Outpatient Treatment of Confirmed COVID-19: Living, Rapid Practice Points From the American College of Physicians (Version 1).

DESCRIPTION: Strategies to manage COVID-19 in the outpatient setting continue to evolve as new data emerge on SARS-CoV-2 variants and the availability of newer treatments. The Scientific Medical Policy Committee (SMPC) of the American College of Physicians (ACP) developed these living, rapid practice points to summarize the best available evidence on the treatment of adults with confirmed COVID-19 in an outpatient setting. These practice points do not evaluate COVID-19 treatments in the inpatient setting or adjunctive COVID-19 treatments in the outpatient setting. METHODS: The SMPC developed these living, rapid practice points on the basis of a living, rapid review done by the ACP Center for Evidence Reviews at Cochrane Austria at the University for Continuing Education Krems (Danube University Krems). The SMPC will maintain these practice points as living by monitoring and assessing the impact of new evidence. PRACTICE POINT 1: Consider molnupiravir to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 to 7 days of the onset of symptoms and at high risk for progressing to severe disease. PRACTICE POINT 2: Consider nirmatrelvir-ritonavir combination therapy to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 days of the onset of symptoms and at high risk for progressing to severe disease. PRACTICE POINT 3: Consider remdesivir to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 7 days of the onset of symptoms and at high risk for progressing to severe disease. PRACTICE POINT 4: Do not use azithromycin to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting. PRACTICE POINT 5: Do not use chloroquine or hydroxychloroquine to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting. PRACTICE POINT 6: Do not use ivermectin to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting. PRACTICE POINT 7: Do not use nitazoxanide to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting. PRACTICE POINT 8: Do not use lopinavir-ritonavir combination therapy to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting. PRACTICE POINT 9: Do not use casirivimab-imdevimab combination therapy to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting unless it is considered effective against a SARS-CoV-2 variant or subvariant locally in circulation. PRACTICE POINT 10: Do not use regdanvimab to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting unless it is considered effective against a SARS-CoV-2 variant or subvariant locally in circulation. PRACTICE POINT 11: Do not use sotrovimab to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting unless it is considered effective against a SARS-CoV-2 variant or subvariant locally in circulation. PRACTICE POINT 12: Do not use convalescent plasma to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting. PRACTICE POINT 13: Do not use ciclesonide to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting. PRACTICE POINT 14: Do not use fluvoxamine to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting.

Outpatient Treatment of Confirmed COVID-19: Living, Rapid Practice Points From the American College of Physicians (Version 2).

DESCRIPTION: Evidence for the use of outpatient treatments in adults with confirmed COVID-19 continues to evolve with new data. This is version 2 of the American College of Physicians (ACP) living, rapid practice points focusing on 22 outpatient treatments for COVID-19, specifically addressing the dominant SARS-CoV-2 Omicron variant. METHODS: The Population Health and Medical Science Committee (formerly the Scientific Medical Policy Committee) developed this version of the living, rapid practice points on the basis of a living, rapid review done by the ACP Center for Evidence Reviews at Cochrane Austria at the University for Continuing Education Krems (Danube University Krems). This topic will be maintained as living and rapid by continually monitoring and assessing the impact of new evidence. PRACTICE POINT 1: Consider molnupiravir to treat symptomatic patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 days of the onset of symptoms and at a high risk for progressing to severe disease. PRACTICE POINT 2: Consider nirmatrelvir-ritonavir combination therapy to treat symptomatic patients with confirmed mild to moderate COVID-19 in the outpatient setting who are within 5 days of the onset of symptoms and at a high risk for progressing to severe disease. PRACTICE POINT 3: Do not use ivermectin to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting. PRACTICE POINT 4: Do not use sotrovimab to treat patients with confirmed mild to moderate COVID-19 in the outpatient setting.

The Use of Race, Ethnicity, and Region Associations in a USMLE Step 1 Resource.

Phenomenon: Mental shortcuts are commonly used in medical education to facilitate the learning and application of a large volume of information. However, the use of demographic identifiers such as race, ethnicity, region, and descent from one of these groups as mental shortcuts in association with disease can perpetuate misconceptions about the construction of these identities and reinforce stereotypes. The United States Medical Licensing Exam (USMLE) Step 1 is a major driver of pre-clinical undergraduate medical education that requires memorization of a large volume of information and application of this information to clinical vignettes. This study assesses how demographic identifiers have been used in a nearly universally used study resource for this exam. Approach: The authors analyzed First Aid for the USMLE Step 1 2020, Thirtieth Edition, a resource that contains "high yield facts" and was built and maintained based on experiences with the USMLE Step 1 for references to race, ethnicity, region, and descent from one of these groups and the distribution of skin tones used in photos. These findings were subsequently compared to the changes made in the 2021 edition of the resource. Findings: The authors found 50 references in the 2020 edition to race, ethnicity, region, and descent from one of these groups, all in relation to disease. More than half of these references had an associated heritable component. Black or African American race was disproportionately represented, comprising more than half of all racial associations (13/24). Additionally, light skin tone was used in 170/204 photos (84.2%) in the 2020 edition. In the 2021 edition, only 12/209 photos (5.7%) were new or changed. Insights: These findings highlight the trend to associate race with disease while also furthering the misconception that there are innate, heritable differences between socially constructed groups and establishing light skin tone as the norm. While some favorable changes were made to the 2021 text, further work within this resource and across medical education is required to avoid further misuse of race and challenge existing implicit biases.

Excess deaths by sex and Age Group in the first two years of the COVID-19 pandemic in the United States.

The COVID-19 pandemic hastened hundreds of thousands of deaths in the United States. Many of these excess deaths are directly attributed to COVID-19, but others stem from the pandemic's social, economic, and health care system disruptions. This study compares provisional mortality data for age and sex subgroups across different time windows, with and without COVID-19 deaths, and assesses whether mortality risks are returning to pre-pandemic levels. Using provisional mortality reports from the CDC, we compute mortality risks for 22 age and sex subgroups in 2021 and compare against 2015-2019 using odds ratios. We repeat this comparison for the first twelve full months of the COVID-19 pandemic in the United States (April 2020-March 2021) against the next twelve full months (April 2021-March 2022). Mortality risks for most subgroups were significantly higher in 2021 than in 2015-2019, both with and without deaths involving COVID-19. For ages 25-54, Year 2 (April 2021-March 2022) was more fatal than Year 1 (April 2020-March 2021), whereas total mortality risks for the 65 + age groups declined. Given so many displaced deaths in the first two years of the COVID-19 pandemic, mortality risks in the next few years may fall below pre-pandemic levels. Provisional mortality data suggest this is already happening for the 75 + age groups when excluding COVID-19 deaths.

The Development of Living, Rapid Practice Points: Summary of Methods From the Scientific Medical Policy Committee of the American College of Physicians.

In response to the COVID-19 pandemic, the Scientific Medical Policy Committee (SMPC) of the American College of Physicians (ACP) began developing "practice points" to provide clinical advice based on the best available evidence for the public, patients, clinicians, and public health professionals. As one of the first organizations in the United States to develop evidence-based clinical guidelines, ACP continues to lead and advance the science of evidence-based medicine by implementing new methods to rapidly publish practice points and maintain them as living advice that regularly assesses and incorporates new evidence. The overarching aim of practice points is to answer targeted key questions for which there is a timely need to synthesize evidence for decision making. The SMPC believes these methods can potentially be adapted to address various clinical and public health topics beyond the COVID-19 pandemic. This article presents an overview of the SMPC's living, rapid practice points development process, which includes a rapid systematic review, use of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method, use of stringent policies on the disclosure of interests and management of conflicts of interest, incorporating a public (nonclinician) perspective, and maintenance of the documents as living through ongoing surveillance and synthesis of new evidence as it emerges.

Appropriate Use of Short-Course Antibiotics in Common Infections: Best Practice Advice From the American College of Physicians.

DESCRIPTION: Antimicrobial overuse is a major health care issue that contributes to antibiotic resistance. Such overuse includes unnecessarily long durations of antibiotic therapy in patients with common bacterial infections, such as acute bronchitis with chronic obstructive pulmonary disease (COPD) exacerbation, community-acquired pneumonia (CAP), urinary tract infections (UTIs), and cellulitis. This article describes best practices for prescribing appropriate and short-duration antibiotic therapy for patients presenting with these infections. METHODS: The authors conducted a narrative literature review of published clinical guidelines, systematic reviews, and individual studies that addressed bronchitis with COPD exacerbations, CAP, UTIs, and cellulitis. This article is based on the best available evidence but was not a formal systematic review. Guidance was prioritized to the highest available level of synthesized evidence. BEST PRACTICE ADVICE 1: Clinicians should limit antibiotic treatment duration to 5 days when managing patients with COPD exacerbations and acute uncomplicated bronchitis who have clinical signs of a bacterial infection (presence of increased sputum purulence in addition to increased dyspnea, and/or increased sputum volume). BEST PRACTICE ADVICE 2: Clinicians should prescribe antibiotics for community-acquired pneumonia for a minimum of 5 days. Extension of therapy after 5 days of antibiotics should be guided by validated measures of clinical stability, which include resolution of vital sign abnormalities, ability to eat, and normal mentation. BEST PRACTICE ADVICE 3: In women with uncomplicated bacterial cystitis, clinicians should prescribe short-course antibiotics with either nitrofurantoin for 5 days, trimethoprim-sulfamethoxazole (TMP-SMZ) for 3 days, or fosfomycin as a single dose. In men and women with uncomplicated pyelonephritis, clinicians should prescribe short-course therapy either with fluoroquinolones (5 to 7 days) or TMP-SMZ (14 days) based on antibiotic susceptibility. BEST PRACTICE ADVICE 4: In patients with nonpurulent cellulitis, clinicians should use a 5- to 6-day course of antibiotics active against streptococci, particularly for patients able to self-monitor and who have close follow-up with primary care.

Beyond COVID-19 deaths during the COVID-19 pandemic in the United States.

COVID-19 has disrupted society and health care systems, creating a fertile environment for deaths beyond the virus. The year 2020 will prove to be the most deadly year on record in the United States. Direct deaths due to COVID-19 have been well documented and reported. Older people (those over 65) have been hardest hit, with over 80% of the COVID-19 deaths in this age group. What has been less clear is the impact on those under 65 years old, particularly those under 44 years old. This study considers both COVID-19 deaths and non-COVID-19 deaths during a 39 weeks period beginning 1 March in both 2020 and averaged over the five years from 2015 to 2019. Across 22 age and gender cohorts, death risks are compared using odds ratios. The results indicate that younger people (those under 15 years old) have experienced the same or a reduction in death risk between 2020 and the average from 2015 to 2019, suggesting that societal changes were protective for some of them. With all COVID-19 deaths removed from the 2020 death counts, 15-64 year olds experienced increased death risk between 2020 and the 2015 to 2019 average. For example, 15-44 year old males experienced a significant increase in their death risk, even though the absolute number of COVID-19 deaths for this cohort is small. The key take away from this study is that COVID-19 resulted in a large number of additional deaths in 2020 compared to the average from 2015 to 2019, both directly from the virus and indirectly due to societal responses to the virus.

Hepatitis B Vaccination, Screening, and Linkage to Care: Best Practice Advice From the American College of Physicians and the Centers for Disease Control and Prevention.

Background: Vaccination, screening, and linkage to care can reduce the burden of chronic hepatitis B virus (HBV) infection. However, recommendations vary among organizations, and their implementation has been suboptimal. The American College of Physicians' High Value Care Task Force and the Centers for Disease Control and Prevention developed this article to present best practice statements for hepatitis B vaccination, screening, and linkage to care. Methods: A narrative literature review of clinical guidelines, systematic reviews, randomized trials, and intervention studies on hepatitis B vaccination, screening, and linkage to care published between January 2005 and June 2017 was conducted. Best Practice Advice 1: Clinicians should vaccinate against hepatitis B virus (HBV) in all unvaccinated adults (including pregnant women) at risk for infection due to sexual, percutaneous, or mucosal exposure; health care and public safety workers at risk for blood exposure; adults with chronic liver disease, end-stage renal disease (including hemodialysis patients), or HIV infection; travelers to HBV-endemic regions; and adults seeking protection from HBV infection. Best Practice Advice 2: Clinicians should screen (hepatitis B surface antigen, antibody to hepatitis B core antigen, and antibody to hepatitis B surface antigen) for HBV in high-risk persons, including persons born in countries with 2% or higher HBV prevalence, men who have sex with men, persons who inject drugs, HIV-positive persons, household and sexual contacts of HBV-infected persons, persons requiring immunosuppressive therapy, persons with end-stage renal disease (including hemodialysis patients), blood and tissue donors, persons infected with hepatitis C virus, persons with elevated alanine aminotransferase levels (≥19 IU/L for women and ≥30 IU/L for men), incarcerated persons, pregnant women, and infants born to HBV-infected mothers. Best Practice Advice 3: Clinicians should provide or refer all patients identified with HBV (HBsAg-positive) for posttest counseling and hepatitis B-directed care.

A double-risk monitoring and movement restriction policy for Ebola entry screening at airports in the United States.

This paper provides an alternative policy for Ebola entry screening at airports in the United States. This alternative policy considers a social contact tracing (SCT) risk level, in addition to the current health risk level used by the CDC. The performances of both policies are compared based on the scenarios that occur and the expected cost associated with implementing such policies. Sensitivity analysis is performed to identify conditions under which one policy dominates the other policy. This analysis takes into account that the alternative policy requires additional data collection, which is balanced by a more cost-effective allocation of resources.