ABSTRACT
Background: The COVID-19 pandemic heavily affected healthcare delivery systems in the United States. However, little is known about its impact on overall antimicrobial consumption, especially in outpatient settings. We assessed the impact of the COVID-19 pandemic on antimicrobial consumption in both outpatient and inpatient (acute-care, long-term care, and mental health) settings in the Veterans' Health Administration (VHA) during the 2 years before and after the start of the pandemic. Methods: We conducted a retrospective study for all patients who received care within the VHA from January 2018 to December 2021. We used antibiotic days as the primary outcome measure (days of therapy for inpatient settings and dispensed days supply for outpatient settings), and we obtained data for antimicrobial consumption from the VHA Corporate Data Warehouse. Antibiotics were categorized into classes by the NHSN protocol and included only systemic agents (oral and parenteral). We defined 2018–2019 as the prepandemic period and 2020–2021 as the pandemic period. We compared the relative and absolute difference in antibiotic consumption between the 2 periods. Results: Across all periods, 8.3 million patients received care in the VHA, and an average of 28,709,680 antibiotic days were prescribed per year. Overall, 92.9% of all antibiotic days were outpatient and 7.1% were inpatient. Total antibiotic days during the pandemic period decreased by 12.4% compared to the prepandemic period (pandemic period: 53,613,840 and prepandemic period: 61,224,878). This reduction was primarily driven by reductions in outpatient settings (relative reduction: 12.7% and absolute reduction: 7,254,880 antibiotic days over 2 years), but antibiotic days in inpatient settings decreased more modestly (relative reduction: 8.4% and absolute reduction: 356,158 antibiotic days over 2 years) (Fig. 1). When frequently prescribed antimicrobials were categorized by classes, fluoroquinolones and lincosamides showed the largest decreases (fluoroquinolones: 29.2% reduction and lincosamides: 27.2% reduction). Tetracyclines and sulfamethoxazole–trimethoprim had the smallest reductions (5.2% and 11.2%, respectively). Conclusions: Compared to the prepandemic period, the pandemic was associated with a substantial reduction in overall antibiotic consumption, especially in outpatient settings, which accounted for 95% of the overall reduction despite being outside the domain of most traditional antibiotic stewardship programs. The impact of the pandemic was most modest in the use of tetracyclines and trimethoprim–sulfamethoxazole and was most prominent in the use of fluoroquinolones and lincosamides. Further studies are required to improve the causal inference between the COVID-19 pandemic and this reduction in antibiotic consumption, as well as its impact on patient outcomes.Funding: NoneDisclosures: None
ABSTRACT
Efforts to improve antimicrobial prescribing are occurring within a changing healthcare landscape, which includes the expanded use of telehealth technology. The wider adoption of telehealth presents both challenges and opportunities for promoting antimicrobial stewardship. Telehealth provides 2 avenues for remote infectious disease (ID) specialists to improve inpatient antimicrobial prescribing: telehealth-supported antimicrobial stewardship and tele-ID consultations. Those 2 activities can work separately or synergistically. Studies on telehealth-supported antimicrobial stewardship have reported a reduction in inpatient antimicrobial prescribing, cost savings related to less antimicrobial use, a decrease in Clostridioides difficile infections, and improved antimicrobial susceptibility patterns for common organisms. Tele-ID consultation is associated with fewer hospital transfers, a shorter length of hospital stay, and decreased mortality. The implementation of these activities can be flexible depending on local needs and available resources, but several barriers may be encountered. Opportunities also exist to improve antimicrobial use in outpatient settings. Telehealth provides a more rapid mechanism for conducting outpatient ID consultations, and increasing use of telehealth for routine and urgent outpatient visits present new challenges for antimicrobial stewardship. In primary care, urgent care, and emergency care settings, unnecessary antimicrobial use for viral acute respiratory tract infections is common during telehealth encounters, as is the case for fact-to-face encounters. For some diagnoses, such as otitis media and pharyngitis, antimicrobials are further overprescribed via telehealth. Evidence is still lacking on the optimal stewardship strategies to improve antimicrobial prescribing during telehealth encounters in ambulatory care, but conventional outpatient stewardship strategies are likely transferable. Further work is warranted to fill this knowledge gap.
ABSTRACT
This SHEA white paper identifies knowledge gaps and challenges in healthcare epidemiology research related to coronavirus disease 2019 (COVID-19) with a focus on core principles of healthcare epidemiology. These gaps, revealed during the worst phases of the COVID-19 pandemic, are described in 10 sections: epidemiology, outbreak investigation, surveillance, isolation precaution practices, personal protective equipment (PPE), environmental contamination and disinfection, drug and supply shortages, antimicrobial stewardship, healthcare personnel (HCP) occupational safety, and return to work policies. Each section highlights three critical healthcare epidemiology research questions with detailed description provided in supplementary materials. This research agenda calls for translational studies from laboratory-based basic science research to well-designed, large-scale studies and health outcomes research. Research gaps and challenges related to nursing homes and social disparities are included. Collaborations across various disciplines, expertise and across diverse geographic locations will be critical.