Sameer S. Kadri

Background: Procalcitonin (PCT) testing may guide antibiotic decisions in community-acquired pneumonia (CAP), but real-world evidence of its impact on antibiotic prescribing in the era of shorter antibiotic courses remains limited. Methods: We conducted a retrospective cohort study of adults with CAP admitted to the wards of 12 hospitals between November 2022 and January 2025. Primary analyses included: (1) PCT testing rates at admission, (2) the association between PCT testing and duration of antibiotic therapy, and (3) among patients initiated on extended-spectrum antibiotics (ESAs), the relationship between PCT results and early de-escalation. We compared outcomes between PCT-tested and untested patients and between those with low (<0.1 μg/L) vs high (≥0.1 μg/L) PCT values using propensity score overlap weighting to control for potential confounders. Results: Among 17 290 non–intensive care unit (ICU) admissions for CAP, PCT testing was performed for 10 658 patients (59.5%) within 24 hours of admission. After adjustments, PCT testing was associated with shorter antibiotic duration (adjusted mean difference, −0.32 days; 95% confidence interval [CI], −.52 to −.12) but was not significantly associated with ESA de-escalation compared with no PCT testing (hazard ratio, 1.05; 95% CI, .99–1.12). Patients with low PCT values received shorter antibiotic courses compared with those with high values (adjusted mean difference, −0.56 days; 95% CI, −.85 to −.49). Conclusions: In non-ICU patients with CAP, PCT testing was associated with modest differences in antibiotic duration, primarily when values were low.

Importance: Some US states established state medical operations coordination centers (SMOCCs) during the pandemic to coordinate transfers and maximize care delivery when available beds were limited. Understanding their associations might inform their continued value in helping reduce delays and minimize strain during public health emergency conditions. Objective: To examine the association of SMOCC establishment with adult interhospital transfers (IHTs) during pandemic surges. Design, Setting, and Participants: This interrupted time series cohort study evaluated hospitalized adults (aged ≥18 years) from 8 US states. Data analysis was completed in March 2025. Exposure: SMOCC establishment. SMOCC initiation was adjudicated through a published survey and inquiries with state health departments. Main Outcomes and Measures: Outcome measures were immediate and long-term change in IHT by emergency medical services (EMS) agencies that continuously reported in the National EMS Information Systems database between June 1, 2020, and December 30, 2022. The inflection point (SMOCC establishment) was centered using relative dates while controlling for seasonality. Hospital occupancy stress was measured using daily hospital census and staffed bed counts and weighted by fixed bed capacity. Effect modification by increasing occupancy stress across study states was tested using an interaction term. Findings were validated in several subset analyses. Results: Across the study’s 8 states (Alaska, Colorado, Idaho, Maryland, North Carolina, Oregon, Utah, and Virginia), 441 709 transfers (median [IQR] age, 61.0 [44.0-73.0] years; 227 982 [51.6%] male) were analyzed, with 321 078 (72.8%) occurring after SMOCC establishment. SMOCC establishment was associated with an immediate increase (rate ratio [RR], 1.35; 95% CI, 1.05-1.74; P = .02) followed by a long-term decrease (RR, 0.94; 95% CI, 0.90-0.97; P < .001) in transfer rates. A significant increase in transfers per decile increase in occupancy stress was observed 40 weeks into SMOCC establishment (RR, 1.23; 95% CI, 1.06-1.42; P = .007). Findings were similar across transfers grouped by urbanicity, mode of transport, patient age, and acuity. Conclusions and Relevance: In this cohort study of 8 US states, pandemic initiation of a SMOCC was associated with an immediate increase in transfer rates between hospitals of approximately 35% after establishment and, after a potential lag, appeared to meet an increasing demand for transferring patients during surges. These results suggest that activating SMOCCs during large-scale public health emergencies might improve access to care and mitigate transfer gridlocks, but their utility during routine times warrants study.

Background: Little is known about the frequency, hospital-level variation, predictors, and outcomes of antibiotic de-escalation in suspected sepsis. Methods: We retrospectively analyzed adults admitted to 236 US hospitals from 2017–2021 with suspected sepsis (defined by blood culture draw, lactate measurement, and intravenous antibiotic administration) who were initially treated with ≥2 days of anti–methicillin-resistant Staphylococcus aureus (MRSA) and anti-pseudomonal antibiotics but had no resistant organisms that required these agents identified through hospital day 4. De-escalation was defined as stopping anti-MRSA and anti-pseudomonal antibiotics or switching to narrower antibiotics by day 4. We created a propensity score for de-escalation using 82 hospital and clinical variables; matched de-escalated to non–de-escalated patients; and assessed associations between de-escalation and outcomes. Results: Among 124 577 patients, antibiotics were de-escalated in 36 806 (29.5%): narrowing in 27 177 (21.8%), cessation in 9629 (7.7%). De-escalation rates varied between hospitals (median, 29.4%; interquartile range, 21.3%–38.0%). Predictors of de-escalation included less severe disease on day 3–4, positive cultures for nonresistant organisms, and negative/absent MRSA nasal swabs. De-escalation was more common in medium, large, and teaching hospitals in the Northeast and Midwest. De-escalation was associated with lower adjusted risks for acute kidney injury (AKI) (odds ratio [OR], 0.80; 95% confidence interval [CI], .76–.84), intensive-care unit (ICU) admission after day 4 (OR, 0.59; 95% CI, .52–.66), and in-hospital mortality (OR, 0.92; 95% CI, .86–.996). Conclusions: Antibiotic de-escalation in suspected sepsis is infrequent, variable across hospitals, linked with clinical and microbiologic factors, and associated with lower risk for AKI, ICU admission, and in-hospital mortality.

Sepsis tends to be more common and lethal in US racial and ethnic minority populations. Is it the patient, the care they receive, or both? Historically,