2062. Improving Antibiotic Prescribing in the Ambulatory Care Setting—Stewardship through Influenza Vaccination, US Flu VE Network 2013–2014 Through 2017–2018

Abstract Background Improving antibiotic use is a key strategy to combat antibiotic resistance and improve patient safety. Acute respiratory illness (ARI) is a common cause of outpatient visits and accounts for ~41% of antibiotics used in the United States. We sought to determine the proportion of antibiotic prescriptions (Rx) prescribed among outpatients with ARI that can be potentially averted through influenza vaccination. Methods From 2013–2014 through 2017–2018 influenza seasons, we enrolled patients aged ≥6 months with ARI in the US Influenza Vaccine Effectiveness (VE) Network of >50 outpatient clinics. Antibiotic Rx and diagnosis codes were collected from medical records. Study influenza test results were not available to treating clinicians at most sites, and clinical influenza testing was infrequently performed (a), prevalence of influenza among unvaccinated ARI patients (b), prevalence of antibiotic Rx among unvaccinated influenza-positive ARI patients (c) and prevalence of antibiotic Rx among ARI patients overall (d), we derived estimates of the proportion of ARI antibiotic Rx that can be averted by influenza vaccination [(a × b × c)/d]. Results Among 37487 outpatients with ARI, 13,316 (36%) were prescribed an antibiotic and 9,689 (26%) tested positive for influenza. Of those positive, 2,496 (26%) were prescribed an antibiotic. Adjusted VE against influenza-associated ARI was 35% (95% confidence interval (CI), 32 to 39). Among unvaccinated patients with ARI, 30% were influenza-positive and 24% received antibiotics. Based on these estimates, we determined that influenza vaccination may prevent 10.6% of all ARI syndromes and may avert 1 in 14 or 7.3% of antibiotic Rx among ARI patients. Conclusion By preventing influenza-associated ARI syndromes, influenza vaccination may substantially reduce antibiotic prescribing. Increasing influenza vaccine coverage and improving protection may facilitate national goals to improve antibiotic use and reduce the global threat of antibiotic resistance. Disclosures All authors: No reported disclosures.

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2742. The Impact of Influenza Vaccination on Antibiotic Use in the United States, 2010–2017

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.2419 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S965-S966

Author(s):

Eili Klein ◽

Emily Schueller ◽

Katie K Tseng ◽

Arindam Nandi

Keyword(s):

United States ◽

Antibiotic Resistance ◽

Influenza Vaccination ◽

Vaccination Coverage ◽

Seasonal Influenza ◽

Antibiotic Use ◽

The United States ◽

Antibiotic Prescribing ◽

Coverage Rates ◽

The Impact

Abstract Background Antibiotic resistance is a cause of morbidity and mortality driven by inappropriate prescribing. In the United States, a third of all outpatient antibiotic prescriptions may be inappropriate. Seasonal influenza rates are significantly associated with antibiotic prescribing rates. The impact of influenza vaccination coverage on antibiotic prescribing is unknown. Methods We conducted a retrospective analysis of state-level vaccination coverage and antibiotic prescribing rates from 2010 to 2017. We used fixed effects regression to analyze the relationship between cumulative vaccine coverage rates for a season and the per capita number of prescriptions for systemic antibiotics for the corresponding season (January–March) controlling for temperature, poverty, healthcare infrastructure, population structure, and vaccine effectiveness. Results Rates of vaccination coverage ranged from 33% in Nevada to 52% in Rhode Island for the 2016–2017 season, while antibiotic use rates ranged from 25 prescriptions per 1,000 inhabitants in Alaska to 377 prescriptions per 1,000 inhabitants in West Virginia (Figure 1). Vaccination coverage rates were highly correlated with reduced prescribing rates, and controlling for other factors, we found that a one percent increase in the influenza vaccination rate was associated with 1.40 (95% CI: 2.22–0.57, P < 0.01) fewer antibiotic prescriptions per 1,000 inhabitants (Table 1). Increases in the vaccination coverage rate in the pediatric population (aged 0–18) had the strongest effect, followed by the elderly (aged 65+). Conclusion Vaccination can reduce morbidity and mortality from seasonal influenza. Though coverage rates are far below levels necessary to generate herd immunity, we found that higher coverage rates in a state were associated with lower antibiotic prescribing rates. While the effectiveness of the vaccine varies from year to year and the factors that drive antibiotic prescribing rates are multi-factorial, these results suggest that increased vaccination coverage for influenza would have significant benefit in terms of reducing antibiotic overuse and correspondingly antibiotic resistance. Disclosures All authors: No reported disclosures.

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Reducing Antibiotic Use in Ambulatory Care Through Influenza Vaccination

Clinical Infectious Diseases ◽

10.1093/cid/ciaa464 ◽

2020 ◽

Vol 71 (11) ◽

pp. e726-e734

Author(s):

Emily R Smith ◽

Alicia M Fry ◽

Lauri A Hicks ◽

Katherine E Fleming-Dutra ◽

Brendan Flannery ◽

...

Keyword(s):

Antibiotic Resistance ◽

Influenza Vaccination ◽

Clinical Decision Making ◽

Respiratory Illness ◽

Clinical Decision ◽

Antibiotic Use ◽

The United States ◽

Diagnostic Code ◽

Upper Respiratory Tract ◽

Global Threat

Abstract Background Improving appropriate antibiotic use is crucial for combating antibiotic resistance and unnecessary adverse drug reactions. Acute respiratory illness (ARI) commonly causes outpatient visits and accounts for ~41% of antibiotics used in the United States. We examined the influence of influenza vaccination on reducing antibiotic prescriptions among outpatients with ARI. Methods We enrolled outpatients aged ≥6 months with ARI from 50–60 US clinics during 5 winters (2013–2018) and tested for influenza with RT-PCR; results were unavailable for clinical decision making and clinical influenza testing was infrequent. We collected antibiotic prescriptions and diagnosis codes for ARI syndromes. We calculated vaccine effectiveness (VE) by comparing vaccination odds among influenza-positive cases with test-negative controls. We estimated ARI visits and antibiotic prescriptions averted by influenza vaccination using estimates of VE, coverage, and prevalence of antibiotic prescriptions and influenza. Results Among 37 487 ARI outpatients, 9659 (26%) were influenza positive. Overall, 36% of ARI and 26% of influenza-positive patients were prescribed antibiotics. The top 3 prevalent ARI syndromes included: viral upper respiratory tract infection (47%), pharyngitis (18%), and allergy or asthma (11%). Among patients testing positive for influenza, 77% did not receive an ICD-CM diagnostic code for influenza. Overall, VE against influenza-associated ARI was 35% (95% CI, 32–39%). Vaccination prevented 5.6% of all ARI syndromes, ranging from 2.8% (sinusitis) to 11% (clinical influenza). Influenza vaccination averted 1 in 25 (3.8%; 95% CI, 3.6–4.1%) antibiotic prescriptions among ARI outpatients during influenza seasons. Conclusions Vaccination and accurate influenza diagnosis may curb unnecessary antibiotic use and reduce the global threat of antibiotic resistance.

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Influenza vaccine effectiveness against hospitalization in the United States, 2019-2020

The Journal of Infectious Diseases ◽

10.1093/infdis/jiaa800 ◽

2020 ◽

Author(s):

Mark W Tenforde ◽

H Keipp Talbot ◽

Christopher H Trabue ◽

Manjusha Gaglani ◽

Tresa M McNeal ◽

...

Keyword(s):

United States ◽

Influenza Vaccine ◽

Influenza Vaccination ◽

Respiratory Illness ◽

The United States ◽

Vaccine Effectiveness ◽

Influenza Viruses ◽

Current Season ◽

Hospital Resources ◽

Negative Controls

Abstract Background Influenza causes significant morbidity and mortality and stresses hospital resources during periods of increased circulation. We evaluated the effectiveness of the 2019-2020 influenza vaccine against influenza-associated hospitalizations in the United States. Methods We included adults hospitalized with acute respiratory illness at 14 hospitals and tested for influenza viruses by reserve transcription polymerase chain reaction. Vaccine effectiveness (VE) was estimated by comparing the odds of current-season influenza vaccination in test-positive influenza cases versus test-negative controls, adjusting for confounders. VE was stratified by age and major circulating influenza types along with A(H1N1)pdm09 genetic subgroups. Results 3116 participants were included, including 18% (553) influenza-positive cases. Median age was 63 years. Sixty-seven percent (2079) received vaccination. Overall adjusted VE against influenza viruses was 41% (95% confidence interval [CI]: 27-52). VE against A(H1N1)pdm09 viruses was 40% (95% CI: 24-53) and 33% against B viruses (95% CI: 0-56). Of the two major A(H1N1)pdm09 subgroups (representing 90% of sequenced H1N1 viruses), VE against one group (5A+187A,189E) was 59% (95% CI: 34-75) whereas no significant VE was observed against the other group (5A+156K) [-1%, 95% CI: -61-37]. Conclusions In a primarily older population, influenza vaccination was associated with a 41% reduction in risk of hospitalized influenza illness.

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Impact of existing vaccines in reducing antibiotic resistance: Primary and secondary effects

Proceedings of the National Academy of Sciences ◽

10.1073/pnas.1721095115 ◽

2018 ◽

Vol 115 (51) ◽

pp. 12896-12901 ◽

Cited By ~ 35

Author(s):

Keith P. Klugman ◽

Steven Black

Keyword(s):

Antibiotic Resistance ◽

Influenza Vaccination ◽

Direct Reduction ◽

Antibiotic Use ◽

The United States ◽

Antibiotic Usage ◽

Secondary Effect ◽

Antibiotic Resistant ◽

Vaccination Programs ◽

The Impact

Vaccines impact antibiotic-resistant infections in two ways: through a direct reduction in the organisms and strains carrying resistant genes that are specifically targeted by the vaccine and also via a secondary effect through a reduction in febrile illnesses that often lead to the use of antibiotics. We review here the impact of pneumococcal conjugate vaccines (PCVs) on the prevalence of antibiotic-resistant disease and antibiotic usage as an example of the direct effect of vaccines on antibiotic resistance and the impact of influenza vaccination on antibiotic usage as an example of a secondary effect. A prelicensure study of a PCV in Africa demonstrated 67% fewer penicillin-resistant invasive disease episodes in the PCV group compared with controls. Similar studies in the United States and Europe demonstrated reductions in antibiotic use consistent with the vaccines’ impact on the risk of otitis media infections in children. Postlicensure reductions in the circulation of antibiotic-resistant strains targeted by the vaccines have been dramatic, with virtual elimination of these strains in children following vaccine introduction. In terms of a secondary effect, following influenza vaccination reductions of 13–50% have been observed in the use of antibiotics by individuals receiving influenza vaccine compared with controls. With the demonstrated effectiveness of vaccination programs in impacting the risk of antibiotic-resistant infections and the increasing threat to public health that these infections represent, more attention needs to be given to development and utilization of vaccines to address antibiotic resistance.

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The Impact of Influenza Vaccination on Antibiotic Use in the United States, 2010–2017

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa223 ◽

2020 ◽

Vol 7 (7) ◽

Author(s):

Eili Y Klein ◽

Emily Schueller ◽

Katie K Tseng ◽

Daniel J Morgan ◽

Ramanan Laxminarayan ◽

...

Keyword(s):

United States ◽

Influenza Vaccination ◽

Vaccination Coverage ◽

State Level ◽

Population Level ◽

Antibiotic Use ◽

The United States ◽

Vaccine Effectiveness ◽

Severe Illness ◽

Antibiotic Prescribing

Abstract Background Influenza, which peaks seasonally, is an important driver for antibiotic prescribing. Although influenza vaccination has been shown to reduce severe illness, evidence of the population-level effects of vaccination coverage on rates of antibiotic prescribing in the United States is lacking. Methods We conducted a retrospective analysis of influenza vaccination coverage and antibiotic prescribing rates from 2010 to 2017 across states in the United States, controlling for differences in health infrastructure and yearly vaccine effectiveness. Using data from IQVIA’s Xponent database and the US Centers for Disease Control and Prevention’s FluVaxView, we employed fixed-effects regression analysis to analyze the relationship between influenza vaccine coverage rates and the number of antibiotic prescriptions per 1000 residents from January to March of each year. Results We observed that, controlling for socioeconomic differences, access to health care, childcare centers, climate, vaccine effectiveness, and state-level differences, a 10–percentage point increase in the influenza vaccination rate was associated with a 6.5% decrease in antibiotic use, equivalent to 14.2 (95% CI, 6.0–22.4; P = .001) fewer antibiotic prescriptions per 1000 individuals. Increased vaccination coverage reduced prescribing rates the most in the pediatric population (0–18 years), by 15.2 (95% CI, 9.0–21.3; P < .001) or 6.0%, and the elderly (aged 65+), by 12.8 (95% CI, 6.5–19.2; P < .001) or 5.2%. Conclusions Increased influenza vaccination uptake at the population level is associated with state-level reductions in antibiotic use. Expanding influenza vaccination could be an important intervention to reduce unnecessary antibiotic prescribing.

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Projected Population Benefit of Increased Effectiveness and Coverage of Influenza Vaccination on Influenza Burden in the United States

Clinical Infectious Diseases ◽

10.1093/cid/ciz676 ◽

2019 ◽

Vol 70 (12) ◽

pp. 2496-2502 ◽

Cited By ~ 11

Author(s):

Michelle M Hughes ◽

Carrie Reed ◽

Brendan Flannery ◽

Shikha Garg ◽

James A Singleton ◽

...

Keyword(s):

United States ◽

Mathematical Model ◽

Influenza Vaccine ◽

Influenza Vaccination ◽

Vaccine Coverage ◽

Age Groups ◽

The United States ◽

Absolute Increase ◽

Policy Agendas ◽

Research And Policy

Abstract Background Vaccination is the best way to prevent influenza; however, greater benefits could be achieved. To help guide research and policy agendas, we aimed to quantify the magnitude of influenza disease that would be prevented through targeted increases in vaccine effectiveness (VE) or vaccine coverage (VC). Methods For 3 influenza seasons (2011–12, 2015–16, and 2017–18), we used a mathematical model to estimate the number of prevented influenza-associated illnesses, medically attended illnesses, and hospitalizations across 5 age groups. Compared with estimates of prevented illness during each season, given observed VE and VC, we explored the number of additional outcomes that would have been prevented from a 5% absolute increase in VE or VC or from achieving 60% VE or 70% VC. Results During the 2017–18 season, compared with the burden already prevented by influenza vaccination, a 5% absolute VE increase would have prevented an additional 1 050 000 illnesses and 25 000 hospitalizations (76% among those aged ≥65 years), while achieving 60% VE would have prevented an additional 190 000 hospitalizations. A 5% VC increase would have resulted in 785 000 fewer illnesses (56% among those aged 18–64 years) and 11 000 fewer hospitalizations; reaching 70% would have prevented an additional 39 000 hospitalizations. Conclusions Small, attainable improvements in effectiveness or VC of the influenza vaccine could lead to substantial additional reductions in the influenza burden in the United States. Improvements in VE would have the greatest impact in reducing hospitalizations in adults aged ≥65 years, and VC improvements would have the largest benefit in reducing illnesses in adults aged 18–49 years.

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Estimating the proportion of bystander selection for antibiotic resistance in the US

10.1101/288704 ◽

2018 ◽

Cited By ~ 4

Author(s):

Christine Tedijanto ◽

Scott Olesen ◽

Yonatan Grad ◽

Marc Lipsitch

Keyword(s):

Antibiotic Resistance ◽

Medical Care ◽

Antibiotic Use ◽

The United States ◽

Microbial Flora ◽

Antibiotic Prescribing ◽

Care Survey ◽

Selection For ◽

Ambulatory Medical Care ◽

The Impact

AbstractBystander selection -- the selective pressures exerted by antibiotics on microbial flora that are not the target pathogen of treatment -- is critical to understanding the total impact of broad-spectrum antibiotic use; however, to our knowledge, this effect has never been quantified. Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (NAMCS/NHAMCS), the Human Microbiome Project, and additional carriage and etiological data from existing literature, we estimate the magnitude of bystander selection for a range of clinically relevant antibiotic-species pairs as the proportion of all exposures of an antibiotic experienced by a species for conditions in which that species was not the causative pathogen (“proportion of bystander exposures”). For outpatient prescribing in the United States, we find that this proportion over all included antibiotics is over 80% for 8 out of 9 organisms of interest. Low proportions of bystander exposure are often associated with infrequent bacterial carriage or a high proportion of antibiotic prescribing focused on conditions caused by the species of interest. Using the proportion of bystander exposures, we roughly estimate that S. aureus and E. coli may benefit from 90.7% and 99.7%, respectively, of the estimated reduction in antibiotic use due to pneumococcal conjugate vaccination, despite not being the pathogen targeted by the vaccine. These results underscore the importance of considering antibiotic exposures to bystanders, in addition to the targeted pathogen, in measuring the impact of antibiotic resistance interventions.Significance StatementThe forces that contribute to changing population prevalence of antibiotic resistance are not well understood. Bystander selection -- the inadvertent pressures imposed by antibiotics on the microbial flora other than the pathogen targeted by treatment -- is hypothesized to be a major factor in the propagation of antibiotic resistance, but its extent has not been characterized. We estimate the proportion of bystander exposures across a range of antibiotics and organisms and describe factors driving variability of these proportions. Impact estimates for antibiotic resistance interventions, including vaccination, are often limited to effects on a target pathogen. However, the reduction of antibiotic treatment for illnesses caused by the target pathogen may have the broader potential to decrease bystander selection pressures for resistance on many other organisms.

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Influenza vaccination coverage in a population-based cohort of Australian-born Aboriginal and non-Indigenous older adults

Communicable Diseases Intelligence ◽

10.33321/cdi.2019.43.30 ◽

2019 ◽

Vol 43 ◽

Author(s):

Amalie Dyda ◽

Surendra Karki ◽

Marlene Kong ◽

Heather F Gidding ◽

John M Kaldor ◽

...

Keyword(s):

Influenza Vaccine ◽

Influenza Vaccination ◽

Vaccination Coverage ◽

Torres Strait Islander ◽

Vaccine Coverage ◽

Vaccine Uptake ◽

P Value ◽

Healthy Weight ◽

Medical Risk ◽

Torres Strait

Background: There is limited information on vaccination coverage and characteristics associated with vaccine uptake in Aboriginal and/or Torres Strait Islander adults. We aimed to provide more current estimates of influenza vaccination coverage in Aboriginal adults. Methods: Self-reported vaccination status (n=559 Aboriginal and/or Torres Strait Islander participants, n=80,655 non-Indigenous participants) from the 45 and Up Study, a large cohort of adults aged 45 years or older, was used to compare influenza vaccination coverage in Aboriginal and/or Torres Strait Islander adults with coverage in non-Indigenous adults. Results: Of Aboriginal and non-Indigenous respondents aged 49 to <65 years, age-standardised influenza coverage was respectively 45.2% (95% CI 39.5–50.9%) and 38.5%, (37.9–39.0%), p-value for heterogeneity=0.02. Coverage for Aboriginal and non-Indigenous respondents aged ≥65 years was respectively 67.3% (59.9–74.7%) and 72.6% (72.2–73.0%), p-heterogeneity=0.16. Among Aboriginal adults, coverage was higher in obese than in healthy weight participants (adjusted odds ratio (aOR)=2.38, 95%CI 1.44–3.94); in those aged <65 years with a medical risk factor than in those without medical risk factors (aOR=2.13, 1.37–3.30); and in those who rated their health as fair/poor compared to those who rated it excellent (aOR=2.57, 1.26–5.20). Similar associations were found among non-Indigenous adults. Conclusions: In this sample of adults ≥65 years, self-reported influenza vaccine coverage was not significantly different between Aboriginal and non-Indigenous adults whereas in those <65 years, coverage was higher among Aboriginal adults. Overall, coverage in the whole cohort was suboptimal. If these findings are replicated in other samples and in the Australian Immunisation Register, it suggests that measures to improve uptake, such as communication about the importance of influenza vaccine and more effective reminder systems, are needed among adults.

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Influenza vaccination and the risk of COVID-19 infection and severe illness in older adults in the United States

Scientific Reports ◽

10.1038/s41598-021-90068-y ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Kelly Huang ◽

Shu-Wen Lin ◽

Wang-Huei Sheng ◽

Chi-Chuan Wang

Keyword(s):

Immune Responses ◽

Influenza Vaccine ◽

Influenza Vaccination ◽

The United States ◽

Cross Sectional Study ◽

Severe Illness ◽

Cross Sectional ◽

Global Pandemic ◽

Study Population ◽

Health Database

AbstractThe coronavirus disease of 2019 (COVID-19) has caused a global pandemic and led to nearly three million deaths globally. As of April 2021, there are still many countries that do not have COVID-19 vaccines. Before the COVID-19 vaccines were developed, some evidence suggested that an influenza vaccine may stimulate nonspecific immune responses that reduce the risk of COVID-19 infection or the severity of COVID-19 illness after infection. This study evaluated the association between influenza vaccination and the risk of COVID-19 infection. We conducted a retrospective cross-sectional study with data from July 1, 2019, to June 30, 2020 with the Claims data from Symphony Health database. The study population was adults age 65 years old or older who received influenza vaccination between September 1 and December 31 of 2019. The main outcomes and measures were odds of COVID-19 infection and severe COVID-19 illness after January 15, 2020. We found the adjusted odds ratio (aOR) of COVID-19 infection risk between the influenza-vaccination group and no-influenza-vaccination group was 0.76 (95% confidence interval (CI), 0.75–0.77). Among COVID-19 patients, the aOR of developing severe COVID-19 illness was 0.72 (95% CI, 0.68–0.76) between the influenza-vaccination group and the no-influenza-vaccination group. When the influenza-vaccination group and the other-vaccination group were compared, the aOR of COVID-19 infection was 0.95 (95% CI, 0.93–0.97), and the aOR of developing a severe COVID-19 illness was 0.95 (95% CI, 0.80–1.13). The influenza vaccine may marginally protect people from COVID-19 infection.

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Prescribers’ Knowledge, Attitudes and Behaviors on Antibiotics, Antibiotic Use and Antibiotic Resistance in Jordan

Antibiotics ◽

10.3390/antibiotics10070858 ◽

2021 ◽

Vol 10 (7) ◽

pp. 858

Author(s):

Reema A. Karasneh ◽

Sayer I. Al-Azzam ◽

Mera Ababneh ◽

Ola Al-Azzeh ◽

Ola B. Al-Batayneh ◽

...

Keyword(s):

Antibiotic Resistance ◽

Antibiotic Use ◽

Cross Sectional Study ◽

Antibiotic Prescribing ◽

Prescribing Practices ◽

Online Questionnaire ◽

Cross Sectional ◽

Attitudes And Behaviors ◽

And Behaviors ◽

Ease Of Access

More research is needed on the drivers of irrational antibiotic prescribing among healthcare professionals and to ensure effective prescribing and an adequate understanding of the issue of antibiotic resistance. This study aimed at evaluating prescribers’ knowledge, attitudes and behaviors about antibiotic use and antibiotic resistance. A cross-sectional study was conducted utilizing an online questionnaire and included physicians and dentists from all sectors in Jordan. A total of 613 prescribers were included (physicians n = 409, dentists n = 204). Respondents’ knowledge on effective use, unnecessary use or associated side effects of antibiotics was high (>90%), compared with their knowledge on the spread of antibiotic resistance (62.2%). For ease of access to the required guidelines on managing infections, and to materials that advise on prudent antibiotic use and antibiotic resistance, prescribers agreed in 62% and 46.1% of cases, respectively. 28.4% of respondents had prescribed antibiotics when they would have preferred not to do so more than once a day or more than once a week. Among respondents who prescribed antibiotics, 63.4% would never or rarely give out resources on prudent use of antibiotics for infections. The findings are of importance to inform antibiotic stewardships about relevant interventions aimed at changing prescribers’ behaviors and improving antibiotic prescribing practices.

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