German S3 Guideline: Oxygen Therapy in the Acute Care of Adult Patients

<b><i>Background:</i></b> Oxygen (O₂) is a drug with specific biochemical and physiological properties, a range of effective doses and may have side effects. In 2015, 14% of over 55,000 hospital patients in the UK were using oxygen. 42% of patients received this supplemental oxygen without a valid prescription. Health care professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. <b><i>Methods:</i></b> A national S3 guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. A literature search was performed until February 1, 2021, to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System (“The Oxford 2011 Levels of Evidence”) was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of evidence and for grading guideline recommendation, and a formal consensus-building process was performed. <b><i>Results:</i></b> The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O₂ therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are based depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. <b><i>Conclusion:</i></b> This is the first national guideline on the use of oxygen in acute care. It addresses health care professionals using oxygen in acute out-of-hospital and in-hospital settings.

Avaliação de guidelines para atenção pós-parto na Atenção Primária: revisão sistemática

Resumo Introdução O cuidado após o parto, denominado de pós-natal, pós-parto ou puerpério, é um importante período para desenvolvimento de estratégias de atenção à saúde das mulheres para redução da morbimortalidade. Com o aumento de publicações de diretrizes clínicas, há preocupações quanto à qualidade delas. Objetivo Avaliar a qualidade de guidelines sobre a atenção às mulheres no pós-parto na Atenção Primária à Saúde. Método Revisão sistemática de guidelines publicados entre 2008 e 2017, nas bases de dados Lilacs e PubMed, e página da internet do National Guideline Clearinghouse, National Institute for Health and Care Excellence e Google®. A ferramenta Appraisal of Guidelines for Research and Evaluation II foi utilizada para avaliação da qualidade dos guidelines nos domínios: escopo e finalidade; envolvimento das partes interessadas (stakeholders); rigor do desenvolvimento; clareza e apresentação; aplicabilidade; e independência editorial. Resultados Foram analisados dez guidelines que apresentaram escore médio geral de avaliação de 77%, com melhor avaliação para “escopo e finalidade” (92%) e pior para “aplicabilidade” (57%). Conclusão Os guidelines apresentaram boa qualidade geral com necessidade de melhorar sua elaboração no domínio aplicabilidade.

Experience in Using Antiviral Agents for the Treatment of Novel Coronavirus Infection (COVID-19) in Kyrgyzstan

The national clinical guidelines for the treatment of novel coronavirus infection (COVID-19) are the main source of information and the reference point for clinical decision-making by healthcare professionals in the Kyrgyz Republic. The recommendations presented in these documents are largely based on data from real clinical practice, but the efficacy and safety of a number of antiviral agents, the indications for which have been expanded to include COVID-19 treatment, remain unclear.The aim of the study was to conduct a retrospective pharmacoepidemiological analysis of lopinavir+ritonavir use in hospitals in the Kyrgyz Republic for the treatment of COVID-19 during the period from March until April 2020.Materials and methods: the paper describes a retrospective study of 145 medical records of patients with confirmed COVID-19 who were hospitalized in infectious disease departments/hospitals of the Kyrgyz Republic. Statistical processing was performed using Microsoft Excel 2017.Results: between 16 March 2020 and 25 April 2020, 145 patients were prescribed lopinavir+ritonavir at a dose of 200 mg + 50 mg, 2 tablets twice a day—in line with the dosage regimen recommended by the national guideline. The national guideline recommended the treatment duration of 10 days, while the actual treatment duration was 1–12 days (5.5 days on average) depending on the tolerability of the drug. The use of the drug was accompanied by adverse drug reactions (ADRs) in 78 patients (53.8%), and caused deterioration in the general condition of 73 of these patients (94.8%) which resulted in discontinuation of the drug. The most common ADRs were nausea, vomiting, diarrhoea, decreased appetite, yellowness of the skin, and, according to laboratory studies, an increase in serum levels of bilirubin, creatinine, glucose, aspartate aminotransferase and amylase activity. A retrospective assessment of the causal relationship probability according to the Naranjo scale showed an interrelation between the use of lopinavir+ritonavir and ADR development.Conclusions: the use of the lopinavir+ritonavir drug in COVID-19 patients led to deterioration of their general condition, which was severe in some cases. The data obtained indicate that the use of this drug for COVID-19 treatment is clinically unreasonable and irrational. Lopinavir+ritonavir was excluded from subsequent revisions of the clinical guidelines for the diagnosis and treatment of COVID-19 in the Kyrgyz Republic.

1137. Effect of an Antibiotic Stewardship Program on Antibiotic Choice, Dosing, and Duration in Pediatric Urgent Care

Background Many studies have focused on decreasing inappropriate antibiotic prescriptions. In August 2018, our institution implemented an outpatient antibiotic stewardship program (ASP). We describe the impact of an outpatient ASP on the antibiotic choice, dose, and duration for common pediatric infections in a pediatric urgent care (PUC) setting. Methods We reviewed all encounters at 4 freestanding PUC centers within our organization of patients &gt;60 days and &lt; 18 years with a discharge diagnosis of acute otitis media (AOM), group A streptococcal (GAS) pharyngitis, community acquired pneumonia (CAP), urinary tract infection (UTI), cellulitis, abscess, and animal bite who received systemic antibiotics between July 2017 and December 2020. We excluded patients who were transferred, admitted, or had a concomitant diagnosis that required systemic antibiotics. We used established national guidelines to determine appropriateness of antibiotic choice, dose, and duration for each diagnosis (Table 1). Our outpatient ASP efforts included the development of an antibiotic handbook, data sharing, education, quality improvement projects, and commitment letters. Pearson’s chi-square test was used to compare appropriate prescribing (choice, dose, and duration) between pre-implementation (July 2017 – July 2018) and post-implementation (August 2018 -forward). Monthly run charts evaluated improvement over time. Results We included 35,915 encounters. Appropriate antibiotic agent improved in AOM (75.8% to 77.2%; p=0.03), UTI (74.9% to 89.5%; p&lt; 0.001), cellulitis (70.5% to 75.1%; p=0.02) and abscess (53.6% to 67.7%; p&lt; 0.001) following implementation of our ASP (Figure 1). Excluding GAS pharyngitis, all diagnoses had improvement in appropriate duration (p&lt; 0.001) (Figure 2). Appropriate dosing improved for AOM (75.7% to 81.6%; p&lt; 0.001), UTI (34.9% to 42.9%; p=0.01) animal bites (37.1% to 45.6%; p=0.048), and cellulitis (28.0% to 42.3%; p&lt; 0.001) (Figure 3). Figure 1. Appropriate Agent Run chart of percentage of encounters with antibiotic choice consistent with national guideline recommendations by discharge diagnosis. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018. Figure 2. Appropriate Duration Run chart of percentage of encounters with antibiotic duration consistent with national guideline recommendations. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018. Figure 3. Appropriate Dose Run chart of percentage of encounters with antibiotic dose consistent with national guideline recommendations. The vertical line indicates the start of outpatient antibiotic stewardship efforts in August 2018. Conclusion Our outpatient ASP improved prescribing patterns for agent, duration, and dose for many common pediatric infections in the PUC setting. Future work will focus on identifying opportunities to improve prescribing practices when antibiotics are indicated. Disclosures Brian R. Lee, PhD, MPH , Merck (Grant/Research Support)Pfizer (Grant/Research Support)

Changes in mammography screening in Ontario and Alberta following national guideline dissemination: an interrupted time series analysis

Background: In November 2011, the Canadian Task Force on Preventive Health Care released guidelines for screening women at average breast cancer risk. Weak recommendations (framed using GRADE methodology) were made for screening women aged 50 to 74 years every two to three years, and for not screening women aged 40 to 49 years. Methods: We conducted an interrupted time series analysis using administrative data to examine bilateral mammography use before and after a national guideline dissemination strategy targeting primary care physicians. Women aged 40 to 74 years living in Ontario or Alberta from 30th November 2008 to 30th November 2014 were included. Strata included age, region of residence, neighbourhood income quintile, immigration status, and education level. Results: In both provinces, mammography use rates were lower in the post-intervention period (527 vs. 556 and 428 vs. 465/1000 participant-months - the monthly screening rate/1000 - in Ontario and Alberta, respectively). In Ontario, mammography trends decreased following guideline release to align with recommendations for women aged 40 to 74 (decrease of 2.21/1000 women, SE 0.26/1000, p<0.0001). In Alberta, mammography trends decreased for women aged 40 to 49 years (3/1000 women, SE 0.32, p<0.001) and 50 to 69 (2.9/1000 women, SE 0.79, p<0.001), but did not change for women aged 70 to 74 (0.7/1000 women, SE 1.23, p=0.553). In both provinces, trends in mammography use rates were sustained for up to three years after guideline release. Conclusions: The guideline dissemination strategy appeared to increase uptake of guideline-concordant screening practice in women aged 40 to 49 years in Ontario and Alberta and for women aged 50 to 74 years in Ontario. Further work is required to understand these findings and whether shared decision making about mammography between women and providers increased among women considering mammography.