passive feedback, active discussion, and increased communication from leadership. Among 2,651 observations during the intervention period, median weekly face-mask compliance was 92.6% (range, 84.6%–97.9%). There was no difference in weekly face-mask compliance between COVID-19 and non–COVID-19 units. The multimodal intervention was associated with an increase in face-mask compliance (β = 0.023; P = .002).

Face-mask compliance remained suboptimal among HCP despite a facility-wide mandate for universal masking. A multimodal intervention consisting of audit and passive feedback, active discussion, and increased communication from leadership was effective in increasing face-mask compliance among HCP.

To investigate risk factors for healthcare worker (HCW) infection in viral respiratory pandemics: severe acute respiratory coronavirus virus 2 (SARS-CoV-2), Middle East respiratory syndrome (MERS), SARS CoV-1, influenza A H1N1, influenza H5N1. To improve understanding of HCW risk management amid the COVID-19 pandemic.

Systematic review and meta-analysis.

We searched MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL databases from conception until July 2020 for studies comparing infected HCWs (cases) and noninfected HCWs (controls) and risk factors for infection. Outcomes included HCW types, infection prevention practices, and medical procedures. Pooled effect estimates with pathogen-specific stratified meta-analysis and inverse variance meta-regression analysis were completed. We used the GRADE framework to rate certainty of evidence. (PROSPERO no. CRD42020176232, 6 April 2020.)

In total, 54 comparative studies were included (n = 191,004 HCWs). Compared to nonfrontline HCWs, frontline HCWs were at increased infection risk (OR, 1.66; 95% CI, 1.24–2.22), and the risk was greater for HCWs involved in endotracheal intubations (risk difference, 35.2%; 95% CI, 21.4–47.9). Use of gloves, gown, surgical mask, N95 respirator, face protection, and infection training were each strongly protective against infection. Meta-regression showed reduced infection risk in frontline HCWs working in facilities with infection designated wards (OR, −1.04; 95% CI, −1.53 to −0.33, P = .004) and performing aerosol-generating medical procedures in designated centers (OR, −1.30; 95% CI, −2.52 to −0.08; P = .037).

During highly infectious respiratory pandemics, widely available protective measures such as use of gloves, gowns, and face masks are strongly protective against infection and should be instituted, preferably in dedicated settings, to protect frontline HCW during waves of respiratory virus pandemics.