Healthcare providers (HCPs) and laypeople both say scarce resource allocation (SRA) policies should aim to save the most lives possible but diverge somewhat on how to achieve that goal, according to a survey launched early in the COVID-19 pandemic.

University of California Los Angeles (UCLA) researchers published the results yesterday in JAMA Network Open. The team surveyed 1,545 adults recruited through social media and community collaborations from May to September 2020 to gauge their values and preferences and how closely they agreed with University of California (UC) SRA policy. The average participant age was 49 years, 74% were women, and 30% were HCPs.

In March 2020, UC convened a critical-care bioethics working group to develop guidance on SRA policy and later sought feedback on the policy, with the goal of modifying it as needed.

HCPs favor reserving SRA for those likely to survive

Alignment with the UC SRA policy was roughly 70% per domain among both HCPs and laypeople. Both groups said an SRA policy's goal should be to save the most lives possible, with a significantly higher 0.29-point average agreement score among laypeople than HCPs (9.04 vs 8.76).

A study involving more than 11,000 patients found that bacteremia from a presumed urinary source was rare in patients with asymptomatic bacteriuria (ASB), even in those with altered mental status (AMS), US researchers reported today in JAMA Network Open.

Although treatment guidelines recommend withholding antibiotic treatment for ASB, which is the presence of bacteria in the urine in the absence of signs or symptoms of a urinary tract infection (UTI), inappropriate antibiotic treatment remains common, particularly in older adults who present with AMS.

One reason is that clinicians fear that poor outcomes, such as bacteremia from a UTI, could occur if antibiotics aren't initiated early. So a team led by researchers at Duke University School of Medicine set out to determine how prevalent bacteremia from a urinary source is in a large, multihospital cohort of patients with ASB.

Data support withholding antibiotics for ASB

Of the 11,590 hospitalized patients with ASB at 68 US hospitals (median age, 78.2 years; 74.2% female; 76.8% White), 72.2% received antibiotic treatment for UTI, and 1.4% had bacteremia from a urinary source. Among patients with ASB, 43.6% had AMS, and only 0.7% of patients with AMS and no systemic signs of infection had bacteremia from a presumed urinary source.

On multivariable analysis, male sex (adjusted odds ratio [aOR], 1.45; 95% confidence interval [CI], 1.02 to 2.05), hypotension (aOR, 1.86; 95% CI, 1.18 to 2.93), two or more systemic inflammatory response criteria (aOR, 1.72; 95% CI, 1.21 to 2.46), urinary retention (aOR, 1.87; 95% CI, 1.18 to 2.96), fatigue (aOR, 1.53; 95% CI, 1.08 to 2.17), log of serum leukocytosis (aOR, 3.38; 95% CI, 2.48 to 4.61), and pyuria (aOR, 3.31; 95% CI, 2.10 to 5.21) were associated with bacteremia.

The researchers estimated that if a 2% or higher risk of bacteremia were used as a cutoff for empiric antibiotics, antibiotics would have been avoided in 78.4% of empirically treated patients with a low risk of bacteremia.

"These data reinforce prior evidence highlighting the poor yield of urine and blood cultures among hospitalized patients without systemic signs of infection and support not empirically treating patients with AMS and no systemic signs of infection," the study authors wrote.

• The National Institutes of Health (NIH) yesterday announced the launch of two phase 2 trials to test the safety and effectiveness of three treatments for adults who have autonomic nervous system dysregulation due to long COVID. The dysfunction leads to problems with heart rate, digestion, and respiratory rate, which are among the symptoms long-COVID patients report as most burdensome. The trial will test Gamunex-C (a form of intravenous immunoglobulin), Ivabradine (an oral medication to reduce heart rate), and coordinator-guided nondrug care such as wearing a compression belt and eating a high-salt diet. The studies are part of the NIH Researching COVID to Enhance Recovery (RECOVER) Initiative, a nationwide research program to fully understand, diagnose, and treat long COVID.
• The World Health Organization (WHO) this week updated its lab biosafety guidance for SARS-CoV-2, which reclassifies the virus from biosafety level 3 (BSL-3) to BSL-2. In its earlier assessment, the WHO classified the pandemic virus at the higher biosafety level due to the lack of vaccines and treatments. In the updated guidance, the WHO recommends BSL-3 precautions under some circumstances, such as when handing high concentrations of live virus that are variants of interest, variants under monitoring, or emerging variants with unknown biological profiles.
• The US Centers for Disease Control and Prevention (CDC) said yesterday that it will expand nasal swab sampling in its traveler-based genomic sequencing program to two more airports: Chicago O'Hare International Airport and Miami International Airport. Over the current winter respiratory season, the CDC has conducted a pilot program to test for multiple pathogens including flu, respiratory syncytial virus (RSV), SARS-CoV-2, and other respiratory pathogens. The public-private sequencing partnership is designed to spot pathogens early and fill in global surveillance gaps, sampling about 300,000 travelers each year from 135 countries. It currently operates at eight US international airports.