When Aways Went Away: How the Elimination of Away Rotations During Covid-19 was Perceived by Applicants Across Specialties

Introduction: COVID-19's emergence and subsequent social distancing guidelines resulted in severe restrictions on away rotations (ARs). This multi-institutional cross-sectional study investigated how these restrictions were perceived by residency applicants across specialties. Method(s): In fall, 2020, an online survey regarding COVID-19's impact on graduating medical students' education was distributed to ACGME Medical Schools. Demographics, specialty choice, and pre- COVID plans to participate in ARs verses one's participation post- COVID were collected. Respondents who provided e-mails received a post-Match follow-up survey in which retrospective thoughts on ARs were explored. Participants were grouped by specialty choice (medical, procedural, surgical) and answers were compared between groups using Kruskal-Wallis test. Result(s): 58 Institutions distributed the initial survey to 8200 graduating students. 1473 responded (18%). 81% were 25-29;65% were female. 49% were medical, 24% procedural and 26% surgical. Surgical and procedural applicants were more likely to have planned to participate in ARs (p<0.001) and be concerned that limitations on ARs would negatively impact their match (p<0.001). Of 1221 initial survey respondents who provided e-mails, 458 participated in the follow-up survey (37.5%). Demographics were similar to the index survey. Post-Match, surgical and procedural applicants were more likely to wish they could have participated in ARs and to propose that future ARs only be offered in-person (p<0.001). Conclusion(s): This multi-institutional survey across specialties highlights the perceived value of ARs for surgical and procedural candidates. Should opportunities for ARs continue to be limited, alternative opportunities for applicants to connect with programs and optimize successful matches should be investigated.

Global Collaboration to Provide Drug Interaction Guidance for Nirmatrelvir/Ritonavir

Background: Nirmatrelvir/ritonavir (NMV/r), a preferred antiviral for high-risk outpatients with COVID-19, is associated with major drug-drug interactions (DDIs). Given the lack of DDI data with short course ritonavir (RTV), initial NMV/r product information was extrapolated from chronic, full dose RTV use. In Jan 2022, DDI experts from the University of Liverpool (UoL), NIH COVID-19 Guidelines Panel, and Ontario Science Table (OST) contributors established a global collaboration to address DDI challenges limiting NMV/r use in real-life settings. We report how safe, pragmatic, and consistent resources were developed to support NMV/r prescribing, and the utilization of these resources globally. Method(s): The 3 teams met monthly to discuss DDIs, review NMV/r DDI literature, and achieve consensus on recommendations. Additional experts were invited as needed. Metrics from the UoL DDI checker guided review of most searched DDIs overall and by severity. 2022 usage metrics for each DDI guide were collected. Differences in recommendations between initial DDI guides and product information were compared. Result(s): In 2022, 12 meetings were convened. Each team's DDI guide was revised and expanded (Table 1). To factor in the lower RTV dose and shorter treatment duration, some recommendations differed from product information. Drug categories that required the most discussion and revision included: anticoagulants (ACs), immunosuppressants, calcium channel blockers. NMV/r accounted for 85% of queries on the UoL site. NMV/r DDI guidance was the most viewed page of the NIH guidelines and among the OST ID/clinical care Science Briefs. Top searched drugs on the UoL site with serious DDIs were certain ACs and statins. Utilization of DDI guides was not limited to in-country resources: 51% and 7% of UoL queries came from the USA and Canada, respectively. NIH users followed links to the UoL and OST sites 161,478 and 37,619 times, respectively. Conclusion(s): Significant efforts have been made by the 3 teams to provide upto-date, complementary DDI guidance. Usage metrics confirm the demand for DDI guidance during the pandemic. Cross-utilization of the DDI guides confirms the need for consistency. DDI recommendations were more permissive than initial product information, expanding clinicians' ability to prescribe NMV/r. DDI guidance for ACs and immunosuppressants was particularly challenging. During drug development, complex interactions likely to be encountered in target populations should be addressed.

Bring your boots: wading through GI PCR panel diagnostic stewardship applications

Background. Infectious diarrhea is a common cause of emergency department (ED) visits and hospital admissions. Polymerase chain reaction (PCR) testing allows for quick and expansive pathogen identification and facilitates earlier targeted treatment. We implemented a multiplex gastrointestinal (GI) PCR panel in 2014. In collaboration with the Antimicrobial and Diagnostic Advisement Program (ADAP), post-launch optimization strategies have changed test use. We evaluate the impact of diagnostic stewardship initiatives. Methods. GI PCR testing was initially unrestricted for ED or inpatients within 72 hours of admission. After fielding many questions regarding interpretation, the ADAP developed a guidance document in June 2019 regarding treatment considerations for all potential organisms detected. In January 2020, organism-specific treatment considerations were embedded in the test results real-time treatment guidance (figure 1). A pre-post quality improvement assessment of the changes was performed. In August 2021, individual GI PCR panel orders were replaced with an order set containing a decision tree to provide passive guidance evaluating acute vs chronic diarrhea, assessing recent antibiotic use (to consider C. difficile testing), no testing scenarios, and avoiding repeat testing (figure 2). Results. GI PCR panel use peaked in 2019 with 3,142 tests processed. The guidance document was less helpful, requiring an external site link. Embedding organismspecific GI PCR guidance significantly improved appropriate antibiotic prescribing (77.9 vs 89.1%, p=0.001). A precipitous drop off in GI PCR test orders occurred after the COVID-19 pandemic began (1,774 in 2020), partly attributed to supply chain issues. When comparing intra-pandemic years (2020 vs 2021), implementation of a smart order set was associated with a 51.3% reduction in orders (1,774 vs 864) and $131,000 in savings despite significant patient volume increases in 2021. Low use rates have persisted into the first quarter of 2022 (n=229). Conclusion. Diagnostic stewardship changes should be proactive and contextually relevant at the time of result interpretation. Antimicrobial stewardship programs are uniquely positioned to lead optimization initiatives and drive clinical and costeffective solutions. (Figure Presented).

Assessment of Bacterial Co-infection Rates and Antibiotic Exposure in COVID-19 Patients

Background. COVID-19 pandemic data suggest risk for bacterial co-infection upon hospital presentation remain extremely low. Despite low co-infection rates, antibiotics are prescribed for most patients. Current data are limited regarding institutional-specific change in antibiotic use over the course of the pandemic. Given the low rates of co-infections, Saint Luke's Health System's COVID-19 Treatment Taskforce developed a COVID-19 evaluation and treatment order set which included procalcitonin (PCT) . As co-infection literature emerged, active education was provided, and order sets were modified to provide passive education regarding co-infection rates. We aimed to assess antibiotic practice changes as data and strategies to influence use evolved during the pandemic. Methods. This was a multi-center, single health-system retrospective cohort study. Ten community hospitals and 1 academic medical center were included in analysis. Inclusion criteria were age ≥18 years, admitted during April or September 2020 and had a positive COVID-19 result on admission. Patients were excluded if they were readmitted for COVID-19 related issues. Both primary and secondary outcomes were analyzed from the first 7 days after admission. The primary outcome was rate of respiratory bacterial co-infections. This was determined through sputum and blood cultures, urinary antigens including Streptococcus pneumoniae and Legionella, and PCT. Secondary outcomes included rate of antibiotic use, antibiotic days of therapy (DOT), length of therapy, and antibiotic use trends. Results. A total of 294 patients were included with 69 patients in April 2020 and 225 in September 2020. Primary and secondary results are shown in Table 2. Rate of culture-confirmed bacterial co-infection when examining April 2020 was 4.38% and 4.44 % in September 2020. Antibiotic uses, antibiotic DOT, and length of therapy were all significantly lower in September 2020 compared to April 2020. Conclusion. Our results show bacterial co-infections were extremely low in our health system. Despite positive trends in antibiotic use, prescribing remained high. More targeted interventions to decrease antibiotic exposure in COVID-19 patients are needed.