Evaluation of a New Clinical Endpoint for Moderate to Severe Influenza Disease in Children: A Prospective Cohort Study

Abstract Background A moderate to severe (M/S) influenza clinical endpoint has been proposed in children, defined as fever >39°C, otitis media, lower respiratory tract infection, or serious extrapulmonary manifestations. The objective of the study was to evaluate the M/S measure against clinically relevant outcomes including hospitalization, emergency room visits, antimicrobial use, and child/parental absenteeism. Methods We conducted a prospective observational study of children aged 6 months–8 years at the Children’s Hospital Colorado emergency department (ED) and urgent care site during 2016–2017 and 2017–2018. Children with influenza-like illness (ILI) underwent influenza testing by polymerase chain reaction (PCR); children who tested positive and a subset of matched test-negative controls underwent follow-up at 2 weeks. The primary outcome was the proportion of children who were hospitalized. Secondary outcomes included recurrent ED visits, antimicrobial use, hospital charges, and child/parental absenteeism within 14 days. Results Among 1478 children enrolled with ILI, 411 (28%) tested positive for influenza by PCR. Of children with influenza illness, 313 (76%) met the M/S definition. Children with M/S influenza were younger (3.8 years vs 4.8 years), infected with influenza A (59% vs 44%), and more frequently hospitalized (unadjusted risk difference [RD], 6.3%; 95% confidence interval [CI], 2.1–10.4; P = .03) and treated with antibiotics (unadjusted RD, 13.3%; 95% CI, 4.3–22.4; P < .01) compared to those with mild disease. Conclusions Children with M/S influenza have a higher risk of hospitalization and antibiotic use compared with mild disease. This proposed definition may be a useful clinical endpoint to study the public health and clinical impact of influenza interventions in children. Clinical Trials Registration NCT02979626.

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986. Evaluation of Moderate-to-Severe Influenza Disease in Children 6 Months to 8 Years of Age in Colorado

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.823 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S291-S292

Author(s):

Suchitra Rao ◽

Molly Lamb ◽

Angela Moss ◽

Emad Yanni ◽

Rafik Bekkat-Berkani ◽

...

Keyword(s):

Risk Difference ◽

Antimicrobial Use ◽

Clinical Endpoint ◽

Research Support ◽

Mild Disease ◽

Significant Difference ◽

Ed Visits ◽

Emergency Room Care ◽

Negative Controls ◽

Research Grant

Abstract Background A clinical endpoint of moderate-to-severe (M/S) influenza has been proposed in children, defined as fever >39°C, otitis media, lower respiratory tract infection, or serious extrapulmonary manifestations. This definition has not been evaluated against clinically relevant outcomes like hospitalization, emergency room care, antimicrobial use, and child/parental absenteeism. Methods We conducted a prospective observational study of children aged 6 months–8 years with influenza at the Children’s Hospital Colorado Emergency Department (ED) and its affiliates during two influenza seasons (2016–2017 and 2017–2018). Children with influenza-like-illness (ILI) were enrolled and tested for influenza by polymerase chain reaction (PCR). Parents of influenza cases and matched influenza-negative controls were contacted 2 weeks later for follow-up. The primary outcome was hospitalization for M/S influenza vs. mild influenza. Secondary outcomes included recurrent ED visits, antimicrobial use, child/parental absenteeism. Interim analyses were conducted using SAS v9.4. Results Among the 1,480 enrolled children with ILI, 410 (28%) tested positive for influenza by PCR. The median age of influenza cases was 4.0 years (IQR 2.2–6.1), and 20% were considered high-risk for influenza complications. Of influenza cases, 284 (69%) met the definition for M/S influenza. Among M/S influenza subjects, 8.4% were hospitalized, compared with 1.6% with mild influenza (risk difference (RD) 6.9%; 95% CI: 3.0–10.8, P < 0.01). Subjects with M/S influenza were more likely to receive antibiotics (RD 12.0%, 95% CI: 3.4–20.6, P < 0.01) with a trend to higher antiviral use (RD 6.9%, 95% CI: −0.7–14.5, P = 0.09). There was no significant difference for recurrent ED visits nor child/parental absenteeism. After adjusting for comorbidities, age, and influenza strain, the relative risk (RR) of hospitalization or recurrent ED visits was higher among those with M/S influenza vs. mild influenza (RR 2.18, 95% CI: 1.02–4.64, P = 0.04). Conclusion Children with M/S influenza have a higher risk of hospitalization compared with mild disease. This proposed definition is a useful clinical endpoint to study the public health and clinical impact of influenza interventions in children. Disclosures S. Rao, GSK: Investigator, Research grant. E. Yanni, GSK: Employee, Salary. R. Bekkat-Berkani, GSK: Employee, Salary. A. Schuind, GSK: Employee, Salary. B. Innis, GSK: Employee, Salary. R. Mistry, GSK: Investigator, Research support. E. J. Asturias, GSK: Investigator, Research grant and Research support.

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Positive Impact of Routine Testing for Enterovirus and Parechovirus on Length of Hospitalization and Antimicrobial Use among Inpatients ≤6 Months of Age

Journal of Clinical Microbiology ◽

10.1128/jcm.02106-20 ◽

2020 ◽

Vol 59 (1) ◽

pp. e02106-20

Author(s):

Brian R. Lee ◽

Anjana Sasidharan ◽

Chris J. Harrison ◽

Rangaraj Selvarangan

Keyword(s):

Kansas City ◽

Positive Impact ◽

Antibiotic Use ◽

Hospital Charges ◽

Cns Infection ◽

Antimicrobial Use ◽

Imaging Data ◽

Rt Pcr ◽

Young Infants ◽

Length Of Hospitalization

ABSTRACTEnterovirus (EV) and parechovirus (PeV) are leading viral causes of central nervous system (CNS) infection among hospitalized neonates and young infants, yet testing for PeV is not routinely performed. The goal of our study was to determine how EV and PeV CSF RT-PCR testing impacted the duration of antibiotic use and the length of hospitalization (LOS) in children ≤6 months old with suspected CNS infection. This retrospective cohort study at Children’s Mercy Kansas City evaluated data from patients ≤6 months old for whom routine CSF EV and PeV reverse transcription-PCR (RT-PCR) testing was performed during January 2011 to December 2018. Electronic data were abstracted from the electronic medical record, including demographics, systemic antimicrobial use, imaging data, herpes simplex virus (HSV) testing, and overall hospital charges. Among 1,926 patients, 345 (17.9%) were RT-PCR positive for EV and 172 (8.9%) were positive for PeV. A significantly shorter LOS was observed for patients with EV (51.6 h; P < 0.001) and PeV (66.3 h; P = 0.048) compared to patients that tested negative for both viruses (74.1 h). Discontinuation of empirical antibiotic therapy following test result availability occurred more frequently for PeV patients (57.8%; P = 0.03) and EV patients (65.4%; P < 0.001) than RT-PCR-negative patients (48.5%). Routine EV/PeV RT-PCR testing of cerebrospinal fluid (CSF) samples in children impacted care of hospitalized neonates and young infants. Rapid and prompt diagnosis has the potential to reduce antibiotic usage, length of stay, and patient charges.

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139. association of Physician Orders for Life-sustaining Treatment (POLST) with Antimicrobial Use at End of Life in Cancer Patients: An Antimicrobial Stewardship Opportunity

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.449 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S199-S200

Author(s):

Olivia Kates ◽

Elizabeth M Krantz ◽

Juhye Lee ◽

John Klaassen ◽

Jessica Morris ◽

...

Keyword(s):

End Of Life ◽

Cancer Patients ◽

Symptom Management ◽

Research Study ◽

Antibiotic Use ◽

Antimicrobial Use ◽

Study Investigator ◽

Days Of Therapy ◽

Life Sustaining Treatment ◽

Rate Ratios

Abstract Background IDSA/SHEA guidelines recommend that antimicrobial stewardship programs support providers in antibiotic decisions for end of life care. Washington State Physician Orders for Life-Sustaining Treatment (POLST) forms allow patients to indicate antimicrobial use preferences. We sought to characterize antimicrobial use in the last 30 days of life for cancer patients by presence of a POLST and antimicrobial use preferences. Methods We performed a single-center, retrospective cohort study of cancer patient deaths from January 1, 2016 - June 30, 3018. Patient demographics, clinical characteristics, POLST, and antimicrobial use within 30 days before death were extracted from electronic records. To test for an association between POLST completed at least 30 days before death and inpatient antimicrobial days of therapy (DOT) in the 30 days before death, we used negative binomial models adjusted for age, sex, race, and service line (hematologic versus solid malignancy); model estimates are presented as incidence rate ratios (IRR) with 95% confidence intervals (CI) Results Of 1796 patients, 406 (23%) had a POLST. 177/406 (44%) were completed less than 30 days before death, and 58/177 (32.8%) specified limited antibiotic use; 40/177 (23%) did not specify any antimicrobial use preference (Fig 1). Of 1295 patients with at least 1 inpatient day in the 30 days before death, 1070 (83%) received at least 1 inpatient antimicrobial with median DOT of 1077 per 1000 inpatient days (Tab 1). There was no difference in DOT among patients with and without a POLST > /= 30 days before death (IRR 0.92, CI 0.77, 1.10). Patients with a POLST specifying limited antibiotic use had significantly lower inpatient IV antimicrobial DOT compared to those without a POLST (IRR 0.64, CI 0.42–0.97) (Fig 2). Figure 1. Classification of Patients by Presence of POLST, Timing, and Antimicrobial Preference Content of POLST. Numbers shown represent the number of patients (percentage). Full antibiotic use refers to the selection “Use antibiotics for prolongation of life.” Limited antibiotic use refers to the selection “Do not use antibiotics except when needed for symptom management.” Table 1: Antimicrobial use for all patients and by advance directive group Figure 2. Forest plot of model estimates, represented as incidence rate ratios (IRR) with 95% confidence intervals (CI), for associations between POLST antimicrobial specifications completed at least 30 days before death and inpatient antibiotic days of therapy (DOT) in the 30 days before death. Estimates represent comparisons between each POLST category and no POLST completed at least 30 days before death. Dots represent the IRR and brackets extend to the lower and upper limit of the 95% CI. Blue estimates are for the inpatient antibiotic DOT outcome and red estimates are for the inpatient IV antibiotic DOT outcome. Conclusion POLST completion is rare > /= 30 days before death, with few POLSTs specifying antimicrobial use. Compared to those with no POLST in this time frame, patients who indicated that antibiotics should be used only for symptom management received significantly fewer inpatient IV antimicrobials. Early discussion of advance directives including POLST with specification of antimicrobial use preferences may promote more thoughtful use of antimicrobials near the end of life in a compassionate, patient-centered way. Disclosures Steven A. Pergam, MD, MPH, Chimerix, Inc (Scientific Research Study Investigator)Global Life Technologies, Inc. (Research Grant or Support)Merck & Co. (Scientific Research Study Investigator)Sanofi-Aventis (Other Financial or Material Support, Participate in clinical trial sponsored by NIAID (U01-AI132004); vaccines for this trial are provided by Sanofi-Aventis)

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152. Applying A Difference-in-Difference Analysis to Assess Effect of Antimicrobial Stewardship Strategies on Changes in Antimicrobial Use

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.197 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S86-S86

Author(s):

Ann F Chou ◽

Yue Zhang ◽

Makoto M Jones ◽

Christopher J Graber ◽

Matthew B Goetz ◽

...

Keyword(s):

Antimicrobial Stewardship ◽

Clinical Pharmacist ◽

Antibiotic Use ◽

Feedback Mechanism ◽

Health Care Facilities ◽

Antimicrobial Use ◽

Time Points ◽

The Difference ◽

The Impact ◽

Over Time

Abstract Background About 30–50% of inpatient antimicrobial therapy is sub-optimal. Health care facilities have utilized various antimicrobial stewardship (AS) strategies to optimize appropriate antimicrobial use, improve health outcomes, and promote patient safety. However, little evidence exists to assess relationships between AS strategies and antimicrobial use. This study examined the impact of changes in AS strategies on antimicrobial use over time. Methods This study used data from the Veterans Affairs (VA) Healthcare Analysis & Informatics Group (HAIG) AS survey, administered at 130 VA facilities in 2012 and 2015, and antimicrobial utilization from VA Corporate Data Warehouse. Four AS strategies were examined: having an AS team, feedback mechanism on antimicrobial use, infectious diseases (ID) attending physicians, and clinical pharmacist on wards. Change in AS strategies were computed by taking the difference in the presence of a given strategy in a facility between 2012–2015. The outcome was the difference between antimicrobial use per 1000 patient days in 2012–2013 and 2015–2016. Employing multiple regression analysis, changes in antimicrobial use was estimated as a function of changes in AS strategies, controlling for ID human resources in and organizational complexity. Results Of the 4 strategies, only change in availability of AS teams had an impact on antimicrobial use. Compared to facilities with no AS teams at both time points, antibiotic use decreased by 63.9 uses per 1000 patient days in facilities that did not have a AS team in 2012 but implemented one in 2015 (p=0.0183). Facilities that had an AS team at both time points decreased use by 62.2 per 1000 patient days (p=0.0324). Conclusion The findings showed that AS teams reduced inpatient antibiotic use over time. While changes in having feedback on antimicrobial use and clinical pharmacist on wards showed reduced antimicrobial use between 2012–2015, the differences were not statistically significant. These strategies may already be a part of a comprehensive AS program and employed by AS teams. In further development of stewardship programs within healthcare organizations, the association between AS teams and antibiotic use should inform program design and implementation. Disclosures All Authors: No reported disclosures

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Perceptions of Antibiotic Use and Resistance: Are Antibiotics the Dentists’ Anxiolytics?

Antibiotics ◽

10.3390/antibiotics10060735 ◽

2021 ◽

Vol 10 (6) ◽

pp. 735

Author(s):

Julie Dormoy ◽

Marc-Olivier Vuillemin ◽

Silvia Rossi ◽

Jean-Marc Boivin ◽

Julie Guillet

Keyword(s):

Public Health ◽

Antibiotic Resistance ◽

Qualitative Method ◽

Oral Surgery ◽

Antibiotic Use ◽

Public Health Issue ◽

Clinical Factors ◽

Structured Interviews ◽

Health Crisis ◽

The Public

Background: Antibiotic resistance is a global health crisis. The aim of this study was to explore dentists’ perceptions of antibiotic resistance. Methods: A qualitative method was used. Seventeen dentists practising in the Nancy (Lorraine, France) region were surveyed. They were general practitioners or specialised in oral surgery, implantology, or periodontology. The practitioners took part in semi-structured interviews between September 2019 and July 2020. All of the interviews were transcribed in full and analysed thematically. Results: Four major themes have been selected: attitudes of the dentists in regard to the guidelines, clinical factors that influence prescriptions, non-clinical factors that influence prescriptions, and the perception of antibiotic resistance. The dentists stated that they were very concerned regarding the public health issue of antibiotic resistance. However, they often prescribe according to their own interests and habits rather than according to the relevant guidelines. Conclusions: Although dentists are generally well aware of antibiotic resistance, they often do not adequately appreciate the link between their prescribing habits and the phenomenon of antibiotic resistance. Regular updating of practitioners’ knowledge in this regard is necessary, but patients and the general public should also be made more aware of the issue.

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Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Pharyngitis

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.728 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s188-s189

Author(s):

Jeffrey Gerber ◽

Robert Grundmeier ◽

Keith Hamilton ◽

Lauri Hicks ◽

Melinda Neuhauser ◽

...

Keyword(s):

Predictive Value ◽

Gold Standard ◽

Antibiotic Stewardship ◽

Chart Review ◽

Antibiotic Use ◽

Audit And Feedback ◽

Urgent Care ◽

Antibiotic Prescribing ◽

Tract Infections ◽

The Impact

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.Funding: NoneDisclosures: None

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Disruption of Services in an Internal Medicine Unit Due to a Nosocomial Influenza Outbreak

Infection Control and Hospital Epidemiology ◽

10.1086/501981 ◽

2002 ◽

Vol 23 (10) ◽

pp. 615-619 ◽

Cited By ~ 81

Author(s):

Catherine Sartor ◽

Christine Zandotti ◽

Fanny Romain ◽

Véronique Jacomo ◽

Sophie Simon ◽

...

Keyword(s):

Internal Medicine ◽

Influenza Virus ◽

Acute Care ◽

Influenza A ◽

Hospital Charges ◽

Influenza Outbreak ◽

Vaccination Rates ◽

Staff Members ◽

Acute Care Settings ◽

Internal Medicine Unit

Objective:To describe a nosocomial influenza A out-break, how it was managed, what impact it had on subsequent delivery of health care, and the additional charges attributable to it.Design:Prospective cohort study and microbiological investigation.Setting:One internal medicine unit in an acute care, university-affiliated hospital.Participants:Twenty-three patients and 22 staff members from February 28 to March 6,1999.Results:Attack rates were 41% (9 of 22) among patients and 23% (5 of 22) among staff members, with 3 of 14 cases being classified as “certain”. The influenza virus isolates were typed as A/SYDNEY/5/97 (H3N2). The index case was a patient who shared a room with the first nosocomial case. Vaccination rates for influenza virus were 43% (10 of 23) among patients and 36% (8 of 22) among staff members. The outbreak resulted in staff members' taking 14 person-days of sick leave. Furthermore, 8 scheduled admissions were postponed and all emergency admissions were suspended for 11 days. Hospital charges attributable to the influenza outbreak totaled $34,179 and the average extra charge per infected patient was $3,798.Conclusions:Nosocomial influenza outbreaks increase charges and alter the quality of care delivered in acute care settings. Strategies for their prevention need to be evaluated in acute care settings. (Infect Control Hosp Epidemiol 2002;23:615-619).

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Prospective Audit for Antimicrobial Use and Stewardship Practices in Intensive Care Unit at a Tertiary-Care Center in India

Antimicrobial Stewardship & Healthcare Epidemiology ◽

10.1017/ash.2021.74 ◽

2021 ◽

Vol 1 (S1) ◽

pp. s40-s40

Author(s):

Parul Singh ◽

Purva Mathur ◽

Kamini Walia ◽

Anjan Trikha

Keyword(s):

Care Center ◽

Tertiary Care ◽

Empirical Therapy ◽

Antibiotic Use ◽

Audit And Feedback ◽

Antimicrobial Use ◽

Defined Daily Dose ◽

Survey Form ◽

Specimen Collection ◽

Days Of Therapy

Background: Antimicrobial decision making in the ICU is challenging. Injudicious use of antimicrobials contributes to the development of resistant pathogens and drug-related adverse events. However, inadequate antimicrobial therapy is associated with mortality in critically ill patients. Antimicrobial stewardship programs are increasingly being implemented to improve prescribing. Methods: This prospective study was conducted over 11 months, during which the pharmacist used a standardized survey form to collect data on antibiotic use. Evaluation of antimicrobial use and stewardship practices in a 12-bed polytrauma ICU and a 20-bed neurosurgery ICU of the 248-bed AIIMS Trauma Center in Delhi, India. Antimicrobial consumption was measured using WHO-recommended defined daily dose (DDD) of given antimicrobials and days of therapy (DOT). Results: Antibiotics were ranked by frequency of use over the 11-month period based on empirical therapy and culture-based therapy. The 11-month DDD and DOT averages when empiric antibiotics were used were 532 of 1,000 patient days and 484 per 1,000 patient days, respectively (Figure 1). When cultures were available, DDD was 486 per 1,000 patient days and DOT was 442 per 1,000 patient days (Figure). Conclusions: The quantity and frequency of antibiotics used in the ICUs allowed the AMSP to identify areas to optimize antibiotic use such as educational initiatives, early specimen collection, and audit and feedback opportunities.Funding: NoDisclosures: None

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Children under 10 years of age were more affected by the 2018/19 influenza A(H1N1)pdm09 epidemic in Canada: ‎possible cohort effect following the 2009 influenza pandemic

Eurosurveillance ◽

10.2807/1560-7917.es.2019.24.15.1900104 ◽

2019 ◽

Vol 24 (15) ◽

Cited By ~ 6

Author(s):

Danuta M Skowronski ◽

Siobhan Leir ◽

Gaston De Serres ◽

Michelle Murti ◽

James A Dickinson ◽

...

Keyword(s):

General Population ◽

Influenza A ◽

Influenza Pandemic ◽

Age Distribution ◽

Cohort Effect ◽

Surveillance Network ◽

Medical Visits ◽

Influenza A H1n1 ◽

2009 Influenza Pandemic ◽

Negative Controls

Introduction Findings from the community-based Canadian Sentinel Practitioner Surveillance Network (SPSN) suggest children were more affected by the 2018/19 influenza A(H1N1)pdm09 epidemic. Aim To compare the age distribution of A(H1N1)pdm09 cases in 2018/19 to prior seasonal influenza epidemics in Canada. Methods The age distribution of unvaccinated influenza A(H1N1)pdm09 cases and test-negative controls were compared across A(H1N1)pdm09-dominant epidemics in 2018/19, 2015/16 and 2013/14 and with the general population of SPSN provinces. Similar comparisons were undertaken for influenza A(H3N2)-dominant epidemics. Results In 2018/19, more influenza A(H1N1)pdm09 cases were under 10 years old than controls (29% vs 16%; p < 0.001). In particular, children aged 5–9 years comprised 14% of cases, greater than their contribution to controls (4%) or the general population (5%) and at least twice their contribution in 2015/16 (7%; p < 0.001) or 2013/14 (5%; p < 0.001). Conversely, children aged 10–19 years (11% of the population) were under-represented among A(H1N1)pdm09 cases versus controls in 2018/19 (7% vs 12%; p < 0.001), 2015/16 (7% vs 13%; p < 0.001) and 2013/14 (9% vs 12%; p = 0.12). Conclusion Children under 10 years old contributed more to outpatient A(H1N1)pdm09 medical visits in 2018/19 than prior seasonal epidemics in Canada. In 2018/19, all children under 10 years old were born after the 2009 A(H1N1)pdm09 pandemic and therefore lacked pandemic-induced immunity. In addition, more than half those born after 2009 now attend school (i.e. 5–9-year-olds), a socio-behavioural context that may enhance transmission and did not apply during prior A(H1N1)pdm09 epidemics.

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Antimicrobial use in COVID-19 patients in the first phase of the SARS-CoV-2 pandemic: Rapid review and evidence synthesis

10.1101/2021.02.18.21251932 ◽

2021 ◽

Author(s):

Wenjuan Cong ◽

Ak Narayan Poudel ◽

Nour Alhusein ◽

Hexing Wang ◽

Guiqing Yao ◽

...

Keyword(s):

Antibiotic Resistance ◽

Critical Illness ◽

Antimicrobial Resistance ◽

Early Phase ◽

Data Extraction ◽

Antibiotic Use ◽

Rapid Review ◽

Antibiotic Prescribing ◽

Antimicrobial Use ◽

Secondary Infections

AbstractBackgroundAs the numbers of people with COVID-19 continue to increase globally, concerns have been raised regarding the widespread use of antibiotics for the treatment of COVID-19 patients and its consequences for antimicrobial resistance during the pandemic and beyond. The scale and determinants of antibiotic use in the early phase of the pandemic, and whether antibiotic prescribing is beneficial to treatment effectiveness in COVID-19 patients, are still unknown. Unwarranted treatment of this viral infection with antibiotics may exacerbate the problem of antibiotic resistance, while antibiotic resistance may render presumptive treatment of secondary infections in COVID-19 patients ineffective.MethodsThis rapid review was undertaken to identify studies reporting antimicrobial use in the treatment of hospitalised COVID-19 patients. The review was conducted to comply with PRISMA guidelines for Scoping Reviews (http://www.prisma-statement.org/Extensions/ScopingReviews) and the protocol was registered with the Open Science Framework (OSF): http://osf.io/vp6t5. The following databases: Web of Science, EMBASE, PubMed, CNKI & VIP were searched to identify the relevant studies from 1 Dec 2019 up to 15 June 2020; no limits were set on the language or the country where studies were conducted. The search terms used were: ((“Covid-19” or “SARS-CoV-2” or “Coronavirus disease 2019” or “severe acute respiratory syndrome coronavirus-2”) and ((“antibiotic prescribing” or “antibiotic use” or “antibiotic*”) or “antimicrobial *” or “antimicrobial therapy” or “antimicrobial resistance” or “antimicrobial stewardship”)). A total of 1216 records were identified through database searching and 118 clinical studies met the inclusion criteria and were taken into data extraction. A bespoke data extraction form was developed and validated through two independent, duplicate extraction of data from five Records. As all the included studies were descriptive in nature, we conducted descriptive synthesis of data and reported pooled estimates such as mean, percentage and frequency. We created a series of scenarios to capture the range of rationales for antibiotic prescribing presented in the included studies.ResultsOur results show that during the early phase of the pandemic, 8501 out of 10 329 COVID-19 patients (82·3%) were prescribed antibiotics; antibiotics were prescribed for COVID-19 patients regardless of reported severity, with a similar mean antibiotic prescribing rate between patients with severe or critical illness (75·4%) and patients with mild or moderate illness (75·1%). The top five frequently prescribed antibiotics for hospitalised COVID-19 patients were azithromycin (28·0 % of studies), ceftriaxone (17·8%), moxifloxacin (14·4%), meropenem (14·4%) and piperacillin/tazobactam (12·7%). The proportion of patients prescribed antibiotics without clinical justification was 51·5% vs 41·9 % for patients with mild or moderate illness and those with severe or critical illness respectively. Comparison of patients who were provided antibiotics with a clinical justification with those who were given antibiotics without clinical justification showed lower mortality rates (9·5% vs 13·1%), higher discharge rates (80·9% vs 69·3%) and shorter length of hospital of stay (9·3 days vs 12·2 days). Only 9·7% of patients in our included studies were reported to have secondary infections.ConclusionsAntibiotics were prescribed indiscriminately for hospitalised COVID-19 patients regardless of severity of illness during the early phase of the pandemic. COVID-19 related concerns and lack of knowledge drove a large proportion of antibiotic use without specific clinical justification. Although we are still in the midst of the pandemic, the goals of antimicrobial stewardship should remain unchanged for the treatment of COVID-19 patients.

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