Predicting antibiotic resistance in Enterobacterales to support optimal empiric treatment of urinary tract infections in outpatient veterans.

Objective: Bacterial resistance is known to diminish the effectiveness of antibiotics for treatment of urinary tract infections. Review of recent healthcare and antibiotic exposures, as well as prior culture results is recommended to aid in selection of empirical treatment. However, the optimal approach for assessing these data is unclear.

Trends in infection incidence and antimicrobial resistance in the US Veterans Affairs Healthcare System: a nationwide retrospective cohort study (2007-22).

Background: Antimicrobial resistance poses a major threat to public health. There are few comprehensive nationwide studies that quantify long-term trends in infection incidence and antimicrobial resistance for multiple pathogens. We aimed to analyse trends in inpatient infection incidence and antimicrobial resistance for nine pathogens over the past 15 years across the USA.

A Linguistic Analysis Examining the Impact of COVID-19 on Pneumonia Diagnosis and Disease Models.

Written clinical language embodies and reflects the clinician's mental models of disease. Prior to the COVID-19 pandemic, pneumonia was shifting away from concern for healthcare-associated pneumonia and toward recognition of heterogeneity of pathogens and host response. How these models are reflected in clinical language or whether they were impacted by the pandemic has not been studied.

Incidence and Outcomes of Non-Ventilator-Associated Hospital-Acquired Pneumonia in 284 US Hospitals Using Electronic Surveillance Criteria.

Importance: Non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is a common and deadly hospital-acquired infection. However, inconsistent surveillance methods and unclear estimates of attributable mortality challenge prevention.

Objective: To estimate the incidence, variability, outcomes, and population attributable mortality of NV-HAP.

Electronic surveillance criteria for non-ventilator-associated hospital-acquired pneumonia: Assessment of reliability and validity.

Objective: Surveillance of non-ventilator-associated hospital-acquired pneumonia (NV-HAP) is complicated by subjectivity and variability in diagnosing pneumonia. We compared a fully automatable surveillance definition using routine electronic health record data to manual determinations of NV-HAP according to surveillance criteria and clinical diagnoses.

Methods: We retrospectively applied an electronic surveillance definition for NV-HAP to all adults admitted to Veterans' Affairs (VA) hospitals from January 1, 2015, to November 30, 2020.

Hospital admission decisions for older Veterans with community-onset pneumonia: An analysis of 118 U.S. Veterans Affairs Medical Centers.

Objectives: Age is important for prognosis in community-onset pneumonia, but how it influences admission decisions in the emergency department (ED) is not well characterized. Using clinical data from the electronic health record in a national cohort, we examined pneumonia hospitalization patterns, variation, and relationships with mortality among older versus younger Veterans.

Methods: In a retrospective cohort of patients ≥ 18 years presenting to EDs with a diagnosis of pneumonia at 118 VA Medical Centers January 1, 2006, to December 31, 2016, we compared observed, predicted, and residual hospitalization risk for Veterans < 70, 70-79, and ≥ 80 years of age using generalized estimating equations and machine learning models with 71 patient factors.

Development and evaluation of an interoperable natural language processing system for identifying pneumonia across clinical settings of care and institutions.

Objective: To evaluate the feasibility, accuracy, and interoperability of a natural language processing (NLP) system that extracts diagnostic assertions of pneumonia in different clinical notes and institutions.

Materials And Methods: A rule-based NLP system was designed to identify assertions of pneumonia in 3 types of clinical notes from electronic health records (EHRs): emergency department notes, radiology reports, and discharge summaries. The lexicon and classification logic were tailored for each note type.

Implementation and outcomes of a clinician-directed intervention to improve antibiotic prescribing for acute respiratory tract infections within the Veterans' Affairs Healthcare System.

Objective: To determine whether a clinician-directed acute respiratory tract infection (ARI) intervention was associated with improved antibiotic prescribing and patient outcomes across a large US healthcare system.

Design: Multicenter retrospective quasi-experimental analysis of outpatient visits with a diagnosis of uncomplicated ARI over a 7-year period.

Participants: Outpatients with ARI diagnoses: sinusitis, pharyngitis, bronchitis, and unspecified upper respiratory tract infection (URI-NOS).

Trends in Illness Severity, Hospitalization, and Mortality for Community-Onset Pneumonia at 118 US Veterans Affairs Medical Centers.

Background: Deaths from pneumonia were decreasing globally prior to the COVID-19 pandemic, but it is unclear whether this was due to changes in patient populations, illness severity, diagnosis, hospitalization thresholds, or treatment. Using clinical data from the electronic health record among a national cohort of patients initially diagnosed with pneumonia, we examined temporal trends in severity of illness, hospitalization, and short- and long-term deaths.

Design: Retrospective cohort PARTICIPANTS: All patients >18 years presenting to emergency departments (EDs) at 118 VA Medical Centers between 1/1/2006 and 12/31/2016 with an initial clinical diagnosis of pneumonia and confirmed by chest imaging report.

A Veterans' Healthcare Administration (VHA) antibiotic stewardship intervention to improve outpatient antibiotic use for acute respiratory infections: A cost-effectiveness analysis.

Objectives: The provides a framework to improve antibiotic use, but cost-effectiveness data on implementation of outpatient antibiotic stewardship interventions are limited. We evaluated the cost-effectiveness of Core Element implementation in the outpatient setting.

Methods: An economic simulation model from the health-system perspective was developed for patients presenting to outpatient settings with uncomplicated acute respiratory tract infections (ARI).

Comparative effectiveness of amoxicillin versus amoxicillin-clavulanate among adults with acute sinusitis in emergency department and urgent care settings.

Objective: To compare the effectiveness of amoxicillin-clavulanate versus amoxicillin for adults diagnosed with acute sinusitis (AS). A secondary objective compared antibiotic effectiveness in patients meeting risk criteria for treatment failure.

Methods: A retrospective cohort study of adults diagnosed with AS prescribed amoxicillin ± clavulanate within Veterans Affairs emergency departments from 2012-2019 was conducted.

Association Between Contact Precautions and Transmission of Methicillin-Resistant Staphylococcus aureus in Veterans Affairs Hospitals.

Importance: The effectiveness and importance of contact precautions for endemic pathogens has long been debated, and their use has broad implications for infection control of other pathogens.

Objective: To estimate the association between contact precautions and transmission of methicillin-resistant Staphylococcus aureus (MRSA) across US Department of Veterans Affairs (VA) hospitals.

Design, Setting, And Participants: This retrospective cohort study used mathematical models applied to data from a population-based sample of adults hospitalized in 108 VA acute care hospitals for at least 24 hours from January 1, 2008, to December 31, 2017.

Computerized Mortality Prediction for Community-acquired Pneumonia at 117 Veterans Affairs Medical Centers.

Computerized severity assessment for community-acquired pneumonia could improve consistency and reduce clinician burden. To develop and compare 30-day mortality-prediction models using electronic health record data, including a computerized score with all variables from the original Pneumonia Severity Index (PSI) except confusion and pleural effusion ("ePSI score") versus models with additional variables. Among adults with community-acquired pneumonia presenting to emergency departments at 117 Veterans Affairs Medical Centers between January 1, 2006, and December 31, 2016, we compared an ePSI score with 10 novel models employing logistic regression, spline, and machine learning methods using PSI variables, age, sex and 26 physiologic variables as well as all 69 PSI variables.

Antibiotic Use and Presumptive Pathogens in the Veterans Affairs Healthcare System.

Background: Empirical antibiotic use is common in the hospital. Here, we characterize patterns of antibiotic use, infectious diagnoses, and microbiological laboratory results among hospitalized patients and aim to quantify the proportion of antibiotic use that is potentially attributable to specific bacterial pathogens.

Methods: We conducted an observational study using electronic health records from acute care facilities in the US Veterans Affairs Healthcare System.

Simulated Adoption of 2019 Community-Acquired Pneumonia Guidelines Across 114 Veterans Affairs Medical Centers: Estimated Impact on Culturing and Antibiotic Selection in Hospitalized Patients.

Background: The 2019 American Thoracic Society/Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) revised recommendations for culturing and empiric broad-spectrum antibiotics. We simulated guideline adoption in Veterans Affairs (VA) inpatients.

Methods: For all VA acute hospitalizations for CAP from 2006-2016 nationwide, we compared observed with guideline-expected proportions of hospitalizations with initial blood and respiratory cultures obtained, empiric antibiotic therapy with activity against methicillin-resistant Staphylococcus aureus (anti-MRSA) or Pseudomonas aeruginosa (antipseudomonal), empiric "overcoverage" (receipt of anti-MRSA/antipseudomonal therapy without eventual detection of MRSA/P.

Impact of Implementation of the Core Elements of Outpatient Antibiotic Stewardship Within Veterans Health Administration Emergency Departments and Primary Care Clinics on Antibiotic Prescribing and Patient Outcomes.

Background: The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use. We report the impact of core elements implementation within Veterans Health Administration sites.

Methods: In this quasiexperimental controlled study, effects of an intervention targeting antibiotic prescription for uncomplicated acute respiratory tract infections (ARIs) were assessed.

Empirical Anti-MRSA vs Standard Antibiotic Therapy and Risk of 30-Day Mortality in Patients Hospitalized for Pneumonia.

Importance: Use of empirical broad-spectrum antibiotics for pneumonia has increased owing to concern for resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA). The association of empirical anti-MRSA therapy with outcomes among patients with pneumonia is unknown, even for high-risk patients.

Objective: To compare 30-day mortality among patients hospitalized for pneumonia receiving empirical anti-MRSA therapy vs standard empirical antibiotic regimens.

Diagnosis and Antibiotic Management of Otitis Media and Otitis Externa in United States Veterans.

Background: Acute otitis media (AOM) and otitis media with effusion (OME) occur primarily in children, whereas acute otitis externa (AOE) occurs with similar frequency in children and adults. Data on the incidence and management of otitis in adults are limited. This study characterizes the incidence, antibiotic management, and outcomes for adults with otitis diagnoses.

Effectiveness of a multisite personal protective equipment (PPE)-free zone intervention in acute care.

Objective: Determine the effectiveness of a personal protective equipment (PPE)-free zone intervention on healthcare personnel (HCP) entry hand hygiene (HH) and PPE donning compliance in rooms of patients in contact precautions.

Design: Quasi-experimental, multicenter intervention, before-and-after study with concurrent controls.

Setting: All patient rooms on contact precautions on 16 units (5 medical-surgical, 6 intensive care, 5 specialty care units) at 3 acute-care facilities (2 academic medical centers, 1 Veterans Affairs hospital).