Discharge Diagnosis Of Pneumonia Research Articles

Timing of influenza antiviral therapy and risk of death in adults hospitalized with influenza-associated pneumonia, FluSurv-NET, 2012-2019.

Pneumonia is common in adults hospitalized with laboratory-confirmed influenza, but the association between timeliness of influenza antiviral treatment and severe clinical outcomes in patients with influenza-associated pneumonia is not well characterized. We included adults aged ≥18 years hospitalized with laboratory-confirmed influenza and a discharge diagnosis of pneumonia over 7 influenza seasons (2012-2019) sampled from a multi-state population-based surveillance network. We evaluated 3 treatment groups based on timing of influenza antiviral initiation relative to admission date (day 0, day 1, days 2-5). Baseline characteristics and clinical outcomes were compared across groups using unweighted counts and weighted percentages accounting for the complex survey design. Logistic regression models were generated to evaluate the association between delayed treatment and 30-day all-cause mortality. 26,233 adults were sampled in the analysis. Median age was 71 years and most (92.2%) had ≥1 non-immunocompromising condition. Overall, 60.9% started antiviral treatment on day 0, 29.5% on day 1, and 9.7% on days 2-5 (median 2 days). Baseline characteristics were similar across groups. Thirty-day mortality occurred in 7.5%, 8.5%, and 10.2% of patients who started treatment on day 0, day 1, and days 2-5, respectively. Compared to those treated on day 0, adjusted OR for death was 1.14 (95%CI: 1.01-1.27) in those starting treatment on day 1 and 1.40 (95%CI: 1.17-1.66) in those starting on days 2-5. Delayed initiation of antiviral treatment in patients hospitalized with influenza-associated pneumonia was associated with higher risk of death, highlighting the importance of timely initiation of antiviral treatment at admission.

Patient and Epidemiological Factors Associated With Influenza Testing in Hospitalized Adults With Acute Respiratory Illnesses, 2016-2017 to 2019-2020.

Data are limited on influenza testing among adults with acute respiratory illness (ARI)-associated hospitalizations. We identified factors associated with influenza testing in adult ARI-associated hospitalizations across the 2016-2017 through 2019-2020 influenza seasons. Using data from 4 health systems in the United States, we identified hospitalizations that had an ARI discharge diagnosis or respiratory virus test. A hospitalization with influenza testing was based on testing performed within 14 days before through 72 hours after admission. We used random forest analysis to identify patient characteristics and influenza activity indicators that were most important in terms of their relationship to influenza testing. Across 4 seasons, testing rates ranged from 14.8%-19.4% at 3 pooled sites and 60.1%-78.5% at a fourth site with different testing practices. Discharge diagnoses of pneumonia or infectious disease of noninfluenza etiology, presence of ARI signs/symptoms, hospital admission month, and influenza-like illness activity level were consistently among the variables with the greatest relative importance. Select ARI diagnoses and indicators of influenza activity were the most important factors associated with influenza testing among ARI-associated hospitalizations. Improved understanding of which patients are tested may enhance influenza burden estimates and allow for more timely clinical management of influenza-associated hospitalizations.

The development of a novel natural language processing tool to identify pediatric chest radiograph reports with pneumonia.

Chest radiographs are frequently used to diagnose community-acquired pneumonia (CAP) for children in the acute care setting. Natural language processing (NLP)-based tools may be incorporated into the electronic health record and combined with other clinical data to develop meaningful clinical decision support tools for this common pediatric infection. We sought to develop and internally validate NLP algorithms to identify pediatric chest radiograph (CXR) reports with pneumonia. We performed a retrospective study of encounters for patients from six pediatric hospitals over a 3-year period. We utilized six NLP techniques: word embedding, support vector machines, extreme gradient boosting (XGBoost), light gradient boosting machines Naïve Bayes and logistic regression. We evaluated their performance of each model from a validation sample of 1,350 chest radiographs developed as a stratified random sample of 35% admitted and 65% discharged patients when both using expert consensus and diagnosis codes. Of 172,662 encounters in the derivation sample, 15.6% had a discharge diagnosis of pneumonia in a primary or secondary position. The median patient age in the derivation sample was 3.7 years (interquartile range, 1.4-9.5 years). In the validation sample, 185/1350 (13.8%) and 205/1350 (15.3%) were classified as pneumonia by content experts and by diagnosis codes, respectively. Compared to content experts, Naïve Bayes had the highest sensitivity (93.5%) and XGBoost had the highest F1 score (72.4). Compared to a diagnosis code of pneumonia, the highest sensitivity was again with the Naïve Bayes (80.1%), and the highest F1 score was with the support vector machine (53.0%). NLP algorithms can accurately identify pediatric pneumonia from radiography reports. Following external validation and implementation into the electronic health record, these algorithms can facilitate clinical decision support and inform large database research.

Predictors of short- and long-term mortality in critically ill, older adults admitted to the emergency department: an observational study

BackgroundIn the future, we can expect an increase in older patients in emergency departments (ED) and acute wards. The main purpose of this study was to identify predictors of short- and long-term mortality in the ED and at hospital discharge.MethodsThis is a retrospective, observational, single-center, cohort study, involving critically ill older adults, recruited consecutively in an ED. The primary outcome was mortality. All patients were followed for 6.5–7.5 years. The Cox proportional hazards model was used.ResultsRegarding all critically ill patients aged ≥ 70 years and identified in the ED (n = 402), there was a significant association between mortality at 30 days after ED admission and unconsciousness on admission (HR 3.14, 95% CI 2.09–4.74), hypoxia on admission (HR 2.51, 95% CI 1.69–3.74) and age (HR 1.06 per year, 95% CI 1.03–1.09), (all p < 0.001).Of 402 critically ill patients aged ≥ 70 years and identified in the ED, 303 were discharged alive from hospital. There was a significant association between long-term mortality and the Charlson Comorbidity Index (CCI) > 2 (HR 1.90, 95% CI 1.46–2.48), length of stay (LOS) > 7 days (HR 1.72, 95% CI 1.32–2.23), discharge diagnosis of pneumonia (HR 1.65, 95% CI 1.24–2.21) and age (HR 1.08 per year, 95% CI 1.05–1.10), (all p < 0.001). The only symptom or vital sign associated with long-term mortality was hypoxia on admission (HR 1.70, 05% CI 1.30–2.22).ConclusionsAmong critically ill older adults admitted to an ED and discharged alive the following factors were predictive of long-term mortality: CCI > 2, LOS > 7 days, hypoxia on admission, discharge diagnosis of pneumonia and age. The following factors were predictive of mortality at 30 days after ED admission: unconsciousness on admission, hypoxia and age. These data might be clinically relevant when it comes to individualized care planning, which should take account of risk prediction and estimated prognosis.

Effectiveness of Beta-Lactam plus Doxycycline for Patients Hospitalized with Community-Acquired Pneumonia.

Despite clinical practice guideline recommendations to use doxycycline as part of combination therapy for some patients hospitalized with pneumonia, there is minimal evidence supporting this recommendation. Our aim was to examine the association between beta-lactam plus doxycycline and mortality for patients hospitalized with community-acquired pneumonia. We identified patients >65 years of age admitted to any US Department of Veterans Affairs hospital in fiscal years 2002-2012 with a discharge diagnosis of pneumonia. We excluded those patients who did not receive antibiotic therapy concordant with the 2019 American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) clinical practice guidelines. Using propensity score matching, we examined the association of doxycycline with 30- and 90-day mortality. Our overall cohort was comprised of 70533 patients and 5282 (7.49%) received doxycycline. Unadjusted 30-day mortality was 6.4% for those who received a beta-lactam plus doxycycline versus 9.1% in those who did not (P < .0001), and 90-day mortality was 13.8% for those who received a beta-lactam + doxycycline versus 16.8% for those who did not (P < .0001). In the propensity score matched models, both 30- (odds ratio 0.72, 95% confidence interval [CI], .63-.84) and 90-day (0.83, 95% CI, .74-.92) mortality were significantly lower for those who received doxycycline. In this retrospective observational cohort study, we found that doxycycline use, as part of guideline-concordant antibiotic therapy, was associated with lower 30- and 90-day mortality than regimens without doxycycline. While this supports the safety and effectiveness of antibiotic regimes that include doxycycline, additional studies, especially randomized clinical trials, are needed to confirm this.

Hyperlipidaemia and mortality among patients hospitalised with pneumonia: retrospective cohort and propensity score matched study

ObjectiveTo characterise the potential association of hyperlipidaemia (HLP) versus no HLP with all-cause mortality among patients hospitalised for pneumonia.DesignPropensity score matched retrospective study.ParticipantsThe study cohort consisted of consecutive 8553 adults...

Audit of oxygen administration to achieve a target oxygen saturation range in acutely unwell medical patients

Purpose of the studyTo evaluate documentation of a target oxygen saturation (SpO2) range and ability to achieve this range in acutely unwell inpatients.Study designIn this single-centre audit, patients with discharge...

Variation in Pediatric Asthmonia Diagnosis and Outcomes among Hospitalized Children

Rationale: Although <5% of children hospitalized with an asthma exacerbation have pneumonia that can be radiographically confirmed, at some hospitals, an asthma-pneumonia co-diagnosis is so common that the term "asthmonia" is used to describe the phenomenon. High rates of asthmonia diagnosis may incur unwarranted health care costs and contribute to unnecessary antibiotic prescribing. Objectives: To characterize hospital variation in rates of pediatric asthmonia diagnosis and analyze associations between hospitals' asthmonia diagnosis rates and clinical outcomes. Methods: We conducted a cross-sectional analysis of 274 hospitals contributing to the Premier Healthcare Database. Children and adolescents 2-17 years of age were included if they were hospitalized with an asthma exacerbation from 10/1/2015 to 6/30/2018. Asthmonia was defined as a discharge diagnosis of pneumonia in a patient with an asthma exacerbation. To compute hospital-level risk-standardized asthmonia rates, hierarchical generalized linear models with hospital random effects were estimated, adjusting for patient characteristics. The median odds ratio was calculated to quantify the effect of hospital-level clustering on asthmonia diagnosis. Hospitals were stratified into quartiles based on risk-standardized asthmonia diagnosis rates to identify associated hospital characteristics. Generalized linear models, adjusting for hospital characteristics, were developed to compute associations between hospital risk-standardized rates and clinical outcomes. Results: Of 24,606 asthma exacerbations, 19,402 (78.9%) were diagnosed with asthma alone and 5,204 (21.1%) received asthma-pneumonia co-diagnoses. The hospital median risk-adjusted asthmonia diagnosis rate was 20.9% (interquartile range, 16.2-27.2%; range, 8.4-55.9%). The median odds ratio was 1.75 (95% confidence interval, 1.63-1.86). Compared with hospitals in the lowest quartile of asthma-pneumonia co-diagnosis, those in the highest quartile were more likely to be smaller, nonteaching, rural hospitals with minimal subspecialty support (all P < 0.001). Hospitals with high rates of risk-standardized asthmonia diagnosis had greater antibiotic use, more prolonged lengths of stay, and higher costs, with no significant differences in risk of transfer or readmission. Conclusions: Marked variation exists in rates of asthmonia diagnosis, and the hospital of admission is one of the strongest predictors of diagnosis. Efforts to reduce rates of unwarranted asthmonia diagnosis are needed, particularly at small, rural, nonteaching hospitals with minimal pediatric specialty support.

1464. Adjuvant Systemic Steroid Therapy and Length of Hospital Stay in Pneumonia Patients: A Retrospective Cohort Study in a Community Hospital

BackgroundPneumonia is a leading cause of morbidity and mortality worldwide resulting in a substantial healthcare expenditure. Antimicrobial agents are the main treatment. Recent studies showed the benefits of steroid therapy as an adjuvant therapy for patients with pneumonia; however, the overall evidence is still controversial.MethodsElectronic medical records of hospitalized patients (age >18) at a community hospital in a rural Maine with the discharge diagnosis of pneumonia in 2015 and 2016 were reviewed. Demographics, comorbidities, physical examination, initial laboratory, and Pneumonia Severity Index (PSI) were collected for each patient. The exposure was a systemic steroid administered by either oral or intravenous. The outcomes included length of hospital stay (LOS), inpatient mortality, and transfer to tertiary care center. Competing-risks regression was utilized to examine the association between steroid and LOS. Multivariable logistic regression analysis adjusted for propensity score was used for other outcomes.ResultsA total of 414 patients were included. 277(63%) patients received systemic steroids. Overall, steroid use was significantly associated with shorter LOS (HR 1.26, 95%CI 1.03-1.54, p=0.02) and decrease inpatient mortality (OR 0.11, 95%CI 0.03-0.45, p< 0.01). In subgroup analysis, steroid associated with shorter LOS only in patients with PSI class IV (HR 1.38, 95%CI 1.02-1.89, p=0.04) and PSI class V (HR 2.04, 95%CI 1.11-3.74, p=0.02). There was an association of steroid and shorter LOS in subgroup of COPD patients (HR 1.42, 95%CI 1.02-1.97, p=0.03).Table 1: The baseline characteristics of hospitalized patients with a diagnosis of pneumonia who received steroid vs non-steroid Figure 1: Subgroup analysis the effect of steroid and lenght of hospital stay (LOS) ConclusionOur study concluded that adjuvant steroid therapy associated with a decrease in length of hospital stay and improved inpatient mortality in hospitalized pneumonia patients. Steroid was most beneficial to those with severe pneumonia (PSI class IV-V) and COPD patients.Disclosures All Authors: No reported disclosures

The prognostic value of C-reactive protein for children with pneumonia.

To measure the prognostic value of C-reactive protein (CRP) and its ability to predict pneumonia-associated complications. A 3.75-years retrospective cohort analysis of all paediatric emergency department visits with a discharge diagnosis of pneumonia. Visits where CRP was not measured or with a discharge diagnosis of viral pneumonia were excluded. The following five outcomes were studied: hospitalisation, presence of parapneumonic effusion (PPE), placement of a chest drain, admission to paediatric intensive care unit (PICU) and bacteremia. A multivariate model was constructed and validated using k-fold cross-validation. During the study time period, there were 2561 visits for pneumonia, of which 810 were included in our analysis. The median age of included children was 3.2years (range 0.2-17.7). Overall, 38.8% visits ended in hospitalisation, 2.2% required admission to PICU, 15.2% were complicated by a PPE of which 28% required the placement of a chest drain. Statistically significant association was found between CRP levels and each of these outcomes (P<.001). Incorporating CRP within a multivariate prediction model provided an area under the curve of up to 0.96. CRP can be a useful prognostic marker when evaluating a patient with suspected bacterial pneumonia and could help the paediatrician in identifying patients needing closer follow-up.

61 Targeting Elderly Patients on Inhaled Corticosteroids for Respiratory Optimisation

Abstract Introduction Inhaled corticosteroids (ICS) are associated with increased rates of pneumonia, fracture and diabetes. ICS have limited short and long term benefits in COPD, and cessation of steroids in selected patients has been proven safe. We observed that a large proportion of inpatients in the geriatric service were prescribed ICS, and we aimed to review the reasoning for this and introduce a program of respiratory review in order to optimise care in these patients. Methods We conducted a retrospective audit of patients discharged from a geriatric service over a 3 month period. Sequential discharges were assessed for the presence and type of inhaled therapies, the documented diagnosis. After identifying high rates of inhaled therapy usage, we undertook a series of quality improvement interventions aimed at optimising respiratory care in these elderly patients. This included a guideline based protocol for reviewing respiratory diagnoses and prescriptions. Results In the retrospective analysis, 67/297 (22.5%) patients were discharged on inhaled therapy. 55/67 (82%) were discharged on an ICS, of which 20/67 (36%) were on high doses, equivalent to &amp;gt;1000micrograms of beclomethasone. Very few of these patients had evidence of inhaled therapy review during admission. 15/55 of these patients were given a discharge diagnosis of pneumonia; whilst only 6/55 were admitted with an exacerbation of their COPD. Our preliminary data suggest that a single paged protocol aimed at improving adherence to best practice lead to practice change: Dose modification has occurred in 50% of patients on ICS, leading to a reduction in steroid burden, and an annual reduction in prescription costs of £75 per patient reviewed. None of these patients have been re-admitted with respiratory exacerbations. Conclusions By introducing measures to assist in the review and modification of inhaled therapies, we were able to change practice. The alteration in practice led to reduction in prescription costs, and a reduced burden of inhaled corticosteroids. We propose that widespread encouragement of geriatrician led respiratory review could lead to harm reduction and cost saving in elderly inpatients.

HEMATOLOGY, C-REACT IVE PROTE IN AND PROCA LCITON IN IN COV ID-19 PAT IENTS AND HISTOR ICA L PNeUMONIA GROUP

Introduction: Laboratory test play an essential role in the early detection and diagnosis in an Emergency Department. Laboratory tests are common w COVID-19, however, they are also encountered in diseases with similar presentation as COVID-19 but other etiopathogeneses. The aim: To compare morphology, procalcitonin, and C-reactive protein in patients admitted with the diagnosis of COVID-19 to the Infectious Hospital to the patients with the discharge diagnosis of pneumonia admitted to the Emergency Department in January and February 2019. Material and methods: The study group consisted of 46 COVID-19 patients (60.9% male) aged 63.3±15.3 and 48 pneumonia patients (56.3% male) aged 75.0±13.7. The COVID-19 patients were admitted to the Infectious Department of Boleslawiec County Hospital or were discharged from the Emergency Departments to the Infectious Departments. The age, gender, leucocyte count, lymphocyte count and percentage, hemoglobin, mean corpuscular volume, platelets number, procalcitonin level and c-reactive protein were retrieved from medical electronic records. Results: The hematology tests did not reveal significant differences in lymphocyte count and percentage, however the white cells number was significantly higher in pneumonia than in COVID-19 group. C-reactive protein did not differ between groups. There was a trend to the higher level of procalcitonin in pneumonia group and hemoglobin level in COVID-19 group. Mean corpuscular volume and leucocyte number were significantly higher in the pneumonia group. Conclusions: 1. Lower leucocyte number and lower mean corpuscular volume of erytrocyte in COVID-19 patients than in pneumonia patients may reflect differences in the reaction of the host to infectious factors or indicate predisposing factors to COVID-19 infection. 2. Further studies are indicated to confirm and explain obtained results.

2671. Outcomes of Clostridium difficile Infection in Solid-Organ Transplant Patients: Nationwide Inpatient Sample 2015–2016

Background Clostridium difficile infection (CDI) is a leading cause of morbidity and mortality in a hospitalized patient. The incidence and severity of nosocomial CDI have increased significantly since the year 2000. Solid-organ transplant recipients (SOT) are at high risk for CDI for multiple reasons including impaired defense mechanisms from immunosuppression, perioperative antibiotic use, and organ failure. For the past decade, there has been the advance modality of diagnosis and treatments for CDI including early detection of toxin, novel antibiotics, and fecal microbiota transplantation. With the innovative measurements and the effort of antibiotic stewardship, the recent study show improvement of mortality in hospitalized CDI; however, there is still lack of such evidence among SOT patients. Therefore, it would be beneficial to scrutinize the prevalence and outcomes of CDI among SOTs with the most current available nationwide database.MethodsOur study utilized the 2015 and 2016 National Inpatient Sample (NIS). It is the largest publicly available all-payer inpatient healthcare database in the United States, yielding national estimates of hospital inpatient stays. Patients with history or undergoing SOT transplant procedure who were hospitalized in 2015 and 2016 NIS database were included in our study. We included heart, lung, liver, intestinal, kidney, pancreas, or at least one of these organs transplanted in our definiton of SOT. History of organ tranplants and CDI were extracted by using ICD-9-CM and ICD-10-CM from discharged diagnosis. Baseline characteristic include age, gender, race, median household income were collected. Confounding includes comorbidities which were calculated into charlson comorbidity index (CCI) and discharge diagnosis of pneumonia and urinary tract infection. Primary outcomes include in-patient mortality, hospital length of stay and total hospital charges. Secondary outcomes include transplant failure or rejection, colectomy and disposition of patients. Multivariable logistic regression was used for the adjusted analysis of the primary and secondary outcomes include all confounders and significant covariates. All reported CIs were two-sided 95% intervals, and tests were done at the two-sided 5% significance level. Stata v14.2 (Stata Corp, College Station, Texas) was utilized for all analyses.ResultsA total of 107,461 discharges of SOTs in 2015–2016 NIS database were included in our study. The mean age was 53 years (SD 17) and 45,666 (42%) were female. History of kidney transplant was found to be the most common (55%) and history of liver tranplants was the second most common (19%) among our population.The incidence of CDI was 3,626 (3.37%) among SOTs. Factors associated with CDI include age (4% increasing of odds for 10-year increment in age), female (OR 1.2; 95% CI 1.16–1.34), history of heart transplant (OR 1.28; 95% CI 1.11–1.48), kidney transplant (OR 0.98; 95% CI 0.82–0.97), UTI (OR 1.65; 95% CI 1.50–1.81) and pneumonia (OR 1.24;; 95% CI 1.122- 1.38). CDI associated with higher inpatient mortality (OR 1.85, 95% CI 1.56–2.20, P < 0.01), longer length of hospital stay (mean difference 5.07 days, 95% CI 4.43–5.71, P < 0.01) and higher total hospital charges (mean difference 43,958 dollars, P < 0.01). Furthermore, SOTs with CDI had higher risk of transplant complication (OR1.67, 95% CI 1.50–1.87, P < 001) and increase risk of colectomy (OR 2.36, 95% CI 1.50–3.72). Those who had CDI were less likely to be discharged home when compare to non-CDI (OR 0.53, 95% CI 0.49–0.58, P < 0.01).ConclusionOur study found that CDI associated with significant overall worse outcomes among hospitalized solid-organ transplant patients. Multicenter prospective study is considered as a future direction to evaluate the impact to healthcare. Despite the improvement of overall mortality of CDI in general population in the United States from prior study, CDI in SOTs remains problematic. More attention is needed in this particular field. Disclosures All authors: No reported disclosures.

2890. Antibiotic Overuse at Discharge in Hospitalized Patients with Bacteriuria or Treated for Pneumonia: A Multi-Hospital Cohort Study

BackgroundAntibiotics prescribed at hospital discharge account for half of antibiotic use related to hospitalization for urinary tract infection or bacterial pneumonia. It is unclear how much antibiotic use at discharge represents overuse, and thus, could potentially be improved through antibiotic stewardship.MethodsFrom July 2017 to December 2018, trained abstractors at 46 Michigan hospitals collected detailed data on a sample of adult, nonintensive care, hospitalized patients with bacteriuria or treated for community-acquired or healthcare-associated pneumonia (discharge diagnosis of pneumonia plus antibiotic treatment). Antibiotic prescriptions at discharge were assessed for overuse using a guideline-based hierarchical algorithm: evaluating first for unnecessary antibiotics (noninfectious/nonbacterial syndrome), then excess duration (antibiotics needed, but prescribed for longer than necessary), and finally avoidable fluoroquinolones (safer alternative antibiotic available) (Figure 1). For each disease state, descriptive results are shown with comparisons by t- or Fisher’s exact tests.ResultsOf 17,157 patients (7,283 with bacteriuria; 9,874 treated for pneumonia), 30.1% of patients with bacteriuria had asymptomatic bacteriuria and 11.4% of patients treated for pneumonia did not meet diagnostic criteria for pneumonia. The most common antibiotics prescribed at discharge were fluoroquinolones. Nearly half (43.6%) of patients had antibiotic overuse at discharge (33.8% bacteriuria, 50.9% pneumonia), with a median 4 days of overuse after discharge (Table 1). For bacteriuria, 45.0% of overuse days at discharge were due to unnecessary antibiotics; for pneumonia, 61.2% were due to excess antibiotic duration (Figure 2). Patients with community-acquired pneumonia and those with sepsis on admission had the highest rates of antibiotic overuse at discharge (Table 2).ConclusionIn the largest assessment of antibiotics at discharge to-date, antibiotic overuse at discharge was extremely common. Specific targets for discharge stewardship vary by disease state. Notably, interventions may be more effective at reducing fluoroquinolone prescribing at discharge indirectly by stopping treatment for asymptomatic bacteriuria and reducing excess duration in pneumonia. Disclosures All Authors: No reported Disclosures.

Impact of 13-Valent Pneumococcal Conjugate Vaccine on Meningitis and Pneumonia Hospitalizations in Children aged

Senegal introduced a 13-valent pneumococcal conjugate vaccine (PCV13) in October 2013, given at 6, 10, and 14 weeks of age. We document trends of meningitis and pneumonia after the PCV13 introduction. From October 2010-October 2016, hospitalization data for clinical meningitis and pneumonia in children aged <5 years were collected from logbooks at a large, tertiary, pediatric hospital in Dakar. We used a set of predetermined keywords to define hospitalizations for extraction from hospital registers. We conducted a time-series analysis and compared hospitalizations before and after the PCV13 introduction, accounting for seasonality. The initial PCV13 uptake period (October 2013-September 2014) was considered to be transitional and was excluded. Over the 7-year period, 1836 and 889 hospitalizations with a discharge diagnosis of pneumonia and meningitis, respectively, occurred in children aged <5 years. In children aged <12 months, a small, significant reduction in pneumonia was observed post-PCV13 (-3.8%, 95% confidence interval [CI] -1.5 to -5.9%). No decline was observed among children aged 12-59 months (-0.7%, 95% CI -0.8 to 2.2%). Meningitis hospitalizations remained stable for children aged <12 months (1.8%, 95% CI -0.9 to 4.4%) and 12-59 months (-0.5%, 95% CI -3.6 to 2.6%). We used data from 1 hospital to detect a small, significant reduction in all-cause pneumonia hospitalizations 2 years post-PCV13 introduction in infants; the same trend was not measurable in children aged 12-59 months or in meningitis cases. There is a need for continued surveillance to assess the long-term impact of sustained PCV13 use and to monitor how pneumococcus is causing disease in the meningitis belt.

Evaluation of a multifaceted approach to antimicrobial stewardship education methods for medical residents.

Medical residents are an important group for antimicrobial stewardship programs (ASPs) to target with interventions aimed at improving antibiotic prescribing. In this study, we compared antimicrobial prescribing practices of 2 academic medical teams receiving different ASP training approaches along with a hospitalist control group. Retrospective cohort study comparing guideline-concordant antibiotic prescribing for 3 common infections among a family medicine (FM) resident service, an internal medicine (IM) resident service, and hospitalists. Community teaching hospital. Adult patients admitted between July 1, 2016, and June 30, 2017, with a discharge diagnosis of pneumonia, cellulitis, and urinary tract infections were reviewed. All 3 medical teams received identical baseline ASP education and daily antibiotic prescribing audit with feedback via clinical pharmacists. The FM resident service received an additional layer of targeted ASP intervention that included biweekly stewardship-focused rounds with an ASP physician and clinical pharmacist leadership. Guideline-concordant prescribing was assessed based on the institution's ASP guidelines. Of 1,572 patients, 295 (18.8%) were eligible for inclusion (FM, 96; IM, 69; hospitalist, 130). The percentage of patients receiving guideline-concordant antibiotic selection empirically was similar between groups for all diagnoses (FM, 87.5%; IM, 87%; hospitalist, 83.8%; P = .702). No differences were observed in appropriate definitive antibiotic selection among groups (FM, 92.4%; IM, 89.1%; hospitalist, 89.9%; P = .746). The FM resident service was more likely to prescribe a guideline-concordant duration of therapy across all diagnoses (FM, 74%; IM, 56.5%; hospitalist, 44.6%; P < .001). Adding dedicated stewardship-focused rounds into the graduate medical curriculum demonstrated increased guideline adherence specifically to duration of therapy recommendations.

Validity of the diagnosis of pneumonia in hospitalised patients with COPD.

RationaleExacerbations of chronic obstructive pulmonary disease (COPD) and pneumonia are two of the most common reasons for acute hospital admissions. Acute exacerbations and pneumonia present with similar symptoms in COPD patients, representing a diagnostic challenge with a significant impact on patient outcomes. The objectives of this study were to compare the prevalence of radiographic consolidation with the discharge diagnoses of hospitalised COPD patients.MethodsCOPD patients admitted to three UK hospitals over a 3-year period were identified. Participants were included if they were admitted with an acute respiratory illness, COPD was confirmed by spirometry and a chest radiograph was performed within 24 h of admission. Pneumonia was defined as consolidation on chest radiograph reviewed by two independent observersResultsThere were 941 admissions in 621 patients included in the final analysis. In 235 admissions, consolidation was present on chest radiography and there were 706 admissions without consolidation. Of the 235 admissions with consolidation, only 42.9% had a discharge diagnosis of pneumonia; 90.7% of patients without consolidation had a discharge diagnosis of COPD exacerbation. The presence of consolidation was associated with increased rate of high-dependency care admission, increased mortality and prolonged length of stay. Inhaled corticosteroid use was associated with recurrent pneumonia.ConclusionsPneumonia is underdiagnosed in patients with COPD. Radiographic consolidation is associated with worse outcomes and prolonged length of stay. Incorrect diagnosis could result in inappropriate use of inhaled corticosteroids. Future guidelines should specifically address the diagnosis and management of pneumonia in COPD.

Abstract P-162: PEDIATRIC INTENSIVE CARE UNIT (PICU) ADMISSIONS DUE TO PNEUMONIA COMPLICATED WITH PARAPNEUMONIC EFFUSION (PPE) OR PLEURAL EMPYEMA (PE) AT COSTA RICA’S (CR) NATIONAL CHILDREN’S HOSPITAL

Aims & Objectives: In Latin America, few studies analyzing children with pneumonia complicated with PPE or PE requiring PICU admission have been published. We describe the first study in Central America focusing on this subgroup of pts. Methods Retrospective descriptive study of ch <13 years who had a discharge diagnosis of pneumonia with PPE or PE who were admitted to the PICU of the only national pediatric tertiary referral teaching hospital of CR from Jan-1st-2006 to Jan-31st-2014. Results Among 121 pts with pneumonia complicated with PPE or PE, 46(38%) required PICU admission. 27(58.7%) were male; median age was 11(1–166) months. Median length of hospitalization in the PICU was 5(1–30) days, and total days in hospital for this group, 19(2–83) days. Mechanical ventilation was required in 43(93.5%) pts, with a mean duration of 6.9(1–30) days. A bacterial pathogen was identified in 33(71.7%) pts, being the 3 most common: Staphylococcus aureus 17(37%)(100% MRSA), Streptococcus pneumoniae 11(23.9%), and Streptococcus pyogenes 3(6.5%). Inotropic support was required in 23(50%) pts, transfusions in 28(60.9%), thoracocentesis 33(71.7%), chest tube insertion 37(80.4%), and decortication 14(30.4%). Septic shock occurred in 16(34.8%) pts. 3 (6.5%) pts died: 2 due to pneumococcal septic shock and 1 due to a culture-negative necrotizing pneumonia with abscess formation. Conclusions Although PICU admissions due to pneumonia complicated with PE or PPE in CR children is associated with significant morbidity, the mortality rate is low if compared with other countries. Due to the concerning high rates of MRSA isolates, antibiotic therapy against this pathogen should be initiated promptly in these pts.

Rates and risk factors associated with hospitalization for pneumonia with ICU admission among adults

BackgroundPneumonia poses a significant burden to the U.S. health-care system. However, there are few data focusing on severe pneumonia, particularly cases of pneumonia associated with specialized care in intensive care units (ICU).MethodsWe used administrative and electronic medical record data from six integrated health care systems to estimate rates of pneumonia hospitalizations with ICU admissions among adults during 2006 through 2010. Pneumonia hospitalization was defined as either a primary discharge diagnosis of pneumonia or a primary discharge diagnosis of sepsis or respiratory failure with a secondary diagnosis of pneumonia in administrative data. ICU admissions were collected from internal electronic medical records from each system. Comorbidities were identified by ICD-9-CM codes coded during the current pneumonia hospitalization, as well as during medical visits that occurred during the year prior to the date of admission.ResultsWe identified 119,537 adult hospitalizations meeting our definition for pneumonia. Approximately 19% of adult pneumonia hospitalizations had an ICU admission. The rate of pneumonia hospitalizations requiring ICU admission during the study period was 76 per 100,000 population/year; rates increased for each age-group with the highest rates among adults aged ≥85 years. Having a co-morbidity approximately doubled the risk of ICU admission in all age-groups.ConclusionsOur study indicates a significant burden of pneumonia hospitalizations with an ICU admission among adults in our cohort during 2006 through 2010, especially older age-groups and persons with underlying medical conditions. These findings reinforce current strategies aimed to prevent pneumonia among adults.

Evaluation of the Empiric use of Levofloxacin in Combination with Antipseudomonal Β-Lactams for the Treatment of Pneumonia

BackgroundWith the release of the 2005 IDSA/ATS pneumonia guidelines healthcare providers were advised to consider numerous patient risk factors for multidrug resistant organisms. Furthermore, these guidelines encouraged empiric treatment with two agents active against pseudomonas, based on the assumption that combination therapy increases treatment success. An evaluation of our institution’s respiratory cultures revealed that levofloxacin covers only 2% of pseudomonas isolates resistant to piperacillin-tazobactam, and no isolates resistant to cefepime or meropenem.Our primary objective was to correlate this evaluation’s findings with patient outcomes by comparing mortality rates experienced by patients receiving levofloxacin plus an antipseudomonal β-lactam vs. those receiving β-lactam alone for the empiric treatment of pneumonia. Secondary objectives were to identify between group differences in length of stay, 30-day readmission, duration of mechanical ventilation, and occurrence of Clostridium difficile infection.MethodsThis single-center, retrospective chart review was conducted by evaluating records of patients with a discharge diagnosis of pneumonia from January 1, 2014 to September 1, 2016. Patients were included if they received at least 48 hours of empiric pneumonia treatment with an IV anti-MRSA agent plus an antipseudomonal β-lactam. Patient enrollment is displayed in Figure 1.ResultsOf 1897 patient screened, 228 patients were included. There were 146 patients who received monotherapy with an antipseudomonal β-lactam and 82 patients who additionally received levofloxacin. Baseline characteristics were comparable between groups. The mean age was 68.8 years, 51% were male, 45.6% had a diagnosis of COPD at baseline, and the average qSOFA score upon admission was 0.66. There was no significant difference in mortality (P = 0.438), nor any secondary objective. No significant difference in the duration of therapies prior to de-escalation was observed (P = 0.395).ConclusionAddition of levofloxacin to β-lactam therapy did not impact clinical outcomes in this population. Further analysis of site-specific data is warranted, as the results of this study may not be generalizable.Figure 1:Patient enrollment.Disclosures All authors: No reported disclosures.