A quality-improvement approach to urgent-care antibiotic stewardship for respiratory tract infections during the COVID-19 pandemic: Lessons learned.

OBJECTIVE: We investigated a decrease in antibiotic prescribing for respiratory illnesses in 2 academic urgent-care clinics during the coronavirus disease 2019 (COVID-19) pandemic using semistructured clinician interviews. METHODS: We conducted a quality-improvement project from November 2020 to May 2021. We investigated provider antibiotic decision making using a mixed-methods explanatory design including interviews. We analyzed transcripts using a thematic framework approach to identify emergent themes. Our performance measure was antibiotic prescribing rate (APR) for encounters with respiratory diagnosis billing codes. We extracted billing and prescribing data from the electronic medical record and assessed differences using run charts, p charts and generalized linear regression. RESULTS: We observed significant reductions in the APR early during the COVID-19 pandemic (relative risk [RR], 0.20; 95% confidence interval [CI], 0.17-0.25), which was maintained over the study period (P < .001). The average APRs were 14% before the COVID-19 pandemic, 4% during the QI project, and 7% after the project. All providers prescribed less antibiotics for respiratory encounters during COVID-19, but only 25% felt their practice had changed. Themes from provider interviews included changing patient expectations and provider approach to respiratory encounters during COVID-19, the impact of increased telemedicine encounters, and the changing epidemiology of non-COVID-19 respiratory infections. CONCLUSIONS: Our findings suggest that the decrease in APR was likely multifactorial. The average APR decreased significantly during the pandemic. Although the APR was slightly higher after the QI project, it did not reach prepandemic levels. Future studies should explore how these factors, including changing patient expectations, can be leveraged to improve urgent-care antibiotic stewardship.

Outpatient hydroxychloroquine prescribing at a large academic health system during the COVID-19 pandemic

To the Editor—The coronavirus disease 2019 (COVID-19) pandemic has attracted widespread attention to experimental treatments, including the antirheumatic drug hydroxychloroquine, raising concerns about its supply for patients already taking the drug for non–COVID-19 indications.1 Currently, multiple manufacturers have reported shortages of hydroxychloroquine.2 We report an exploratory analysis of hydroxychloroquine prescribing in outpatient and urgent care clinics of a large academic health system in northern California. The CDC guidance has recommended that patients request larger prescription drug quantities to minimize pharmacy visits.3 However, the American College of Rheumatology has suggested limiting outpatient prescription refills of hydroxychloroquine to a 30-day supply as a potential mitigation strategy for any supply disruptions in select circumstances.4 Our analysis was observational in nature, and further interpretation is limited by several factors. [...]these results are unique to practice paradigms of a single health system and are subject to regional epidemiology of COVID-19.

Pharmacotherapy Considerations for COVID-19

Remdesivir Remdesivir is a prodrug of an adenosine nucleoside, which inhibits viral RNA-dependent RNA polymerase.3,4 At the time of this writing, remdesivir is not approved by the Food and Drug Administration (FDA) and is available only as an investigational drug through Gilead Sciences.5 It was studied originally for Ebola virus disease and found to produce no benefit vs. comparators. Exclusions vary between trials, but, notably, they generally exclude patients 17 years of age or younger, those with severe hepatic or renal impairment, and pregnant or breastfeeding women.9-11 Chloroquine or Hydroxychloroquine Chloroquine has been proposed as another treatment for COVID-19 and has exhibited in vitro activity against SARS-CoV-2.7 Its antiviral activity may be afforded by an increase in endosomal pH and interference with glycosylation of cellular receptors of SARS-CoV.12 Initial reports from more than 100 patients asserted that there was superiority of chloroquine to control treatment in inhibiting exacerbation of pneumonia, promoting negative conversion, and shortening the disease. The fourth patient, with severe COVID-19, showed signs of improvement at the end of data collection.19 Guidelines for 2019-nCoV pneumonia from the Zhongnan Hospital of Wuhan University Novel Coronavirus Management and Research Team provided a weak recommendation for the use of lopinavir/ritonavir based on benefits found in patients with SARS or Middle East respiratory syndrome (MERS), especially with earlier administration.20 Adjunctive Therapies Adjunctive corticosteroids have not shown clinical benefit, have delayed viral RNA clearance in other coronavirus disease (SARS and MERS), and may increase the risk of side effects (e.g., psychosis, diabetes, and avascular necrosis) and increased mortality in influenza.21 Chinese guidance has suggested the use of tocilizumab for cytokine storm in patients with severe disease (e.g., acute respiratory distress syndrome) and elevated interleukin-6 levels.22