Antibiotic prescribing trends in the US during the first 11 months of the COVID-19 pandemic.

BACKGROUND: The study aims to compare antibiotic prescribing trends for U.S. COVID-19 patients, categorized by disease severity, and non-COVID-19 population with similar symptoms during 2019-2020 pandemic. METHODS: A retrospective observational cohort design using Symphony Health (January-November 2020). Sample population included about 13.3 million patients with at least one prescription claim ±6 months from date of diagnosis of COVID-19 or COVID-19 like symptom. Cohorts were categorized based on diagnosis codes; COVID-19 positive cohorts 1 to 3 with severe, mild, and no symptoms, respectively and non-COVID-19 cohorts 4 and 5 with severe and mild symptoms, respectively. Descriptive statistics were calculated for demographic characteristics and acute antibiotic utilization (≤7 days) including total number of antibiotics, weekly rate of prescribing, and proportion of fills in three "appropriateness" categories (always appropriate, potentially appropriate, never appropriate). RESULTS: Three cohorts with a positive COVID-19 diagnosis code constituted a total of about 1.8 million patients (13.53%). About 22.79% of COVID-19 positive groups had severe symptoms, 24.43% had moderate symptoms and the majority, 52.78%, had no symptoms. In the analytical sample of 13 million, about 4.2 million antibiotic prescriptions were prescribed to 2.5 million patients (19%) within 7 days of the first diagnosis of either COVID-19 or COVID-19-like symptoms. Within the COVID-19 positive cohorts, about 11% received an antibiotic prescription, while the non-COVID-19 cohorts, about 19.70% received an antibiotic. Among patients with antibiotic prescriptions, about 37.01% were prescribed an antibiotic "appropriately", 39.46% were prescribed a "potentially appropriate" antibiotic and about 22.64% received an "inappropriate" antibiotic. Among patients prescribed antibiotics, azithromycin was the most common, ranging from 21.80 to 44.80% for each cohort. CONCLUSIONS: Although the overall proportion of COVID-19 patients receiving antibiotics was much lower than non-COVID-19 patients, the findings suggest use of antibiotics persisted despite guidelines against widespread use, particularly for patients with moderate and mild COVID-19 symptoms.

Transparency, health equity, and strategies in state-based protocols for remdesivir allocation and use.

BACKGROUND: The Emergency Use Authorization (EUA) of remdesivir for coronavirus disease 2019 raised questions on transparency of applied strategy, and how to equitably allocate and prioritize eligible patients given limited supply of the medication. The absence of federal oversight highlighted the critical role by states in health policymaking during a pandemic. OBJECTIVE: To identify public state-based protocols for remdesivir allocation and clinical guidance for prioritizing remdesivir use and assess approaches and inclusion of language promoting equitable access or mitigating health disparities. METHODS: We identified remdesivir allocation strategies and clinical use guidelines for all 50 states in the U.S. and the District of Columbia accessible on state health department websites or via internet searches. Public protocols dated between May 1, 2020 and September 30, 2020 were included in the study. We reviewed strategies for allocation and clinical use, including whether protocols contained explicit language on equitable access to remdesivir or mitigating health disparities. RESULTS: A total of 38 states had a remdesivir allocation strategy, with 33 states (87%) making these public. States used diverse allocation strategies, and only 10 (30%) of the 33 states included language on equitable allocation. A total of 30 states had remdesivir clinical use guidelines, where all were publicly accessible. All guidelines referenced recommendations by federal agencies but varied in their presentation format. Of the 30 states, 12 (40%) had guidelines that included language on equitable use. Neither an allocation strategy or clinical use guideline were identified (public or non-public) for 10 states and the District of Columbia during the study period. CONCLUSIONS: The experience with the remdesivir EUA presents an opportunity for federal and state governments to develop transparent protocols promoting fair and equal access to treatments for future pandemics.