Citations

Abstract Background These recommendations provide guidance on the optimal duration of antibiotics in patients with complicated urinary tract infection (cUTI), especially in presence of associated Gram-negative bacteremia. Methods The panel's recommendations are based upon evidence derived from systematic literature reviews which focused on comparative benefits and harms of shorter (5–7 days) vs prolonged (10–14 days) duration of antibiotics, including publications since 2000. These recommendations adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Results The guidelines panel suggests that patients with cUTI who are improving on effective therapy can be treated with shorter duration of antimicrobials (either 5–7 days of a fluoroquinolone or 7 days of a non-fluoroquinolone) rather than longer courses of antibiotics, regardless of the presence of associated Gram-negative bacteremia. An effective antimicrobial agent achieves therapeutic levels in the urine and relevant tissue and is active against the causative pathogen. However, men with febrile UTI in whom acute bacterial prostatitis is suspected may benefit from a longer treatment duration (10–14 days), and a short courses of oral beta lactams may require higher doses for efficacy. Conclusions Shorter durations of antibiotics for cUTI provide similar efficacy as longer courses, except in men with febrile UTI in whom acute bacterial prostatitis is suspected. This recommendation places a high value on antibiotic stewardship considerations as well as reducing the burden of antimicrobial administration from a healthcare perspective and reducing the burden of taking antibiotics from a patient perspective.

Abstract Background These recommendations address the empiric choice of antibiotics in suspected complicated urinary tract infection (cUTI). Issues to balance include the need for appropriate initial empiric antimicrobial therapy, the patient's severity of illness, and antimicrobial stewardship concerns. Methods The panel's recommendations are based upon evidence derived from systematic literature reviews that focused on comparative benefits and harms of classes of antibiotics approved for cUTI, starting with publications from 2008 onwards, and our review of predictors of resistance in uropathogens included references identified since 2000. These recommendations adhere to a standardized methodology for rating the certainty of evidence and strength of recommendation according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. Results The guidelines panel suggests initially selecting among preferred empiric antibiotic choices rather than alternative options, stratified for the patient's severity of illness and antimicrobial stewardship considerations. When choosing among these antibiotics for a specific patient, the guideline panel suggests a 4-step process to account for changing resistance patterns and individualized patient needs. The steps are: (1) assess the severity of illness (for initial prioritization of antibiotics), (2) consider patient-specific risk factors for resistant uropathogens (for optimization of coverage), (3) evaluate other patient-specific considerations (to reduce the risk of adverse events), and (4) for patients with sepsis, consult a relevant local antibiogram if available (to further improve the likelihood of giving appropriate empiric therapy). Lastly, the guideline panel suggests selecting definitive effective therapy with a targeted spectrum based on the result of the urine culture. Conclusions Many of the classes of antibiotics approved to treat cUTI demonstrate similar efficacy as other classes of antibiotics in randomized controlled trials. Bacterial resistance prevalence is always changing, and new antibiotics will be developed. In this context, the guidelines panel provides recommendations for choosing empiric antibiotic therapy for cUTI that will help clinicians decide among available antibiotic options at the point of care.

Abstract Background Hospital discharge summaries are critical for ensuring continuity of care, but their quality often varies. Large language models (LLMs) have the potential to standardize and enhance the efficiency of this documentation process. Objectives To evaluate the quality of hospital discharge summaries created by an LLM‐based hospital course drafting tool created by Epic Systems compared with human‐written summaries. Methods Retrospective study at a single tertiary‐care institution in 2024. The cohort included 100 adult hospitalizations lasting >72 h across medical and surgical dismissing services. No interventions were performed. Summaries (LLM‐generated vs. human‐written) were independently reviewed using a standardized rubric covering nine domains (e.g., comprehensiveness, clarity, relevance). Scores were normalized and compared. Readability was assessed using Flesch Reading Ease. Results LLM‐generated summaries outperformed human‐written summaries across all criteria ( p < .05), with the greatest difference observed in comprehensiveness (LLM median 0.62 vs. human −0.23). Human‐written summaries from surgical services scored lower than those from medical services, but LLM performance was consistent across both. Human summaries had higher Flesch Reading Ease scores (33.11 vs. 26.2; p < .05), reflecting simpler language. Conclusions LLM‐generated summaries demonstrated superior quality, consistency, and clinical utility compared with human‐written summaries, highlighting their potential to improve documentation efficiency and standardization.

Background: Prophylactic antimicrobials for pediatric patients requiring extracorporeal membrane oxygenation (ECMO) support are not well delineated; there are no consistent guidelines nationally or internationally. We analyzed antimicrobial use before and after implementing a narrow-spectra ECMO antimicrobial prophylaxis protocol intended to standardize prophylaxis by risk related to ECMO type and configuration. Methods: This retrospective, single-center study included children under 18 years old requiring ECMO between May 2018 and December 2021. Medical and cardiac surgical patients requiring open-chested (central) or peripheral veno-venous or veno-arterial ECMO were included. We evaluated the impact of an ECMO antimicrobial prophylaxis protocol by comparing the appropriateness of antimicrobial use as well as nosocomial infections in the pre versus post protocol. Results: Our study included 55 children with 58 individual ECMO episodes. More than 50% of the patients were open-chested during ECMO support, and the majority of ECMO support was veno-arterial. In the post protocol period, patients were 4 times as likely to have appropriate antimicrobial prescribing (Odds ratio 4.4; 95% confidence interval: 1.1–19; P = 0.036), including both prophylactic (per protocol) and therapeutic (chart documentation of an infection with appropriate therapeutic antimicrobials, including drug and duration). There was no difference in the odds of nosocomial infection occurring during ECMO pre protocol versus post protocol (pre vs. post protocol, P = 0.71 for invasive infections, P = 0.73 for all infections including potential colonization). Conclusions: After implementation of a standardized narrow-spectra ECMO antimicrobial prophylaxis protocol, we observed an increase in appropriate and standardized antimicrobial prescribing without concomitant increase in nosocomial infections.

ABSTRACT Clinical and Laboratory Standards Institute (CLSI) recommends a blood culture contamination (BCC) threshold of <3%, with ≤1% considered optimal. However, there is not a standardized definition of BCC, and the effect of multiple definitions on BCC rates or what definitions laboratories use remain unknown. We surveyed 52 hospitals and analyzed 362,078 blood cultures (BCx) collected 1 September 2019 to 31 August 2021 from 62 intensive care units (ICUs) and 231 wards from 48 of these hospitals. We calculated and compared BCC rates using the College of American Pathologists (CAP) or CLSI criteria (both utilize a limited number of skin commensals to define BCC) and the comprehensive National Healthcare Safety Network (NHSN) commensal list. We characterized factors associated with BCC and related outcomes (central-line associated bloodstream infection [CLABSI] and vancomycin use). BCC, BCx positivity, and single BCx rates were monitored by 100%, 39%, and 21% of hospitals, respectively. Hospitals used CAP (65%), CLSI (17%), and NHSN (17%) criteria to define BCC. Mean BCC rate by CAP (CAP-BCC) was 1.38% for ICUs and 0.96% for wards. BCC rates remained similar by CLSI criteria but increased when using NHSN list. Sharing BCC data outside of the laboratory, measuring additional BCx quality indicators, and limiting central catheter-drawn BCx were associated with lower BCC rates. BCC was associated with higher CLABSI rates in ICUs. This study demonstrated variability in laboratory practices and opportunities to optimize BCx stewardship. IMPORTANCE Blood culture contamination (BCC) is associated with patient harm and unnecessary use of healthcare resources. BCC thresholds have been established; however, multiple BCC definitions exist. There is limited data on how BCC rates differ depending on the BCC definition used, what definitions laboratories most commonly use, or their approach to other blood cultures (BCx) quality indicators such as single rates or BCx positivity. A cross-sectional multicenter survey and analysis of BCx data from intensive care unit and wards revealed that most laboratories did not track single BCx or BCx positivity rates and that there was variability in how BCC was defined. Additionally, BCC rates were influenced by the definition used. BCC was associated with increased central-line associated bloodstream infection rates.

Abstract Background We examined how the COVID-19 pandemic influenced influenza vaccination, healthcare engagement, and patient satisfaction. Methods We retrospectively analyzed influenza vaccination records and patient experience surveys of adult primary care patients in southeastern Minnesota during two 3-year phases: Prepandemic (1 January 2017–28 February 2020) and Pandemic-Plus (1 March 2020–31 December 2023). Vaccination status was defined as “always vaccinated” (AV), “never vaccinated” (NV), or “intermittently vaccinated” (IV) for seasonal influenza. Results During the Pandemic-Plus phase, 7.0% (n = 3556) of the Prepandemic AV and 48.7% (n = 16 710) of the Prepandemic IV patients never received another influenza vaccine. Compared to AV, IV and NV patients were more likely to reside in areas with greater socioeconomic deprivation (odds ratio [OR], 1.58 [95% confidence interval {CI}, 1.53–1.62] and 1.99 [1.94–2.05], respectively), have a high school education or less (2.86 [2.74–2.98] and 3.38 [3.23–3.53]), and report healthcare disengagement (1.59 [1.55–1.64] and 4.21 [4.09–4.33]). After adjusting for Area Deprivation Index and medical comorbidities, healthcare disengagement increased among the NV versus AV between phases (3.33 [3.24–3.41] and 4.23 [4.10–4.35]). In a subgroup analysis those with severe comorbidities were less likely AV (NV vs AV: 1.21 [1.14–1.27]) and more dissatisfied with care (NV vs AV: 1.25 [1.18–1.33]). Conclusions The COVID-19 pandemic altered vaccination behaviors and healthcare satisfaction, especially among those at high risk of developing influenza-related complications. Medical providers and public health officials should be aware of factors associated with vaccine refusal to better target interventions.

Background Electronic health records (EHRs) serve as a critical tool for clinical documentation, yet their complexity has raised concerns about readability and usability for healthcare providers and patients. Readability scores, such as the Flesch-Kincaid (FK) Grade Level, offer a quantitative method to assess documentation clarity. In this study, the authors evaluated the impact of an EHR transition on the readability of clinical notes across multiple medical specialties. Methods All clinical notes recorded between 2016 and 2019 at a large healthcare organization were evaluated across specialties. The organization transitioned EHR systems during the study period, in May 2018. FK Grade Level scores were calculated for each clinical consultation note and stratified by specialty and EHR. Results Across 10 medical specialties, 630,246 clinical notes were evaluated. The median FK grade levels from notes composed in the new EHR were similar to those composed in the previous EHR (8.228 vs 8.240; p=0.58). The variation in FK grade level as measured by standard deviation was lower in the new EHR compared with the old EHR (1.405 vs 1.764; p <0.01). Conclusions Calculation of FK grade level of clinical notes is a feasible method to assess clinical note readability. Study results showed that clinical documentation readability may not be strongly associated with underlying EHR. Migrating to a new EHR alone should not be expected to improve readability of clinical notes.

Abstract Objectives To compare the efficacy and safety of antibiotic lock therapy (ALT) versus catheter removal in managing central vascular catheter–associated bloodstream infection (CVC-BSI). Methods We conducted a single-centre, retrospective cohort study of adult patients treated with ALT or catheter removal for management of CVC-BSI between 2018 and 2022. The primary outcome was a composite of 90 day microbiological relapse or recurrent BSI. Secondary outcomes included 30 day mortality, CVC-associated complications and Clostridioides difficile infection (CDI). Logistic regression with propensity score-adjustment was used to evaluate differences in outcomes and identify predictors of relapse. Results During the study period, 106 participants received ALT and 181 underwent catheter removal. Patients treated with ALT received shorter courses of systemic antimicrobials (11 versus 14 days; P &lt; 0.001) and had shorter hospital stays (4 versus 10 days; P &lt; 0.001). Median duration of catheter salvage in patients receiving ALT was 28 days (IQR 7–80). Primary composite outcome was similar between both groups, but ALT was associated with a significantly higher risk of microbiological relapse within 90 days (20% versus 7%; adjusted odds ratio 3.93, 95% CI 1.64–9.40; P = 0.002). No significant difference in 30 day mortality, CVC-related complications or CDI was observed. CoNS BSI was an independent predictor of microbiological relapse in patients treated with ALT (OR 2.28; P = 0.05). Conclusions Although ALT offers a non-invasive catheter salvage strategy, its association with higher relapse rates, particularly in CoNS BSI, suggests catheter removal should remain the preferred approach when feasible. ALT could be considered a short-term catheter salvage strategy for pathogens with low virulence when used with close surveillance.

Abstract Objective: Patients with Opioid Use Disorder (OUD) are prone to Multidrug-Resistant Organism (MDRO) colonization and infections, thus at risk for worse outcomes during critical illness. Understanding the prevalence and predictors of MDRO infections is essential to optimize interventions and treatments. Design: Retrospective cohort study. Methods: The study evaluated the prevalence of MDRO isolation among adults with OUD admitted to an intensive care unit (ICU) between January 1, 2018, and July 31, 2023. It included adults admitted to an ICU with bacterial infections and positive cultures obtained within 48 hours of admission. Demographics, clinical traits, and MDRO isolation rates were analyzed using descriptive statistics, univariate methods, and Least Absolute Shrinkage and Selection Operator (LASSO) regression. Results: MDRO isolation occurred in 178 of 790 patients (22.5%), with methicillin-resistant Staphylococcus aureus as the most frequently isolated organism. LASSO regression identified housing insecurity (OR: 1.79, 95% CI 1.09–2.93, P = .022), no receipt of medications for OUD treatment (OR: 1.56, 95% CI 1.06–2.29, P = .023), positive hepatitis C virus (HCV) status (OR: 2.19, 95% CI 1.19–4.03, P = .012), and intravenous antibiotic use in the prior 90 days (OR: 1.04 per 24 h, 95% CI 1.01–1.07, P = .007) as significant predictors of MDRO isolation. Conclusions: The study highlights a high prevalence of MDRO isolation in critically ill OUD patients admitted for infection-related issues with positive cultures obtained within 48 hours of admission, influenced by factors like housing insecurity, no receipt of medications for OUD treatment, HCV status, and prior antibiotic use.