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Seibert AM, Hersh AL, Patel PK, Hicks LA, Fino N, Stanfield V, Stenehjem EA. Impact of an antibiotic stewardship initiative on urgent-care respiratory prescribing across patient race, ethnicity, and language. Infect Control Hosp Epidemiol 2024; 45:530-533. [PMID: 38073559 PMCID: PMC11003825 DOI: 10.1017/ice.2023.258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/15/2023] [Accepted: 10/24/2023] [Indexed: 04/10/2024]
Abstract
We conducted a post hoc analysis of an antibiotic stewardship intervention implemented across our health system's urgent-care network to determine whether there was a differential impact among patient groups. Respiratory urgent-care antibiotic prescribing decreased for all racial, ethnic, and preferred language groups, but disparities in antibiotic prescribing persisted.
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Affiliation(s)
- Allan M. Seibert
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, Utah
| | - Adam L. Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Payal K. Patel
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, Utah
| | - Lauri A. Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Valoree Stanfield
- Office of Patient Experience, Intermountain Health, Salt Lake City, Utah
| | - Edward A. Stenehjem
- Division of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado
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Seibert AM, Schenk C, Buckel WR, Patel PK, Fino N, Stanfield V, Hersh AL, Stenehjem E. Beyond antibiotic prescribing rates: first-line antibiotic selection, prescription duration, and associated factors for respiratory encounters in urgent care. Antimicrob Steward Healthc Epidemiol 2023; 3:e146. [PMID: 37771738 PMCID: PMC10523551 DOI: 10.1017/ash.2023.416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 07/03/2023] [Accepted: 07/09/2023] [Indexed: 09/30/2023]
Abstract
Objective Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis. Design Retrospective cohort study. Participants All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019-June 30th, 2020. Methods Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5-10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration. Results Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non-first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]). Conclusions First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts.
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Affiliation(s)
- Allan M. Seibert
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
| | | | | | - Payal K. Patel
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Valoree Stanfield
- Office of Patient Experience, Intermountain Health, Salt Lake City, UT, USA
| | - Adam L. Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Eddie Stenehjem
- Division of Infectious Diseases, Intermountain Health, Salt Lake City, UT, USA
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Stenehjem E, Wallin A, Willis P, Kumar N, Seibert AM, Buckel WR, Stanfield V, Brunisholz KD, Fino N, Samore MH, Srivastava R, Hicks LA, Hersh AL. Implementation of an Antibiotic Stewardship Initiative in a Large Urgent Care Network. JAMA Netw Open 2023; 6:e2313011. [PMID: 37166794 PMCID: PMC10176123 DOI: 10.1001/jamanetworkopen.2023.13011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/19/2023] [Indexed: 05/12/2023] Open
Abstract
Importance Urgent Care (UC) encounters result in more inappropriate antibiotic prescriptions than other outpatient setting. Few stewardship interventions have focused on UC. Objective To evaluate the effectiveness of an antibiotic stewardship initiative to reduce antibiotic prescribing for respiratory conditions in a UC network. Design, Setting, and Participants This quality improvement study conducted in a UC network with 38 UC clinics and 1 telemedicine clinic included 493 724 total UC encounters. The study compared the antibiotic prescribing rates of all UC clinicians who encountered respiratory conditions for a 12-month baseline period (July 1, 2018, through June 30, 2019) with an intervention period (July 1, 2019, through June 30, 2020). A sustainability period (July 1, 2020, through June 30, 2021) was added post hoc. Interventions Stewardship interventions included (1) education for clinicians and patients, (2) electronic health record (EHR) tools, (3) a transparent clinician benchmarking dashboard, and (4) media. Occurring independently but concurrent with the interventions, a stewardship measure was introduced by UC leadership into the quality measures, including a financial incentive. Main Outcomes and Measures The primary outcome was the percentage of UC encounters with an antibiotic prescription for a respiratory condition. Secondary outcomes included antibiotic prescribing when antibiotics were not indicated (tier 3 encounters) and first-line antibiotics for acute otitis media, sinusitis, and pharyngitis. Interrupted time series with binomial generalized estimating equations were used to compare periods. Results The baseline period included 207 047 UC encounters for respiratory conditions (56.8% female; mean [SD] age, 30.0 [21.4] years; 92.0% White race); the intervention period included 183 893 UC encounters (56.4% female; mean [SD] age, 30.7 [20.8] years; 91.2% White race). Antibiotic prescribing for respiratory conditions decreased from 47.8% (baseline) to 33.3% (intervention). During the initial intervention month, a 22% reduction in antibiotic prescribing occurred (odds ratio [OR], 0.78; 95% CI, 0.71-0.86). Antibiotic prescriptions decreased by 5% monthly during the intervention (OR, 0.95; 95% CI, 0.94-0.96). Antibiotic prescribing for tier 3 encounters decreased by 47% (OR, 0.53; 95% CI, 0.44-63), and first-line antibiotic prescriptions increased by 18% (OR, 1.18; 95% CI, 1.09-1.29) during the initial intervention month. Antibiotic prescriptions for tier 3 encounters decreased by an additional 4% each month (OR, 0.96; 95% CI, 0.94-0.98), whereas first-line antibiotic prescriptions did not change (OR, 1.00; 95% CI, 0.99-1.01). Antibiotic prescribing for respiratory conditions remained stable in the sustainability period. Conclusions and relevance The findings of this quality improvement study indicated that a UC antibiotic stewardship initiative was associated with decreased antibiotic prescribing for respiratory conditions. This study provides a model for UC antibiotic stewardship.
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Affiliation(s)
- Edward Stenehjem
- Division of Infectious Diseases and Epidemiology, Intermountain Health, Salt Lake City, Utah
| | - Anthony Wallin
- Intermountain Urgent Care, Intermountain Health, Salt Lake City, Utah
| | - Park Willis
- Intermountain Urgent Care, Intermountain Health, Salt Lake City, Utah
| | - Naresh Kumar
- Office of Research, Intermountain Health, Salt Lake City, Utah
| | - Allan M. Seibert
- Division of Infectious Diseases and Epidemiology, Intermountain Health, Salt Lake City, Utah
| | - Whitney R. Buckel
- System Pharmacy Services, Intermountain Health, Salt Lake City, Utah
| | - Valoree Stanfield
- Division of Infectious Diseases and Epidemiology, Intermountain Health, Salt Lake City, Utah
| | | | - Nora Fino
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City
| | - Matthew H. Samore
- Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City
| | - Rajendu Srivastava
- Intermountain Health Delivery Institute, Intermountain Health, Salt Lake City, Utah
- Department of Pediatrics, Division of Pediatric Inpatient Medicine, University of Utah School of Medicine, Salt Lake City
| | - Lauri A. Hicks
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Adam L. Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah School of Medicine, Salt Lake City
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Imlay H, Seibert AM, Hanson KE. Pathogen-agnostic immune biomarkers that predict infection after solid organ transplantation. Transpl Infect Dis 2023; 25:e14020. [PMID: 36705292 DOI: 10.1111/tid.14020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 01/28/2023]
Abstract
Solid organ transplant recipients (SOTRs) remain at high risk for infection throughout their post-transplant course. Dosing of immunosuppressive medications, strategies that prevent infection, and choice of empiric antimicrobial treatment could be optimized by a better understanding of an individual patient's risk for infectious complications. Diagnostic tests that qualitatively or quantitatively measure the function of the immune system and/or its response to infection may be useful for individualized management decisions. Numerous studies have identified an association between infectious outcomes after solid organ transplantation (SOT) and the results of a variety of non-pathogen-specific or "pathogen-agnostic" immune monitoring tests. These biomarkers include humoral immune markers, functional or quantitative assessments of cellular immunity, transcriptomic-based diagnostics, and replication of viruses within the human virome, which have been used to predict or diagnose a variety of different infectious diseases complicating SOT. In this narrative review, we discuss several host-derived immune biomarkers that show promise for either predicting or diagnosing infection among SOTRs. However, additional studies are needed to determine the optimal use of immune response testing. Whether immune biomarkers contribute added benefits to current standard clinical care has not yet been determined. Testing must be validated across a range of clinical scenarios, including surveillance to predict infection risk and diagnosis of active infection at various time points post transplant.
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Affiliation(s)
- Hannah Imlay
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Allan M Seibert
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA.,Office of Research, Intermountain Healthcare, Murray, Utah, USA
| | - Kimberly E Hanson
- Division of Infectious Diseases, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA.,Clinical Microbiology Section, Department of Pathology, University of Utah and ARUP Laboratories, Salt Lake City, Utah, USA
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Seibert AM, Stanfield VK, Fino N, Gwiazdon M, Hersh A, Stenehjem EA. 1739. An Exploratory Analysis to Examine Urgent Care Antibiotic Prescribing Inequities in a Vertically Integrated Healthcare System. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Previous studies have shown antibiotic prescribing differences based on patient demographics which may represent inequitable care. Our objective was to perform an exploratory analysis of antibiotic prescribing rates for respiratory conditions to better understand possible inequities and identify disparities in our health system.
Methods
This was a retrospective cohort study of urgent care encounters for respiratory conditions in the Intermountain Healthcare (IH) network from July 1st 2018 – June 30th 2019. Individual respiratory encounters were identified using a validated methodology based on ICD10 codes. Overall antibiotic prescribing rates and rates for Tier 1 (antibiotics indicated), 2 (sometimes indicated), and 3 (not indicated, eg bronchitis) conditions were assessed. Prescribing rates for categories in which inequities might exist, including age, weight, patient race/ethnicity, preferred language, provider type, and provider/patient gender combinations, were examined. We considered an absolute percentage difference between groups within a category of ≥5.0% to represent a potential disparity.
Results
93,588 (48.5%) of 193,107 respiratory urgent care encounters were associated with an antibiotic prescription. Overall antibiotic prescribing rates (Results Image 1) were higher in white compared to non-white patients (49.0% vs 38.2%) and in those reporting non-Hispanic ethnicity compared to Hispanics (49.1% vs 43.2%). Patients over 18 years-old were prescribed antibiotics more frequently than younger patients. Among Tier 3 encounters male providers prescribed antibiotics more frequently for male patients than female providers did for female patients (20.8% vs 15.6). Overweight and obese patients with Tier 3 diagnoses received antibiotic prescriptions more frequently than non-obese patients (22.8% vs 15.3%). Minimal differences between patients who preferred English and those who preferred non-English languages were observed. Results Image 1 - Table 1
Overall antibiotic prescribing rates and antibiotic prescribing rates for Tier 3 conditions for urgent care respiratory condition encounters July 1st, 2018 – June 30th, 2019*¥. *Tier 3 codes are those where antibiotics are not indicated (eg bronchitis). ¥Absolute differences of ≥5.0% between groups within each category are indicated in bold.
Conclusion
Antibiotic prescribing rates for respiratory conditions in urgent care encounters in our system differed based on race, ethnicity, age, obesity, and gender. These differences may represent biases contributing to inequities in care and may serve as potential targets for improved stewardship efforts.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | | | - Nora Fino
- University of Utah , Salt Lake City, Utah
| | | | - Adam Hersh
- University of Utah , Salt Lake City, Utah
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Gwiazdon M, Matheu MM, Seibert AM, Stanfield VK, Kumar N, Stenehjem EA. 2219. Syphilis Diagnosis and Treatment Practices in the Ambulatory Setting of a Large Vertically Integrated Healthcare Organization: An Opportunity for Infectious Diseases Physician Engagement. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Sexually transmitted infections (STIs) continue to increase in the United States. Syphilis management may challenge busy outpatient clinicians and diagnostic delays have been described. To better understand syphilis treatment practices and identify targets for improvement in our organization, we characterized outpatient encounters associated with a positive syphilis test.
Methods
Intermountain Healthcare (IH) is an integrated healthcare system with 23 emergency departments (ED), 34 urgent care (UC), and >100 primary care (PC) clinics. Protocols favor treponemal testing as the initial screening test. All positive treponemal tests associated with a positive non-treponemal test in the ambulatory setting were routed to an electronic inbox within the electronic health record (EHR) and reviewed by a team of Infectious Disease (ID) clinicians from May 1st 2021 – January 31st, 2022. Positive results originating from ID or HIV-trained primary care clinicians were excluded. Each encounter was assessed for staging and treatment plans based on CDC guidelines as well as HIV pre-exposure prophylaxis (PrEP) and HIV treatment eligibility.
Results
119 encounters were reviewed. Patients 30-44 years old were most likely to have a positive test (50, 42.0%). PC (63, 52.9%) and UC (24, 20.2%) accounted for the most positive tests. 102 (85.7%) positive tests were from white patients, consistent with racial demographics of Utah. Only 40 (33.6%) encounters could be clinically staged after chart review by an ID clinician. Of these, 17 (42.5%) were determined to be staged and treated inappropriately by the treating provider. 54 (45.4%) encounters could not be staged and required further testing or more clinical history to determine the significance of positive test. 18 (15.1%) patients could possibly have benefitted from PrEP evaluation and one new HIV diagnosis was referred to ID clinic.
Conclusion
Our exploratory analysis revealed many syphilis cases unable to be staged on chart review and opportunities to improve care. Strategies such as prospective audit and feedback or eConsults may be insufficient and clinical evaluation may be necessary to stage syphilis infection. Syphilis care improvements in our system may be a future target for ID physician engagement and novel stewardship strategies.
Disclosures
All Authors: No reported disclosures.
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Seibert AM, Matheu MM, Stanfield VK, Gwiazdon M, Kumar N, Brunisholz KD, Willis P, Wallin A, Stenehjem EA. 2212. Improving Sexually Transmitted Infection Co-testing in a Large Urgent Care Network. Open Forum Infect Dis 2022. [PMCID: PMC9752697 DOI: 10.1093/ofid/ofac492.1831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Sexually transmitted infections (STIs) remain a serious public health concern. The state of Utah has the lowest percentage of adults 18-64 years-old ever tested for HIV (26.5%) and the lowest percentage tested for HIV in the previous 12 months (6.5%). Increasing HIV testing in Utah is of the utmost importance. Delayed diagnoses and missed testing opportunities for HIV and other STIs exist. Encounters for evaluation of possible gonorrhea (GC) or chlamydia (CT) infection is a critical opportunity to co-test for HIV and syphilis. With continued growth, urgent care (UC) sites are well-positioned to increase STI diagnosis and treatment. We aimed to develop a multi-faceted quality improvement (QI) bundle to increase STI testing in our UC centers. Methods Intermountain Healthcare (IH) is a vertically integrated healthcare network predominantly in Utah and operates a network of 35 UC clinics across the state. In 2020, qualitative interviews to evaluate barriers to STI testing were performed with UC clinicians. Based on these interviews a QI initiative was designed and implemented throughout 2021. The bundle included clinician education, electronic health record (EHR) improvements, and automatic referral for patients with a new diagnosis of HIV to an Infectious Diseases (ID) physician (Methods Image 1). We compared co-testing rates before (July 2018 – December 2020) and after the intervention began (March 2021 – April 2022).
Methods Table 1 ![]() The quality improvement (QI) initiative began in 2021 and consisted of multiple components as detailed below. Results 13,715 and 5,628 UC encounters were associated with GC/CT testing during the pre-intervention and intervention periods, respectively. HIV co-testing was performed in 2,784 (20.3%) GC/CT testing encounters in the pre-intervention period and in 1,674 (29.7%) encounters during the intervention, a relative increase of 37.6%. HIV/syphilis co-testing was performed in 2,304 (16.8%) GC/CT testing encounters and 1,225 (21.8%) encounters during the pre-intervention and intervention phases, respectively. From January 1 2022 – April 1 2022 3 new outpatient HIV diagnoses were identified. The average time from diagnosis to contact with an ID provider was 30.0 hours. Results Image 1
![]() Co-testing rates for GC/CT UC encounters are presented for HIV (blue), syphilis (green), and HIV/syphilis (orange). Testing reagent quality issues in early 2022 lead to an abrupt decline in syphilis co-testing and once these issues were resolved co-testing trends returned to similar rates prior to the reagent quality issue and testing limitation. Conclusion Multi-modal QI initiatives may increase STI testing rates within UC centers of integrated healthcare systems. Further study is needed to optimize STI screening, diagnosis, and care in UC centers. Disclosures Kimberly D. Brunisholz, PhD, MST, Johnson and Johnson: Advisor/Consultant.
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Seibert AM, Hersh AL, Patel PK, Matheu M, Stanfield V, Fino N, Hicks LA, Tsay SV, Kabbani S, Stenehjem E. Urgent-care antibiotic prescribing: An exploratory analysis to evaluate health inequities. Antimicrob Steward Healthc Epidemiol 2022; 2:e184. [PMID: 36406162 PMCID: PMC9672912 DOI: 10.1017/ash.2022.329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 06/16/2023]
Abstract
Healthcare disparities and inequities exist in a variety of environments and manifest in diagnostic and therapeutic measures. In this commentary, we highlight our experience examining our organization's urgent care respiratory encounter antibiotic prescribing practices. We identified differences in prescribing based on several individual characteristics including patient age, race, ethnicity, preferred language, and patient and/or clinician gender. Our approach can serve as an electronic health record (EHR)-based methodology for disparity and inequity audits in other systems and for other conditions.
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Affiliation(s)
- Allan M. Seibert
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
| | - Adam L. Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Payal K. Patel
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
| | - Michelle Matheu
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
| | | | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Lauri A. Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sharon V. Tsay
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sarah Kabbani
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Edward Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Murray, Utah
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Wolfe CR, Tomashek KM, Patterson TF, Gomez CA, Marconi VC, Jain MK, Yang OO, Paules CI, Palacios GMR, Grossberg R, Harkins MS, Mularski RA, Erdmann N, Sandkovsky U, Almasri E, Pineda JR, Dretler AW, de Castilla DL, Branche AR, Park PK, Mehta AK, Short WR, McLellan SLF, Kline S, Iovine NM, El Sahly HM, Doernberg SB, Oh MD, Huprikar N, Hohmann E, Kelley CF, Holodniy M, Kim ES, Sweeney DA, Finberg RW, Grimes KA, Maves RC, Ko ER, Engemann JJ, Taylor BS, Ponce PO, Larson L, Melendez DP, Seibert AM, Rouphael NG, Strebe J, Clark JL, Julian KG, de Leon AP, Cardoso A, de Bono S, Atmar RL, Ganesan A, Ferreira JL, Green M, Makowski M, Bonnett T, Beresnev T, Ghazaryan V, Dempsey W, Nayak SU, Dodd LE, Beigel JH, Kalil AC. Baricitinib versus dexamethasone for adults hospitalised with COVID-19 (ACTT-4): a randomised, double-blind, double placebo-controlled trial. Lancet Respir Med 2022; 10:888-899. [PMID: 35617986 PMCID: PMC9126560 DOI: 10.1016/s2213-2600(22)00088-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/25/2022] [Accepted: 02/28/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND Baricitinib and dexamethasone have randomised trials supporting their use for the treatment of patients with COVID-19. We assessed the combination of baricitinib plus remdesivir versus dexamethasone plus remdesivir in preventing progression to mechanical ventilation or death in hospitalised patients with COVID-19. METHODS In this randomised, double-blind, double placebo-controlled trial, patients were enrolled at 67 trial sites in the USA (60 sites), South Korea (two sites), Mexico (two sites), Singapore (two sites), and Japan (one site). Hospitalised adults (≥18 years) with COVID-19 who required supplemental oxygen administered by low-flow (≤15 L/min), high-flow (>15 L/min), or non-invasive mechanical ventilation modalities who met the study eligibility criteria (male or non-pregnant female adults ≥18 years old with laboratory-confirmed SARS-CoV-2 infection) were enrolled in the study. Patients were randomly assigned (1:1) to receive either baricitinib, remdesivir, and placebo, or dexamethasone, remdesivir, and placebo using a permuted block design. Randomisation was stratified by study site and baseline ordinal score at enrolment. All patients received remdesivir (≤10 days) and either baricitinib (or matching oral placebo) for a maximum of 14 days or dexamethasone (or matching intravenous placebo) for a maximum of 10 days. The primary outcome was the difference in mechanical ventilation-free survival by day 29 between the two treatment groups in the modified intention-to-treat population. Safety analyses were done in the as-treated population, comprising all participants who received one dose of the study drug. The trial is registered with ClinicalTrials.gov, NCT04640168. FINDINGS Between Dec 1, 2020, and April 13, 2021, 1047 patients were assessed for eligibility. 1010 patients were enrolled and randomly assigned, 516 (51%) to baricitinib plus remdesivir plus placebo and 494 (49%) to dexamethasone plus remdesivir plus placebo. The mean age of the patients was 58·3 years (SD 14·0) and 590 (58%) of 1010 patients were male. 588 (58%) of 1010 patients were White, 188 (19%) were Black, 70 (7%) were Asian, and 18 (2%) were American Indian or Alaska Native. 347 (34%) of 1010 patients were Hispanic or Latino. Mechanical ventilation-free survival by day 29 was similar between the study groups (Kaplan-Meier estimates of 87·0% [95% CI 83·7 to 89·6] in the baricitinib plus remdesivir plus placebo group and 87·6% [84·2 to 90·3] in the dexamethasone plus remdesivir plus placebo group; risk difference 0·6 [95% CI -3·6 to 4·8]; p=0·91). The odds ratio for improved status in the dexamethasone plus remdesivir plus placebo group compared with the baricitinib plus remdesivir plus placebo group was 1·01 (95% CI 0·80 to 1·27). At least one adverse event occurred in 149 (30%) of 503 patients in the baricitinib plus remdesivir plus placebo group and 179 (37%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 7·5% [1·6 to 13·3]; p=0·014). 21 (4%) of 503 patients in the baricitinib plus remdesivir plus placebo group had at least one treatment-related adverse event versus 49 (10%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 6·0% [2·8 to 9·3]; p=0·00041). Severe or life-threatening grade 3 or 4 adverse events occurred in 143 (28%) of 503 patients in the baricitinib plus remdesivir plus placebo group and 174 (36%) of 482 patients in the dexamethasone plus remdesivir plus placebo group (risk difference 7·7% [1·8 to 13·4]; p=0·012). INTERPRETATION In hospitalised patients with COVID-19 requiring supplemental oxygen by low-flow, high-flow, or non-invasive ventilation, baricitinib plus remdesivir and dexamethasone plus remdesivir resulted in similar mechanical ventilation-free survival by day 29, but dexamethasone was associated with significantly more adverse events, treatment-related adverse events, and severe or life-threatening adverse events. A more individually tailored choice of immunomodulation now appears possible, where side-effect profile, ease of administration, cost, and patient comorbidities can all be considered. FUNDING National Institute of Allergy and Infectious Diseases.
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Affiliation(s)
| | - Kay M Tomashek
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Thomas F Patterson
- University of Texas Health San Antonio, University Health, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | | | | | - Mamta K Jain
- University of Texas Southwestern and Parkland Health and Hospital System, Dallas, TX, USA
| | - Otto O Yang
- University of California, Los Angeles, CA, USA
| | - Catharine I Paules
- Pennsylvania State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | | | - Robert Grossberg
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | | | | | | | - Eyad Almasri
- University of California, San Francisco, CA, USA
| | | | - Alexandra W Dretler
- Infectious Disease Specialists of Atlanta and Emory Decatur Hospital, Decatur, GA, USA
| | | | | | | | | | | | | | - Susan Kline
- The University of Minnesota Medical School, Minneapolis, MN, USA
| | - Nicole M Iovine
- University of Florida Health, Shands Hospital, Gainesville, FL, USA
| | | | | | - Myoung-Don Oh
- Seoul National University Hospital, Seoul, South Korea
| | - Nikhil Huprikar
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | | | | | - Eu Suk Kim
- Seoul National University Bundang Hospital, Seongnam, South Korea
| | | | | | | | | | | | | | - Barbara S Taylor
- University of Texas Health San Antonio, University Health, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Philip O Ponce
- University of Texas Health San Antonio, University Health, and the South Texas Veterans Health Care System, San Antonio, TX, USA
| | - LuAnn Larson
- University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | | | - Joslyn Strebe
- University of Texas Southwestern and Parkland Health and Hospital System, Dallas, TX, USA
| | | | - Kathleen G Julian
- Pennsylvania State Health Milton S Hershey Medical Center, Hershey, PA, USA
| | - Alfredo Ponce de Leon
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | | | | | | | | | - Tyler Bonnett
- Clinical Monitoring Research Program Directorate, Frederick National Laboratory, Frederick, MD, USA
| | - Tatiana Beresnev
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Varduhi Ghazaryan
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Walla Dempsey
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Seema U Nayak
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Lori E Dodd
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - John H Beigel
- The National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Andre C Kalil
- University of Nebraska Medical Center, Omaha, NE, USA.
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Seibert AM, Stenehjem E, Wallin A, Willis P, Brunisholz K, Kumar N, Stanfield V, Fino N, Shapiro DJ, Hersh A. Rapid streptococcal pharyngitis testing and antibiotic prescribing before and during the coronavirus disease 2019 (COVID-19) pandemic. Antimicrob Steward Healthc Epidemiol 2022; 2:e80. [PMID: 36483435 PMCID: PMC9726542 DOI: 10.1017/ash.2022.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 06/17/2023]
Affiliation(s)
- Allan M. Seibert
- Office of Research, Intermountain Healthcare, Salt Lake City, Utah
| | - Edward Stenehjem
- Division of Infectious Diseases and Clinical Epidemiology, Intermountain Healthcare, Salt Lake City, Utah
| | - Anthony Wallin
- Intermountain Urgent Care, Intermountain Healthcare, Salt Lake City, Utah
| | - Park Willis
- Intermountain Urgent Care, Intermountain Healthcare, Salt Lake City, Utah
| | - Kim Brunisholz
- Healthcare Delivery Institute Intermountain Healthcare, Salt Lake City, Utah
| | - Naresh Kumar
- Office of Research, Intermountain Healthcare, Salt Lake City, Utah
| | | | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Daniel J. Shapiro
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Adam Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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