Identifying racial disparities in the management of heart failure with reduced ejection fraction.

OBJECTIVE(S): Heart failure (HF) is chronic and progressive. Individuals with a left ventricular ejection fraction (LVEF or EF) < 40% are classified as having heart failure with reduced ejection fraction (HFrEF). Black patients have the highest incidence of HF and are more likely to suffer serious consequences from the disease. Identifying and addressing racial disparities in care is vital to ensuring health equity. The primary objective was to determine the association of race with 1-year heart HF admission rates for white and black patients, when adjusted for EF and age. The secondary objective was to determine the proportion of patients not on guideline-directed medication therapy (GDMT). DESIGN: This study was a retrospective chart review conducted between 10/22/2021 and 11/22/2022 of Veteran patients with HFrEF who were identified via the VA Heart Failure Dashboard. Only White and Black patients were included. A multivariable logistic regression was used to determine odds of admission due to HF. Pharmacotherapy was analyzed to identify gaps in GDMT and if racial disparities existed. SETTING AND PARTICIPANTS: Veterans within the Veterans Affairs Western New York Healthcare System. OUTCOME MEASURES: One-year HF admission rates for white and black patients, when adjusted for EF and age. Proportion of patients not on GDMT. RESULTS: Of the 345 patients with HF originally identified, 172 were included; 22% were admitted within one year. Black patients were 2.9 times more likely to be admitted. (P = 0.031). A median of two drugs (interquartile range [IQR] 1-3) could be added and one dose could be optimized (IQR 1-4) to reach GDMT goals. No differences were found in the prescribing of GDMT or in proportion of patients not on GDMT at recommended doses between white and black patients. CONCLUSION: Black patients were more likely to be admitted for HF than white patients. Pharmacists can play an important role in identifying the need for optimizing GDMT. Future studies could focus on pharmacist-led prospective interventions with an aim to close the gap in racial disparities.

Increased Stroke Risk Following Herpes Zoster Infection and Protection With Zoster Vaccine.

BACKGROUND: Studies evaluating stroke following varicella zoster virus (VZV) infection are limited, and the utility of zoster vaccination against this phenomenon is unclear. This study aimed to determine the risk of stroke 30 days following zoster infection and to evaluate the impact of zoster vaccinations on the risk of stroke in VZV-infected patients. METHODS: This retrospective case-control study was conducted from January 2010 to January 2020 utilizing nationwide patient data retrieved from the Veterans Affairs' Corporate Data Warehouse. RESULTS: A total of 2 165 505 patients ≥18 years of age who received care at a Veterans Affairs facility were included in the study, of whom 71 911 had a history of zoster infection. Zoster patients were found to have 1.9 times increased likelihood of developing a stroke within 30 days following infection (odds ratio [OR], 1.93 [95% confidence interval {CI}, 1.57-2.4]; P < .0001). A decreased risk of stroke was seen in patients who received the recombinant zoster vaccine (OR, 0.57 [95% CI, .46-.72]; P < .0001) or the live zoster vaccine (OR, 0.77 [95% CI, .65-.91]; P = .002). CONCLUSIONS: Patients had a significantly higher risk of stroke within the first month following recent herpes zoster infection. Receipt of at least 1 zoster vaccination was found to mitigate this increased risk. Vaccination may therefore be viewed as a protective tool against the risk of neurologic postinfection sequelae.

Clinical Course and Outcome of COVID-19 Acute Respiratory Distress Syndrome: Data From a National Repository.

BACKGROUND: Mortality attributable to coronavirus disease-19 (COVID-19) 2 infection occurs mainly through the development of viral pneumonia-induced acute respiratory distress syndrome (ARDS). RESEARCH QUESTION: The objective of the study is to delineate the clinical profile, predictors of disease progression, and 30-day mortality from ARDS using the Veterans Affairs Corporate Data Warehouse. STUDY DESIGN AND METHODS: Analysis of a historical cohort of 7,816 hospitalized patients with confirmed COVID-19 infection between January 1, 2020, and August 1, 2020. Main outcomes were progression to ARDS and 30-day mortality from ARDS, respectively. RESULTS: The cohort was comprised predominantly of men (94.5%) with a median age of 69 years (interquartile range [IQR] 60-74 years). 2,184 (28%) were admitted to the intensive care unit and 643 (29.4%) were diagnosed with ARDS. The median Charlson Index was 3 (IQR 1-5). Independent predictors of progression to ARDS were body mass index (BMI) ≥40 kg/m2, diabetes, lymphocyte counts <700 × 109/L, LDH >450 U/L, ferritin >862 ng/ml, C-reactive protein >11 mg/dL, and D-dimer >1.5 ug/ml. In contrast, the use of an anticoagulant lowered the risk of developing ARDS (OR 0.66 [95% CI 0.49-0.89]. Crude 30-day mortality rate from ARDS was 41% (95% CI 38%-45%). Risk of death from ARDS was significantly higher in those who developed acute renal failure and septic shock. Use of an anticoagulant was associated with 2-fold reduction in mortality. Survival benefit was observed in patients who received corticosteroids and/or remdesivir but there was no advantage of combination therapy over either agent alone. CONCLUSIONS: Among those hospitalized for COVID-19, nearly 1 in 10 progressed to ARDS. Septic shock, and acute renal failure are the leading causes of death in these patients. Treatment with either remdesivir and corticosteroids reduced the risk of mortality from ARDS. All hospitalized patients with COVID-19 should be placed at a minimum on prophylactic doses of anticoagulation.

Determining the Utility of Methicillin-Resistant Staphylococcus aureus Nares Screening in Antimicrobial Stewardship.

BACKGROUND: Treatment of suspected methicillin-resistant Staphylococcus aureus (MRSA) is a cornerstone of many antibiotic regimens; however, there is associated toxicity. The Department of Veterans Affairs (VA) hospitals screen each patient for MRSA nares colonization on admission and transfer. The objective was to determine the negative predictive value (NPV) of MRSA screening in the determination of subsequent positive clinical culture for MRSA. High NPVs with MRSA nares screening may be used as a stewardship tool. METHODS: This was a retrospective cohort study across VA medical centers nationwide from 1 January 2007 to 1 January 2018. Data from patients with MRSA nares screening were obtained from the VA Corporate Data Warehouse. Subsequent clinical cultures within 7 days of the nares swab were evaluated for the presence of MRSA. Sensitivity, specificity, positive predictive values, and NPVs were calculated for the entire cohort as well as subgroups for specific culture sites. RESULTS: This cohort yielded 561 325 clinical cultures from a variety of anatomical sites. The sensitivity and specificity for positive MRSA clinical culture were 67.4% and 81.2%, respectively. The NPV of MRSA nares screening for ruling out MRSA infection was 96.5%. The NPV for bloodstream infections was 96.5%, for intraabdominal cultures it was 98.6%, for respiratory cultures it was 96.1%, for wound cultures it was 93.1%, and for cultures from the urinary system it was 99.2%. CONCLUSION: Given the high NPVs, MRSA nares screening may be a powerful stewardship tool for deescalation and avoidance of empirical anti-MRSA therapy.

Utility of Methicillin-Resistant Staphylococcus aureus Nares Screening for Patients with a Diabetic Foot Infection.

Treatment of suspected methicillin-resistant Staphylococcus aureus (MRSA) is a cornerstone of severe diabetic foot infections; however, antibiotics can be associated with toxicity. The objective of this study was to determine the negative predictive value (NPV) of MRSA nares screening in the determination of subsequent MRSA in patients with a diabetic foot infection. This was a retrospective cohort study across Veterans Affairs (VA) medical centers from 1 January 2007 to 1 January 2018. Data from patients with an International Classification of Diseases (ICD) code for a diabetic foot infection with MRSA nares screening, and subsequent cultures were evaluated for the presence of MRSA. NPVs were calculated for the entire cohort, as well as for a subgroup representing deep cultures. Additionally, the distribution of all pathogens isolated from diabetic foot infections was determined. A total of 8,163 episodes were included in the analysis for NPV. The NPV of MRSA nares screening for MRSA diabetic foot infection was 89.6%. For the deep cultures, the NPV was 89.2%. The NPV for cultures originating from the foot was 89.7%, and the NPV for those originating from the toe was 89.4%. There were 17,822 pathogens isolated from the diabetic foot cultures. MRSA was isolated in 7.5% of cultures, and methicillin-susceptible S. aureus was isolated in 24.8%. Enterococcus was identified in 14.7% of cultures, Proteus in 7.3%, and Pseudomonas in 6.8% of cultures. Given the high NPVs, the use of MRSA nares screening may be appropriate as a stewardship tool for deescalation and avoidance of empirical anti-MRSA therapy in patients who are not nasal carries of MRSA.

Fact versus Fiction: a Review of the Evidence behind Alcohol and Antibiotic Interactions.

Many antibiotics carry caution stickers that warn against alcohol consumption. Data regarding concurrent use are sparse. An awareness of data that address this common clinical scenario is important so health care professionals can make informed clinical decisions and address questions in an evidence-based manner. The purpose of this systematic review was to determine the evidence behind alcohol warnings issued for many common antimicrobials. The search was conducted from inception of each database to 2018 using PubMed, Medline via Ovid, and Embase. It included studies that involved interactions, effects on efficacy, and toxicity/adverse drug reactions (ADR) due to concomitant alcohol consumption and antimicrobials. All interactions were considered in terms of three components: (i) alteration in pharmacokinetics/pharmacodynamics (PK/PD) of antimicrobials and/or alcohol, (ii) change in antimicrobial efficacy, and (iii) development of toxicity/ADR. Available data support that oral penicillins, cefdinir, cefpodoxime, fluoroquinolones, azithromycin, tetracycline, nitrofurantoin, secnidazole, tinidazole, and fluconazole can be safely used with concomitant alcohol consumption. Data are equivocal for trimethoprim-sulfamethoxazole. Erythromycin may have reduced efficacy with alcohol consumption, and doxycycline may have reduced efficacy in chronic alcoholism. Alcohol low in tyramine may be consumed with oxazolidinones. The disulfiram-like reaction, though classically associated with metronidazole, occurs with uncertain frequency and with varied severity. Cephalosporins with a methylthiotetrazole (MTT) side chain or a methylthiodioxotriazine (MTDT) ring, ketoconazole, and griseofulvin have an increased risk of a disulfiram-like reaction. Alcohol and antimicrobial interactions are often lacking evidence. This review questions common beliefs due to poor, often conflicting data and identifies important knowledge gaps.

Antibiotic prescribing in the emergency department versus primary care: Implications for stewardship.

OBJECTIVE: This study sought to compare the appropriateness of antibiotic prescribing by drug, dose, duration, and indication between the emergency department (ED) and primary care (PC) within the Veterans Affairs Western New York Healthcare System (VAWNYHCS) to aid in focusing antimicrobial stewardship efforts. DESIGN: In this prospective observational cohort study, patients were identified using electronic alerts at the time of antibiotic prescribing. Prescriptions were retrospectively analyzed for appropriateness of antibiotic indication, drug choice, dose, and duration on the basis of current guideline recommendations. Data were compared between the ED and PC to determine the impact of visit location on prescribing habits. Baseline characteristics were compared using descriptive statistics, and a multivariable analysis was performed to identify statistically significant risk factors for inappropriate prescribing. SETTING AND PARTICIPANTS: Patients prescribed outpatient antibiotics at the VAWNYHCS ED and PC settings between June 2017 and February 2018. OUTCOME MEASURES: Appropriateness of antibiotic prescribing by drug, dose, duration, and indication between the ED and PC settings. RESULTS: The cohort included 1566 antibiotic prescriptions (ED = 488, PC = 1078). The appropriate drug, dose, and duration for antibiotics prescribed in the ED versus PC were 63.1% versus 43.4% (P < 0.001), 88.1% versus 88.2% (P = 0.953), and 86.1% versus 71.1% (P < 0.001), respectively. Azithromycin was the most inappropriately prescribed antibiotic in both the ED (37.8%) and PC (49.0%). Two factors predicted whether patients received the correct antibiotic empirically: location of the visit and antibiotic allergy. Overall, 56.6% of ED prescriptions and 82% of PC prescriptions were inappropriate with respect to at least 1 component. CONCLUSION: Stewardship is needed in both the ED and PC settings. However, initial efforts should be focused on PC because this setting had a statistically significant amount of inappropriate antibiotic prescribing. Pharmacist-led education and interventions should focus on the determination of drug, duration, and indication for the use of antibiotics.

Identification of risk factors for failure in patients with skin and soft tissue infections.

PURPOSE: The purpose was to determine significant predictors of treatment failure of skin and soft tissue infections (SSTI) in the inpatient and outpatient setting. METHODS: A retrospective chart review of patients treated between January 1, 2005 to July 1, 2016 with ICD-9 or ICD-10 code of cellulitis or abscess. The primary outcome was failure defined as an additional prescription or subsequent hospital admission within 30 days of treatment. Risk factors for failure were identified through multivariate logistic regression. RESULTS: A total of 541 patients were included. Seventeen percent failed treatment. In the outpatient group, 24% failed treatment compared to 9% for inpatients. Overweight/obesity (body mass index (BMI) > 25 kg/m2) was identified in 80%, with 15% having a BMI >40 kg/m2. BMI, heart failure, and outpatient treatment were determined to be significant predictors of failure. The unit odds ratio for failure with BMI was 1.04 (95% [Cl] = 1.01 to 1.1, p = 0.0042). Heart failure increased odds by 2.48 (95% [Cl] = 1.3 to 4.7, p = 0.0056). Outpatients were more likely to fail with an odds ratio of 3.36. CONCLUSION: Patients with an elevated BMI and heart failure were found to have increased odds of failure with treatment for SSTIs. However, inpatients had considerably less risk of failure than outpatients. These risk factors are important to note when making the decision whether to admit a patient who presents with SSTI in the emergency department. Thoughtful strategies are needed with this at-risk population to prevent subsequent admission.

Proper Antibiotic Use in a Home-Based Primary Care Population Treated for Urinary Tract Infections.

OBJECTIVE: To evaluate the trends associated with diagnosis and treatment of urinary tract infections (UTI) in a home-based primary care population of Veterans Health System patients from 2006 to 2015. DESIGN: Retrospective cohort study. SETTING: Veterans Healthcare System. PARTICIPANTS: Home-based primary care patients treated for UTI from 2006 to 2015. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Appropriate therapy was determined based on the McGeer criteria. Multivariate logistic regression was used to determine factors leading to appropriate UTI treatment. RESULTS: Of 366 available patients, 68 (18.6%) were tested for a UTI. Appropriate therapy occurred in 26% of patients. Allergy to any antibiotic increased the odds of appropriate treatment (odds ratio [OR] = 5.6, 95% confidence interval [CI] 1.5-23.2). Flank pain and increased urinary frequency also increased the likelihood of being treated appropriately (OR = 25.9, 95% CI 2.9-584.0 and OR = 4.49, 95% CI 0.99-21.2, respectively). CONCLUSION: Antibiotics were overused for treating UTIs in the homebound population. Patients with flank pain, increased urinary frequency, and antibiotic allergy were more likely to receive appropriate treatment. Pharmacists, therefore, have a viable opportunity to increase appropriate antibiotic prescribing in the home-based primary care population.

Obesity and Heart Failure as Predictors of Failure in Outpatient Skin and Soft Tissue Infections.

The purpose of this study was to evaluate risk factors for failure of antibiotic treatment within 30 days for uncomplicated skin infections of outpatients treated in a Veterans Affairs hospital. A retrospective chart review of outpatients between January 2006 and July 2015 with an ICD-9 (International Statistical Classification of Diseases and Related Health Problems) code of cellulitis or abscess was included in the analysis. The primary outcome was success versus failure of the antibiotic, with failure defined as another antibiotic prescribed or hospitalization within 30 days for the original indication. A total of 293 patients were included in the final analysis, 24% of whom failed within 30 days. Obesity/overweight (body mass index [BMI] of >25 kg/m2) was identified in 83% of the overall population, with 16% of that population having a BMI greater than 40 kg/m2 An elevated mean BMI of 34.2 kg/m2 (P = 0.0098) was found in the subset of patients who failed oral antibiotics compared to a BMI of 31.32 kg/m2 in patients who were treated successfully. Additionally, the patients who failed had an increased prevalence of heart failure at 16% (P = 0.027). Using multivariate logistic regression, BMI and heart failure were determined to be significant predictors of antibiotic prescription failure. Each 10-kg/m2 unit increase in BMI was associated with a 1.62-fold-greater odds of failure. A diagnosis of heart failure increased the odds of failure by 2.6-fold (range, 1.1- to 5.8-fold). Outpatients with uncomplicated skin infections with an elevated BMI and heart failure were found to have increased odds of failure, defined as hospitalization or additional antibiotics within 30 days.

The Effect of Psychosocial Factors on Success Rates of Hepatitis C Treatment.

OBJECTIVE: Our study was to determine which psychosocial factors interfere with patients reaching sustained virologic response (SVR), a marker for hepatitis C virus eradication. METHODS: A retrospective chart review was performed between January 6, 2015 and February 24, 2016. The primary outcome was to assess which social and psychological factors may interfere with patients reaching SVR. SVR was defined as having an undetectable viral load 12 weeks after the completion of the treatment regimen. Bivariate analysis was followed by a multivariate logistic regression analysis to determine significant factors for SVR. Depression and generalized anxiety disorder were included. RESULTS: A total of 204 patients completed treatment within the designated time frame and were included in the final analysis. Social or home support was associated with SVR (odds ratio = 7.0, p = 0.02). Cocaine use was also a significant factor predicting SVR. Historical cocaine use compared with active cocaine use during treatment was associated with an odds ratio of SVR of 39.3 (p = 0.04). Interestingly, historical cocaine use vs no history of cocaine use did not influence SVR. No history of depression or generalized anxiety disorder was associated with a higher rate of SVR (odds ratio = 10.4, p = 0.05). No depression/generalized anxiety disorder compared with untreated depression/generalized anxiety disorder was associated with a 13.1 times greater rate of SVR (p = 0.04). CONCLUSION: It is important to recognize and address psychosocial factors related to mental illness and active cocaine addictions before hepatitis C virus treatment. Furthermore, patients without home or social support are at greater risk for failing treatment, thus strategies to provide support during treatment are necessary.

Factors associated with antibiotic misuse in outpatient treatment for upper respiratory tract infections.

The Centers for Disease Control and Prevention has promoted the appropriate use of antibiotics since 1995 when it initiated the National Campaign for Appropriate Antibiotic Use in the Community. This study examined upper respiratory tract infections included in the campaign to determine the degree to which antibiotics were appropriately prescribed and subsequent admission rates in a veteran population. This study was a retrospective chart review conducted among outpatients with a diagnosis of a respiratory tract infection, including bronchitis, pharyngitis, sinusitis, or nonspecific upper respiratory tract infection, between January 2009 and December 2011. The study found that 595 (35.8%) patients were treated appropriately, and 1,067 (64.2%) patients received therapy considered inappropriate based on the Get Smart Campaign criteria. Overall the subsequent readmission rate was 1.5%. The majority (77.5%) of patients were prescribed an antibiotic. The most common antibiotics prescribed were azithromycin (39.0%), amoxicillin-clavulanate (13.2%), and moxifloxacin (7.5%). A multivariate regression analysis demonstrated significant predictors of appropriate treatment, including the presence of tonsillar exudates (odds ratio [OR], 0.6; confidence interval [CI], 0.3 to 0.9), fever (OR, 0.6; CI, 0.4 to 0.9), and lymphadenopathy (OR, 0.4; CI, 0.3 to 0.6), while penicillin allergy (OR, 2.9; CI, 1.7 to 4.7) and cough (OR, 1.6; CI, 1.1 to 2.2) were significant predictors for inappropriate treatment. Poor compliance with the Get Smart Campaign was found in outpatients for respiratory infections. Results from this study demonstrate the overprescribing of antibiotics, while providing a focused view of improper prescribing. This article provides evidence that current efforts are insufficient for curtailing inappropriate antibiotic use.

Corticosteroid use is associated with a reduced incidence of Clostridium difficile-associated diarrhea: a retrospective cohort study.

The impact of corticosteroid use on the incidence of Clostridium difficile-associated diarrhea (CDAD) was examined retrospectively in 532 patients receiving antibiotic treatment for respiratory infections. As determined by logistic regression, corticosteroids were associated with a decreased incidence of CDAD (Odds Ratio 0.12, 95% Confidence Interval 0.006-0.95).

An evaluation of antimicrobial prophylaxis for transrectal prostate biopsies: A potential stewardship target.

BACKGROUND: Transrectal prostate biopsy (TRPB) is a common procedure used to obtain a prostate biopsy. Although generally safe, complications may occur including infection. Preprocedural antimicrobial prophylaxis is recommended to minimize risk of subsequent infection. METHODS: This study is a retrospective chart review via the computerized patient record system from January 1, 2018 to February 28, 2022. The study included patients who underwent a TRPB at the Western New York, Syracuse, or Albany Stratton Veterans Affairs Healthcare Systems. RESULTS: This study included a total of 932 patients who underwent TRPB. Postoperative infection occurred in 3.2% (n = 30) of patients within 14days of the TRPB. Of the 30 patients who developed an infection, 30% (n = 9) resulted in bacteremia. For the 932 patients evaluated, 24 different antibiotic regimens were used, none of which followed guideline recommendations. None of the regimens were found to have an impact on rates of subsequent infection. CONCLUSIONS: The results of this study suggest a need for guideline adherence. There was no benefit to using the guideline-discordant regimens as they were not associated with a decreased risk of infection, and in many cases exposed patients to unnecessarily broad and prolonged antibiotic regimens.

Impact of doxycycline on Clostridioides difficile infection in patients hospitalized with community-acquired pneumonia.

BACKGROUND: Antibiotic use is a significant risk factor associated with Clostridioides difficile (C difficile) infection (CDI). Community-acquired pneumonia (CAP) is a common infection leading to hospital admission and the use of antibiotics that are highly associated with CDI. It has been proposed that doxycycline, a tetracycline antibiotic, may be protective against CDI. METHODS: A retrospective analysis was conducted in hospitalized patients in Veterans Affairs Hospitals across the United States to determine if doxycycline was associated with a decreased risk of CDI. The primary outcome was the development of CDI within 30 days of initiation of doxycycline or azithromycin, as part of a standard pneumonia regimen. RESULTS: Approximately 156,107 hospitalized patients who received care at a Veterans Affairs Hospital and were diagnosed with CAP during the study timeframe were included. A 17% decreased risk of CDI was identified with doxycycline compared to azithromycin when used with ceftriaxone for the treatment of pneumonia (P = .03). In patients who had a prior history of CDI, doxycycline decreased the incidence of CDI by 45% (odds ratio 0.55; P = .02). CONCLUSIONS: Doxycycline is associated with a lower risk of CDI compared to azithromycin when used for atypical coverage in CAP. Thus, patients who are at such risk may benefit from doxycycline as a first-line agent for atypical coverage, rather than the use of a macrolide antibiotic, if Legionella is not of concern.

Effectiveness and safety of dual renin-angiotensin system blockade: a comparison between younger and older cohorts.

OBJECTIVE: The purpose of this review was to evaluate blood pressure (BP) reductions and adverse events between patients younger than 65 and older than 65 years of age receiving a combination of an angiotensin converting enzyme inhibitor (ACE-I) and an angiotensin receptor blocker (ARB). DESIGN: A retrospective cohort study comparing the effectiveness of ACE-I and ARB combination in patients < 65 (younger) and ≥ 65 years of age (elderly). SETTING: This study was conducted at the VA Western New York Healthcare System. PARTICIPANTS: A total of 176 patients: 54 patients in the younger group and 122 in the elderly cohort. INTERVENTIONS: No specific interventions were performed. MAIN OUTCOME MEASURES: The purpose was to evaluate differences in BP reductions and incidence of adverse events in younger and elderly patients receiving a combination of an ACE-I and an ARB. RESULTS: In the elderly group (mean age 76), the mean reduction in standing blood pressure (SBP) was 14.2 ± 15.6 mmHg (95% confidence interval [CI] 11.2-17.3; P < 0.0001). Similar results were obtained in the younger group (mean age 59), with a mean SBP reduction of 10 ± 14.9 (95% CI 5.6-14.5; P < 0.0001). The mean SBP reduction was not significantly different between the two age cohorts (P = 0.57). The incidence of adverse events was not different between the two age groups (cough P = 0.67, hyperkalemia P = 1.0, angioedema P = 0.31). CONCLUSION: There was no significant difference in effectiveness or safety between the elderly and younger cohorts. The pharmacist monitoring elderly patients on combination therapy should still closely follow these patients; however it is reassuring that elderly patients do not experience adverse reactions at rates higher than do younger patients.

Risk factors associated with mortality in hospitalized patients with laboratory confirmed SARS-CoV-2 infection during the period of omicron (B.1.1.529) variant predominance.

BACKGROUND: SARS-CoV-2 Omicron variant has a high transmission rate. In December 2021, Omicron became the dominant variant and quickly accounted for majority of infections in the United States. Drug shortages have led to prioritization of patients for COVID-19 treatment based on risk factors for severe disease. METHODS: A retrospective analysis of hospitalized patients with COVID-19 infection at Veteran Affairs Healthcare System across the United States. The primary outcome was 14-day all-cause mortality after the first documented positive SARS-CoV-2 laboratory test. Odds ratios were generated from a multivariate logistic regression of significant factors. RESULTS: This study included 12,936 COVID-19 inpatients during a period of Omicron predominance. Age ≥ 65 years is a predictor of 14-day mortality among the vaccinated and unvaccinated population (OR 4.05, CI 3.06-5.45, P ≤ .0001). Triple vaccinated patients demonstrated a 52% decreased risk of death with COVID-19 infection (OR 0.48, CI 0.37-0.61, P ≤ .0001). Patients who were double vaccinated had a 39% decreased risk of death with COVID-19 infection (OR 0.61, CI 0.46-0.80, P = .003). CONCLUSION: Advanced age ≥ 65 is the greatest risk factor for mortality in hospitalized COVID-19 patients. COVID-19 vaccination, especially booster doses, was associated with a decreased risk of 14-day mortality compared to double vaccinated or non-vaccinated patients. Results of this study suggest that advanced age should be considered first for prioritization of COVID-19 treatments for Omicron.

Increased Myocardial Infarction Risk Following Herpes Zoster Infection.

Background: Myocardial infarction (MI) has been reported as a postinfection sequela of herpes zoster, but with limited data on incidence after zoster and protective effect of the zoster vaccine. This study investigates the risk of developing an MI 30 days postzoster, determines patient-specific risk factors, and investigates the impact of herpes zoster vaccination. Methods: This retrospective cohort study included patients who received care at a Veterans Affairs facility between 2015 and 2020. Time to MI was determined from either 30 days post-zoster infection (zoster cohort) or a primary care appointment (control cohort). Results: This study assessed a total of 2 165 584 patients. MI within 30 days occurred in 0.34% (n = 244) of the zoster cohort and 0.28% (n = 5782) of the control cohort (P = .0016). Patients with a documented herpes zoster infection during the study period were 1.35 times more likely to develop an MI within the first 30 days postinfection compared to the control cohort. Patients who received the recombinant zoster vaccine were less likely to have an MI postinfection (odds ratio, 0.82 [95% confidence interval, .74-.92]; P = .0003). Conclusions: Herpes zoster infection was associated with an increased risk of MI within the first 30 days postinfection. History of prior MI, male sex, age ≥50 years, history of heart failure, peripheral vascular disease, human immunodeficiency virus, prior cerebrovascular accident, and renal disease increased odds of MI 30 days postinfection with herpes zoster. Herpes zoster vaccination decreased the odds of developing an MI in patients aged ≥50 years.