See editorial by Dayan and Udell, pages 13e16 of this issue.

Background To examine antibiotic stewardship program (ASP) structure among high-performing hospitals and determine which components of the 2016 Infectious Diseases Society of America (IDSA)/Society for Hospital Epidemiology of America (SHEA) ASP guidelines are implemented at each site. Methods A survey of the highest-ranking hospitals, compiled from the 2015–2016 US News and World Report’s Best Hospital Rankings, was conducted from August to December 2016. This corresponded to 138 adult and 62 pediatric unique hospitals. We inquired as to which components of the 2016 IDSA/SHEA ASP guidelines were implemented at each site. Appropriate persons at each hospital were emailed surveys after telephone or email conversations confirmed that they belonged to that hospital’s ASP. Results Overall, 101 of 200 hospitals responded (51%). Of these, 82% (n = 83/101) had an active ASP, and 59% (n = 47/80) were active for more than 5 years. Most report to a committee rather than to an individual (n = 68/80, 85%), do not have their own budget (n = 42/80, 53%), and selectively implement IDSA/SHEA recommendations. Additionally, the majority of ASPs in top hospitals follow aspects of The Joint Commission Standards for Antimicrobial Stewardship, which were released after the survey was administered. Conclusions Of leading US hospitals responding to our survey, >80% had an ASP, and most implemented the majority of commitments, interventions, and optimization strategies suggested by IDSA/SHEA. Understanding the structure of ASPs in these hospitals will assist other hospitals in program implementation.

Injection drug use poses a public health challenge. Clinical experience indicates that people who inject drugs (PWID) are hospitalized frequently for infectious diseases, but little is known about outcomes when admitted. Charts were identified from local hospitals between 2013–2018 using consultation lists and hospital record searches. Included individuals injected drugs in the past six months and presented with infection. Charts were accessed using the hospital information system, undergoing primary and secondary reviews using Research Electronic Data Capture (REDCap). The Wilcoxon rank-sum test was used for comparisons between outcome categories. Categorical data were summarized as count and frequency, and compared using Fisher’s exact test. Of 240 individuals, 33% were admitted to the intensive care unit, 36% underwent surgery, 12% left against medical advice (AMA), and 9% died. Infectious diagnoses included bacteremia (31%), abscess (29%), endocarditis (29%), cellulitis (20%), sepsis (10%), osteomyelitis (9%), septic arthritis (8%), pneumonia (7%), discitis (2%), meningitis/encephalitis (2%), or other (7%). Sixty-six percent had stable housing and 60% had a family physician. Fifty-four percent of patient-initiated discharges were seen in the emergency department within 30 days and 29% were readmitted. PWID are at risk for infections. Understanding their healthcare trajectory is essential to improve their care.

Background and Aim: Vedolizumab is a novel monoclonal antibody used in patients with inflammatory bowel disease, often affecting women of child-bearing age. We aimed to compare maternal and fetal adverse outcomes in pregnancies of women with inflammatory bowel disease exposed to vedolizumab versus those on other treatment. Methods: We performed a systematic literature search through December 2020 looking for studies including outcomes from pregnancies of female inflammatory bowel disease patients treated with vedolizumab. Our primary outcome was a composite of adverse pregnancy-related events in pregnancies of female patients on vedolizumab compared with those of disease-matched controls on other medication regimens. Events of interest included preterm births, early loss of pregnancy, late fetal death, elective termination of pregnancy, and congenital anomalies. Results: Four studies were included in our review meeting criteria for our primary analysis. Compared with those with no vedolizumab exposure, pregnancies with vedolizumab exposure had an increase in overall adverse pregnancy-related outcomes (odds ratio [OR] 2.18, 95% confidence interval [CI], 1.52-3.13). The vedolizumab group also had increased preterm births (OR 2.16, 95% CI, 1.28-3.66), and early loss of pregnancies (OR 1.79, 95% CI, 1.06-3.01) but no difference in number of live births (OR 0.60, 95%CI, 0.36-1.00), or congenital malformations (OR 1.56, 95% CI, 0.56-4.37). Conclusions: Our systematic review highlights possible concern with the general safety of vedolizumab in pregnancy, as an increase in overall total unfavorable outcomes was observed. Premature births and early loss of pregnancy were also more prevalent in pregnant female patients on vedolizumab. It is possible these findings are confounded by disease activity, and further prospective cohort studies of vedolizumab and pregnancy outcomes are warranted. contributions were as follows: Conor Bell: literature search, data entry, data interpretation and drafting of the manuscript. Parul Tandon: critical review of the manuscript. Eric Lentz: literature search, data entry, and poster creation. John K Marshall: critical review of manuscript. Neeraj Narula: study concept and design, data acquisition, data analysis and critical review of manuscript.

Objective To examine whether prenatal biochemical screening analytes are associated with an increased risk of severe maternal morbidity (SMM) or maternal mortality. Study Design This population-based cohort study includes all women in Ontario, Canada, who underwent prenatal screening from 2001 to 2011. Increasing fifth percentiles of the multiple of the median (MoM) for alphafetoprotein (AFP), total human chorionic gonadotropin, unconjugated estriol (uE3), dimeric inhibin-A (DIA), and pregnancy-associated plasma protein A were evaluated. An abnormally high concentration (>95th percentile MoM) for each analyte, individually and combined, was also evaluated. The main outcome assessed was the adjusted relative risk (aRR) of SMM or maternal mortality from 20 weeks' gestation up to 26 weeks thereafter. Results Among 748,972 pregnancies, 11,177 resulted in SMM or maternal mortality (1.5%). Except for uE3, the aRR of SMM or maternal mortality increased in association with increasing fifth percentiles of the MoM for all analytes. AFP (aRR: 2.10; 95% confidence interval [CI]: 1.97–2.25) and DIA (aRR: 2.33; 95% CI: 1.98–2.74) > 95th versus ≤ 5th percentile of the MoM were especially associated with SMM or death. Conclusion Women with abnormally high concentrations of certain prenatal biochemical analytes may be at a higher risk of SMM or death in pregnancy or postpartum.