The Natural History of Asymptomatic Gallstones: A Longitudinal Study and Prediction Model.

BACKGROUND & AIMS: Despite the high prevalence of asymptomatic gallstones (AGs), there are limited data on their natural history. We aimed to determine the rate of symptom development in a contemporary population, determine factors associated with progression to symptomatic gallstones (SGs), and develop a clinical prediction model. METHODS: We used a retrospective cohort design. The time to first SG was shown using Kaplan-Meier curves. Multivariable competing risk (death) regression analysis was used to identify variables associated with SGs. A prediction model for the development of SGs after 10 years was generated and calibration curves were plotted. Participants were patients with AGs based on ultrasound or computed tomography from the general medical population. RESULTS: From 1996 to 2016, 22,257 patients (51% female) with AGs were identified; 14.5% developed SG with a median follow-up period of 4.6 years. The cumulative incidence was 10.1% (±0.22%) at 5 years, 21.5% (±0.39%) at 10 years, and 32.6% (±0.83%) at 15 years. In a multivariable model, the strongest predictors of developing SGs were female gender (hazard ratio [HR], 1.50; 95% CI, 1.39-1.61), younger age (HR per 5 years, 1.15; 95% CI, 1.14-1.16), multiple stones (HR, 2.42; 95% CI, 2.25-2.61), gallbladder polyps (HR, 2.55; 95% CI, 2.14-3.05), large stones (HR, 2.03; 95% CI, 1.80-2.29), and chronic hemolytic anemia (HR, 1.90; 95% CI, 1.33-2.72). The model showed good discrimination (C-statistic, 0.70) and calibration. CONCLUSIONS: In general medical patients with AGs, symptoms developed at approximately 2% per year. A predictive model with good calibration could be used to inform patients of their risk of SGs.

A Validated Model to Identify Patients With Low Likelihood of High-Risk Coronary Artery Disease Anatomy.

In stable coronary artery disease (CAD), revascularization improves outcomes only for patients with high-risk coronary anatomy (HRCA). We sought to derive and validate a prediction model, incorporating clinical and exercise stress test characteristics, to identify patients with HRCA. We conducted a retrospective analysis of patients undergoing exercise stress testing at Cleveland Clinic (2005 to 2014), followed by invasive coronary angiography within 3 months. We excluded patients with acute coronary syndrome, known CAD or ejection fraction <50%. HRCA was defined as left main, 3-vessel, or 2-vessel disease involving the proximal left anterior descending artery. Clinical and stress test predictors of HRCA were identified in a multivariable logistic regression model, internally validated with 1,000-fold bootstrapping. The model was then externally validated at the University of Pittsburgh Medical Center (2017 to 2019). The model was derived from 2,758 patients with complete data. HRCA was identified in 418 patients (15.2%) in the derivation cohort. The model consisted of 10 variables: age, male gender, hypertension, hypercholesterolemia, diabetes mellitus, family history of premature CAD, high-density lipoprotein, chest pain, exercise time, and Duke Treadmill Score. Bias-corrected c-statistic was 0.79 (95% confidence interval 0.77 to 0.81) with excellent calibration. In all, 762 patients (27.6%) had a predicted probability and observed prevalence of HRCA <5%. In the validation cohort, the model had a c-statistic of 0.79 (95% confidence interval 0.74 to 0.85) and 210 patients had an observed prevalence of HRCA <5% (40%). In conclusion, an externally validated prediction model, based on clinical characteristics and exercise stress test variables, can identify stable patients with CAD who have HRCA.

Patient and physician factors contributing to polypharmacy among older patients.

OBJECTIVE: Polypharmacy, or use of multiple medications, is associated with patient factors. Less is known regarding variation in polypharmacy by individual physicians. The objective of this study was to assess patient and physician factors associated with polypharmacy among older patients. METHODS: This is a cross-sectional study of patients aged ≥65 years with a primary care visit at Cleveland Clinic Health System in 2015 and their physicians. We collected patient demographics, comorbidities and current medications from the electronic health record, including potentially inappropriate medications (PIMs). We used mixed effects linear regression to estimate adjusted differences in the number of medications by patient factors. We generated adjusted prescribing rates for individual physicians and assessed differences in physician performance on quality measures by their prescribing rate. RESULTS: Our study included 44,570 patients who were prescribed an average of 6.8 medications (standard deviation: 4.0) by 701 physicians. Female sex, higher BMI, having Medicaid insurance, current or former smoking status, comorbidities and seeing a specialist were associated with number of medications. Age was not. Among 267 physicians who saw ≥20 study-eligible patients, the adjusted mean number of medications per patient ranged from 5.2 to 9.6. Compared to physicians who prescribed above the mean, lower prescribing physicians performed significantly better on medication reconciliation (p = .007) and hypertension control (p < .001) and prescribed fewer PIMs (p < .001). CONCLUSIONS: Individual physicians varied in their prescribing practices, even after adjusting for patient demographic and clinical characteristics. Interventions to reduce polypharmacy in older adults should target high prescribing physicians, as physician behavior is more actionable than patient factors.

Lyme Carditis: A Reversible Cause of Acquired Third-Degree AV Block.

BACKGROUND Lyme borreliosis, caused by spirochetes of the Borrelia burgdorferi genospecies complex, is the most commonly reported tickborne infection in North America and those infected may present with cutaneous, cardiac, articular, and neuropsychiatric abnormalities. The protean nature of many of its clinical manifestations presents a diagnostic conundrum. Lyme disease can affect the heart, albeit rarely, with cardiac abnormalities usually manifesting as varying degrees of heart block or arrhythmias. CASE REPORT We present a case of complete heart block in a young man who participated in outdoor activities in a Lyme-endemic area and developed fatigue and palpitations weeks after a flu-like illness. He noticed that his heart rate was low; he had an intermediate suspicious index in Lyme carditis (SILC) score with positive Lyme serologies. His initial electrocardiogram when he presented to the emergency department showed a complete heart block. In this case, he was successfully managed with intravenous ceftriaxone, amoxicillin, and a transcutaneous pacemaker, obviating the need for a permanent pacemaker. CONCLUSIONS Electrocardiographic changes such as heart block and arrhythmias with or without symptoms may be the initial manifestation of Lyme carditis in a patient who may or may not remember a tick bite or have a typical skin rash. The SILC score may assist in recognizing these cases and prompt initiation of antibiotics usually leads to the resolution of these electrocardiographic abnormalities and symptoms that may be present.

Peroral endoscopic myotomy is highly effective for achalasia patients with recurrent symptoms after pneumatic dilatation.

BACKGROUND: Previous interventions in achalasia such as pneumatic dilation (PD) might lead to difficulties with peroral endoscopic myotomy (POEM) along with sub-optimal outcomes. There are limited data in the literature on outcomes of POEM after PD, especially from the western hemisphere. Hence, we aimed to determine the safety and efficacy of POEM for recurrent symptoms after PD compared to treatment naïve achalasia patients. METHODS: Medical records of achalasia patients who underwent POEM at our institution between April 2014 and October 2019 were reviewed. Patients who had POEM for recurrent symptoms after prior PD were matched at 1:2 ratio with treatment naïve achalasia patients using propensity score matching. Patients who had prior Heller myotomy were excluded. Patient demographics, Eckardt scores, timed barium swallow (TBE), high-resolution esophageal manometry (HREM), and pH study findings were compared between the two groups, pre- and 2 months post-POEM. Treatment success was defined as reduction of Eckardt score to ≤ 3. RESULTS: A total of 39 patients (prior PD = 13; treatment naïve = 26) were included. Patient demographics, procedural, and peri-procedural outcomes were similar in both groups. Treatment success was similar in both groups, 100.0% in prior PD vs 91.7% in treatment naïve group (p = 0.53). On adjusted analysis, there was no significant difference in the pre-post-POEM improvement in Eckardt scores, TBE, and HREM parameters in the two groups. Gastroesophageal reflux disease rates were also similar in both groups. CONCLUSIONS: In achalasia with recurrent symptoms after PD, POEM is a safe and highly effective treatment modality. Prior PD does not seem to influence the outcomes or efficacy of POEM.

Trends and risk factors for 30-day readmissions in patients with acute cholangitis: analysis from the national readmission database.

INTRODUCTION: Acute cholangitis (AC) can be associated with significant mortality and high risk of readmissions, if not managed promptly. We used national readmission database (NRD) to identify trends and risk factors associated with 30-day readmissions in patients with AC. METHODS: We conducted a retrospective cohort study of adult patients admitted with AC from 2010-2014 and Q1-Q3 of 2015 by extracting data from NRD. Initial admission with a primary diagnosis of acute cholangitis (ICD-9 code: 576.1) was considered as the index admission and any admission after index admission was considered a readmission regardless of the primary diagnosis. Multivariable regression analyses were performed to assess the association. RESULTS: From 52,906 AC index admissions, overall 30-day readmission rate was 21.48% without significant differences in the readmission rates across the study period. There was significant increase in the overall hospital charges for readmissions, while a significant reduction in the death rate was observed during the first readmission. Recurrent cholangitis (14%), septicemia (6.4%), and mechanical complication of bile duct prosthesis (3%) were the most common reasons for readmissions. The risk of readmission was significantly higher in patients with pancreatic neoplasm (OR 1.6, 95% CI 1.4-1.8), those who underwent percutaneous biliary procedures (OR 1.4, 95% CI 1.2-1.6), and who had an acute respiratory failure (OR 1.2, 95% CI 1.0-1.15). Other factors contributing to increased risk of readmissions included patients with Charleston comorbidity index > 3, diabetes, and length of stay > 3 days. Readmission risk was significantly lower in patients who underwent ERCP (OR 0.80, 95% CI 0.73-0.88) or cholecystectomy (OR 0.54, 95% CI 0.43-0.69). CONCLUSIONS: AC is associated with a high 30-day readmission rate of over 21%. Patients with malignant biliary obstruction, increased comorbidities, and those who undergo percutaneous drainage rather than ERCP seem to be at the highest risk.

Comparative Effectiveness of Commercial Bowel Preparations in Ambulatory Patients Presenting for Screening or Surveillance Colonoscopy.

BACKGROUND: Inadequate bowel preparation (IBP) is associated with reduced adenoma detection. However, limited research has examined the impact of different commercial bowel preparations (CBPs) on IBP and adenoma detection. We aim to determine whether type of CBP used is associated with IBP or adenoma detection. METHODS: We retrospectively evaluated outpatient, screening or surveillance colonoscopies performed in the Cleveland Clinic health system between January 2011 and June 2017. IBP was defined by the Aronchick scale. Multilevel mixed-effects logistic regression was performed to assess the association between CBP type and IBP and adenoma detection. Fixed effects were defined as demographics, comorbidities, medication use, and colonoscopy factors. Random effect of individual endoscopist was considered. RESULTS: Of 153,639 colonoscopies, 75,874 records met inclusion criteria. Median age was 54; 50% were female; 17.7% had IBP, and adenoma detection rate was 32.6%. In adjusted analyses, compared to GoLYTELY, only NuLYTELY [OR 0.66 (95% CI 0.60, 0.72)] and SuPREP [OR 0.53 (95% CI 0.40, 0.69)] were associated with reduced IBP. Adenoma detection did not vary based on the type of bowel preparation used. CONCLUSIONS: Among patients referred for screening or surveillance colonoscopy, choice of CBP was not associated with adenoma detection. Decisions about CBP should be based on other factors, such as tolerability, cost, or safety.

Pneumonia and alcohol use disorder: Implications for treatment.

Patients with alcohol use disorder (AUD) are at higher risk of pneumonia and of poor outcomes. This article reviews the etiology of pneumonia in patients with AUD, its impact on mortality and resource utilization, and its implications for treatment.

Weil's Disease: A Rare Cause of Jaundice.

Weil's disease is a complication of untreated leptospirosis and can be fatal. Awareness of leptospirosis and its hepatic manifestations are limited. We report the case of a 50-year-old man with gastrointestinal symptoms and a cholestatic pattern of liver injury diagnosed with Weil's disease. The patient showed remarkable improvement after treatment with appropriate antibiotics with normalization of liver function in one month. This case highlights the importance of recognizing leptospirosis and its myriad presentations.

Assessment of Physician Priorities in Delivery of Preventive Care.

Importance: Primary care physicians have limited time to discuss preventive care, but it is unknown how they prioritize recommended services. Objective: To understand primary care physicians' prioritization of preventive services. Design, Setting, and Participants: This online survey was administered to primary care physicians in a large health care system from March 17 to May 12, 2017. Physicians were asked whether they prioritize preventive services and which factors contribute to their choice (5-point Likert scale). Results were analyzed from July 8, 2017, to September 19, 2019. Exposures: A 2 × 2 factorial design of 2 hypothetical patients: (1) a 50-year-old white woman with hypertension, type 2 diabetes, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of breast cancer; and (2) a 45-year-old black man with hypertension, hyperlipidemia, obesity, a 30-pack-year history of smoking, and a family history of colorectal cancer. Two visit lengths (40 minutes vs 20 minutes) were given. Each patient was eligible for at least 11 preventive services. Main Outcomes and Measures: Physicians rated their likelihood of discussing each service during the visit and reported their top 3 priorities for patients 1 and 2. Physician choices were compared with the preventive services most likely to improve life expectancy, using a previously published mathematical model. Results: Of 241 physicians, 137 responded (57%), of whom 74 (54%) were female and 85 (62%) were younger than 50 years. Physicians agreed they prioritized preventive services (mean score, 4.27 [95% CI, 4.12-4.42] of 5.00), mostly by ability to improve quality (4.56 [95% CI, 4.44-4.68] of 5.00) or length (4.53 [95% CI, 4.40-4.66] of 5.00) of life. Physicians reported more prioritization in the 20- vs 40-minute visit, indicating that they were likely to discuss fewer services during the shorter visit (median, 5 [interquartile range {IQR}, 3-8] vs 11 [IQR, 9-13] preventive services for patient 1, and 4 [IQR, 3-6] vs 9 [IQR, 8-11] for patient 2). Physicians reported similar top 3 priorities for both patients: smoking cessation, hypertension control, and glycemic control for patient 1 and smoking cessation, hypertension control, and colorectal cancer screening for patient 2. Physicians' top 3 priorities did not usually include diet and exercise or weight loss (ranked in their top 3 recommendations for either patient by only 48 physicians [35%]), although these were among the 3 preventive services most likely to improve life expectancy based on the mathematical model. Conclusions and Relevance: In this survey study, physicians prioritized preventive services under time constraints, but priorities did not vary across patients. Physicians did not prioritize lifestyle interventions despite large potential benefits. Future research should consider whether physicians and patients would benefit from guidance on preventive care priorities.

National trends in healthcare outcomes and utilization of endoscopic and surgical interventions in patients hospitalized with esophageal foreign body and food impaction.

The incidence and number of emergency room visits for esophageal foreign body and food impaction (EFB) are on the rise. However, its impact on the rate of inpatient admissions, utilization of endoscopic and surgical interventions, and healthcare outcomes is poorly understood. We conducted a study to analyze these outcomes using the national inpatient sample (NIS) database. Data on all adult patients (≥18 years) admitted with EFB was extracted from the NIS database from 1998 to 2013. The temporal trends in discharge rates as well as in length of stay (LOS), hospital charges, and in-hospital mortality rates were assessed by linear and polynomial regression. Average age, gender, and race of inpatients with EFB were not significantly different between 1998 and 2013. The rate of EFB admissions increased significantly from 1998 to 2005 followed by a decline thereafter (p = 0.01). LOS and hospital charges significantly increased by 0.02 days/year (p = 0.015) and $1,547/year (p < 0.001), respectively. There was a trend towards less utilization of overall esophagogastroduodenoscopy (EGD) over the last decade with significant lower use of EGD within 24 hours in 2013 as compared to 1998 (p = 0.026). The rates of surgical intervention and inpatient mortality did not change significantly over the study period. The rate of inpatient admissions for EFB is on the decline in recent years, suggesting the modern-day practice of cost-effective medicine. Hospitalization costs for EFB have increased, whereas rates of surgical intervention and inpatient mortality have not changed significantly over the study period.

The Effect of Starting the Protein-Sparing Modified Fast on Weight Change over 5 years.

BACKGROUND: Ketogenic diets have been highlighted as a way to lose weight while experiencing reduced hunger. The protein-sparing modified fast (PSMF) induces ketosis but may be difficult to maintain. OBJECTIVE: To track weight loss for individuals initiating PSMF versus all other diets (e.g., balanced, high protein) for up to 5 years. DESIGN: Retrospective cohort study PARTICIPANTS: Adults who discussed the PSMF with a clinician between 2007 and 2014 INTERVENTION: Initiating the PSMF diet versus other diets MEASURES: The main outcome was percent weight change up to 5 years. Demographic and health data were collected using electronic health records. We fit regression models including age, sex, race, insurance, new medication prescriptions, and specialist visit to identify the effect of PSMF diet on percent weight change. We grouped patients by percent weight change at each year (≥ 5% loss, 4% loss to 4% gain, ≥ 5% gain) and used Pearson χ2 tests to compare proportions. RESULTS: Of 1,403 eligible patients, 879 (63%) started the PSMF. The PSMF group was slightly younger (52 vs. 54 years, p < 0.01) and had a higher body mass index (41.9 kg/m2 vs. 40.4 kg/m2, p < 0.001). In the adjusted analysis, the PSMF group averaged 3% more weight loss than the other group over the 5-year follow-up (95% CI - 3.5, - 2.0, p < 0.001). PSMF patients lost more weight initially, but by year 4, there was no difference between diets (1.6% versus 1.3%, PSMF versus other diets, p = 0.12). Patients starting the PSMF were more likely to experience ≥ 5% weight loss at 1 year (55% vs 20%, p < 0.001) and 3 years (33% vs. 23% p < 0.05), but not 5 years (34% vs 29%, p = 0.16, PSMF versus other diets, respectively). CONCLUSIONS: In clinical practice, the PSMF achieves rapid weight loss in the first 6 months, but only a small percentage of patients maintained significant weight loss long term.

Obesity Does Not Impact Outcomes or Rates of Gastroesophageal Reflux After Peroral Endoscopic Myotomy in Achalasia.

BACKGROUND: Outcomes of laparoscopic Heller myotomy in obese patients with achalasia are suboptimal along with the increased risk of gastroesophageal reflux disease (GERD). The impact of obesity on treatment success and GERD after peroral endoscopic myotomy (POEM) are not well known. Hence, our study aims were to compare the clinical outcomes and rates of GERD after POEM in nonobese versus obese patients with achalasia. METHODS: Chart review of all achalasia patients who underwent POEM at our institution between April 2014 and June 2018. Patients with timed barium esophagram (TBE) and high-resolution esophageal manometry (HREM) before POEM along with post-POEM TBE, HREM, and esophageal pH study were included. Patients were categorized into 2 groups, nonobese (body mass index <30 kg/m) and obese (body mass index ≥30 kg/m). Patient demographics, TBE, HREM, pH study findings, and Eckardt scores were compared between the 2 groups. RESULTS: A total of 89 patients (46 nonobese; 43 obese) met the study criteria. There were no significant differences in age, gender, achalasia subtype, operative time, length of stay and complication rates between the 2 groups. Treatment success (Eckardt score ≤3) was similar in both groups (97.7% nonobese vs. 92.7% obese, P=0.35). Abnormal DeMeester scores on pH study (>14.72) were similar in nonobese and obese patients (58.7% vs. 46.5%, P=0.25). Symptomatic GERD was also similar in both groups (17.8% in nonobese vs. 20% in obese, P=0.79). CONCLUSIONS: POEM is an equally safe and effective treatment option for both nonobese and obese patients with achalasia in the short-term. Interestingly, POEM does not lead to higher rates of GERD in obese compared with nonobese patients.

Attitudes of High Versus Low Antibiotic Prescribers in the Management of Upper Respiratory Tract Infections: a Mixed Methods Study.

IMPORTANCE: Inappropriate antibiotic use for upper respiratory tract infections (URTIs) is an ongoing problem in primary care. There is extreme variation in the prescribing practices of individual physicians, which cannot be explained by clinical factors. OBJECTIVE: To identify factors associated with high and low prescriber status for management of URTIs in primary care practice. DESIGN AND PARTICIPANTS: Exploratory sequential mixed-methods design including interviews with primary care physicians in a large health system followed by a survey. Twenty-nine physicians participated in the qualitative interviews. Interviews were followed by a survey in which 109 physicians participated. MAIN MEASURES: Qualitative interviews were used to obtain perspectives of high and low prescribers on factors that influenced their decision making in the management of URTIs. A quantitative survey was created based on qualitative interviews and responses compared to actual prescribing rates. An assessment of self-prescribing pattern relative to their peers was also conducted. RESULTS: Qualitative interviews identified themes such as clinical factors (patient characteristics, symptom duration, and severity), nonclinical factors (physician-patient relationship, concern for patient satisfaction, preference and expectation, time pressure), desire to follow evidence-based medicine, and concern for adverse effects to influence prescribing. In the survey, reported concern regarding antibiotic side effects and the desire to practice evidence-based medicine were associated with lower prescribing rates whereas reported concern for patient satisfaction and patient demand were associated with high prescribing rates. High prescribers were generally unaware of their high prescribing status. CONCLUSIONS AND RELEVANCE: Physicians report that nonclinical factors frequently influence their decision to prescribe antibiotics for URTI. Physician concerns regarding antibiotic side effects and patient satisfaction are important factors in the decision-making process. Changes in the health system addressing both physicians and patients may be necessary to attain desired prescribing levels.

Management of Urinary Tract Infections in Direct to Consumer Telemedicine.

BACKGROUND: Urinary tract infections (UTI) are a common reason for seeking care via direct to consumer (DTC) telemedicine, yet patterns of care, including antibiotic prescribing, have not been reported. OBJECTIVE: To describe management of UTI in a large nationwide DTC telemedicine platform. DESIGN: Cross-sectional observational study. PARTICIPANTS: Patients seeking care for or diagnosed with UTI via DTC telemedicine between July 2016 and July 2018. MAIN MEASURES: Patient measures included age, sex, geographic region, satisfaction with care, and patient-reported call reason. High-risk patients were defined as males, patients over 65 years, or those diagnosed with pyelonephritis. Physician measures included specialty and geographic region. Antibiotic prescription was assessed overall and by antibiotic type. Variation in antibiotic prescriptions was assessed by patient and physician factors, including geographic region of both parties. KEY RESULTS: Of the 20,600 patients diagnosed with a UTI during the study period, 96% were female. Most (84%) stated their call reason was a UTI. Overall, 94% of UTI patients received an antibiotic; 56% got nitrofurantoin, 29% got trimethoprim-sulfamethoxazole, and 10% got a quinolone. Receipt of an antibiotic was associated with higher satisfaction with care (p < 0.001). While nitrofurantoin was the most common antibiotic for all physician regions, antibiotic type varied by physician region. Of the 6% of the study population defined as high risk, 69% received an antibiotic: 72% of males, 91% of women over 65, and 21% of patients diagnosed with pyelonephritis. CONCLUSIONS: Management of UTI via DTC telemedicine appears to be appropriate for average-risk patients, and most are able to self-diagnose. Most patients received guideline-concordant care, but over half of high-risk patients received antibiotics. DTC telemedicine offers convenient, low-cost care that is generally appropriate. Efforts should be made to ensure high-risk patients get proper follow-up.

The Colonic Single Stripe Sign: A Case of Ischemic Colitis.

Sudden, transient reduction in the blood flow especially in the "watershed" regions of the colon can lead to intestinal ischemia causing a decrease in the delivery of oxygen and nutrients to the intestinal wall. Patients with ischemic colitis often have elevated white blood cell counts, serum lactate, and serum amylase levels. Colonoscopy can confirm the diagnosis of ischemia and the findings include edematous, friable mucosa, erythema with interspersed pale areas, scattered hemorrhagic erosions or linear ulcerations. A single, linear ulcer running along the anti-mesenteric colonic wall, "single-stripe sign"- favors the diagnosis of ischemic colitis. Management of mild and moderate colonic ischemia includes supportive care with bowel rest, gastric suction for associated ileus, fluid-electrolyte balance, and broad-spectrum antibiotics. Patients with severe colonic ischemia may require abdominal exploration and colectomy.

Association Between Alcohol Use Disorders and Outcomes of Patients Hospitalized With Community-Acquired Pneumonia.

Importance: Patients with alcohol use disorder (AUD) are at elevated risk of developing pneumonia, but few studies have assessed the outcomes of pneumonia in patients with AUD. Objectives: To compare the causes, treatment, and outcomes of pneumonia in patients with and without AUD and to understand the associations of comorbid illnesses, alcohol withdrawal, and any residual effects due to alcohol itself with patient outcomes. Design, Setting, and Participants: A retrospective cohort study was conducted of 137 496 patients 18 years or older with pneumonia who were admitted to 177 US hospitals participating in the Premier Healthcare Database from July 1, 2010, to June 30, 2015. Statistical analysis was conducted from October 27, 2017, to August 20, 2018. Exposure: Alcohol use disorders identified from International Classification of Diseases, Ninth Revision, Clinical Modification codes. Main Outcomes and Measures: Pneumonia cause, antibiotic treatment, inpatient mortality, clinical deterioration, length of stay, and cost. Associations of AUD with these variables were studied using generalized linear mixed models. Results: Of 137 496 patients with community-acquired pneumonia (70 358 women and 67 138 men; mean [SD] age, 69.5 [16.2] years), 3.5% had an AUD. Patients with an AUD were younger than those without an AUD (median age, 58.0 vs 73.0 years; P < .001), more often male (77.3% vs 47.8%; P < .001), and more often had principal diagnoses of aspiration pneumonia (10.9% vs 9.8%; P < .001), sepsis (38.6% vs 30.7%; P < .001), or respiratory failure (9.3% vs 5.5%; P < .001). Their cultures more often grew Streptococcus pneumoniae (43.7% vs 25.5%; P < .001) and less frequently grew organisms resistant to guideline-recommended antibiotics (25.0% vs 43.7%; P < .001). Patients with an AUD were treated more often with piperacillin-tazobactam (26.2% vs 22.5%; P < .001) but equally as often with anti-methicillin-resistant Staphylococcus aureus agents (32.9% vs 31.8%; P = .11) compared with patients without AUDs. When adjusted for demographic characteristics and insurance, AUD was associated with higher mortality (odds ratio, 1.40; 95% CI, 1.25-1.56), length of stay (risk-adjusted geometric mean ratio, 1.24; 95% CI, 1.20-1.27), and costs (risk-adjusted geometric mean ratio, 1.33; 95% CI, 1.28-1.38). After additional adjustment for differences in comorbidities and risk factors for resistant organisms, AUD was no longer associated with mortality but remained associated with late mechanical ventilation (odds ratio, 1.28; 95% CI, 1.12-1.46), length of stay (risk-adjusted geometric mean ratio, 1.04; 95% CI, 1.01-1.06), and costs (risk-adjusted geometric mean ratio, 1.06; 95% CI, 1.03-1.09). Models segregating patients undergoing alcohol withdrawal showed that poorer outcomes among patients with AUD were confined to the subgroup undergoing alcohol withdrawal. Conclusions and Relevance: This study suggests that, compared with hospitalized patients with community-acquired pneumonia but without AUD, those with AUD less often harbor resistant organisms. The higher age-adjusted risk of death among patients with AUD appears to be largely attributable to differences in comorbidities, whereas greater use of health care resources may be attributable to alcohol withdrawal.