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Objective: We investigated a decrease in antibiotic prescribing for respiratory illnesses in 2 academic urgent-care clinics during the coronavirus disease 2019 (COVID-19) pandemic using semistructured clinician interviews. Methods: We conducted a quality-improvement project from November 2020 to May 2021. We investigated provider antibiotic decision making using a mixed-methods explanatory design including interviews. We analyzed transcripts using a thematic framework approach to identify emergent themes. Our performance measure was antibiotic prescribing rate (APR) for encounters with respiratory diagnosis billing codes. We extracted billing and prescribing data from the electronic medical record and assessed differences using run charts, p charts and generalized linear regression. Results: We observed significant reductions in the APR early during the COVID-19 pandemic (relative risk [RR], 0.20; 95% confidence interval [CI], 0.17–0.25), which was maintained over the study period (P < .001). The average APRs were 14% before the COVID-19 pandemic, 4% during the QI project, and 7% after the project. All providers prescribed less antibiotics for respiratory encounters during COVID-19, but only 25% felt their practice had changed. Themes from provider interviews included changing patient expectations and provider approach to respiratory encounters during COVID-19, the impact of increased telemedicine encounters, and the changing epidemiology of non–COVID-19 respiratory infections. Conclusions: Our findings suggest that the decrease in APR was likely multifactorial. The average APR decreased significantly during the pandemic. Although the APR was slightly higher after the QI project, it did not reach prepandemic levels. Future studies should explore how these factors, including changing patient expectations, can be leveraged to improve urgent-care antibiotic stewardship.

We compared antibiotic prescribing before and during the ­coronavirus disease 2019 (COVID-19) pandemic at 2 academic urgent care clinics and found a sustained decrease in prescribing driven by respiratory encounters and despite transitioning to telemedicine. Antibiotics were rarely prescribed during encounters for COVID-19 or COVID-19 symptoms. COVID-19 revealed opportunities for outpatient stewardship programs.

Background Urgent care practices were significantly impacted by the COVID-19 pandemic. Studies conducted early in the pandemic demonstrated dramatic decreases in outpatient antibiotic prescribing, particularly amongst agents typically used for respiratory infections. We observed a 33% decline in urgent care antibiotics prescribing during the COVID-19 pandemic in our urgent care clinics. We investigated the prescriber experience to elucidate factors influencing antibiotic use for respiratory conditions during the COVID-19 pandemic at two academic urgent care clinics. Methods We employed a mix method approach, first distributing a survey to all full-time prescribers. We then followed up with qualitative interviews (12 of 22 prescribers) which was conducted by a single, trained interviewer using a standardized guide. Interviews were recorded and transcribed verbatim. Each transcription was independently reviewed and coded by two blinded investigators using standardized themes and adjudicated by a third investigator for stability, robustness, and interrater reliability. Individually, researchers identified and coded key themes and statements. These themes were then discussed as a group and combined where they shared meaning. This project was reviewed and deemed to be non-human subjects research by the Stanford University School of Medicine Panel on Human Subjects in Medical Research. Results A total of 20 of the 22 prescribers (13 MDs and 9 APPs) completed the survey (91% response rate). Notably, only 25% of prescribers agreed that COVID-19 had changed their antibiotic prescribing practices for patients with respiratory infections despite objective data that all prescribed less. In the qualitative interviews, we identified four major themes impacting the appropriateness of antibiotic prescribing practices as shown in Table 1. Conclusion Urgent care prescribers attributed a decrease in antibiotic prescribing during COVID-19 to changes in patient expectations and knowledge base, a switch to telemedicine-based encounters, and changing epidemiology. These shifts could be utilized by outpatient antimicrobial stewardship efforts to sustain low prescribing rates for conditions in which antibiotics are generally not indicated. Disclosures Marisa Holubar, MD, MS, Nothing to disclose

Key Points Question What risk factors and mechanisms can help explain documented allergic reactions to Food and Drug Administration–authorized mRNA COVID-19 vaccines? Findings In this case series of 22 patients with suspected vaccine allergy receiving clinical skin prick testing (SPT) and basophil activation testing (BAT) to the whole vaccine and key components (ie, polyethylene glycol [PEG] and polysorbate 80), none exhibited immunoglobulin (Ig) E–mediated allergy to components via SPT. However, most had positive BAT results to PEG, and all had positive BAT results to their administered mRNA vaccine, with no patient sample having detectable PEG IgE. Meaning These findings suggest that non–IgE-mediated allergic reactions to PEG may be responsible for many documented cases of allergy to mRNA vaccines., This case series characterizes the immunologic mechanisms underlying allergic reactions to mRNA COVID-19 vaccines., Importance As of May 2021, more than 32 million cases of COVID-19 have been confirmed in the United States, resulting in more than 615 000 deaths. Anaphylactic reactions associated with the Food and Drug Administration (FDA)–authorized mRNA COVID-19 vaccines have been reported. Objective To characterize the immunologic mechanisms underlying allergic reactions to these vaccines. Design, Setting, and Participants This case series included 22 patients with suspected allergic reactions to mRNA COVID-19 vaccines between December 18, 2020, and January 27, 2021, at a large regional health care network. Participants were individuals who received at least 1 of the following International Statistical Classification of Diseases and Related Health Problems, Tenth Revision anaphylaxis codes: T78.2XXA, T80.52XA, T78.2XXD, or E949.9, with documentation of COVID-19 vaccination. Suspected allergy cases were identified and invited for follow-up allergy testing. Exposures FDA-authorized mRNA COVID-19 vaccines. Main Outcomes and Measures Allergic reactions were graded using standard definitions, including Brighton criteria. Skin prick testing was conducted to polyethylene glycol (PEG) and polysorbate 80 (P80). Histamine (1 mg/mL) and filtered saline (negative control) were used for internal validation. Basophil activation testing after stimulation for 30 minutes at 37 °C was also conducted. Concentrations of immunoglobulin (Ig) G and IgE antibodies to PEG were obtained to determine possible mechanisms. Results Of 22 patients (20 [91%] women; mean [SD] age, 40.9 [10.3] years; 15 [68%] with clinical allergy history), 17 (77%) met Brighton anaphylaxis criteria. All reactions fully resolved. Of patients who underwent skin prick tests, 0 of 11 tested positive to PEG, 0 of 11 tested positive to P80, and 1 of 10 (10%) tested positive to the same brand of mRNA vaccine used to vaccinate that individual. Among these same participants, 10 of 11 (91%) had positive basophil activation test results to PEG and 11 of 11 (100%) had positive basophil activation test results to their administered mRNA vaccine. No PEG IgE was detected; instead, PEG IgG was found in tested individuals who had an allergy to the vaccine. Conclusions and Relevance Based on this case series, women and those with a history of allergic reactions appear at have an elevated risk of mRNA vaccine allergy. Immunological testing suggests non–IgE-mediated immune responses to PEG may be responsible in most individuals.