ABSTRACT
Purpose: Data shows COVID vaccine response after 2 doses in patients on Belatacept immunosuppression (IS) is low, with reported rates of seroconversion (as measured by COVID spike IgG antibody (IgG Ab) detection) of <10%. It is suggested that T cell immunity provides more nuanced marker of immunity. We seek to describe immune response with third dose of vaccine using T cell immunity and spike Ab as surrogate markers. Method(s): 12 kidney transplant patients on long term belatacept maintenance therapy were included. All patients received induction rabbit anti thymocyte globulin at transplant and were maintained on triple IS with mycophenolate and steroids. All patients received 3 doses of the Pfizer BioNTech SARS CoV2 mRNA vaccine. IgG Ab and T cell immunity response were monitored after 2 doses of vaccine, on the date of 3rd dose with repeat testing done about 4 weeks after 3rd dose. Due to small sample size, T cell response detection was treated qualitatively as "detected" and "negative" results based upon manufacturer instructions (Eurofins Viracor). IgG Ab response was treated qualitatively as "detected" and "negative", as many responses were too low to be reliably quantifiable. Result(s): Of the 12 included patients, 58% were female, 50% were African American, at mean of 77 months post transplant. After 2 vaccine doses, immunity was detected using the T cell based assay in 6/12 [50.0%, 95% CI: (21.1%-78.9%)];after 3 doses, T cell immunity detection remained the same (6/12). After 2 doses, IgG was detected in 2/12 patients [16.7%, 95% CI: (2.1%-48.4%)]. After 3 doses, this rate doubled to 4/12 [33.3%, 95% CI: (9.9%-65.1%)]. All IgG Ab detected patients were within the T Cell detected patients. There were statistically significant differences between patients that showed a response vs those that did not although patients with no response had been on a numerically higher duration of belatacept (mean=56 months) vs those with any response (mean=34 months;p=0.23). No patients developed a COVID 19 infection during the study period. Conclusion(s): In this cohort, T cell response identified a bigger subset of patients with vaccine response with 2 mRNA vaccine doses compared with those identified with an IgG response only. However, both T cell immunity and IgG Ab response remained low after 2 or 3 doses, and no patient in in the 2 dose group developed new T cell immunity response after third vaccination. IgG Ab response increased in half of the patients, but these were patients who already had developed a T cell immune response after second dose of vaccine. Total change in COVID spike IgG response after the third dose was up to 33% from an initial 16%, which may demonstrate improved total response to 3 doses. Further research is needed to assess if response rates improve with additional (fourth) doses of COVID vaccine or 'mix and match' strategies.
ABSTRACT
Purpose/Objectives: The AHRQ Safety Program for Improving Antibiotic Use aimed to improve antibiotic use by engaging clinicians and staff to incorporate antibiotic stewardship principles into practice culture, communication, and decision making. We report on changes in visits and antibiotic prescribing among participating pediatric primary and urgent care ambulatory practices during the COVID-19 pandemic. Design/Methods: The Safety Program used webinars, audio presentations, educational tools, and office hours to engage clinician champions and staff leaders to: (a) establish antibiotic stewardship programs, (b) address attitudes and culture that pose challenges to judicious antibiotic prescribing, and (c) incorporate best practices for the management of common infections into their workflow using the Four Moments of Antibiotic Decision Making framework. Monthly data on total visits (in-person and virtual), acute respiratory infection (ARI) visits, and antibiotic prescribing were collected from all participating practices during the pre-intervention period (September 2019-November 2019) and during the Safety Program (December 2019-November 2020). Data from the beginning to the end of the Safety Program were compared using linear mixed models to account for random effects of participating sites and repeated measurements of outcomes within practices over time. Results: The 63 participating pediatric practices included 23 general pediatric clinics (37%) and 40 pediatric urgent care clinics (63%). 60 practices submitted complete data for analysis, including 1,040,810 visits. Visits/practice-month declined March-April 2020 but exceeded baseline by Safety Program end (Figure 1). Total antibiotic prescribing declined by 16 prescriptions/100 visits (95% CI: -18 to -14) from November 2019 and November 2020. ARI visits/practice-month similarly declined March-June 2020 after widespread recognition of the COVID-19 epidemic, and remained below baseline by Safety Program end (Figure 2). ARIrelated antibiotic prescriptions decreased by 16 prescriptions/100 ARI visits (95% CI: -20 to -12) from November 2019 to November 2020. Among antibiotic classes, the greatest change was in penicillins. Prescriptions for penicillins was reduced by 11 prescriptions/100 ARI visits (95% CI: -14 to -8). Conclusion/Discussion: During the COVID-19 pandemic, while visit rates gradually normalized, a national ambulatory Antibiotic Stewardship program was associated with declines in overall and ARI-related antibiotic prescribing.
ABSTRACT
Background: We have previously described the prognostic utility of QRS amplitude diminution (LoQRS) in predicting mortality and clinical decompensation in patients with COVID-19. However, whether and how COVID-19 vaccination status modulates risk prediction is not currently known. Objective: To assess any effect vaccination status may have on prevalence or risk prediction of LoQRS. Methods: We performed a retrospective analysis of patients admitted with laboratory confirmed COVID-19. Patients were excluded if the ECG was not acquired within 72 hrs of admission. Low QRS Amplitude (LoQRS) was defined by a composite of QRS amplitude <5mm in the limb leads or <10mm in the precordial leads (a composite of V1-V3 and V4-V6), or a ≥ 50% reduction in QRS amplitude. LoQRS was considered present even if found only in leads V1-V3 or V4-V6. Results: Among 3,365 patients, 11% were vaccinated and 89% were unvaccinated. LoQRS occurred in 30.9% of patients (33.5% of vaccinated patients and 30.5% in unvaccinated patients). Mortality occurred in 20.4% of patients without LoQRS compared to 30.2% in patients with LoQRS. The same pattern was seen in ICU admission, with 23.5% of patients without LoQRS being admitted to the ICU compared to 33.4% of patients with LoQRS. In multivariable models, LoQRS was independently associated with mortality and ICU admission regardless of vaccination status (or for mortality in unvaccinated patients: 1.24, 95% CI 1.03-1.49, P<0.01 vs 1.27 (95% CI 1.05-1.52, p<0.01). LoQRS also predicts ICU admission (OR 1.7, 95%CI 1.4-2.0) in unvaccinated patients vs. 1.73 (95%CI 1.5-2.1). In a survival analysis, vaccinated patients demonstrated improved mortality over unvaccinated counterparts, with a marked increase in mortality with, and stratification by, the presence of LoQRS in the unvaccinated. Conclusion: QRS amplitude on either the presenting or follow-up ECG independently predicts mortality and ICU admission in hospitalized patients with COVID-19 regardless of vaccination status. Patients who were vaccinated overall had better outcomes. [Formula presented]
ABSTRACT
Background. The AHRQ Safety Program for Improving Antibiotic Use aimed to improve antibiotic use by engaging clinicians and staff to incorporate antibiotic stewardship (AS) into practice culture, communication, and decision making. We report on changes in visits and antibiotic prescribing in AHRQ Safety Program ambulatory practices during the COVID-19 pandemic. Methods. The Safety Program used webinars, audio presentations, educational tools, and office hours to engage clinician champions and staff leaders to: (a) address attitudes and culture that pose challenges to judicious antibiotic prescribing and (b) incorporate best practices for the management of common infections into their workflow using the Four Moments of Antibiotic Decision Making framework. Total visits (in-person and virtual), acute respiratory infection (ARI) visits, and antibiotic prescribing data were collected. Using linear mixed models to account for random effects of participating practices and repeated measurements of outcomes within practices over time, data from the pre-intervention period (September-November 2019) and the Ambulatory Care Safety Program (December 2019-November 2020) were compared. Results. Of 467 practices enrolled, 389 (83%) completed the program, including 162 primary care practices (42%;23 [6%] pediatric), 160 urgent care practices (41%;40 [10%] pediatric), and 49 federally-supported practices (13%). 292 practices submitted complete data for analysis, including 6,590,485 visits. Visits/practice-month declined March-May 2020 but gradually returned to baseline by program end (Figure 1). Total antibiotic prescribing declined by 9 prescriptions/100 visits (95% CI: -10 to -8). ARI visits/practice-month declined significantly in March-May 2020, then increased but remained below baseline by program end (Figure 2). ARI-related antibiotic prescriptions decreased by 15/100 ARI visits by program end (95% CI: -17 to -12). The greatest reduction was in penicillin class prescriptions with a reduction of 7/100 ARI visits by program end (95% CI: -9 to -6). Conclusion. During the COVID-19 pandemic, a national ambulatory AS program was associated with declines in overall and ARI-related antibiotic prescribing.