Low rates of antibiotics prescribed during telehealth primary-care visits persisted during the coronavirus disease 2019 (COVID-19) pandemic.

For primary care clinics at a Veterans' Affairs (VA) medical center, the shift from in-person to telehealth visits during the coronavirus disease 2019 (COVID-19) pandemic was associated with low rates of antibiotic prescription. Understanding contextual factors associated with antibiotic prescription practices during telehealth visits may help promote antibiotic stewardship in primary care settings.

Neither Race nor Ethnicity Impact the Mortality of Residents of Veterans Affairs Community Living Center With COVID-19.

OBJECTIVES: COVID-19 disproportionately affected nursing home residents and people from racial and ethnic minorities in the United States. Nursing homes in the Veterans Affairs (VA) system, termed Community Living Centers (CLCs), belong to a national managed care system. In the period prior to the availability of vaccines, we examined whether residents from racial and ethnic minorities experienced disparities in COVID-19 related mortality. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Residents at 134 VA CLCs from April 14 to December 10, 2020. METHODS: We used the VA Corporate Data Warehouse to identify VA CLC residents with a positive SARS-CoV-2 polymerase chain reaction test during or 2 days prior to their admission and without a prior case of COVID-19. We assessed age, self-reported race/ethnicity, frailty, chronic medical conditions, Charlson comorbidity index, the annual quarter of the infection, and all-cause 30-day mortality. We estimated odds ratios and 95% confidence intervals of all-cause 30-day mortality using a mixed-effects multivariable logistic regression model. RESULTS: During the study period, 1133 CLC residents had an index positive SARS-CoV-2 test. Mortality at 30 days was 23% for White non-Hispanic residents, 15% for Black non-Hispanic residents, 10% for Hispanic residents, and 16% for other residents. Factors associated with increased 30-day mortality were age ≥70 years, Charlson comorbidity index ≥6, and a positive SARS-CoV-2 test between April 14 and June 30, 2020. Frailty, Black race, and Hispanic ethnicity were not independently associated with an increased risk of 30-day mortality. CONCLUSIONS AND IMPLICATIONS: Among a national cohort of VA CLC residents with COVID-19, neither Black race nor Hispanic ethnicity had a negative impact on survival. Further research is needed to determine factors within the VA health care system that mitigate the influence of systemic racism on COVID-19 outcomes in US nursing homes.

Antibiotic exposure and acquisition of antibiotic-resistant gram-negative bacteria among outpatients at a US Veterans Affairs medical center.

Objectives: To assess the prevalence of antibiotic-resistant gram-negative bacteria (R-GNB) among patients without recent hospitalization and to examine the influence of outpatient antibiotic exposure on the risk of acquiring R-GNB in this population. Design: 2-year retrospective cohort study. Setting: Regional Veterans Affairs healthcare system. Patients: Outpatients at 13 community-based clinics. Methods: We examined the rate of acquisition of R-GNB within 90 days following an outpatient visit from 2018 to 2019. We used clinical and administrative databases to determine and summarize prescriptions for systemic antibiotics, associated infectious diagnoses, and subsequent R-GNB acquisition among patients without recent hospitalizations. We also calculated the odds ratio of R-GNB acquisition following antibiotic exposure. Results: During the 2-year study period, 7,215 patients had outpatient visits with microbiological cultures obtained within 90 days. Of these patients, 206 (2.9%) acquired an R-GNB. Among patients receiving antibiotics at the visit, 4.6% acquired a R-GNB compared to 2.7% among patients who did not receive antibiotics, yielding an unadjusted odds ratio of 1.75 (95% confidence interval, 1.18-2.52) for a R-GNB following an outpatient visit with versus without an antibiotic exposure. Regardless of R-GNB occurrence, >50% of antibiotic prescriptions were issued at visits without an infectious disease diagnosis or issued without documentation of an in-person or telehealth clinical encounter. Conclusions: Although the rate of R-GNBs was low (2.9%), the 1.75-fold increased odds of acquiring a R-GNB following an outpatient antibiotic highlights the importance of antimicrobial stewardship efforts in outpatient settings. Specific opportunities include reducing antibiotics prescribed without an infectious diagnosis or a clinical visit.

Exercising empathy: Pharmacists possess skills to increase coronavirus vaccine confidence.

The coronavirus disease 2019 (COVID-19) vaccines are the essential public health intervention to confer immunity against severe acute respiratory syndrome coronavirus 2, while decreasing the risks of severe COVID-19 disease, hospitalizations, and death associated with natural infection. Public health experts agree that the public health interventions of social distancing and face coverings will only be able to successfully curtail the COVID-19 pandemic in the United States when combined with the highly effective COVID-19 vaccines. The risk for severe COVID-19 is higher in Americans with highly prevalent metabolic and cardiovascular chronic conditions as well as vulnerable demographics, such as minorities and pregnant women. Unfortunately, experience with past unethical health practices can influence current vaccine confidence in people of color and women of childbearing age. Pharmacists are well-positioned in myriad health care settings across the nation to listen to these concerns and have the conversations necessary to increase vaccine confidence. Similar to effective roles that pharmacists have had in other health prevention efforts such as smoking cessation, pharmacists possess the motivational interviewing skills to guide patients from the "precontemplation" to the "action" stages of health behavior change. This nonjudgmental, mutual understanding will help identify the individual factors influencing vaccine decision-making and bring us closer to achieving "community immunity."

Influence of microbiological culture results on antibiotic choices for veterans with hospital-acquired pneumonia and ventilator-associated pneumonia.

OBJECTIVE: We examined the impact of microbiological results from respiratory samples on choice of antibiotic therapy in patients treated for hospital-acquired pneumonia (HAP) or ventilator-associated pneumonia (VAP). DESIGN: Four-year retrospective study. SETTING: Veterans' Health Administration (VHA). PATIENTS: VHA patients hospitalized with HAP or VAP and with respiratory cultures between October 1, 2014, and September 30, 2018. INTERVENTIONS: We compared patients with positive and negative respiratory culture results, assessing changes in antibiotic class and Antibiotic Spectrum Index (ASI) from the day of sample collection (day 0) through day 7. RESULTS: Between October 1, 2014, and September 30, 2018, we identified 5,086 patients with HAP/VAP: 2,952 with positive culture results and 2,134 with negative culture results. All-cause 30-day mortality was 21% for both groups. The mean time from respiratory sample receipt in the laboratory to final respiratory culture result was longer for those with positive (2.9 ± 1.3 days) compared to negative results (2.5 ± 1.3 days; P < .001). The most common pathogens were Staphylococcus aureus and Pseudomonas aeruginosa. Vancomycin and ß-lactam/ß-lactamase inhibitors were the most commonly prescribed agents. The decrease in the median ASI from 13 to 8 between days 0 and 6 was similar among patients with positive and negative respiratory cultures. Patients with negative cultures were more likely to be off antibiotics from day 3 onward. CONCLUSIONS: The results of respiratory cultures had only a small influence on antibiotics used during the treatment of HAP/VAP. The decrease in ASI for both groups suggests the integration of antibiotic stewardship principles, including de-escalation, into the care of patients with HAP/VAP.