To evaluate the epidemiological and clinical characteristics of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection among healthcare workers (HCWs) in Hubei Province, China.

Retrospective cohort study.

Hubei Provincial Center for Disease Control and Prevention.

The participants in this study are cases identified by epidemiological investigation in Hubei Province, as of February 27, 2020, and were followed until March 7, 2020. In total, 1,989 HCWs and 41,137 other occupational cases were included for analysis.

We used descriptive statistics to summarize patient characteristics.

Of 1,989 laboratory-confirmed HCWs, 297 (14.93%) had severe or critical cases, 73 (3.67%) had asymptomatic infections, and 18 died of coronavirus disease 2019 (COVID-19). The case fatality rate was 0.9%. The proportion of severe or critical cases decreased from the beginning to the end of the outbreak (from 21.29% to 3.52%), and the proportion of asymptomatic cases increased from 0.0% to 47.18%. Nearly half of HCWs with confirmed COVID-19 reported no known contact with COVID-19 patients (969, 48.72%). Fever and cough were the most common symptoms at disease onset in both HCWs and other occupational cases; however, HCWs had higher rates of fatigue (30.90% vs 25.02%; P < .001) and myalgia (19.15% vs 13.43%; P < .001). Additionally, compared with other occupational groups, HCWs were associated with a lower risk of death after adjustment for potential confounders (odd ratio [OR], 0.50; 95% confidence interval [CI], 0.30–0.79).

Compared with COVID-19 cases in other occupational groups, HCWs with COVID-19 have half the risk of death, although they have been shown to have higher rates of fatigue and myalgia.

Social distancing policies are key in curtailing severe acute respiratory coronavirus virus 2 (SARS-CoV-2) spread, but their effectiveness is heavily contingent on public understanding and collective adherence. We studied public perception of social distancing through organic, large-scale discussion on Twitter.

Retrospective cross-sectional study.

Between March 27 and April 10, 2020, we retrieved English-only tweets matching two trending social distancing hashtags, #socialdistancing and #stayathome. We analyzed the tweets using natural language processing and machine-learning models, and we conducted a sentiment analysis to identify emotions and polarity. We evaluated the subjectivity of tweets and estimated the frequency of discussion of social distancing rules. We then identified clusters of discussion using topic modeling and associated sentiments.

We studied a sample of 574,903 tweets. For both hashtags, polarity was positive (mean, 0.148; SD, 0.290); only 15% of tweets had negative polarity. Tweets were more likely to be objective (median, 0.40; IQR, 0–0.6) with ~30% of tweets labeled as completely objective (labeled as 0 in range from 0 to 1). Approximately half of tweets (50.4%) primarily expressed joy and one-fifth expressed fear and surprise. Each correlated well with topic clusters identified by frequency including leisure and community support (ie, joy), concerns about food insecurity and quarantine effects (ie, fear), and unpredictability of coronavirus disease 2019 (COVID-19) and its implications (ie, surprise).

Considering the positive sentiment, preponderance of objective tweets, and topics supporting coping mechanisms, we concluded that Twitter users generally supported social distancing in the early stages of their implementation.

United States dentists prescribe 10% of all outpatient antibiotics. Assessing appropriateness of antibiotic prescribing has been challenging due to a lack of guidelines for oral infections. In 2019, the American Dental Association (ADA) published clinical practice guidelines (CPG) on the management of acute oral infections. Our objective was to describe baseline national antibiotic prescribing for acute oral infections prior to the release of the ADA CPG and to identify patient-level variables associated with an antibiotic prescription.

Cross-sectional analysis.

We performed an analysis of national VA data from January 1, 2017, to December 31, 2017. We identified cases of acute oral infections using International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Antibiotics prescribed by a dentist within ±7 days of a visit were included. Multivariable logistic regression identified patient-level variables associated with an antibiotic prescription.

Of the 470,039 VA dental visits with oral infections coded, 12% of patient visits with irreversible pulpitis, 17% with apical periodontitis, and 28% with acute apical abscess received antibiotics. Although the median days’ supply was 7, prolonged use of antibiotics was frequent (≥8 days, 42%–49%). Patients with high-risk cardiac conditions, prosthetic joints, and endodontic, implant, and oral and maxillofacial surgery dental procedures were more likely to receive antibiotics.

Most treatments of irreversible pulpitis and apical periodontitis cases were concordant with new ADA guidelines. However, in cases where antibiotics were prescribed, prolonged antibiotic courses >7 days were frequent. These findings demonstrate opportunities for the new ADA guidelines to standardize and improve dental prescribing practices.

Extensive environmental contamination by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been reported in hospitals during the coronavirus disease 2019 (COVID-19) pandemic. We report our experience with the practice of directly observed environmental disinfection (DOED) in a community isolation facility (CIF) and a community treatment facility (CTF) in Hong Kong.

The CIF, with 250 single-room bungalows in a holiday camp, opened on July 24, 2020, to receive step-down patients from hospitals. The CTF, with 500 beds in open cubicles inside a convention hall, was activated on August 1, 2020, to admit newly diagnosed COVID-19 patients from the community. Healthcare workers (HCWs) and cleaning staff received infection control training to reinforce donning and doffing of personal protective equipment and to understand the practice of DOED, in which the cleaning staff observed patient and staff activities and then performed environmental disinfection immediately thereafter. Supervisors also observed cleaning staff to ensure the quality of work. In the CTF, air and environmental samples were collected on days 7, 14, 21, and 28 for SARS-CoV-2 detection by RT-PCR. Patient compliance with mask wearing was also recorded.

Of 291 HCWs and 54 cleaning staff who managed 243 patients in the CIF and 674 patients in the CTF from July 24 to August 29, 2020, no one acquired COVID-19. All 24 air samples and 520 environmental samples collected in the patient area of the CTF were negative for SARS-CoV-2. Patient compliance with mask wearing was 100%.

With appropriate infection control measures, zero environmental contamination and nosocomial transmission of SARS-CoV-2 to HCWs and cleaning staff was achieved.

To characterize postextraction antibiotic prescribing patterns, predictors for antibiotic prescribing and the incidence of and risk factors for postextraction oral infection.

Retrospective analysis of a random sample of veterans who received tooth extractions from January 1, 2017 through December 31, 2017.

VA dental clinics.

Overall, 69,610 patients met inclusion criteria, of whom 404 were randomly selected for inclusion. Adjunctive antibiotics were prescribed to 154 patients (38.1%).

Patients who received or did not receive an antibiotic were compared for the occurrence of postextraction infection as documented in the electronic health record. Multivariable logistic regression was performed to identify factors associated with antibiotic receipt.

There was no difference in the frequency of postextraction oral infection identified among patients who did and did not receive antibiotics (4.5% vs 3.2%; P = .59). Risk factors for postextraction infection could not be identified due to the low frequency of this outcome. Patients who received antibiotics were more likely to have a greater number of teeth extracted (aOR, 1.10; 95% CI, 1.03–1.18), documentation of acute infection at time of extraction (aOR, 3.02; 95% CI, 1.57–5.82), molar extraction (aOR, 1.78; 95% CI, 1.10–2.86) and extraction performed by an oral maxillofacial surgeon (aOR, 2.29; 95% CI, 1.44–3.58) or specialty dentist (aOR, 5.77; 95% CI, 2.05–16.19).

Infectious complications occurred at a low incidence among veterans undergoing tooth extraction who did and did not receive postextraction antibiotics. These results suggest that antibiotics have a limited role in preventing postprocedural infection; however, future studies are necessary to more clearly define the role of antibiotics for this indication.

Evaluate changes in antimicrobial use during COVID-19 and after implementation of a multispecialty COVID-19 clinical guidance team compared to pre–COVID-19 antimicrobial use.

Retrospective observational study.

Tertiary-care academic medical center.

Internal medicine and medical intensive care unit (MICU) provider teams and hospitalized COVID-19 patients.

Difference-in-differences analyses of antibiotic days of therapy per 1,000 patient days present (DOT) for internal medicine and MICU teams treating COVID-19 patients versus teams that did not were performed for 3 periods: before COVID-19, initial COVID-19 period, and after implementation of a multispecialty COVID-19 clinical guidance team which included daily, patient-specific antimicrobial stewardship recommendations. Patient characteristics associated with antibiotic DOT were evaluated using multivariable Poisson regression.

In the initial COVID-19 period, compared to the pre–COVID-19 period, internal medicine and MICU teams increased weekly antimicrobial use by 145.3 DOT (95% CI, 35.1–255.5) and 204.0 DOT (95% CI, −16.9 to 424.8), respectively, compared to non–COVID-19 teams. In the intervention period, internal medicine and MICU COVID-19 teams both had significant weekly decreases of 362.3 DOT (95% CI, −443.3 to −281.2) and 226.3 DOT (95% CI, −381.2 to –71.3). Of 131 patients hospitalized with COVID-19, 86 (65.6%) received antibiotics; no specific patient factors were significantly associated with an expected change in antibiotic days.

Antimicrobial use initially increased for COVID-19 patient care teams compared to pre–COVID-19 levels but significantly decreased after implementation of a multispecialty clinical guidance team, which may be an effective strategy to reduce unnecessary antimicrobial use.

To describe the pattern of transmission of severe acute respiratory coronavirus virus 2 (SARS-CoV-2) during 2 nosocomial outbreaks of coronavirus disease 2019 (COVID-19) with regard to the possibility of airborne transmission.

Contact investigations with active case finding were used to assess the pattern of spread from 2 COVID-19 index patients.

A community hospital and university medical center in the United States, in February and March, 2020, early in the COVID-19 pandemic.

Two index patients and 421 exposed healthcare workers.

Exposed healthcare workers (HCWs) were identified by analyzing the electronic medical record (EMR) and conducting active case finding in combination with structured interviews. Healthcare coworkers (HCWs) were tested for COVID-19 by obtaining oropharyngeal/nasopharyngeal specimens, and RT-PCR testing was used to detect SARS-CoV-2.

Two separate index patients were admitted in February and March 2020, without initial suspicion for COVID-19 and without contact or droplet precautions in place; both patients underwent several aerosol-generating procedures in this context. In total, 421 HCWs were exposed in total, and the results of the case contact investigations identified 8 secondary infections in HCWs. In all 8 cases, the HCWs had close contact with the index patients without sufficient personal protective equipment. Importantly, despite multiple aerosol-generating procedures, there was no evidence of airborne transmission.

These observations suggest that, at least in a healthcare setting, most SARS-CoV-2 transmission is likely to take place during close contact with infected patients through respiratory droplets, rather than by long-distance airborne transmission.

The seroprevalence of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) IgG antibody was evaluated among employees of a Veterans Affairs healthcare system to assess potential risk factors for transmission and infection.

All employees were invited to participate in a questionnaire and serological survey to detect antibodies to SARS-CoV-2 as part of a facility-wide quality improvement and infection prevention initiative regardless of clinical or nonclinical duties. The initiative was conducted from June 8 to July 8, 2020.

Of the 2,900 employees, 51% participated in the study, revealing a positive SARS-CoV-2 seroprevalence of 4.9% (72 of 1,476; 95% CI, 3.8%–6.1%). There were no statistically significant differences in the presence of antibody based on gender, age, frontline worker status, job title, performance of aerosol-generating procedures, or exposure to known patients with coronavirus infectious disease 2019 (COVID-19) within the hospital. Employees who reported exposure to a known COVID-19 case outside work had a significantly higher seroprevalence at 14.8% (23 of 155) compared to those who did not 3.7% (48 of 1,296; OR, 4.53; 95% CI, 2.67–7.68; P < .0001). Notably, 29% of seropositive employees reported no history of symptoms for SARS-CoV-2 infection.

The seroprevalence of SARS-CoV-2 among employees was not significantly different among those who provided direct patient care and those who did not, suggesting that facility-wide infection control measures were effective. Employees who reported direct personal contact with COVID-19–positive persons outside work were more likely to have SARS-CoV-2 antibodies. Employee exposure to SARS-CoV-2 outside work may introduce infection into hospitals.

We report our experience with an emergency room (ER) shutdown related to an accidental exposure to a patient with coronavirus disease 2019 (COVID-19) who had not been isolated.

A 635-bed, tertiary-care hospital in Daegu, South Korea.

To prevent nosocomial transmission of the disease, we subsequently isolated patients with suspected symptoms, relevant radiographic findings, or epidemiology. Severe acute respiratory coronavirus 2 (SARS-CoV-2) reverse-transcriptase polymerase chain reaction assays (RT-PCR) were performed for most patients requiring hospitalization. A universal mask policy and comprehensive use of personal protective equipment (PPE) were implemented. We analyzed effects of these interventions.

From the pre-shutdown period (February 10–25, 2020) to the post-shutdown period (February 28 to March 16, 2020), the mean hourly turnaround time decreased from 23:31 ±6:43 hours to 9:27 ±3:41 hours (P < .001). As a result, the proportion of the patients tested increased from 5.8% (N=1,037) to 64.6% (N=690) (P < .001) and the average number of tests per day increased from 3.8±4.3 to 24.7±5.0 (P < .001). All 23 patients with COVID-19 in the post-shutdown period were isolated in the ER without any problematic accidental exposure or nosocomial transmission. After the shutdown, several metrics increased. The median duration of stay in the ER among hospitalized patients increased from 4:30 hours (interquartile range [IQR], 2:17–9:48) to 14:33 hours (IQR, 6:55–24:50) (P < .001). Rates of intensive care unit admissions increased from 1.4% to 2.9% (P = .023), and mortality increased from 0.9% to 3.0% (P = .001).

Problematic accidental exposure and nosocomial transmission of COVID-19 can be successfully prevented through active isolation and surveillance policies and comprehensive PPE use despite longer ER stays and the presence of more severely ill patients during a severe COVID-19 outbreak.

The Tennessee Department of Health (TDH) investigated a hepatitis A virus (HAV) outbreak to identify risk factors for infection and make prevention recommendations.

Case series.

Community hospital.

Healthcare workers (HCWs) or patients with laboratory-confirmed acute HAV infection during October 1, 2018–January 10, 2019.

HCWs with suspected or confirmed hepatitis A infections were interviewed to assess their exposures and activities. Patient medical records and hospital administrative records were reviewed to identify common exposures. We conducted a site investigation to assess knowledge of infection control practices among HCWs. Serum specimens from ill persons were tested for HAV RNA by polymerase chain reaction (PCR) and genotyped.

We identified 6 HCWs and 2 patients with laboratory-confirmed HAV infection. All cases likely resulted from exposure to a homeless patient with a history of recreational substance use and undiagnosed HAV infection. Breaches in hand hygiene and use of standard precautions were identified. HAV RNA was detected in 7 serum specimens and all belonged to an identical strain of HAV genotype 1b.

A hepatitis A outbreak among hospital patients and HCWs resulted from exposure to a single patient with undiagnosed HAV infection. Breakdowns in infection control practices contributed to the outbreak. The likelihood of nosocomial transmission can be reduced with proper hand hygiene, standard precautions, and routine disinfection. During community outbreaks, medical providers can better prevent ongoing transmission by including hepatitis A in the differential diagnosis among patients with a history of recreational substance use and homelessness.

To assess influenza symptoms, adherence to mask use recommendations, absenteesm and presenteeism in acute care healthcare workers (HCWs) during influenza epidemics.

The TransFLUas influenza transmission study in acute healthcare prospectively followed HCWs prospectively over 2 consecutive influenza seasons. Symptom diaries asking for respiratory symptoms and adherence with mask use recommendations were recorded on a daily basis, and study participants provided midturbinate nasal swabs for influenza testing.

In total, 152 HCWs (65.8% nurses and 13.2% physicians) were included: 89.1% of study participants reported at least 1 influenza symptom during their study season and 77.8% suffered from respiratory symptoms. Also, 28.3% of HCW missed at least 1 working day during the study period: 82.6% of these days were missed because of symptoms of influenza illness. Of all participating HCWs, 67.9% worked with symptoms of influenza infection on 8.8% of study days. On 0.3% of study days, symptomatic HCWs were shedding influenza virus while at work. Among HCWs with respiratory symptoms, 74.1% adhered to the policy to wear a mask at work on 59.1% of days with respiratory symptoms.

Respiratory disease is frequent among HCWs and imposes a significant economic burden on hospitals due to the number of working days lost. Presenteesm with respiratory illness, including influenza, is also frequent and poses a risk for patients and staff.

NCT02478905 (clinicaltrials.gov)

We quantitatively assessed the fit failure rate of N95 respirators according to the number of donning/doffing and hours worn.

Experimental study.

A tertiary-care referral center in South Korea.

In total, 10 infection control practitioners participated in the fit test.

The first experiment comprised 4 consecutive 1-hour donnings and fit tests between each donning. The second experiment comprised 2 consecutive 3-hour donnings and fit tests between each donning. The final experiment comprised fit tests after an 1-hour donning or a 2-hour donning.

For 1-hour donnings, 60%, 70%, and 90% of the participants had fit failures after 2, 3, and 4 consecutive donnings, respectively. For 3-hour donnings, 50% had fit failure after the first donning and 70% had failures after 2 consecutive donnings. All participants passed the fit test after refitting whenever fit failure occurred. The final experiment showed that 50% had fit failure after a single use of 1 hour, and 30% had fit failure after a single use of 2 hours.

High fit-failure rates were recorded after repeated donning and extended use of N95 respirators. Caution is needed for reuse (≥1 time) and extended use (≥1 hour) of N95 respirators in high-risk settings such as those involving aerosol-generating procedures. Although adequate refitting may recover the fit factor, the use of clean gloves and strict hand hygiene afterward should be ensured when touching the outer surfaces of N95 respirators for refitting.

Current COVID-19 guidelines recommend symptom-based screening and regular nasopharyngeal (NP) testing for healthcare personnel in high-risk settings. We sought to estimate case detection percentages with various routine NP and saliva testing frequencies.

Simulation modeling study.

We constructed a sensitivity function based on the average infectiousness profile of symptomatic coronavirus disease 2019 (COVID-19) cases to determine the probability of being identified at the time of testing. This function was fitted to reported data on the percent positivity of symptomatic COVID-19 patients using NP testing. We then simulated a routine testing program with different NP and saliva testing frequencies to determine case detection percentages during the infectious period, as well as the presymptomatic stage.

Routine biweekly NP testing, once every 2 weeks, identified an average of 90.7% (SD, 0.18) of cases during the infectious period and 19.7% (SD, 0.98) during the presymptomatic stage. With a weekly NP testing frequency, the corresponding case detection percentages were 95.9% (SD, 0.18) and 32.9% (SD, 1.23), respectively. A 5-day saliva testing schedule had a similar case detection percentage as weekly NP testing during the infectious period, but identified ~10% more cases (mean, 42.5%; SD, 1.10) during the presymptomatic stage.

Our findings highlight the utility of routine noninvasive saliva testing for frontline healthcare workers to protect vulnerable patient populations. A 5-day saliva testing schedule should be considered to help identify silent infections and prevent outbreaks in nursing homes and healthcare facilities.

The risk of environmental contamination by severe acute respiratory coronavirus virus 2 (SARS-CoV-2) in the intensive care unit (ICU) is unclear. We evaluated the extent of environmental contamination in the ICU and correlated this with patient and disease factors, including the impact of different ventilatory modalities.

In this observational study, surface environmental samples collected from ICU patient rooms and common areas were tested for SARS-CoV-2 by polymerase chain reaction (PCR). Select samples from the common area were tested by cell culture. Clinical data were collected and correlated to the presence of environmental contamination. Results were compared to historical data from a previous study in general wards.

In total, 200 samples from 20 patient rooms and 75 samples from common areas and the staff pantry were tested. The results showed that 14 rooms had at least 1 site contaminated, with an overall contamination rate of 14% (28 of 200 samples). Environmental contamination was not associated with day of illness, ventilatory mode, aerosol-generating procedures, or viral load. The frequency of environmental contamination was lower in the ICU than in general ward rooms. Eight samples from the common area were positive, though all were negative on cell culture.

Environmental contamination in the ICU was lower than in the general wards. The use of mechanical ventilation or high-flow nasal oxygen was not associated with greater surface contamination, supporting their use and safety from an infection control perspective. Transmission risk via environmental surfaces in the ICUs is likely to be low. Nonetheless, infection control practices should be strictly reinforced, and transmission risk via droplet or airborne spread remains.

The relation between type of ventilation used in the operating room and surgical site infection has drawn considerable attention with its conflicting results. A possible relationship between the type of ventilation used in the operating room and surgical site infection has been reported. This meta-analysis was performed to evaluate this relationship.

A systematic literature search up to May 2020 identified 14 studies with 590,121 operations, 328,183 operations of which were performed under laminar airflow ventilation and 261,938 of which were performed operations under conventional ventilation. These articles reported relationships between type of operating-room ventilation with its different categories and surgical site infection: 10 studies were related to surgical site infection in the total hip replacement; 7 studies in total knee arthroplasties; and 3 studies in different abdominal and open vascular surgery. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated comparing surgical site infection prevalence and type of operating room ventilation using the dichotomous method with a random-effects or fixed-effects model.

No significant difference was found between operation performed under laminar airflow ventilation and conventional ventilation in total hip replacement (OR, 1.23; 95% CI, 0.97–1.56, P = .09), in total knee arthroplasties (OR, 1.14; 95% CI, 0.62–2.09; P = .67), and in different abdominal and open vascular surgery (OR, 0.75; 95% CI, 0.43-1.33; P = .33). The impact of the type of operating room ventilation may have no influence on surgical site infection as a tool for decreasing its occurrence.

Based on this meta-analysis, operating under laminar airflow or conventional ventilation may have no independent relationship with the risk of surgical site infection. This relationship forces us not to recommend the use of laminar airflow ventilation because it has a much higher cost compared to conventional ventilation.

To develop a pediatric research agenda focused on pediatric healthcare-associated infections and antimicrobial stewardship topics that will yield the highest impact on child health.

The study included 26 geographically diverse adult and pediatric infectious diseases clinicians with expertise in healthcare-associated infection prevention and/or antimicrobial stewardship (topic identification and ranking of priorities), as well as members of the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention (topic identification).

Using a modified Delphi approach, expert recommendations were generated through an iterative process for identifying pediatric research priorities in healthcare associated infection prevention and antimicrobial stewardship. The multistep, 7-month process included a literature review, interactive teleconferences, web-based surveys, and 2 in-person meetings.

A final list of 12 high-priority research topics were generated in the 2 domains. High-priority healthcare-associated infection topics included judicious testing for Clostridioides difficile infection, chlorhexidine (CHG) bathing, measuring and preventing hospital-onset bloodstream infection rates, surgical site infection prevention, surveillance and prevention of multidrug resistant gram-negative rod infections. Antimicrobial stewardship topics included β-lactam allergy de-labeling, judicious use of perioperative antibiotics, intravenous to oral conversion of antimicrobial therapy, developing a patient-level “harm index” for antibiotic exposure, and benchmarking and or peer comparison of antibiotic use for common inpatient conditions.

We identified 6 healthcare-associated infection topics and 6 antimicrobial stewardship topics as potentially high-impact targets for pediatric research.

The hands of healthcare personnel are the most important source for transmission of healthcare-associated pathogens. The role of contaminated fomites such as portable equipment, stethoscopes, and clothing of personnel in pathogen transmission is unclear.

To study routes of transmission of cauliflower mosaic virus DNA markers from 31 source patients and from environmental surfaces in their rooms.

A 3-month observational cohort study.

A Veterans’ Affairs hospital.

After providing care for source patients, healthcare personnel were observed during interactions with subsequent patients. Putative routes of transmission were identified based on recovery of DNA markers from sites of contact with the patient or environment. To assess plausibility of fomite-mediated transmission, we assessed the frequency of transfer of methicillin-resistant Staphylococcus aureus (MRSA) from the skin of 25 colonized patients via gloved hands versus fomites.

Of 145 interactions involving contact with patients and/or the environment, 41 (28.3%) resulted in transfer of 1 or both DNA markers to the patient and/or the environment. The DNA marker applied to patients’ skin and clothing was transferred most frequently by stethoscopes, hands, and portable equipment, whereas the marker applied to environmental surfaces was transferred only by hands and clothing. The percentages of MRSA transfer from the skin of colonized patients via gloved hands, stethoscope diaphragms, and clothing were 52%, 40%, and 48%, respectively.

Fomites such as stethoscopes, clothing, and portable equipment may be underappreciated sources of pathogen transmission. Simple interventions such as decontamination of fomites between patients could reduce the risk for transmission.

Viruses are more common than bacteria in patients hospitalized with community-acquired pneumonia. Little is known, however, about the frequency of respiratory viral testing and its associations with antimicrobial utilization.

Retrospective cohort study.

The study included 179 US hospitals.

Adults admitted with pneumonia between July 2010 and June 2015.

We assessed the frequency of respiratory virus testing and compared antimicrobial utilization, mortality, length of stay, and costs between tested versus untested patients, and between virus-positive versus virus-negative patients.

Among 166,273 patients with pneumonia on admission, 40,787 patients (24.5%) were tested for respiratory viruses, 94.8% were tested for influenza, and 20.7% were tested for other viruses. Viral assays were positive in 5,133 of 40,787 tested patients (12.6%), typically for influenza and rhinovirus. Tested patients were younger and had fewer comorbidities than untested patients, but patients with positive viral assays were older and had more comorbidities than those with negative assays. Blood cultures were positive for bacterial pathogens in 2.7% of patients with positive viral assays versus 5.3% of patients with negative viral tests (P < .001). Antibacterial courses were shorter for virus-positive versus -negative patients overall (mean 5.5 vs 6.4 days; P < .001) but varied by bacterial testing: 8.1 versus 8.0 days (P = .60) if bacterial tests were positive; 5.3 versus 6.1 days (P < .001) if bacterial tests were negative; and 3.3 versus 5.2 days (P < .001) if bacterial tests were not obtained (interaction P < .001).

A minority of patients hospitalized with pneumonia were tested for respiratory viruses; only a fraction of potential viral pathogens were assayed; and patients with positive viral tests often received long antibacterial courses.

To determine whether a multifaceted approach effectively influenced antibiotic use in an orthopedics department.

Retrospective cohort study comparing the readmission rate and antibiotic use before and after an intervention.

A 1,000-bed, tertiary-care, university hospital.

Adult patients admitted to the orthopedics department between January 2015 and December 2018.

During the preintervention period (2015–2016), 1 general orthopedic department was in operation. In the postintervention period (2017–2018), 2 separate departments were created: one designated for elective “clean” surgeries and another that included a “complicated wound” unit. A multifaceted strategy including infection prevention measures and introducing antibiotic stewardship practices was implemented. Admission rates, hand hygiene practice compliance, surgical site infections, and antibiotic treatment before versus after the intervention were analyzed.

The number of admissions and hospitalization days in the 2 periods did not change. Seven-day readmissions per annual quarter decreased significantly from the preintervention period (median, 7 days; interquartile range [IQR], 6–9) to the postintervention period (median, 4 days; IQR, 2–7; P = .038). Hand hygiene compliance increased and surgical site infections decreased in the postintervention period. Although total antibiotic use was not reduced, there was a significant change in the breakdown of the different antibiotic classes used before and after the intervention: increased use of narrow-spectrum β-lactams (P < .001) and decreased use of β-lactamase inhibitors (P < .001), third-generation cephalosporins (P = .044), and clindamycin (P < .001).

Restructuring the orthopedics department facilitated better infection prevention measures accompanied by antibiotic stewardship implementation, resulting in a decreased use of broad-spectrum antibiotics and a significant reduction in readmission rates.

To examine rural–urban differences in temporal trends and risk of inappropriate antibiotic use by agent and duration among women with uncomplicated urinary tract infection (UTI).

Observational cohort study.

Using the IBM MarketScan Commercial Database (2010–2015), we identified US commercially insured women aged 18–44 years coded for uncomplicated UTI and prescribed an oral antibiotic agent. We classified antibiotic agents and durations as appropriate versus inappropriate based on clinical guidelines. Rural–urban status was defined by residence in a metropolitan statistical area. We used modified Poisson regression to determine the association between rural–urban status and inappropriate antibiotic receipt, accounting for patient- and provider-level characteristics. We used multivariable logistic regression to estimate trends in antibiotic use by rural–urban status.

Of 670,450 women with uncomplicated UTI, a large proportion received antibiotic prescriptions for inappropriate agents (46.7%) or durations (76.1%). Compared to urban women, rural women were more likely to receive prescriptions with inappropriately long durations (adjusted risk ratio 1.10, 95% CI, 1.10–1.10), which was consistent across subgroups. From 2011 to 2015, there was slight decline in the quarterly proportion of patients who received inappropriate agents (48.5% to 43.7%) and durations (78.3% to 73.4%). Rural–urban differences varied over time by agent (duration outcome only), geographic region, and provider specialty.

Inappropriate antibiotic prescribing is quite common for the treatment of uncomplicated UTI. Rural women are more likely to receive inappropriately long antibiotic durations. Antimicrobial stewardship interventions are needed to improve outpatient UTI antibiotic prescribing and to reduce unnecessary exposure to antibiotics, particularly in rural settings.