Improving care for patients with Clostridioides difficile infection: A clinical practice and healthcare systems perspective.

Introduction: Arriving at a C. difficile infection (CDI) diagnosis, treating patients and dealing with recurrences is not straightforward, but a comprehensive and well-rounded understanding of what is needed to improve patient care is lacking. This manuscript addresses the paucity of multidisciplinary perspectives that consider clinical practice related and healthcare system-related challenges to optimizing care delivery. Methods: We draw on narrative review, consultations with clinical experts and patient representatives, and a survey of 95 clinical and microbiology experts from the UK, France, Italy, Australia and Canada, adding novel multi-method evidence to the knowledge base. Results and discussion: We examine the patient pathway and variations in clinical practice and identify, synthesize insights on and discuss associated challenges. Examples of key challenges include the need to conduct multiple tests for a conclusive diagnosis, treatment side-effects, the cost of some antibiotics and barriers to access of fecal microbiota transplantation, difficulties in distinguishing recurrence from new infection, workforce capacity constraints to effective monitoring of patients on treatment and of recurrence, and ascertaining whether a patient has been cured. We also identify key opportunities and priorities for improving patient care that target both clinical practice and the wider healthcare system. While there is some variety across surveyed countries' healthcare systems, there is also strong agreement on some priorities. Key improvement actions seen as priorities by at least half of survey respondents in at least three of the five surveyed countries include: developing innovative products for both preventing (Canada, Australia, UK, Italy, and France) and treating (Canada, Australia, and Italy) recurrences; facilitating more multidisciplinary patient care (UK, Australia, and France); updating diagnosis and treatment guidelines (Australia, Canada, and UK); and educating and supporting professionals in primary care (Italy, UK, Canada, and Australia) and those in secondary care who are not CDI experts (Italy, Australia, and France) on identifying symptoms and managing patients. Finally, we discuss key evidence gaps for a future research agenda.

Persistence of Disparities Among Racially/Ethnically Marginalized Groups in the Coronavirus Disease 2019 Pandemic Regardless of Statewide Shelter-in-Place Policies: An Analysis From Northern California.

To measure disparities in coronavirus disease 2019 (COVID-19) hospitalization and intensive care unit (ICU) transfer among racially/ethnically marginalized groups before and after implementation of the California statewide shelter-in-place (SIP) policy, we conducted a retrospective cohort study within a health-care system in California. COVID-19 patients diagnosed from January 1, 2020, to August 31, 2020, were identified from electronic health records. We examined hospitalizations and ICU transfers by race/ethnicity and pandemic period using logistic regression. Among 16,520 people with COVID-19 (mean age = 46.6 (standard deviation, 18.4) years; 54.2% women), during the post-SIP period, patients were on average younger and a larger proportion were Hispanic. In adjusted models, odds of hospitalization were 20% lower post-SIP as compared with the SIP period, yet all non-White groups had higher odds (odds ratios = 1.6-2.1) than non-Hispanic White individuals, regardless of period. Among hospitalized patients, odds of ICU transfer were 33% lower post-SIP than during SIP. Hispanic and Asian patients had higher odds than non-Hispanics. Disparities in hospitalization persisted and ICU risk became more pronounced for Asian and Hispanic patients post-SIP. Policy-makers should consider ways to proactively address racial/ethnic inequities in risk when considering future population-level policy interventions for public health crises.

Public Protests and the Risk of Novel Coronavirus Disease Hospitalizations: A County-Level Analysis from California.

The objective of this study was to assess the relationship between public protests and county-level, novel coronavirus disease (COVID-19) hospitalization rates across California. Publicly available data were included in the analysis from 55 of 58 California state counties (29 March-14 October 2020). Mixed-effects negative binomial regression models were used to examine the relationship between daily county-level COVID-19 hospitalizations and two main exposure variables: any vs. no protests and 1 or >1 protest vs. no protests on a given county-day. COVID-19 hospitalizations were used as a proxy for viral transmission since such rates are less sensitive to temporal changes in testing access/availability. Models included covariates for daily county mobility, county-level characteristics, and time trends. Models also included a county-population offset and a two-week lag for the association between exposure and outcome. No significant associations were observed between protest exposures and COVID-19 hospitalization rates among the 55 counties. We did not find evidence to suggest that public protests were associated with COVID-19 hospitalization within California counties. These findings support the notion that protesting during a pandemic may be safe, ostensibly, so long as evidence-based precautionary measures are taken.