ABSTRACT
Background. The percentage of all respiratory diagnoses prescribed an antibiotic is an outpatient stewardship metric and was introduced as a HEDIS measure in 2022. Given a stable case mix, this metric is not affected by differences in coding practices between clinicians or health systems since all respiratory diagnoses are considered together. The onset of the COVID-19 pandemic introduced a high number of viral illness episodes where antibiotics are not recommended. The impact of this shift in case mix on respiratory diagnosis coding and prescribing metrics has not been explored. Methods. We examined antibiotic prescribing rates for respiratory diagnoses in a network of urgent care clinics affiliated with the University of Utah during two periods. Pre-Pandemic was Mar 2019-Feb 2020 and Pandemic was Mar 2020-Mar 2022. Respiratory diagnoses were identified using ICD10 codes and further stratified into 3 Tiers (Tier 1: antibiotics indicated;Tier 2: antibiotics sometimes indicated;Tier 3: antibiotics not indicated). We examined trends in antibiotic prescribing across these periods including the percentage of all respiratory visits prescribed antibiotics and by Tier and the distribution of diagnoses by Tier. No formalized stewardship interventions were introduced during these periods. Results. There were 146,897 urgent care visits during the study period (47,423 Pre Pandemic and 99,474 Pandemic). The respiratory prescribing rate declined from 42.3% Pre Pandemic to 26.2% during the Pandemic (Figure). The distribution of respiratory diagnoses by Tier and prescribing within Tier are shown in the Table. Tier 3 diagnoses increased from 48% to 67%, while Tier 2 diagnoses declined from 47% to 31%. Antibiotic prescribing declined for both Tier 2 and Tier 3 diagnoses. 15,429 (23%) of Tier 3 diagnoses during the Pandemic were coded as COVID-19. 50% of the reduction in prescribing is attributable to changes in Tiers alone. Figure Table Conclusion. The COVID 19 pandemic was associated with a reduction in the percentage of respiratory diagnoses prescribed antibiotics. Half was due to an increase in Tier 3 encounters although declines in prescribing occurred with Tiers in addition. Using this metric for benchmarking requires accounting for the impact of case mix differences over time or between systems and clinicians.
ABSTRACT
INTRODUCTION: In patients requiring extracorporeal membrane oxygenation (ECMO), 13% of blood stream infections are attributable to fungus, which is associated with >30% mortality in the critically ill (1, 2). There is currently limited published data on fungemia in ECMO patients and best practices for circuit management and antifungals are unknown. We present our experience with 12 cases of fungemia in 11 patients. METHODS: This is a retrospective case series of patients admitted to Brooke Army Medical Center from January 2012 to December 2020 who required ECMO. Patients were included if fungi were recovered from blood cultures. Data regarding hospitalization days, ECMO days, treatment, treatment length, metastatic focus, and outcome were reviewed. RESULTS: There were 235 patients placed on ECMO during the study period with eleven (5%) patients developing fungemia. The cohort was 82% male and had a median age of 32±8 years with the most common admission for thermal burns (n=3, 27%) and SARS-CoV-2 (n=3, 27%). The most common organism isolated was C. albicans (n=3, 27%) and C. tropicalis(n=3, 27%). Prior to developing fungemia, patients were hospitalized for a median 21±26 days and were cannulated for a median of 14±25 days. Four patients had metastatic foci secondary to fungemia. Echinocandins were used as initial therapy in nine (81%) patients with a median treatment duration of 20±10 days. Four (37%) patients died prior to completing therapy, six (55%) patients survived to discharge, and one (9%) patient was transferred for lung transplant. Of the seven patients who completed therapy, four (57%) patients were decannulated on therapy and three (43%) patients remained on ECMO after treatment. While fungemic, six (72%) patients had circuit changes and two (18%) patients had circuit reconfigurations, with only one of the reconfigurations done due to fungemia. One patient (33%) who remained on ECMO developed recurrence 29 days after completing a 14-day course of micafungin. DISCUSSION: In our cohort, fungemia appeared late in the ECMO course and was associated with a 36% mortality. All patients who were decannulated during therapy survived without recurrence. Further studies focusing on outcomes of patients who remain on ECMO after completion of antifungal therapy are needed.