Prescription of antibiotics by general practitioners in patients with a diagnosis of SARS- CoV-2 infection: analysis of an electronic French health record

Objective To define the factors associated with overprescription of antibiotics by general practitioners for patients diagnosed with COVID-19 during the first wave. Methods Anonymized electronic prescribing records of 1370 physicians were analyzed. Diagnosis and prescriptions were retrieved. The initiation rate by physician for 2020 was compared to 2017-2019. Prescribing habits of physicians who initiated antibiotics for more than 10% of COVID-19 patients were compared to those who did not. Regional differences in prescribing habits of physicians who have seen at least one COVID-19 patient were also analyzed. Results For the March-April 2020 period, physicians who initiated antibiotics for more than 10% of COVID-19 patients had more consultations than those who did not. They also prescribed antibiotics more frequently for non-COVID-19 patients consulting with rhinitis. They also prescribed broad-spectrum antibiotics more frequently for treatment of cystitis. Finally, doctors in Île-de-France region saw more COVID-19 patients and initiated antibiotics more frequently. General Practitioners in southern France had a higher but non-significant ratio of azithromycin initiation rate over total antibiotics initiation rate. Conclusion We identified a subset of physicians with overprescribing profile not only for COVID-19 but also for other viral infection, and also with a tendency to prescribe broad spectrum antibiotics for a long duration. There were also regional differences concerning antibiotics initiation rate and the ratio of azithromycin prescribed. It will be necessary to evaluate the evolution of prescribing practices during subsequent waves.

Prescription of antibiotics by general practitioners for patients with a diagnosis of SARS- CoV-2 infection: Analysis of an electronic French health record.

OBJECTIVE: To define the factors associated with overprescription of antibiotics by general practitioners (GPs) for patients diagnosed with COVID-19 during the first wave of the pandemic. METHODS: Anonymised electronic prescribing records of 1370 GPs were analysed. Diagnosis and prescriptions were retrieved. The initiation rate by GP for 2020 was compared with 2017-2019. Prescribing habits of GPs who initiated antibiotics for > 10% of COVID-19 patients were compared with those who did not. Regional differences in prescribing habits of GPs who had consulted at least one COVID-19 patient were also analysed. RESULTS: For the March-April 2020 period, GPs who initiated antibiotics for > 10% of COVID-19 patients had more consultations than those who did not. They also more frequently prescribed antibiotics for non-COVID-19 patients consulting with rhinitis and broad-spectrum antibiotics for treating cystitis. Finally, GPs in the Île-de-France region saw more COVID-19 patients and more frequently initiated antibiotics. General practitioners in southern France had a higher but non-significant ratio of azithromycin initiation rate over total antibiotic initiation rate. CONCLUSION: This study identified a subset of GPs with overprescribing profiles for COVID-19 and other viral infections; they also tended to prescribe broad-spectrum antibiotics for a long duration. There were also regional differences concerning antibiotic initiation rates and the ratio of azithromycin prescribed. It will be necessary to evaluate the evolution of prescribing practices during subsequent waves.

Factors associated with delay in seeking healthcare for imported malaria: a retrospective study in a French hospital.

BACKGROUND: Delayed treatment is associated with a higher risk of severe malaria. In malaria-endemic areas, the main factors associated with delay in seeking healthcare are low educational level and traditional beliefs. In imported malaria, determinants of delay in seeking healthcare are currently unknown. METHODS: We studied all patients presenting with malaria, from 1 January 2017 to 14 February 2022, in the hospital of Melun, France. Demographic and medical data were recorded for all patients, and socio-professional data were recorded for a subgroup of hospitalized adults. Relative-risks and 95% confidence intervals were determined using univariate analysis by cross-tabulation. RESULTS: There were 234 patients included, all travelling from Africa. Among them, 218 (93%) were infected with P. falciparum, 77 (33%) had severe malaria, 26 (11%) were <18 years old and 81 were included during the SARS-CoV-2 pandemic. There were 135 hospitalized adults (58% of all patients). The median time to hospital admission (THA) , defined by the period from onset of symptoms to arrival at hospital, was 3 days (IQR = 2-5). A THA ≥3 days tended to be more frequent in travellers visiting friends and relatives (VFR; RR = 1.44, 95% CI = [1.0-2.05], P = 0.06), while it was less frequent in children and teenagers (RR = 0.58, 95% CI = [0.39-0.84], P = 0.01). Gender, African background, unemployment, living alone and absence of referring physician were not associated with delay in seeking healthcare. Consulting during the SARS-CoV-2 pandemic was neither associated with a longer THA nor with a higher rate of severe malaria. CONCLUSION: In contrast to an endemic area, socio-economic factors did not impact on delay in seeking healthcare in imported malaria. Prevention should focus on VFR subjects, who tend to consult later than other travellers.

Association of high SARS-CoV-2 RNAemia with diabetes and mortality in critically ill COVID-19 patients.

It has been suggested that during the period of respiratory worsening of severe COVID-19 patients, viral replication plays a less important role than inflammation. Using the droplet-based digital PCR (ddPCR) for precise quantification of plasma SARS-CoV-2 viral load (SARS-CoV-2 RNAemia), we investigated the relationship between plasma viral load, comorbidities, and mortality of 122 critically ill COVID-19 patients. SARS-CoV-2 RNAemia was detected by ddPCR in 90 (74%) patients, ranging from 70 to 213,152 copies per mL. A high (>1 000 copies/ml) or very high (>10,000 copies/ml) SARS-Cov-2 RNAemia was observed in 46 patients (38%), of which 26 were diabetic. Diabetes was independently associated with a higher SARS-CoV-2 RNAemia. In multivariable logistic regression models, SARS-CoV-2 RNAemia was strongly and independently associated with day-60 mortality. Early initiation of antiviral therapies might be considered in COVID-19 critically ill patients with high RNAemia.

Ventilator-Associated Pneumonia in COVID-19 Patients: A Retrospective Cohort Study.

INTRODUCTION: Aim of this study is to analyse the characteristics of ventilator-associated pneumonia (VAP) inpatients infected by severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). MATERIALS AND METHODS: A retrospective study was conducted, including coronavirus infectious disease 2019 (COVID-19) patients who developed VAP from March to May 2020 (VAP COVID-19). They were compared to non-COVID-19 patients who developed VAP from January 2011 to December 2019 (VAP NO COVID-19) and COVID-19 patients who did not develop VAP (NO VAP COVID-19). RESULTS: Overall, 42 patients were included in the VAP COVID-19group, 37 in the NO VAP COVID-19 group, and 188 in the VAP NO COVID-19 group. VAP COVID-19 had significantly higher rates of shock (71% vs. 48%, p = 0.009), death in ICU (52% vs. 30%, p = 0.011), VAP recurrence (28% vs. 4%, p < 0.0001), positive blood culture (26% vs. 13%, p = 0.038), and polymicrobial culture (28% vs. 13%, p = 0.011) than VAP NO COVID-19. At the multivariate analysis, death in patients with VAP was associated with shock (p = 0.032) and SARS-CoV-2 (p = 0.008) infection. CONCLUSIONS: VAP in COVID-19 patients is associated with shock, bloodstream, and polymicrobial infections.

Hydroxychloroquine in mild-to-moderate coronavirus disease 2019: a placebo-controlled double blind trial.

OBJECTIVES: To determine whether hydroxychloroquine decreases the risk of adverse outcome in patients with mild to moderate coronavirus disease 2019 (COVID-19) at high risk of worsening. METHODS: We conducted a multicentre randomized double-blind placebo-controlled trial evaluating hydroxychloroquine in COVID-19 patients with at least one of the following risk factors for worsening: need for supplemental oxygen, age ≥75 years, age between 60 and 74 years and presence of at least one co-morbidity. Severely ill patients requiring oxygen therapy >3 L/min or intensive care were excluded. Eligible patients were randomized in a 1:1 ratio to receive either 800 mg hydroxychloroquine on day 0 followed by 400 mg per day for 8 days or a placebo. The primary end point was a composite of death or start of invasive mechanical ventilation within 14 days following randomization. Secondary end points included mortality and clinical evolution at days 14 and 28, and viral shedding at days 5 and 10. RESULTS: The trial was stopped after 250 patients were included because of a slowing down of the pandemic in France. The intention-to-treat population comprised 123 and 124 patients in the placebo and hydroxychloroquine groups, respectively. The median age was 77 years (interquartile range 58-86 years) and 151/250 (60.4%) patients required oxygen therapy. The primary end point occurred in 9/124 (7.3%) patients in the hydroxychloroquine group and 8/123 (6.5%) patients in the placebo group (relative risk 1.12; 95% CI 0.45-2.80). The rates of positive SARS-CoV-2 RT-PCR tests at days 5 and 10 were 72.8% (75/103) and 57.1% (52/91) in the hydroxychloroquine group, versus 73.0% (73/100) and 56.6% (47/83) in the placebo group, respectively. No difference was observed between the two groups in any of the other secondary end points. CONCLUSION: In this underpowered trial involving mainly older patients with mild to moderate COVID-19, patients treated with hydroxychloroquine did not experience better clinical or virological outcomes than those receiving the placebo. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04325893 (https://clinicaltrials.gov/ct2/show/NCT04325893).

Clinical features and medical care factors associated with mortality in French nursing homes during the COVID-19 outbreak.

OBJECTIVES: This study aimed to identify demographic, clinical and medical care factors associated with mortality in three nursing homes in France. METHODS: Two nursing homes were hospital-dependent, had connections with infection prevention and control departments, and had permanent physicians. A third nursing home had no direct connection with a general hospital, no infection control practitioner, and no permanent physician. The main outcome was death. RESULTS: During the first 3 months of the outbreak, 224 of 375 (59.7%) residents were classified as COVID-19 cases and 57 of 375 (15.2%) died. The hospital-dependent nursing homes had lower COVID-19 case fatality rates in comparison with the non-hospital-dependent nursing home (15 [6.6%] vs 38 [25.8%], OR 0.20 [0.11-0.38], p = 0.001). During the first 3 weeks of the outbreak, mortality in COVID-19 patients decreased if they had a daily clinical examination (OR: 0.09 [0.03-0.35], p = 0.01), three vital signs measurement per day (OR: 0.06 [0.01-0.30], p = 0.001) and prophylactic anticoagulation (OR: 0 [0.00-0.24], p = 0.001). CONCLUSIONS: This study suggested that high mortality rates in some nursing homes during the COVID-19 outbreak might have been contributed by a lack of medical care management. Increasing human and material resources, encouraging presence of nursing home physicians and establishing a connection with general hospitals should be considered to deal with present and future health disasters in nursing homes.

COVID-19 among nursing home residents: results of an urgent pre-hospital intervention by a multidisciplinary task force.

The current coronavirus disease-2019 (COVID-19) pandemic caused 10,541 deaths among nursing home residents in France, by July 17th, 2020. This study reported the results of an urgent pre-hospital intervention in eight French nursing homes. A retrospective study was conducted from March 26th to May 7th, 2020, before and after the intervention of a task force which took action from April 9th to April 11th, 2020. The task force included nurses and specialists of the county general hospital. The intervention had four steps: i) daily notification of deaths; ii) audit by infectious diseases and hygiene specialists focused on nursing team reinforcing, tracking of suspected cases, patients' cohorting, review of preventive and protective measures, hydration, thromboembolism prevention; iii) intervention of an emergency team which urgently performed procedures suggested; iv) relay with a geriatric team. There were a total of 770 residents distributed in eight facilities with capacity varying from 53 to 145 residents. The number of deaths peaked at 139 in week 2 and the trough at 0 occurred in weeks 6-7. Comparison between periods (before vs after intervention) showed a significant decrease in number of new deaths (83/770; 11% vs 35/687; 5%, p = 0.0001) and new COVID-19 cases (348/770; 45% vs 123/422; 29%, p < 0.001). The urgent pre-hospital intervention by a multidisciplinary task force achieved mortality reduction during COVID-19 outbreak in nursing homes. Pre-hospital intervention is a valid alternative to hospitalization in case of hospital saturation.