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Background: Improving antibiotic use is a key strategy to combat antimicrobial resistance. Here, we have described national outpatient antibiotic prescribing trends during the COVID-19 pandemic. We compared the monthly numbers of prescriptions in 2020–2021 to those from 2019 to describe the impact of the pandemic and to highlight areas for improvement. Methods: We used the IQVIA National Prescription Audit (NPA) data set to identify all antibiotic prescriptions dispensed from US retail pharmacies during January 2019–October 2021. We calculated the percentage change in volume of prescriptions for each month during the pandemic (beginning in March 2020) compared to the baseline (defined as the corresponding month in 2019). Data were characterized by patient age group (0–19 years, 20–64 years, ≥65 years) and antibiotic class and drug, including azithromycin. Results: Antibiotic prescriptions were lower than baseline during March 2020–June 2021. The greatest decrease in antibiotic prescribing volume occurred in May 2020 (40.0% lower than May 2019) (Fig. 1), with the greatest decreases among children 0–19 years of age. However, prescribing was similar to baseline levels in July–August 2021 (Fig. 1). Specifically, azithromycin prescribing exceeded the 2019 baseline by 11.0% in July and further to a 34.5% increase in August 2021 (Fig. 2). Increases in azithromycin prescribing in August 2021 were observed across all age groups: 20–64 years (46.9% above baseline), ≥65 years (25.3% above baseline), and children 0–19 years (7.8% above baseline). Conclusions: Antibiotic prescribing volume was lower during 2020 and the first half of 2021 compared to the corresponding months in 2019. Decreases in outpatient antibiotic prescriptions during the pandemic likely reflect decreased utilization of outpatient healthcare and decreased transmission of non–COVID-19 infections secondary to nonpharmaceutical interventions (eg, masking, social distancing, school closures). However, outpatient antibiotic prescribing levels in general, and azithromycin prescribing in particular, approached or exceeded prepandemic levels in July and August 2021. Ongoing surveillance and sustained outpatient antibiotic stewardship efforts are needed to optimize antibiotic use during the COVID-19 pandemic and beyond. Funding: None Disclosures: None

Background: In 2021, the CDC awarded >$100 million to 62 state, local, and territorial health departments (SLTHDs) to expand antibiotic stewardship expertise and implement antibiotic stewardship activities in different healthcare settings. Our objective was to describe SLTHD antibiotic stewardship personnel and activities to characterize the impact of the funding. Methods: SLTHDs submitted performance measures, including quantitative and qualitative responses, describing personnel supporting antibiotic stewardship activities, types of activities, and healthcare facilities and professionals engaged from January through June 2022. A quantitative analysis of performance measures and qualitative thematic analysis of select narrative responses are reported. Results: Most SLTHDs (58 of 62, 94%) submitted performance measures. Among them, 37 (64%) reported identifying an antibiotic stewardship leader or coleader; most were pharmacists (57%) or physicians (38%) with infectious diseases training (68%) (Table 1). Of the remaining STLHDs, 20 reported barriers to identifying a leader or coleader, including hiring process delays and programmatic barriers (Table 2). SLTHDs reported 254 antibiotic stewardship activities; most reported activities involving multiple activity types (44%). Education and communication (eg, providing stewardship expertise) was the most common single activity (30%), followed by antibiotic use tracking and reporting (13%), assessment of antibiotic stewardship implementation (8%), and action and implementation (eg, audit and feedback letters) (4%). The highest number of activities were implemented in multiple healthcare settings (35%), followed by acute care (21%), outpatient (18%), long-term care (17%), and other (9%) (Fig. 1). SLTHDs reported engaging 4,970 healthcare facilities and 15,194 healthcare professionals in antibiotic stewardship activities across healthcare settings, to date, as part of this funding opportunity (Fig. 2). Conclusions: Antibiotic stewardship funding to SLTHDs allowed for increases in capacity and expanded outreach to implement a variety of antibiotic stewardship activities across multiple healthcare settings. Sustaining STLHD antibiotic stewardship activities can help increase engagement and coordination with healthcare facilities, healthcare professionals, and other partners to optimize antibiotic prescribing and patient safety. Disclosure: None

We updated a descriptive analysis of national outpatient antibiotic prescribing during the COVID-19 pandemic. Prescribing volume was lower during 2020 and January–June in 2021 and 2022 compared to corresponding baseline months in 2019. Prescribing approached or exceeded baseline during July–December of 2021 and 2022 for all antibiotics, especially for azithromycin.

Abstract Background Better understanding differences associated with antibiotic prescribing for acute sinusitis can help inform antibiotic stewardship strategies. We characterized antibiotic prescribing patterns for acute sinusitis among commercially insured adults and explored differences by patient- and prescriber-level factors. Methods Outpatient encounters among adults aged 18 to 64 years diagnosed with sinusitis between 2016 and 2020 were identified by national administrative claims data. We classified antibiotic agents—first-line (amoxicillin-clavulanate or amoxicillin) and second-line (doxycycline, levofloxacin, or moxifloxacin)—and ≤7-day durations as guideline concordant based on clinical practice guidelines. Modified Poisson regression was used to examine the association between patient- and prescriber-level factors and guideline-concordant antibiotic prescribing. Results Among 4 689 850 sinusitis encounters, 53% resulted in a guideline-concordant agent, 30% in a guideline-discordant agent, and 17% in no antibiotic prescription. About 75% of first-line agents and 63% of second-line agents were prescribed for >7 days, exceeding the length of therapy recommended by clinical guidelines. Adults with sinusitis living in a rural area were less likely to receive a prescription with guideline-concordant antibiotic selection (adjusted risk ratio [aRR], 0.92; 95% CI, .92–.92) and duration (aRR, 0.77; 95% CI, .76–.77). When compared with encounters in an office setting, urgent care encounters were less likely to result in a prescription with a guideline-concordant duration (aRR, 0.76; 95% CI, .75–.76). Conclusions Opportunities still exist to optimize antibiotic agent selection and treatment duration for adults with acute sinusitis, especially in rural areas and urgent care settings. Recognizing specific patient- and prescriber-level factors associated with antibiotic prescribing can help inform antibiotic stewardship interventions. Among commercially insured adults, rural-urban status and type of outpatient setting significantly influenced antibiotic prescribing for acute sinusitis and guideline-concordant agent selection and duration.

To describe acute respiratory illnesses (ARI) visits and antibiotic prescriptions in 2011 and 2018 across outpatient settings to evaluate progress in reducing unnecessary antibiotic prescribing for ARIs. Cross-sectional study. Outpatient medical and pharmacy claims captured in the IBM MarketScan commercial database, a national convenience sample of privately insured individuals aged <65 years. We calculated the annual number of ARI visits and visits with oral antibiotic prescriptions per 1,000 enrollees overall and by age category, sex, and setting in 2011 and 2018. We compared these and calculated prevalence rate ratios (PRRs). We adapted existing tiered-diagnosis methodology for (ICD-10-CM) codes. In our study population, there were 829 ARI visits per 1,000 enrollees in 2011 compared with 760 ARI visits per 1,000 enrollees in 2018. In 2011, 39.3% of ARI visits were associated with ≥1 oral antibiotic prescription versus 36.2% in 2018. In 2018 compared with 2011, overall ARI visits decreased 8% (PRR, 0.92; 99.99% confidence interval [CI], 0.92-0.92), whereas visits with antibiotic prescriptions decreased 16% (PRR, 0.84; 99.99% CI, 0.84-0.85). Visits for antibiotic-inappropriate ARIs decreased by 9% (PRR, 0.91; 99.99% CI, 0.91-0.92), and visits with antibiotic prescriptions for these conditions decreased by 32% (PRR, 0.68; 99.99% CI, 0.67-0.68) from 2011 to 2018. Both the rate of antibiotic prescriptions per 1,000 enrollees and the percentage of visits with antibiotic prescriptions decreased modestly from 2011 to 2018 in our study population. These decreases were greatest for antibiotic-inappropriate ARIs; however, additional reductions in inappropriate antibiotic prescribing are needed.

To determine whether differences exist in antibiotic prescribing for respiratory infections in pediatric urgent cares (PUCs) by patient race/ethnicity, insurance, and language. Multi-center cohort study. Nine organizations (92 locations) from 22 states and Washington, DC. Patients ages 6 months-18 years evaluated April 2022-April 2023, with acute viral respiratory infections, otitis media with effusion (OME), acute otitis media (AOM), pharyngitis, community-acquired pneumonia (CAP), and sinusitis. We compared the use of first-line (FL) therapy as defined by published guidelines. We used race/ethnicity, insurance, and language as exposures. Multivariable logistic regression models estimated the odds of FL therapy by group. We evaluated 396,340 ARI encounters. Among all encounters, 351,930 (88.8%) received FL therapy (98% for viral respiratory infections, 85.4% for AOM, 96.0% for streptococcal pharyngitis, 83.6% for sinusitis). OME and CAP had the lowest rates of FL therapy (49.9% and 60.7%, respectively). Adjusted odds of receiving FL therapy were higher in Black Non-Hispanic (NH) (adjusted odds ratio [aOR] 1.53 [1.47, 1.59]), Asian NH (aOR 1.46 [1.40, 1.53], and Hispanic children (aOR 1.37 [1.33, 1.41]), compared to White NH. Additionally, odds of receiving FL therapy were higher in children with Medicaid/Medicare (aOR 1.21 [1.18-1.24]) and self-pay (aOR 1.18 [1.1-1.27]) compared to those with commercial insurance. This multicenter collaborative showed lower rates of FL therapy for children of the White NH race and those with commercial insurance compared to other groups. Exploring these differences through a health equity lens is important for developing mitigating strategies.

Abstract Background Studies have shown that the Southern United States has higher rates of outpatient antibiotic prescribing rates compared with other regions in the country, but the reasons for this variation are unclear. We aimed to determine whether the regional variability in outpatient antibiotic prescribing for respiratory diagnoses can be explained by differences in prescriber clinical factors found in a commercially insured population. Methods We analyzed the 2017 IBM MarketScan Commercial Database of commercially insured individuals aged <65 years. We included visits with acute respiratory tract infection (ARTI) diagnoses from retail clinics, urgent care centers, emergency departments, and physician offices. ARTI diagnoses were categorized based on antibiotic indication. We calculated risk ratios and 95% CIs stratified by ARTI tier and region using log-binomial models controlling for patient age, comorbidities, care setting, prescriber type, and diagnosis. Results Of the 14.9 million ARTI visits, 40% received an antibiotic. The South had the highest proportion of visits with an antibiotic prescription (43%), and the West the lowest (34%). ARTI visits in the South are 34% more likely receive an antibiotic for rarely antibiotic-appropriate ARTI visits when compared with the West in multivariable modeling (relative risk, 1.34; 95% CI, 1.33–1.34). Conclusions It is likely that higher antibiotic prescribing in the South is in part due to nonclinical factors such as regional differences in clinicians' prescribing habits and patient expectations. There is a need for future studies to define and characterize these factors to better inform regional and local stewardship interventions and achieve greater health equity in antibiotic prescribing. Regional variability in antibiotic prescribing for antibiotic-inappropriate acute respiratory tract infections persists after controlling for patient and clinical factors, suggesting that non-clinical factors may be driving prescribing and can be considered as a focus for future stewardship interventions.

Using a machine-learning model, we examined drivers of antibiotic prescribing for antibiotic-inappropriate acute respiratory illnesses in a large US claims data set. Antibiotics were prescribed in 11% of the 42 million visits in our sample. The model identified outpatient setting type, patient age mix, and state as top drivers of prescribing.

Background The aim of this study was to investigate the impact of Mental Health First Aid (MHFA) training for Bhutanese refugee community leaders in the U.S. We hypothesized that training refugee leaders would improve knowledge of mental health problems and treatment process and decrease negative attitudes towards people with mental illness. Methods One hundred and twenty community leaders participated in MHFA training, of whom 58 had sufficient English proficiency to complete pre- and post-tests. The questionnaires assessed each participant's ability to recognize signs of depression, knowledge about professional help and treatment, and attitudes towards people with mental illness. Results Between the pre- and post-test, participants showed significant improvement in the recognition of symptoms of depression and expressed beliefs about treatment that became more concordant with those of mental health professionals. However, there was no reduction in negative attitudes towards people with mental illness. Conclusions MHFA training course is a promising program for Bhutanese refugee communities in the U.S. However, some adaptations may be necessary to ensure that MHFA training is optimized for this community.

Although isoniazid-resistant tuberculosis is more common than multidrug-resistant tuberculosis, it has been much less studied. We examined the impact of isoniazid resistance and treatment regimen, including use of a fluoroquinolone, on clinical outcomes. A retrospective cohort study among patients with sputum culture-positive tuberculosis was performed. Early fluoroquinolone (FQ) use was defined as receiving ≥5 doses during the first month of treatment. The primary outcome was time to sputum culture conversion (tSCC). A multivariate proportional hazards model was used to determine the association of isoniazid resistance with tSCC. Among 236 patients with pulmonary tuberculosis, 59 (25%) had isoniazid resistance. The median tSCC was similar for isoniazid-resistant and -susceptible cases (35 vs 29 days; P = .39), and isoniazid resistance was not associated with tSCC in multivariate analysis (adjusted hazard ratio = 0.83; 95% confidence interval [CI], .59-1.17). Early FQ use was higher in isoniazid-resistant than -susceptible cases (20% vs 10%; P = .05); however, it was not significantly associated with tSCC in univariate analysis (hazard ratio = 1.48; 95% CI, .95-2.28). Patients with isoniazid-resistant tuberculosis were treated with regimens containing rifampin, pyrazinamide, and ethambutol +/- a FQ for a median of 9.7 months. Overall, 191 (83%) patients were cured. There was no difference in initial treatment outcomes; however, all cases of acquired-drug resistance (n = 1) and recurrence (n = 3) occurred among patients with isoniazid-resistant tuberculosis. There was no significant association with isoniazid resistance and tSCC or initial treatment outcomes. Although patients with isoniazid-resistant tuberculosis had a high cure rate, the cases of recurrence and acquired drug resistance are concerning and highlight the need for longer-term follow-up studies.