ABSTRACT
Background. The disease caused by SARS-CoV-2, COVID-19, has caused a global public health crisis. Lower respiratory tract infections (LRTIs) caused by COVID-19 has led to an increase in hospitalizations. Disease severity and concerns for bacterial co-infections can increase antimicrobial pressure. Our aim is to define and compare the impact of COVID-19 on antimicrobial use (AU) and antimicrobial resistance (AMR) in the Dominican Republic (DR) and the United States (US). Methods. We performed a retrospective review of AU and antimicrobial susceptibility patterns from 2019-20 at a hospital in the US (H-US) and the DR (H-DR). Our sites are community teaching hospitals with 151 beds in H-US and 295 beds in H-DR. After AU was tabulated, percent changes between 2019-20 were calculated. Resistance patterns for extended-spectrum beta-lactamase producing (ESBL) E coli, ESBL Klebsiella pneumoniae (ESBL-Kp), carbapenem resistant Pseudomonas aeruginosa (CR-PSAR) and Klebsiella pneumoniae (CR-Kp) were tabulated and percent changes between 2019-20 were calculated. Results. AU increased by 10% in H-US and 25% in H-DR, with carbapenem use increasing by 268% and 144% respectively. Ceftriaxone use increased by 30% in H-US and 33% in H-DR. Azithromycin increased 54% in H-US and 338% in the H-DR. Resistance increased from 10% to 28% for ESBL-Kp and from 10% to 12% for ESBL E coli at H-US. CR-PSAR decreased from 20% to 12%, while cefepime and piperacillin resistance increased from 5% to 20% and 3% to 16% respectively (Figure 1). At H-DR, ESBL-Kp resistance decreased from 68% to 64% and increased from 58% to 59% for ESBL E coli. CR-PSAR and cefepime resistance increased from 5% to 19% and from 9% to 29% respectively (Figure 2). Conclusion. COVID-19 had a major impact on antimicrobial consumption and resistance in the US and DR. A greater impact was seen on ESBL rates in the US whilst a greater impact on carbapenem resistance was seen in the DR. The rise in carbapenem use in H-US reflected a rise in ESBL rates. In the DR, ESBL producing organisms were common prior to COVID-19 and carbapenem use was more widespread. The impact of the COVID-19 pandemic on AU may accelerate AMR worldwide. The scale up of antimicrobial stewardship across the globe is urgently needed to curb AMR.
ABSTRACT
Background. Neutralizing monoclonal antibodies (mAbs) bind to the receptor binding domain of the spike protein of SARS-CoV-2. In November 2020, several mAbs were issued an EUA by the FDA as single-dose intravenous (IV) infusions for treatment of mild to moderate COVID-19. mABs were allocated to local health facilities capable of administering infusions and managing side effects. Creating an outpatient infusion program during the COVID-19 winter surge can be logistically difficult. Our goal was to implement a mAb outpatient infusion program at an urban safety-net community hospital designed to serve communities most heavily impacted by COVID-19. Methods. The emergency department (ED) fast-track was repurposed for the mAb program with protocols from the infectious diseases physician and antimicrobial stewardship. Education materials with indications for mAbs were distributed in surrounding clinics serving our community. The program was available to all patients meeting criteria outlined in the protocol, 24/7, including but not limited to current ED patients and referrals from facilities in the vicinity. Results. Between December 1, 2020 and March 1, 2021, a total of 37 patients were treated: 51% male, 57% Hispanic or Latinx, 27% Black, and 95% (35) represented ZIP codes with high COVID-19 burden (Figure 1). Bamlanivimab was used for each instance and all infusions met criteria. Patient indications for mAb infusion are listed in Figure 2. Parenteral antibiotics were given to 10.8% and 35% received oral antibiotics upon discharge. At 30 days post-infusion, 8% (3) required hospitalization and there were no deaths. Zip codes with high COVID-19 disease burden served by our mAB infusion program Distribution of patients who received mAB infusions by indication Conclusion. A mAb outpatient infusion program was successfully deployed in a safety-net community hospital. We believe strengths of the program included the flexible infusion hours and convenient referral site for patients and providers. Of importance, this program was able to provide services to minorities from ZIP codes most heavily impacted by COVID-19. Unfortunately, antibacterial use was common and may reflect broader unnecessary use in COVID-19 patients. Whilst mAb treatment was deemed appropriate in all instances via protocol inclusion criteria, antibacterial stewardship programs may need to expand to ED settings for COVID-19 management.
ABSTRACT
Background. COVID-19 was declared a global Public Health Emergency by the WHO in January 2020. Limited treatment options existed early in the pandemic. As COVID-19 spread across the globe and new therapeutics emerged, different interpretations of the literature grew, and major societies relayed conflictive recommendations. There is a paucity of data on COVID-19 management in low- and middle-income countries. As a result, we performed a nationwide survey of local treatment practices in the Dominican Republic (DR). Methods. We performed an anonymous survey of infectious diseases specialists in the DR and US. The survey collected hospital characteristics and COVID-19 management protocols during different quarters of 2020-21. Management was categorized by drug and disease severity based on supplemental oxygen requirements. A convenience sample in the US representing community and academic sites was surveyed for point comparison between the US and DR. Results. The survey was completed by physicians from a total of 11 sites located in 4 cities of the DR: Santo Domingo (3), Santiago (4), La Vega (2) and San Francisco (2). These cities were representative of all regions in the country. The survey included 7 (64%) hospitals with < 200 beds, 3 (27%) with 201-300 beds, and 1 (9%) with >400 beds. Seven (47%) were private, 2 (13%) public, and 6 (40%) were teaching hospitals. In the US, 2 academic hospitals with >400 beds and 2 community hospitals with < 200 beds in a major city were surveyed. Management of COVID-19 at sites in the DR and US throughout the pandemic is plotted in Figure 1. Remdesivir use by disease severity is plotted in Figure 2. Conclusion. Throughout the pandemic, as therapeutic options evolved, hospitals and physicians had to adapt to changing guidelines and availability of novel drugs. Variability between countries and sites emerged. The use of hydroxychloroquine and convalescent plasma waned more rapidly in the US. Dexamethasone was widely used at all sites. Tocilizumab and remdesivir were used more liberally in the DR. Antimicrobial stewardship limited these agents at US sites to more narrow therapeutic windows which could explain the discrepancies seen between the US and DR. Uncertainty of benefit in certain disease states, limited availability, and cost may also play a role.
ABSTRACT
Background. The United States (US) is one of the most affected countries by the COVID-19 pandemic. A disproportionate burden of COVID-19 deaths is seen in Black, Asian, and Latinx groups. COVID-19 vaccines are the primary mitigation strategy to reduce morbidity and mortality. However, vaccine hesitancy is high in these communities due to factors such as low health literacy, language barriers, and other health inequities. Our objective was to implement a culturally sensitive, multi-lingual, community outreach model to promote vaccine education and facilitate vaccine administration. Methods. Community healthcare workers or "promotoras" were deployed to high traffic areas such as supermarkets, laundromats, churches, and commercial hubs from February-May 2021. The promotoras provided culturally sensitive vaccine counseling to individuals in their preferred language and facilitated vaccine appointments at our hospital. Our data was compared with publicly available data from other facilities organized by ZIP codes defined by the Department of Public Health as low, medium, or high-vulnerability to COVID-19. Results. A total of 109 outreach workers were hired, of which 67% (73) were Latinx, 27% (29) Black and 6% (7) Asian. Overall, 8,806 individual encounters led to 6,149 scheduled appointments and 3,192 completed first doses (Figure 1). A total of 14,636 individuals were vaccinated. Average age was 45.5 (range 12-98). Preferred language was 54% Spanish, 38% English, and 8% Chinese. Ethnicity was mostly Hispanic (66%) with race mostly white (54%) (Figure 2). High and medium-risk ZIP codes represented 69.4% of vaccinations at our facility (Figure 3). Conclusion. We successfully implemented a culturally sensitive community outreach model which resulted in higher vaccination rates from at risk ZIP codes when compared to other hospitals. Promotoras encouraged vaccination in native languages, thereby increasing vaccine awareness and appointment faciliation. Barriers to vaccine access remain in these vulnerable communities. This model educated the community via its own members and may help reduce barriers, increase vaccine awareness and vaccination rates.