Associations between Present-on-Admission Do-Not-Resuscitate Orders and Short-Term Outcomes in Patients with Pneumonia.

OBJECTIVES: Do-not-resuscitate (DNR) orders are used to express patient preferences for cardiopulmonary resuscitation. This study examined whether early DNR orders are associated with differences in treatments and outcomes among patients hospitalized with pneumonia. METHODS: This is a retrospective cohort study of 768,015 adult patients hospitalized with pneumonia from 2010 to 2015 in 646 US hospitals. The exposure was DNR orders present on admission. Secondary analyses stratified patients by predicted in-hospital mortality. Main outcomes included in-hospital mortality, length of stay, cost, intensive care admission, invasive mechanical ventilation, noninvasive ventilation, vasopressors, and dialysis initiation. RESULTS: Of 768,015 patients, 94,155 (12.3%) had an early DNR order. Compared with those without, patients with DNR orders were older (mean age 80.1 ± 10.6 years vs 67.8 ± 16.4 years), with higher comorbidity burden, intensive care use (31.6% vs 30.6%), and in-hospital mortality (28.2% vs 8.5%). After adjustment via propensity score weighting, these patients had higher mortality (odds ratio [OR] 2.39, 95% confidence interval [CI] 2.33-2.45) and lower use of intensive therapies such as vasopressors (OR 0.83, 95% CI 0.81-0.85) and invasive mechanical ventilation (OR 0.68, 95% CI 0.66-0.70). Although there was little relationship between predicted mortality and DNR orders, among those with highest predicted mortality, DNR orders were associated with lower intensive care use compared with those without (66.7% vs 80.8%). CONCLUSIONS: Patients with early DNR orders have higher in-hospital mortality rates than those without, but often receive intensive care. These orders have the most impact on the care of patients with the highest mortality risk.

Characterizing burnout among healthcare epidemiologists in the early phases of the COVID-19 pandemic: A study of the SHEA Research Network.

A multisite research team proposed a survey to assess burnout among healthcare epidemiologists. Anonymous surveys were disseminated to eligible staff at SRN facilities. Half of the respondents were experiencing burnout. Staffing shortages were a key stressor. Allowing healthcare epidemiologists to provide guidance without directly enforcing policies may improve burnout.

Bacterial coinfection in influenza pneumonia: Rates, pathogens, and outcomes.

BACKGROUND: Evidence from pandemics suggests that influenza is often associated with bacterial coinfection. Among patients hospitalized for influenza pneumonia, we report the rate of coinfection and distribution of pathogens, and we compare outcomes of patients with and without bacterial coinfection. METHODS: We included adults admitted with community-acquired pneumonia (CAP) and tested for influenza from 2010 to 2015 at 179 US hospitals participating in the Premier database. Pneumonia was identified using an International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) algorithm. We used multiple logistic and gamma-generalized linear mixed models to assess the relationships between coinfection and inpatient mortality, intensive care unit (ICU) admission, length of stay, and cost. RESULTS: Among 38,665 patients hospitalized with CAP and tested for influenza, 4,313 (11.2%) were positive. In the first 3 hospital days, patients with influenza were less likely than those without to have a positive culture (10.3% vs 16.2%; P < .001), and cultures were more likely to contain Staphylococcus aureus (34.2% vs 28.2%; P = .007) and less likely to contain Streptococcus pneumoniae (24.9% vs 31.0%; P = .008). Of S. aureus isolates, 42.8% were methicillin resistant among influenza patients versus 53.2% among those without influenza (P = .01). After hospital day 3, pathogens for both groups were similar. Bacterial coinfection was associated with increased odds of in-hospital mortality (aOR, 3.00; 95% CI, 2.17-4.16), late ICU transfer (aOR, 2.83; 95% CI, 1.98-4.04), and higher cost (risk-adjusted mean multiplier, 1.77; 95% CI, 1.59-1.96). CONCLUSIONS: In a large US inpatient sample hospitalized with influenza and CAP, S. aureus was the most frequent cause of bacterial coinfection. Coinfection was associated with worse outcomes and higher costs.

Complications of seasonal and pandemic influenza.

Influenza is a seasonal viral infection associated with significant morbidity and mortality. In 2009, a novel H1N1 influenza A virus emerged and has been classified as a pandemic. In contrast to seasonal influenza, severe disease from pandemic H1N1 seems concentrated in older children and young adults, with almost no cases reported in patients older than 60 yrs. Although patients with underlying cardiopulmonary disease remain at risk, most complications have occurred among previously healthy individuals, with obesity and respiratory disease as the strongest risk factors. Pulmonary complications are common. Primary influenza pneumonia occurs most commonly in adults and may progress rapidly to acute lung injury requiring mechanical ventilation. Secondary bacterial infection is more common in children. Staphylococcus aureus, including methicillin-resistant strains, is an important cause of secondary bacterial pneumonia with a high mortality rate. Treatment of pneumonia should include empirical coverage for this pathogen. Neuromuscular and cardiac complications are unusual but may occur.

Assessment of the Accuracy of Using ICD-9 Diagnosis Codes to Identify Pneumonia Etiology in Patients Hospitalized With Pneumonia.

Importance: Administrative databases may offer efficient clinical data collection for studying epidemiology, outcomes, and temporal trends in health care delivery. However, such data have seldom been validated against microbiological laboratory results. Objective: To assess the validity of International Classification of Diseases, Ninth Revision (ICD-9) organism-specific administrative codes for pneumonia using microbiological data (test results for blood or respiratory culture, urinary antigen, or polymerase chain reaction) as the criterion standard. Design, Setting, and Participants: Cross-sectional diagnostic accuracy study conducted between February 2017 and June 2019 using data from 178 US hospitals in the Premier Healthcare Database. Patients were aged 18 years or older admitted with pneumonia and discharged between July 1, 2010, and June 30, 2015. Data were analyzed from February 14, 2017, to June 27, 2019. Exposures: Organism-specific pneumonia identified from ICD-9 codes. Main Outcomes and Measures: Sensitivity, specificity, positive predictive value, and negative predictive value of ICD-9 codes using microbiological data as the criterion standard. Results: Of 161 529 patients meeting inclusion criteria (mean [SD] age, 69.5 [16.2] years; 51.2% women), 35 759 (22.1%) had an identified pathogen. ICD-9-coded organisms and laboratory findings differed notably: for example, ICD-9 codes identified only 14.2% and 17.3% of patients with laboratory-detected methicillin-sensitive Staphylococcus aureus and Escherichia coli, respectively. Although specificities and negative predictive values exceeded 95% for all codes, sensitivities ranged downward from 95.9% (95% CI, 95.3%-96.5%) for influenza virus to 14.0% (95% CI, 8.8%-20.8%) for parainfluenza virus, and positive predictive values ranged downward from 91.1% (95% CI, 89.5%-92.6%) for Staphylococcus aureus to 57.1% (95% CI, 39.4%-73.7%) for parainfluenza virus. Conclusions and Relevance: In this study, ICD-9 codes did not reliably capture pneumonia etiology identified by laboratory testing; because of the high specificities of ICD-9 codes, however, administrative data may be useful in identifying risk factors for resistant organisms. The low sensitivities of the diagnosis codes may limit the validity of organism-specific pneumonia prevalence estimates derived from administrative data.

Hospital Procalcitonin Testing and Antibiotic Treatment of Patients Admitted for Chronic Obstructive Pulmonary Disease Exacerbation.

RATIONALE: Randomized trials suggest that assessment of serum procalcitonin (PCT) levels can be used to safely limit antibiotic use among patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD). OBJECTIVES: To determine the impact of PCT testing on antibiotic treatment of patients hospitalized for exacerbations of COPD in routine practice. METHODS: We conducted a series of cross-sectional and longitudinal multivariable analyses using data from 2009 to 2011 and 2013 to 2014 from a sample of 505 U.S. hospitals. RESULTS: Of 203,177 patients hospitalized for COPD exacerbation in 2013 to 2014, nearly 9 out of 10 were treated with antibiotics. Hospital PCT testing rates ranged from 0 to 83%. In cross-sectional analysis, there was a weak negative association between the rate of PCT testing and risk-adjusted rates of antibiotic initiation (Spearman correlation, -0.12; P = 0.005); each 10-point increase in the percentage of patients undergoing PCT testing was associated with a 0.7% decline in risk-adjusted antibiotic use (P = 0.001). There was no association between hospital rates of PCT testing and duration of antibiotic treatment. In a longitudinal analysis, comparing treatment patterns in 2009 to 2011 and 2013 to 2014, we did not observe a significant difference in the change in antibiotic treatment rates or duration of therapy between hospitals that had adopted PCT testing compared with those that had not. CONCLUSIONS: As currently implemented, PCT testing appears to have had little impact on decisions to initiate antibiotic therapy or on duration of treatment for COPD exacerbations. Implementation research is necessary to translate the promising outcomes from PCT testing observed in randomized trials into clinical practice.

Homozygous lecithin:cholesterol acyltransferase (LCAT) deficiency due to a new loss of function mutation and review of the literature.

BACKGROUND: A case of homozygous familial lecithin:cholesterol acyltransferase (LCAT) deficiency with a novel homozygous LCAT missense mutation (replacement of methionine by arginine at position 293 in the amino acid sequence of the LCAT protein) is reported. METHODS AND RESULTS: The probable diagnosis was suggested by findings of marked high density lipoprotein (HDL) deficiency, corneal opacification, anemia, and renal insufficiency. The diagnosis was confirmed by two dimensional gel electrophoresis of HDL, the measurement of free and esterified cholesterol, and sequencing of the LCAT gene. CONCLUSIONS: In our view the most important aspects of therapy to prevent the kidney disease that these patients develop is careful control of blood pressure and lifestyle measures to optimize non HDL lipoproteins. In the future replacement therapy by gene transfer or other methods may become available.

Emergence of gentamicin-resistant bacteremia in hemodialysis patients receiving gentamicin lock catheter prophylaxis.

BACKGROUND AND OBJECTIVES: Antibiotic locks in catheter-dependent chronic hemodialysis patients reduce the rate of catheter-related blood stream infections (CRIs), but there are no data regarding the long-term consequences of this practice. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Over a 4-year period, from October 1, 2002, to September 30, 2006, we initiated a gentamicin and heparin lock (GHL) protocol in 1410 chronic hemodialysis patients receiving dialysis through a tunneled catheter in eight outpatient units. RESULTS: Within the first year of the GHL protocol, our CRI rate decreased from 17 to 0.83 events per 1000 catheter-days. Beginning 6 months after initiation of the GHL protocol, febrile episodes occurred in 13 patients with coagulase-negative Staphylococcus bacteremia resistant to gentamicin. Over the 4 years of GHL use, an additional 10 patients developed 11 episodes of gentamicin-resistant CRI (including 7 with Enterococcus faecalis), in which there were 4 deaths, 2 cases of septic shock requiring intensive care unit admission, and 4 cases of endocarditis. Because of these events, the GHL protocol was discontinued at the end of 2006. CONCLUSIONS: Although the use of GHL effectively lowered the CRI rate in our dialysis population, gentamicin-resistant CRIs emerged within 6 months. Gentamicin-resistant infections are a serious complication of the long-term use of GHLs. Alternative nonantibiotic catheter locks may be preferable to decrease the incidence of CRIs without inducing resistant pathogens.

Complications of viral influenza.

Viral influenza is a seasonal infection associated with significant morbidity and mortality. In the United States more than 35,000 deaths and 200,000 hospitalizations due to influenza occur annually, and the number is increasing. Children aged less than 1 year and adults aged more than 65 years, pregnant woman, and people of any age with comorbid illnesses are at highest risk. Annual vaccination is the cornerstone of prevention, but some older patients may derive less benefit from immunization than otherwise fit individuals. If started promptly, antiviral medications may reduce complications of acute influenza, but increasing resistance to amantadine and perhaps neuraminidase inhibitors underscores the need for novel prevention and treatment strategies. Pulmonary complications of influenza are most common and include primary influenza and secondary bacterial infection. Either may cause pneumonia, and each has a unique clinical presentation and pathologic basis. Staphylococcus aureus, including methicillin-resistant strains, is an important cause of secondary bacterial pneumonia with high mortality. During influenza season, treatment of pneumonia should include empiric coverage for this pathogen. Neuromuscular and cardiac complications are unusual but may manifest in persons of any age.