Influenza With an Infiltrate: Investigating the New Community-Acquired Pneumonia Guidelines

Background: The Infectious Diseases Society of America released updated community-acquired pneumonia (CAP) guidelines in October 2019. One of the recommendations, with a low quality of supporting evidence, is the standard administration of antibiotics in adult patients with influenza and radiographic evidence of pneumonia. Procalcitonin (PCT) is not endorsed as a strategy to withhold antibiotic therapy, but it could be used to de-escalate appropriate patients after 48–72 hours. Radiographic findings are not indicative of the etiology of pneumonia. Prescribing antibiotics for all influenza-positive patients with an infiltrate has significant implications for stewardship. Therefore, we reviewed hospitalized, influenza-positive patients at our institution during the 2018–2019 season, and we sought to assess the impact of an abnormal chest x-ray (CXR) and PCT on antibiotic prescribing and outcomes. Methods: We conducted a retrospective chart review of all influenza-positive admissions at 2 urban, community-based, teaching hospitals. Demographic data, vaccination status, PCT levels, CXR findings, and treatment regimens were reviewed. The primary outcome was the difference in receipt of antibiotics between patients with a negative (<0.25 ng/mL) and positive PCT. Secondary outcomes included the impact of CXR result on antibiotic prescribing, duration, 30-day readmission, and 90-day mortality. Results: We reviewed the medical records of 117 patients; 43 (36.7%) received antibiotics. The vaccination rate was 36.7%. Also, 11% of patients required intensive care unit (ICU) admission and 84% received antibiotics. Moreover, 109 patients had a CXR: 61 (55.9%) were negative, 29 (26.6%) indeterminate, and 19 (17.4%) positive per radiologist interpretation. Patients with a positive PCT (OR, 12.7; 95% CI, 3.43–60.98; P < .0007) and an abnormal CXR (OR, 7.4; 95% CI, 2.9–20.1; P = .000003) were more likely to receive antibiotics. There was no significant difference in 30-day readmission (11.6% vs 13.5%; OR, 0.89; 95% CI, 0.21–3.08; P = 1) and 90-day mortality (11.6% vs 5.4%; OR, 2.37; 95% CI, 0.48–12.75; P = .28) between those that received antibiotics and those that did not, respectively. Furthermore, 30 patients (62.5%) with an abnormal CXR received antibiotics and 21 (43.7%) had negative PCT. There was no difference in 30-day readmission or 90-day mortality between those that did and did not receive antibiotics. Conclusions: Utilization of PCT allowed selective prescribing of antibiotics without impacting readmission or mortality. Antibiotics should be initiated for critically ill patients and based on clinical judgement, rather than for all influenza-positive patients with CXR abnormalities.Funding: NoneDisclosures: None

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Novel Technique to Reduce the Incidence of SSI after Colorectal Surgery

The American Surgeon ◽

10.1177/000313481908500725 ◽

2019 ◽

Vol 85 (7) ◽

pp. 695-699

Author(s):

Danielle Kay ◽

Avinash Bhakta ◽

Jitesh A. Patel ◽

Jon S. Hourigan ◽

Shyanie Kumar ◽

...

Keyword(s):

Health Care Cost ◽

Demographic Data ◽

Retrospective Chart Review ◽

Patient Characteristics ◽

University Of Kentucky ◽

Significant Difference ◽

Acs Nsqip Database ◽

The University ◽

The Impact ◽

Wound Class

SSI is a leading cause of morbidity and increases health-care cost after colorectal operations. It is a key hospital-level patient safety indicator. Previous literature has identified perioperative risk factors associated with SSI and interventions to decrease rate of infection. The purpose of this study was to evaluate the impact of blowhole closure on the rate of superficial and deep SSI. The ACS-NSQIP database was queried for patients undergoing colectomy at the University of Kentucky from 2013 to 2016. Retrospective chart review was performed to gather demographic data and perioperative variables. Wounds left open and packed were excluded. Rates of postoperative SSI were measured between the groups. One thousand eighty-three patients undergoing elective and emergent colectomy were reviewed. Nine hundred and forty-five had closed incision and 138 had blowhole closure. Patient characteristics between the groups were well matched. Patients with a blowhole closure were more likely to have an open procedure ( P = 0.037) and a higher wound class ( P < 0.001). The rate of superficial and deep SSI was 9.1 per cent in patients with a closed incision and 5.1 per cent in patients with blowhole closure ( P = 0.142). With adjustment for approach and wound class, blowhole closure decreased the incidence of SSI ( P = 0.04). There was no significant difference in morbidity or mortality. Patients undergoing elective and emergent colectomy had decreased incidence of SSI when blowhole closure was used. Given that it does not increase resource usage and its technical ease, blowhole closure should become the standard method of surgical wound closure.

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The impact of prior urethral sling on artificial urinary sphincter outcomes

Canadian Urological Association Journal ◽

10.5489/cuaj.3922 ◽

2016 ◽

Vol 10 (11-12) ◽

pp. 405 ◽

Cited By ~ 6

Author(s):

Matthew J. Ziegelmann ◽

Brian J. Linder ◽

Marcelino E. Rivera ◽

Boyd R. Viers ◽

Daniel S. Elliott

Keyword(s):

Retrospective Chart Review ◽

Artificial Urinary Sphincter ◽

Device Failure ◽

Kaplan Meier ◽

Hazard Ratios ◽

Urinary Sphincter ◽

Device Infection ◽

Significant Difference ◽

History Of ◽

The Impact

Introduction: We sought to evaluate device outcomes in men who underwent primary artificial urinary sphincter (AUS) placement after failed male urethral sling (MUS).Methods: We performed a retrospective chart review of 990 men who underwent an AUS procedure between 2003 and 2014. Of these, 540 were primary AUS placements, including 30 (5.5%) with a history of MUS. AUS revisions and explantations were compared between men stratified by the presence of prior sling. Hazard ratios (HR) adjusting for competing risks were used to determine the association with prior sling and AUS outcomes (infection/ erosion, urethral atrophy, and mechanical malfunction), while overall device failure was estimated using Kaplan-Meier and Coxregression analysis.Results: There was no significant difference in age, body mass index, prior prostatectomy, or pelvic radiation when stratified by history of MUS. However, patients with a history of MUS were more likely to have undergone prior collagen injection (p=0.01). On univariate and multivariate analysis, prior MUS was not associated with device failure (HR 1.54; p=0.27). Three-year overall device survival did not significantly differ between those with and without prior MUS (70% vs. 85%; p=0.21). Also, there were no significant differences in the incidence of device infection/erosion, mechanical malfunction, and urethral atrophy.Conclusions: AUS remains a viable treatment option for men with persistent or recurrent stress urinary incontinence after MUS. However, while not statistically significant, we identified a trend towards lower three-year device outcomes in patients with prior urethral sling. These findings indicate the need for longer-term studies to determine if slings pose an increased hazard.

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Abstract 257: Urban Teaching and Non-Teaching Hospitals Outcomes: Myocardial Infarction

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.257 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Priscilla O Okunji ◽

Johnnie Daniel

Keyword(s):

Myocardial Infarction ◽

Mortality Rate ◽

Income Group ◽

The United States ◽

Teaching Hospitals ◽

Age Difference ◽

Age Group ◽

Urban Teaching ◽

Significant Difference ◽

The Impact

Background: Patients with myocardial infarction reportedly have different outcomes on discharge according to hospital characteristics. In the present study, we evaluated the differences between urban teaching hospitals (UTH) and non-teaching hospitals (NTH), discharged in 2012. We also investigated on the outcomes. Methods: Sample of 117,808 subjects diagnosed with myocardial infarction were extracted from a nationwide inpatient stay dataset using the International Classification Data, ICD 9 code 41000 in the United States, according to hospital location, size, and teaching status. Results: The analysis of the data showed that more whites were admitted to both teaching and non teaching hospitals with more males (~24%) admitted than their female counterparts. However, blacks were admitted more (~15%) in urban teaching hospitals than medium urban non teaching hospitals. Age difference was noted as well, while age group (60-79 years) were admitted more in UTH, inversely urban non-teaching hospitals admitted more older (80 years or older) age group. A significant difference (~28%) was observed in both hospital categories with UTH admitting more patients of $1.00 - $38,999.00 income group than other income categories. In addition, it was observed that patients with MI stayed more (~5%) for 14 or more days, and charged more especially for income group of $80,000 or above in UTH than NTH. No significant difference was found in the mortality rate for both hospital categories. Conclusion: The overall outcomes showed that the mortality rate between urban teaching and non-teaching hospitals were non significant, though the inpatients MI stayed longer and were charged more in UTH than NTH. The authors call for the study to be replicated with a higher level of statistical measures to ascertain the impact of the variables on the outcomes for a more validated result.

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Impact of health disparities on treatment for single-suture craniosynostosis in an era of multimodal care

Neurosurgical FOCUS ◽

10.3171/2021.1.focus201000 ◽

2021 ◽

Vol 50 (4) ◽

pp. E13

Author(s):

Caitlin Hoffman ◽

Alyssa B. Valenti ◽

Eseosa Odigie ◽

Kwanza Warren ◽

Ishani D. Premaratne ◽

...

Keyword(s):

Open Surgery ◽

Statistical Significance ◽

Demographic Data ◽

Tertiary Care ◽

Insurance Status ◽

Significant Difference ◽

Race Ethnicity ◽

The Impact ◽

Type Of Surgery ◽

Surgical Group

Craniosynostosis is the premature fusion of the skull. There are two forms of treatment: open surgery and minimally invasive endoscope-assisted suturectomy. Candidates for endoscopic treatment are less than 6 months of age. The techniques are equally effective; however, endoscopic surgery is associated with less blood loss, minimal tissue disruption, shorter operative time, and shorter hospitalization. In this study, the authors aimed to evaluate the impact of race/ethnicity and insurance status on age of presentation/surgery in children with craniosynostosis to highlight potential disparities in healthcare access. Charts were reviewed for children with craniosynostosis at two tertiary care hospitals in New York City from January 1, 2014, to August 31, 2020. Clinical and demographic data were collected, including variables pertaining to family socioeconomic status, home address/zip code, insurance status (no insurance, Medicaid, or private), race/ethnicity, age and date of presentation for initial consultation, type of surgery performed, and details of hospitalization. Children with unknown race/ethnicity and those with syndromic craniosynostosis were excluded. The data were analyzed via t-tests and chi-square tests for statistical significance (p < 0.05). A total of 121 children were identified; 62 surgeries were performed open and 59 endoscopically. The mean age at initial presentation of the cohort was 6.68 months, and on the day of surgery it was 8.45 months. Age at presentation for the open surgery cohort compared with the endoscopic cohort achieved statistical significance at 11.33 months (SD 12.41) for the open cohort and 1.86 months (SD 1.1473) for the endoscopic cohort (p < 0.0001). Age on the day of surgery for the open cohort versus the endoscopic cohort demonstrated statistical significance at 14.19 months (SD 15.05) and 2.58 months (SD 1.030), respectively. A statistically significant difference between the two groups was noted with regard to insurance status (p = 0.0044); the open surgical group comprised more patients without insurance and with Medicaid compared with the endoscopic group. The racial composition of the two groups reached statistical significance when comparing proportions of White, Black, Hispanic, Asian, and other (p = 0.000815), with significantly more Black and Hispanic patients treated in the open surgical group. The results demonstrate a relationship between race and lack of insurance or Medicaid status, and type of surgery received; Black and Hispanic children and children with Medicaid were more likely to present later and undergo open surgery.

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A Standardized Approach to Cesarean Surgical Technique and Its Effect on Operative Time and Surgical Morbidity

American Journal of Perinatology ◽

10.1055/s-0038-1667370 ◽

2018 ◽

Vol 36 (03) ◽

pp. 277-284 ◽

Cited By ~ 3

Author(s):

M. Pallister ◽

J. Ballas ◽

J. Kohn ◽

C. S. Eppes ◽

M. Belfort ◽

...

Keyword(s):

Surgical Technique ◽

Operative Time ◽

Retrospective Chart Review ◽

Surgical Morbidity ◽

Entire Cohort ◽

Cesarean Deliveries ◽

Significant Difference ◽

Secondary Outcomes ◽

The Impact ◽

Academic Year

Objective To evaluate the impact of a standardized surgical technique for primary cesarean deliveries (CDs) on operative time and surgical morbidity. Materials and Methods Two-year retrospective chart review of primary CD performed around the implementation of a standardized CD surgical technique. The primary outcome was total operative time (TOT). Secondary outcomes included incision-to-delivery time (ITDT), surgical site infection, blood loss, and maternal and fetal injuries. Results When comparing pre- versus postimplementation surgical times, there was no significant difference in TOT (76.5 vs. 75.9 minutes, respectively; p = 0.42) or ITDT (9.8 vs. 8.8 minutes, respectively; p = 0.06) when the entire cohort was analyzed. Subgroup analysis of CD performed early versus late in an academic year among the pre- and postimplementation groups showed no significant difference in TOT (79.3 early vs. 73.8 minutes late; p = 0.10) or ITDT (10.8 early vs. 8.8 minutes late; p = 0.06) within the preimplementation group. In the postimplementation group, however, there was significant decrease in TOT (80.5 early vs. 71.3 minutes late; p = 0.02) and ITDT (10.6 early vs. 6.8 minutes late; p < 0.01). Secondary outcomes were similar for both groups. Conclusion A standardized surgical technique combined with surgical experience can decrease TOT and ITDT in primary CD without increasing maternal morbidity.

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1139. Multidisciplinary Initiative to Increase Guideline-Concordant Antibiotic Prescriptions at Discharge for Hospitalized Children with Uncomplicated Community-Acquired Pneumonia

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1003 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S405-S406

Author(s):

Alexandra B Yonts ◽

Michael Jason Bozzella ◽

Matthew Magyar ◽

Laura O’Neill ◽

Nada Harik

Keyword(s):

Infectious Diseases ◽

Treatment Guidelines ◽

Tertiary Care ◽

Hospital Medicine ◽

Community Acquired Pneumonia ◽

Antibiotic Prescribing ◽

Hospitalized Children ◽

Median Percentage ◽

Common Diagnosis ◽

The Impact

Abstract Background Community-acquired pneumonia (CAP) is the most common diagnosis in hospitalized children. The Pediatric Infectious Diseases Society and the Infectious Diseases Society of America published evidenced-based clinical practice guidelines for the management of CAP in children 3 months of age or older in 2011. These guidelines are not consistently followed. Our objective was to evaluate if quality improvement (QI) methods could improve guideline-concordant antibiotic prescribing, specifically addressing the use of oral third-generation cephalosporins, at hospital discharge for children with uncomplicated CAP. Methods QI interventions, implemented at a single tertiary care children’s hospital in Washington, D.C., focused on key drivers targeting hospital medicine resident teams. Multiple plan-do-study-act (PDSA) cycles were performed. Initial interventions included educational sessions (in small group and lecture formats) aimed at pediatric resident physicians, as well as visual job aids (Figure 1) and guideline summaries posted in resident physician work areas. Interventions were implemented in series to allow for statistical analysis via run chart. Medical records of eligible patients were reviewed monthly after each intervention to determine the impact on appropriate discharge antibiotic prescribing. Results At baseline, the median percentage of children with a diagnosis of uncomplicated CAP discharged with guideline-concordant antibiotics was 50%. Median rates of guideline-concordant antibiotic prescribing improved to 87.5% after initial interventions (Figure 2). Conclusion A fellow-led multidisciplinary QI initiative was successful in decreasing rates of non-guideline-concordant antibiotic prescribing at discharge. These interventions can be tailored for use at other institutions and for other infectious processes with established treatment guidelines. To ensure sustained improvement in guideline-concordant prescribing, future planned interventions include additional educational sessions with residents, faculty, and pharmacists, EMR order set modification and physician benchmarking. These tactics are intended to address the anticipated challenge of resident/faculty turnover and automate antibiotic choice for uncomplicated CAP. Disclosures All authors: No reported disclosures.

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The influence of a community intervention on influenza vaccination knowledge and behavior among diabetic patients

BMC Public Health ◽

10.1186/s12889-019-8101-6 ◽

2019 ◽

Vol 19 (1) ◽

Author(s):

Lili Tao ◽

Ming Lu ◽

Xiaoning Wang ◽

Xiaoyan Han ◽

Shuming Li ◽

...

Keyword(s):

Influenza Vaccine ◽

Influenza Vaccination ◽

Community Intervention ◽

Vaccination Rate ◽

Control Group ◽

Diabetic Patients ◽

Vaccination Rates ◽

Significant Difference ◽

The Impact ◽

Experimental Group

Abstract Background This study was conducted to evaluate the impact of a comprehensive community intervention on cognition and inoculation behaviors of diabetic patients immunized with influenza vaccine. Methods A total of 1538 diabetic patients aged 35 years and above for outpatient visits and follow-up treatments were selected from six community health service centers (three for the experimental group, and the other three for the control group) in Chaoyang District, Beijing. Comprehensive interventions applied to the experimental group include patient intervention and community climate interventions. We compared the total awareness of influenza vaccine knowledge and influenza vaccination rates between the two groups before and after the intervention. Results Before the intervention, the total awareness rate of influenza vaccine in the experimental group and the control group was similar (50.6 and 50.2%, respectively. P = 0.171). After the intervention, the awareness rate of influenza vaccine in the experimental group and the control group increased. The amplitude of the increase was similar (70.3 and 70.1%, respectively. P = 0.822,). Before the intervention, there was no significant difference in the influenza vaccination rate between the experimental group and the control group (29.0 and 26.8%, respectively. P = 0.334). After the intervention, the vaccination rate of the experimental group was higher than that of the control group. The difference was statistically significant (The vaccination rate 45.8 and 27.4% for the experimental group and the control group, respectively. P < 0.001). Conclusion Comprehensive community interventions had a positive effect on vaccination in diabetic patients. Trial registration ChiCTR1900025194, registered in Aug,16th, 2019. Retrospectively registered.

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Association of Resident Duty Hour Restrictions on Mortality of Nervous System Disease and Disorder

Journal of Graduate Medical Education ◽

10.4300/jgme-d-15-00306.1 ◽

2016 ◽

Vol 8 (4) ◽

pp. 576-580 ◽

Cited By ~ 1

Author(s):

Ian Churnin ◽

Joel Michalek ◽

Ali Seifi

Keyword(s):

Nervous System ◽

Hospital Mortality ◽

Nationwide Inpatient Sample ◽

Teaching Hospitals ◽

Nonteaching Hospital ◽

System Disease ◽

Significant Difference ◽

Reform Period ◽

Teaching Status ◽

The Impact

ABSTRACT Background The impact of the 2003 residency duty hour reform on patient care remains a debated issue. Objective Determine the association between duty hour limits and mortality in patients with nervous system pathology. Methods Via a retrospective cohort study using the Nationwide Inpatient Sample from 2000–2010, the authors evaluated in-hospital mortality status in those with a primary discharge level diagnosis of disease or disorder of the nervous system. Odds ratios were calculated, and Bonferroni corrected P values and confidence intervals were determined to account for multiple comparisons relating in-hospital mortality with teaching status of the hospital by year. Results The pre-reform (2000–2002) and peri-reform (2003) periods revealed no significant difference between teaching and nonteaching hospital mortality (P > .99). The post-reform period (2004–2010) was dominated by years of significantly higher mortality rates in teaching hospitals compared to nonteaching hospitals: 2004 (P < .001); 2006 (P = .043); 2007 (P = .042); and 2010 (P = .003). However, data for 2005 (P ≥ .99), 2008 (P = .80), and 2009 (P = .09) did not show a significant difference in mortality. Conclusions Teaching and nonteaching hospital mortality was similar in patients with nervous system pathology prior to the duty hour reform. While nonteaching institutions demonstrated steadily declining mortality over the decade, teaching hospital mortality spiked in 2004 and declined at a more restricted rate. The timing of these changes could suggest a negative correlation of duty hour restrictions on outcomes of patients with nervous system pathology.

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2193. Factors Impacting the Duration of Antimicrobial Therapy for Community-Acquired Pneumonia

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1873 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S746-S747

Author(s):

Avnish Sandhu ◽

Erin Goldman ◽

Jordan Polistico ◽

Sarah Polistico ◽

Ahmed Oudeif ◽

...

Keyword(s):

Risk Factors ◽

Medical Center ◽

Clinical Signs ◽

Retrospective Chart Review ◽

Signs And Symptoms ◽

Community Acquired Pneumonia ◽

Prescribing Patterns ◽

Antibiotic Prescribing ◽

Factors Associated ◽

Specific Risk

Abstract Background Pneumonia is a common cause of infection associated with hospitalization. Treatment durations for community-acquired pneumonia (CAP) often exceed guideline recommended durations of 5–7 days without a clear explanation. The objective of this study was to determine factors that may lead to durations exceeding this recommendation. Methods A retrospective chart review of 89 patients admitted to the Detroit Medical Center (DMC) for the treatment of pneumonia was conducted. Demographics, clinical signs and symptoms, antibiotic data, pneumonia severity score (CURB 65), risk factors for resistance, microbiology results, and outcomes were recorded and analyzed for factors associated with increased durations of antibiotics. Average durations of antibiotics and durations of antibiotics greater that 7 days were assessed for each risk factor. Results Average durations of antibiotics was 9 days (SD 3.8) for the cohort, and 55 (61%) received durations of > 7 days. Average durations of antibiotics for risk factors are shown in Table 1. Factors associated with durations of antibiotics longer than 7 days are shown in Table 2. There was a trend toward longer average durations of antibiotics for persons with risk factors for resistance [Drug Resistance in Pneumonia (DRIP) score ≥ 4 (increased duration of antibiotics by 1.7 days, P = 0.07] and those with a positive legionella antigen [increased durations of antibiotics by 6.6 days, P = 0.07]. Conclusion Specific risk factors could not be associated with increased durations of antibiotics, although there was a trend toward longer durations for persons with markers for resistance and positive legionella testing. Efforts to reduce durations of antibiotics must target global clinician antibiotic prescribing patterns and not specific risk factors. Disclosures All authors: No reported disclosures.

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Impact of robotic-assisted approach on lymphadenectomy for colorectal cancer.

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.4_suppl.787 ◽

2017 ◽

Vol 35 (4_suppl) ◽

pp. 787-787

Author(s):

Reza Gamagami ◽

Paul Kozak ◽

Venkata R. Kakarla

Keyword(s):

Colorectal Cancer ◽

Lymph Node ◽

Laparoscopic Surgery ◽

Lymph Nodes ◽

Demographic Data ◽

Robotic Assisted ◽

Lymph Node Harvest ◽

Significant Difference ◽

The Mean ◽

The Impact

787 Background: In most recent years, robotic assisted laparoscopic surgery (RALS) has proven to be a viable alternative to laparoscopic and traditional open surgery for colorectal cancer. Obtaining the adequate number of lymph nodes is not only essential for accurate staging, but also impacts both prognosis and the need for adjuvant chemotherapy. To date, the efficacy of lymph node harvest for RALS is not well studied or established. The aim of our study is to analyze the impact of RALS on lymphadenectomy for colorectal cancer. Methods: We performed a retrospective review of patients who underwent curative resections for colorectal cancer over a five-year period at a single institution by a single surgeon. Resections were classified as right-sided, sigmoid, or rectal, and subdivided into robotic and non-robotic surgery groups. The demographic data and histopathology were obtained, with an emphasis on the number lymph nodes harvested (LNH) during resections. Emergencies and non-curative resections were excluded. Results: Between January 2010 and December 2015, 136 patients with colorectal cancer underwent curative resections. Sixty-four underwent right-sided resections (28 laparoscopic, 36 robotic). Twenty-five underwent sigmoid resections (11 laparoscopic, 14 robotic), and 47 underwent rectal resections (15 open, 32 robotic). There was no significant difference in age, sex, BMI and ASA scores between the cohorts examined. The mean number of LNH with RALS was significantly higher in all three groups (right-sided—24 vs. 15 ( p= .0001), sigmoid—16 vs. 12 ( p= .046), rectal—19 vs. 4 ( p= .0016)). There was no difference in the rate of adequate lymph node extraction for staging purpose, i.e., 12 lymph nodes in all three groups. Conclusions: Robotic-assisted laparoscopic surgery is associated with a statistically significant increase in lymph node harvest for right-sided, sigmoid and rectal resections for malignancy. Future studies with larger sample sizes are necessary to validate these findings.

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