ABSTRACT
Background. Outpatient antibiotic (OP Abx) prescribing in adults in Arkansas (AR) was among the country's highest in 2019. AR Medicaid analyzed prescription (Rx) claims data and communicated the relative prescribing intensity as an informational metric to each patient-centered medical home (PCMH) beginning in 2020. We describe the Abx prescribing patterns in calendar years 2019 and 2020, during the COVID-19 pandemic. Methods. Data from AR Medicaid paid claims for OP Abx Rxs in adult patients attributed to a PCMH practice for > 6 months were analyzed. Annual Abx Rx claims per 1000 patients were calculated for rural or urban status and by 2019 prescribing rate histories, defined as the low-,middle-, and high-rate prescribers based on 1st, 2nd - 3rd, & 4th quartiles, respectively. The five most common classes in 2019 and fluoroquinolones were explored.A paired t-test, Wilcoxon signed rank test, and one-wayANOVA with post hoc least significant difference test were used to determine statistical significance. Results. 183 PCMHs qualified for analysis. There was a significant decrease in overall annual Abx claim rate, from 1034 to 910 (-12.0%, p< 0.0001). Claim rates decreased in rural (-10.9%, p< 0.0001) and urban areas (-13.3%, p< 0.0001) with no difference between groups (p=0.240). Low-rate prescribers did not change practice from 2019 to 2020, with claim rates of 666 to 665 (-0.2%, p=0.957), while middle- and highrate prescribers decreased, from 1032 to 897 (-13.1%, p< 0.0001), and from 1404 to 1183 (-15.7%, p< 0.0001), respectively. Claim rates significantly decreased for penicillins (-16.0%, p< 0.0001), fluoroquinolones (-15.5%, p< 0.0001), sulfonamides (-13.1%, p< 0.0001), macrolides (-9.9%, p=0.0001), and tetracyclines (-6.3%, p=0.021). First-generation cephalosporins down trended (-7.9%, p=0.111). Conclusion. OP Abx Rx claims significantly decreased from 2019 to 2020 in middle and high-rate prescribers. Low-rate prescribers maintained low Abx Rx claim rates throughout 2020. Future analyses are needed to highlight any rebound effect of Abx prescribing when the pandemic subsides, discerning the informational metric effect versus COVID-19, and informing the next steps for antimicrobial stewardship for PCMHs in AR.
ABSTRACT
Background. The FDA has issued emergency use authorization (EUA) for neutralizing monoclonal antibodies (mAb) for the treatment of mild-moderate coronavirus disease 2019 (COVID-19) in patients who are at high risk of disease progression. The EUA allows for COVID-19 mAb infusion to occur up to 10 days from symptom onset and due to logistics, mAb treatment typically occurs later in this 10 day window. Efficacy of early versus late mAb treatment is unknown Methods. In this single center, retrospective case-control study, we performed a risk factor analysis of patients with mild COVID-19 infection treated with mAb on the composite outcome of subsequent evaluation in the Emergency Department (ED) or inpatient admission December 2020 through May 2021. Multivariate analysis of variables found to be significant in univariate analysis was performed using STATA 15 statistical software Results. Two-hundred eighty-eight patients who received mAb treatment were included in analysis. The mean age was 58.6 years and 59.7% were female, 64.9% white, and 27.1% African American. Following mAb infusion, 31 (10.8%) had disease progression resulting in an ED encounter or inpatient admission. Patients who received early (days 1-5 of symptoms) mAb infusion were less likely to have progressive disease than patients with late (days 6-12 of symptoms) infusion;(6.1% vs 13.2%;P= 0.048). Zero of 21 patients who received mAb infusion on day 1-3 of symptoms had disease progression. Patients with CHF (7.4% vs 19.4%;P=0.038), cirrhosis (9.3% vs 25.8%;p=0.012), CKD (12.5% vs 35.5%;p=0.001) and hypertension (70.8% vs 90.3%;p=0.021) were more likely to have disease progression. There were no differences in sex, race, BMI, or symptoms between groups. Multivariate analysis revealed cirrhosis (OR 3.0;95% CI 1.1-7.9) and CKD (OR 2.6;95% CI 1.0-6.4) increased risk of disease progression while early mAb infusion was protective (OR 0.38;95% CI 0.14-1.0) Conclusion. Infusion of mAb for the treatment of mild to moderate Covid-19 within 5 days of symptom onset reduces rate of disease progression compared to delayed (day 6-12 of symptoms) infusion. This finding was significant when controlling for comorbidities. Efforts should be made to infuse high risk patients with COVID-19 mAb therapy within 5 days of symptom onset.