Development and Validation of the Hospital Medicine Safety Sepsis Initiative Mortality Model.

BACKGROUND: When comparing outcomes after sepsis, it is essential to account for patient case mix to make fair comparisons. We developed a model to assess risk-adjusted 30-day mortality in the Michigan Hospital Medicine Safety sepsis initiative (HMS-Sepsis). RESEARCH QUESTION: Can HMS-Sepsis registry data adequately predict risk of 30-day mortality? Do performance assessments using adjusted vs unadjusted data differ? STUDY DESIGN AND METHODS: Retrospective cohort of community-onset sepsis hospitalizations in the HMS-Sepsis registry (April 2022-September 2023), with split derivation (70%) and validation (30%) cohorts. We fit a risk-adjustment model (HMS-Sepsis mortality model) incorporating acute physiologic, demographic, and baseline health data and assessed model performance using concordance (C) statistics, Brier scores, and comparisons of predicted vs observed mortality by deciles of risk. We compared hospital performance (first quintile, middle quintiles, fifth quintile) using observed vs adjusted mortality to understand the extent to which risk adjustment impacted hospital performance assessment. RESULTS: Among 17,514 hospitalizations from 66 hospitals during the study period, 12,260 hospitalizations (70%) were used for model derivation and 5,254 hospitalizations (30%) were used for model validation. Thirty-day mortality for the total cohort was 19.4%. The final model included 13 physiologic variables, two physiologic interactions, and 16 demographic and chronic health variables. The most significant variables were age, metastatic solid tumor, temperature, altered mental status, and platelet count. The model C statistic was 0.82 for the derivation cohort, 0.81 for the validation cohort, and ≥ 0.78 for all subgroups assessed. Overall calibration error was 0.0%, and mean calibration error across deciles of risk was 1.5%. Standardized mortality ratios yielded different assessments than observed mortality for 33.9% of hospitals. INTERPRETATION: The HMS-Sepsis mortality model showed strong discrimination and adequate calibration and reclassified one-third of hospitals to a different performance category from unadjusted mortality. Based on its strong performance, the HMS-Sepsis mortality model can aid in fair hospital benchmarking, assessment of temporal changes, and observational causal inference analysis.

A Statewide Quality Initiative to Reduce Unnecessary Antibiotic Treatment of Asymptomatic Bacteriuria.

Importance: Hospitalized patients with asymptomatic bacteriuria (ASB) often receive unnecessary antibiotic treatment, which increases antibiotic resistance and adverse events. Objective: To determine whether diagnostic stewardship (avoiding unnecessary urine cultures) or antibiotic stewardship (reducing unnecessary antibiotic treatment after an unnecessary culture) is associated with better outcomes in reducing antibiotic use for ASB. Design, Setting, and Participants: This 3-year, prospective quality improvement study included hospitalized general care medicine patients with a positive urine culture among 46 hospitals participating in a collaborative quality initiative, the Michigan Hospital Medicine Safety Consortium. Data were collected from July 1, 2017, through March 31, 2020, and analyzed from February to October 2022. Exposure: Participation in the Michigan Hospital Medicine Safety Consortium with antibiotic and diagnostic stewardship strategies at hospital discretion. Main Outcomes and Measures: Overall improvement in ASB-related antibiotic use was estimated as change in percentage of patients treated with antibiotics who had ASB. Effect of diagnostic stewardship was estimated as change in percentage of patients with a positive urine culture who had ASB. Effect of antibiotic stewardship was estimated as change in percentage of patients with ASB who received antibiotics and antibiotic duration. Results: Of the 14 572 patients with a positive urine culture included in the study (median [IQR] age, 75.8 [64.2-85.1] years; 70.5% female); 28.4% (n = 4134) had ASB, of whom 76.8% (n = 3175) received antibiotics. Over the study period, the percentage of patients treated with antibiotics who had ASB (overall ASB-related antibiotic use) declined from 29.1% (95% CI, 26.2%-32.2%) to 17.1% (95% CI, 14.3%-20.2%) (adjusted odds ratio [aOR], 0.94 per quarter; 95% CI, 0.92-0.96). The percentage of patients with a positive urine culture who had ASB (diagnostic stewardship metric) declined from 34.1% (95% CI, 31.0%-37.3%) to 22.5% (95% CI, 19.7%-25.6%) (aOR, 0.95 per quarter; 95% CI, 0.93-0.97). The percentage of patients with ASB who received antibiotics (antibiotic stewardship metric) remained stable, from 82.0% (95% CI, 77.7%-85.6%) to 76.3% (95% CI, 68.5%-82.6%) (aOR, 0.97 per quarter; 95% CI, 0.94-1.01), as did adjusted mean antibiotic duration, from 6.38 (95% CI, 6.00-6.78) days to 5.93 (95% CI, 5.54-6.35) days (adjusted incidence rate ratio, 0.99 per quarter; 95% CI, 0.99-1.00). Conclusions and Relevance: This quality improvement study showed that over 3 years, ASB-related antibiotic use decreased and was associated with a decline in unnecessary urine cultures. Hospitals should prioritize reducing unnecessary urine cultures (ie, diagnostic stewardship) to reduce antibiotic treatment related to ASB.

Temporal Association between Influenza Vaccination Coverage and Ambulatory Antibiotic Use in Children.

In this population-based retrospective cohort study, increased influenza vaccination coverage was temporally associated with a reduction in ambulatory antibiotic use in children. After adjustment for yearly vaccine effectiveness, antibiotic prescription rate declined by 3/1000 person-months for each 1% increase in influenza vaccination coverage between 2012 and 2017 in South Carolina (P < 0.001).

Development of Venous Thromboembolism After COVID-19 mRNA-1273 Vaccine Inoculation.

A 79-year-old man suddenly developed right lower extremity (RLE) pain and swelling a few days after receiving his 1st dose of the mRNA-1273 COVID-19 vaccine. Despite this, he proceeded to receive the 2nd dose of his mRNA-1273 COVID-19 vaccine. Investigations confirmed extensive acute deep venous thrombosis and a concurrent acute pulmonary embolism. Therapeutic anticoagulation was initiated and he was eventually discharged home on supplemental oxygen. The overall benefits of the vaccine in curbing severe disease overwhelmingly outweigh the handful of cases of reported adverse events. To our knowledge, this is one of the first few cases of provoked venous thrombosis after receiving the mRNA-1273 COVID-19 vaccine during the pharmacovigilance period.

Clostridioides difficile infection and antibiotic prescription rates in the community: Explaining the gender gap.

In this cross-sectional population-based study, women had significantly higher crude incidence rates of both community-associated Clostridioides difficile infection (CA-CDI) and ambulatory antibiotic prescriptions compared to men in South Carolina in 2015. After adjustments for antibiotic prescription rates, there was no difference in the incidence rates of CA-CDI between the genders.

Temporal trends in ambulatory antibiotic prescription rates in South Carolina: Impact of age, gender, and resident location.

OBJECTIVE: To examine the temporal trends in ambulatory antibiotic prescription fill rates and to determine the influences of age, gender, and location. DESIGN: Population-based cohort study. SETTING: Ambulatory setting in South Carolina. PATIENTS: Patients ≤64 years of age from January 2012 to December 2017. METHODS: Aggregated pharmacy claims data for oral antibiotic prescriptions were utilized to estimate community antibiotic prescription rates. Poisson regression or Student t tests were used to examine overall temporal trend in antibiotic prescription rates, seasonal variation, and the trends across age group, gender, and rural versus urban location. RESULTS: Overall antibiotic prescription rates decrease from 1,127 to 897 per 1,000 person years (P < .001). The decrease was more noticeable in persons aged <18 years (26%) and 18-39 years (20%) than in those aged 40-64 years (5%; P < .001 for all). Prescription rates were higher among females than males in all age groups, although this finding was the most pronounced in group aged 18-39 years (1,232 vs 585 per 1,000 person years; P < .0001). Annualized antibiotic prescription rates were higher during the winter months (December-March) than the rest of the year (1,145 vs 885 per 1,000 person years; P < .0001), and rates were higher in rural areas than in urban areas (1,032 vs 941 per 1,000 person years; P < .0001). CONCLUSIONS: The decline in ambulatory antibiotic prescription rates is encouraging. Ongoing ambulatory antibiotic stewardship efforts across South Carolina should focus on older adults, rural areas, and during the winter season when antibiotic prescriptions peak.

Burden of community-associated Clostridioides difficile infection in southeastern United States: a population-based study.

OBJECTIVES: This cross-sectional population-based study aims to determine overall incidence rate of Clostridioides difficile infection (CDI) in the State of South Carolina and provide an estimated cost of hospitalization due to community-associated CDI (CA-CDI). METHODS: All CDI cases in South Carolina were identified through National Healthcare Safety Network (NHSN) and the South Carolina Infectious Disease and Outbreak Network (SCION) from January 1, 2015 to June 30, 2016, excluding infants < 1 year of age. RESULTS: During the 18-month study period, 10,254 CDI events were identified in South Carolina residents with an overall incidence rate of 139/100,000 person-years. Over one-half of CDI cases were CA-CDI (5192; 51%) with an incidence rate of 71/100,000 person-years. Among patients with CA-CDI, 2127 (41%) required hospitalization with a median length of stay of 5 days. The annual burden of CA-CDI in South Carolina was estimated to be 9282 hospital days and $16,217,295 in hospitalization costs. CONCLUSION: The incidence rate of CA-CDI in South Carolina has surpassed both community-onset healthcare facility associated and hospital-onset CDI combined. The heavy burden of CA-CDI justifies dedication of public health resources to combat CDI in ambulatory settings, through antimicrobial stewardship initiatives.

Chronic progressive disseminated histoplasmosis in a renal transplant recipient.

Hematopoietic and solid organ transplant recipients are at increased risk of opportunistic infections and infections usually are severe due to impaired cell mediated immunity. We report an unusual case of disseminated histoplasmosis in a renal transplant recipient manifesting with a chronic progressive course over several years. After starting treatment with itraconazole, the patient showed marked improvement in his symptoms and had clinical resolution.

Lymphocytic choriomeningitis virus meningoencephalitis in a renal transplant recipient following exposure to mice.

Solid organ transplant recipients (SOTR) are at increased risk for a wide variety of typical and atypical infections as a consequence of impaired cell mediated and humoral immunity. We report a case of meningoencephalitis in a renal transplant recipient caused by lymphocytic choriomeningitis virus (LCMV) acquired by exposure to mice excreta. The clinical course was complicated by the development of hydrocephalus, requiring a ventriculoperitoneal shunt. To our knowledge, this is the first reported case of LCMV infection in a SOTR that was not organ donor derived.