Unnecessary antibiotic use is common in outpatient settings, particularly for acute respiratory illnesses. Monitoring antibiotic prescribing and appropriateness is important for identifying stewardship priorities and tracking progress toward national goals. We evaluated changes in outpatient antibiotic prescribing practices and estimated proportions of unnecessary prescribing.Figure 1.Proportion of outpatient visits with an antibiotic prescription by tier* and age group, Merative MarketScan (<65 years) and CMS Medicare (≥65 years) data, 2019 and 2022.*Tier 1 antibiotics are indicated; including pneumonia, urinary tract infection, and miscellaneous bacterial infection.Tier 2 antibiotics are sometimes indicated; including pharyngitis, sinusitis, suppurative otitis media, non-bacterial pneumonia, acute exacerbation of chronic bronchitis, gastrointestinal infection, skin/mucosal infection, and acne.Tier 3 antibiotics are not indicated; including asthma/allergy, bronchitis/bronchiolitis, non-suppurative otitis media, viral upper respiratory infection, COVID-19, respiratory syncytial virus, miscellaneous non-bacterial infection, and fever.†Total of tier 1, tier2, and tier 3 diagnoses.Figure 2.Rate of outpatient visits with an antibiotic prescription by tier* and age group, Merative MarketScan (<65 years) and CMS Medicare (≥65 years) data, 2022.*Tier 1 antibiotics are indicated; including pneumonia, urinary tract infection, and miscellaneous bacterial infection.Tier 2 antibiotics are sometimes indicated; including pharyngitis, sinusitis, suppurative otitis media, non-bacterial pneumonia, acute exacerbation of chronic bronchitis, gastrointestinal infection, skin/mucosal infection, and acne.Tier 3 antibiotics are not indicated; including asthma/allergy, bronchitis/bronchiolitis, non-suppurative otitis media, viral upper respiratory infection, COVID-19, respiratory syncytial virus, miscellaneous non-bacterial infection, and fever. We used Merative MarketScan commercial claims (patients < 65 years) and CMS Medicare carrier claims and Part D event files (patients ≥65 years) to identify enrollees with medical and prescription coverage for 2019 and 2022. Enrollees were weighted based on number of months enrolled. A tiered algorithm assigned a single diagnosis to outpatient visits based on most likely indication for antibiotics using ICD-10 codes. Tier 1 included diagnoses where antibiotics are indicated (e.g., pneumonia), tier 2 was diagnoses where antibiotics are sometimes indicated (e.g., sinusitis), and tier 3 was diagnoses where antibiotics are not indicated (e.g., bronchitis). Oral antibiotics dispensed on visit date or within 7 days after were linked. We calculated the proportion and rate (per 100 patient-years) of antibiotic visits by tier and age group, and determined percent change from 2019 to 2022. The proportion of outpatient visits resulting in an antibiotic was lower in 2022 compared to 2019, regardless of age group or tier (Figure 1). Change in prescribing was greatest for tier 3 conditions, where antibiotic visits decreased 47% for adults ages 20-64 years and 34% for both children ages 0-19 years and adults ages ≥ 65 years. Tier 3 prescribing increased with age and was highest for adults ages ≥ 65 years. During 2022, the highest prescribing rates were for tier 2 conditions, with children ages 0-19 years receiving 60 antibiotics/100 patient-years (Figure 2). The proportion of antibiotic visits decreased among all age groups in 2022 compared to 2019, with the greatest decline occurring for tier 3 conditions. Opportunities to further reduce unnecessary prescribing for tier 3 conditions exist, particularly among older adults. Stewardship efforts should also prioritize tier 2 conditions, but diagnosis-specific evaluations of appropriate prescribing are needed to guide interventions. Christine Kim, PhD, Moderna, Inc.: Epidemiologist|Moderna, Inc.: Stocks/Bonds (Public Company)

Importance:Acute sinusitis has the highest rate of antibiotic prescribing in adults younger than 65 years. There is no consensus regarding whether amoxicillin-clavulanate or amoxicillin should be first-line treatment for uncomplicated acute sinusitis in adults. Objective:To compare the risk of treatment failure and adverse events between standard-dose amoxicillin-clavulanate vs standard-dose amoxicillin for acute sinusitis in adults. Design, Setting, and Participants:New-user, active comparator retrospective cohort study using a nationwide health care utilization database comparing amoxicillin-clavulanate vs amoxicillin for adults aged 18 to 64 years with outpatient acute sinusitis. Patients with a new acute sinusitis diagnosis between January 1, 2018, and December 1, 2023, were eligible. Statistical analysis was conducted between July and November 2025. Propensity score matching was used to help mitigate confounding. Exposures:Standard-dose amoxicillin-clavulanate (875 mg-125 mg twice daily) or standard-dose amoxicillin (875 mg twice daily or 500 mg 3 times daily). Main Outcomes and Measures:The primary outcome was treatment failure, defined as the first occurrence of a new antibiotic dispensation (with or without an outpatient visit), emergency department or inpatient encounter for acute sinusitis, or inpatient encounter for a sinusitis complication assessed 1 to 14 days after treatment initiation. Antibiotic-associated adverse events and secondary infections were also assessed. Results:The full cohort included 521 244 eligible patients. After propensity score matching, there were 234 608 patients (117 304 patients per group; 65.5% female; median [IQR] age, 43 [31-54] years). Treatment failure occurred in 3.1% of patients overall, with 0.03% requiring an emergency department or inpatient encounter. There was no observed difference in the risk of treatment failure between the amoxicillin-clavulanate vs amoxicillin groups (3.0% vs 3.1%; risk ratio [RR], 0.96 [95% CI, 0.92-1.01]), which was consistent across sensitivity analyses. There was no difference in antibiotic-associated adverse events (1.3% vs 1.2%; RR, 1.04 [95% CI, 0.97-1.12]). The risk of secondary infections was higher for amoxicillin-clavulanate vs amoxicillin, including yeast infections (1.1% vs 0.8%; RR, 1.40 [95% CI, 1.29-1.53]) and Clostridioides difficile infections (0.04% vs 0.02%; RR, 2.14 [95% CI, 1.29-3.54]). Conclusions and Relevance:In this observational study of patients aged 18 to 64 years with acute sinusitis treated in the outpatient setting with standard-dose amoxicillin-clavulanate or standard-dose amoxicillin, there was no observed difference in treatment failure. Amoxicillin-clavulanate was associated with a higher, albeit rare, risk of adverse events. These findings suggest standard-dose amoxicillin may be a preferred first-line treatment for adults with uncomplicated acute sinusitis.

Acute sinusitis ranks among the top conditions leading to antibiotic prescriptions. There is no agreement on the optimal first-line antibiotic; IDSA guidelines provide a weak recommendation supported by low-quality evidence for amoxicillin-clavulanate over amoxicillin. No study has directly compared these antibiotics for treating acute sinusitis in adults.Table 1:Baseline Demographic and Clinical Characteristics of Adult Sinusitis PatientsFigure 1:Treatment Failure after Propensity Score Matching The cohort included adults 18 to 64 years with an office-based encounter for acute sinusitis (ICD-10: J01.x0) and a same-day dispensation for amoxicillin (875mg BID or 500mg TID) or amoxicillin-clavulanate (875mg-125mg BID) in the MarketScan Commercial Database (2018-2022). Patients with chronic sinus disease or alternative infections were excluded. Treatment failure (subsequent antibiotic dispensation ± an outpatient encounter or an ED/inpatient admission) was evaluated within 14 days after index antibiotic dispensation. Adverse events and negative control outcomes were captured over up to 90 days following treatment initiation. Relative risks (RR) and risk differences (RD) were estimated after 1:1 propensity score matching for confounding control.Figure 2:Risk of Adverse Events after Propensity Score MatchingFigure 3:Risk of Negative Control Outcomes before and after Propensity Score Matching The final cohort included 107,577 propensity score-matched patients per group (Table 1). Treatment failure occurred in 765 (0.8%) patients dispensed amoxicillin-clavulanate and 818 (0.8%) dispensed amoxicillin (RR 0.94 [95% CI, 0.83, 1.03], Figure 1). Amoxicillin-clavulanate was associated with a higher risk of adverse events overall (RR 1.17 [95% CI, 1.10, 1.24]; number needed to harm = 291), as well as several individual adverse events (yeast infection (RR 1.28 [95% CI, 1.17, 1.40]), gastrointestinal symptoms (RR 1.12 [95% CI, 1.02, 1.22]), C. difficile infection (RR 2.33 [95% CI, 1.40, 3.89]) (Figure 2)). Negative control outcomes revealed no difference between groups, suggesting no residual confounding from differential health-seeking behavior (Figure 3). Among adults with new diagnoses of acute sinusitis treated in the office setting, amoxicillin-clavulanate was associated with no treatment failure benefit but increased risk of harms compared to amoxicillin. When an antibiotic is indicated for adults with sinusitis seen in the office setting, clinicians should consider amoxicillin rather than amoxicillin-clavulanate. Timothy Savage, MD, MPH, MSc, UCB: Grant/Research Support Krista F. Huybrechts, PhD, MS, Takeda: Grant/Research Support|UCB: Grant/Research Support

Description: The American College of Physicians (ACP) developed this guideline based on the best available evidence on the comparative benefits and harms of pharmacologic treatments of acute episodic migraine headache, patients' values and preferences, and economic evidence about these pharmacologic treatments. Methods: This guideline is based on a systematic review and network meta-analysis of the comparative benefits and harms of pharmacologic treatments of acute episodic migraine headaches, as well as systematic reviews of patients' values and preferences and comparative cost-effectiveness analyses. The Clinical Guidelines Committee evaluated the following clinical outcomes using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach: pain freedom and pain relief at 2 hours; sustained pain freedom and sustained pain relief up to 48 hours; need for rescue medication within 24 hours; nausea, vomiting, and restored physical function at 2 hours; and overall and serious adverse events (AEs). Additional data on AEs were captured through U.S. Food and Drug Administration medication labels. Audience and Population: The audience for this clinical guideline is physicians and other clinicians. The population is adults with acute episodic migraine headache (defined as 1 to 14 headache days per month) managed in outpatient settings. Recommendation 1: ACP recommends that clinicians add a triptan to a nonsteroidal anti-inflammatory drug to treat moderate to severe acute episodic migraine headache in outpatient settings for nonpregnant adults who do not respond adequately to a nonsteroidal anti-inflammatory drug (strong recommendation; moderate-certainty evidence). Recommendation 2: ACP suggests that clinicians add a triptan to acetaminophen to treat moderate to severe acute episodic migraine headache in outpatient settings for nonpregnant adults who do not respond adequately to acetaminophen (conditional recommendation; low-certainty evidence).

BACKGROUND:Feedback reports summarizing clinician performance are effective tools for improving antibiotic use in the ambulatory setting, but the effectiveness of feedback reports in the hospital setting is unknown. METHODS:Quasi-experimental study conducted between December 2021 and November 2023 within a pediatric health system measuring the impact of clinician feedback reports delivered by email and reviewed in a monthly meeting on appropriate antibiotic use in children hospitalized with community-acquired pneumonia (CAP). We used an interrupted time series analysis (ITSA) to estimate the immediate change and change over time in the proportion of CAP encounters adherent to validated metrics of antibiotic choice and duration, then used Poisson regression to estimate intervention effect as a risk ratio (RR). RESULTS:Preintervention, 213 of 413 (52%) encounters received the appropriate antibiotic choice and duration, which increased to 308 of 387 (80%) postintervention. The ITSA demonstrated an immediate 18% increase in the proportion of CAP encounters receiving both the appropriate antibiotic choice and duration (95% confidence interval [CI]: 3-33%), with no further change over time (-0.3% per month, 95% CI: -2%-2%). In the Poisson model adjusted for age, sex, race, season, site, and intensive care unit admission, the intervention was associated with a 32% increase in the rate of appropriate antibiotic choice and duration (RR 1.32, 95% CI: 1.12-1.56, P < .01). No difference in length of stay or revisits were detected postintervention. CONCLUSIONS:The intervention was associated with an increase in clinician adherence to antibiotic choice and duration recommendations for children hospitalized with CAP.

Background National data on transfusion-related adverse events (TAEs) in the United States are limited. Administrative and payment-related data may augment hemovigilance systems to assess transfusion safety. Study Design and Methods A nationwide administrative database was analyzed to characterize transfusion-related hospitalizations and TAEs by trends, patient/hospital characteristics, and outcomes. Transfusions and TAEs were identified using medical codes and charges. Generalized estimating equations (GEE) modeled transfusion trends, while logistic regression assessed transfusion-associated circulatory overload (TACO) and transfusion-related acute lung injury (TRALI) risk factors. Results During 2016-2020, 8.4% of hospitalizations involved transfusions, with red blood cell (RBC) transfusion being most common (5.2%). In 2020, compared to 2016, hospitalizations with RBC transfusion decreased by 2% (Rate Ratio (RR) 0.98; 95% CI: 0.97-0.99), while plasma transfusion hospitalizations increased by 13% (RR 1.13; 95% CI: 1.08-1.19). TAEs occurred in 0.35% of hospitalizations (3.5/1000 transfusion hospitalizations). Among the TAEs included in the study, TACO, febrile nonhemolytic reactions, and TRALI were most common. In 27% of cases, the specific TAE was unidentified. TAEs were associated with higher inpatient mortality and longer lengths of stay. Variability in TAE rates was observed by patient and hospital characteristics. Risk factors for TACO included age >64, female sex, teaching hospitals, rural location, and Northeast region. TRALI risk was higher in teaching hospitals and those with >200 beds. Conclusion Administrative data provide insights into transfusion practices and associated morbidity and mortality but have limitations. Linking administrative, electronic health record, and blood bank data may enhance TAE identification.

Abstract Background Antibiotics are commonly prescribed for acute respiratory illnesses (ARIs) in outpatient settings, yet up to 50% of antibiotics prescribed for ARIs are unnecessary. We aimed to estimate the prevalence of outpatient antibiotic prescribing for ARIs with no clinical indication for antibiotics (“No Antibiotics Indicated ARIs” or “NAI-ARIs”) and compare it to previously published estimates. Methods Patients ages 0–64 years and ≥ 65 years with medical and prescription drug coverage were identified from Merative MarketScan commercial claims and Medicare Part B claims and Part D event files, respectively. We included outpatient visits in 2022 associated with a NAI-ARI diagnosis of asthma/allergy, bronchitis/bronchiolitis, COVID-19, influenza, non-suppurative otitis media, respiratory syncytial virus (RSV) or viral upper respiratory infection (URI). We calculated the visit rate per 1,000 patient-years and proportion of visits resulting in an oral antibiotic for each diagnosis stratified by age group and outpatient setting. The proportion of unnecessary prescribing for individuals ages < 65 years was compared to published proportions from 2011 and 2018; no comparable prior estimates are available for adults ages ≥ 65 years. Results The proportion of NAI-ARI visits resulting in an antibiotic was 18% for adults ages ≥ 65 years, 11% for adults ages 20–64 years, and 8% for children ages 0–19 years. The overall proportion of prescribing for individuals ages < 65 years was lower in 2022 compared to both 2011 and 2018 (Figure 1). Across all age groups, bronchitis/bronchiolitis had the highest proportion of visits with an antibiotic, while viral URI had the highest rate of visits with an antibiotic (Table 1). Urgent care settings had the highest proportion of visits with an antibiotic across outpatient settings, irrespective of age (Figure 2 and Figure 3). Conclusion Among patients ages < 65 years, the proportion of unnecessary antibiotic prescribing for NAI-ARIs declined over the past decade, possibly due to antibiotic stewardship activities. Continued efforts to improve outpatient antibiotic use should focus on viral URI, bronchitis/bronchiolitis, and emphasize reducing unnecessary prescribing in older adults and urgent care settings. Disclosures All Authors: No reported disclosures

BACKGROUND:Dentists play a role in combatting antimicrobial resistance. This analysis characterizes antibiotic prescribing changes by dentists after the American Dental Association's dental infection treatment guideline was released in 2019. METHODS:The Xponent (IQVIA) database was used to extract antibiotic prescriptions dispensed from 2018 through 2022. General dentist prescriptions were compared with total outpatient oral antibiotics and summarized by patient and provider characteristics. Census denominators were used to calculate prescribing rates per 1,000 people. RESULTS:Dentists prescribed 24.65 million antibiotics in 2018 compared with 25.17 million in 2022, resulting in 75.5 prescriptions per 1,000 people for both years. From 2018 through 2022, dentists prescribed 9.8% through 12.1% of all outpatient antibiotics. Females, patients 65 years and older, and patients in the Northeast received the most antibiotic prescriptions. CONCLUSIONS:Prescribing by general dentists remained stable from 2018 through 2022 despite guideline recommendations to limit antibiotic use for dental infections. Variation by patient and provider characteristics may represent unnecessary antibiotic use. PRACTICAL IMPLICATIONS:Antibiotic stewardship is needed to optimize prescribing in the dental care setting. The Centers for Disease Control and Prevention's Core Elements of Outpatient Antibiotic Stewardship framework can be adapted for dental stewardship implementation.

In prior work, we demonstrated that clinician audit and feedback reports summarizing adherence to appropriate antibiotic choice and duration metrics in previously healthy children with nonsevere community-acquired pneumonia were associated with improved antibiotic use in this population. In this exploratory study, we evaluated the off-target impact of these reports on antibiotic choice and duration in a small cohort of medically complex children cared for concurrently by these same clinicians. The feedback report-based intervention was also associated with an increase in adherence to the appropriate antibiotic choice and duration metrics among the medically complex children, despite these children being excluded from the reports. These preliminary, hypothesis-generating findings provide proof-of-principle that the impact of clinician feedback reports is broader than the population specifically included in the report, and should inform future studies evaluating the safety and effectiveness of feedback-report-based interventions.

DESCRIPTION:The American College of Physicians (ACP) developed this clinical guideline to update recommendations on newer pharmacologic treatments of type 2 diabetes. This clinical guideline is based on the best available evidence for effectiveness, comparative benefits and harms, consideration of patients' values and preferences, and costs. METHODS:This clinical guideline is based on a systematic review of the effectiveness and harms of newer pharmacologic treatments of type 2 diabetes, including glucagon-like peptide-1 (GLP-1) agonists, a GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist, sodium-glucose cotransporter-2 (SGLT-2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and long-acting insulins, used either as monotherapy or in combination with other medications. The Clinical Guidelines Committee prioritized the following outcomes, which were evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach: all-cause mortality, major adverse cardiovascular events, myocardial infarction, stroke, hospitalization for congestive heart failure, progression of chronic kidney disease, serious adverse events, and severe hypoglycemia. Weight loss, as measured by percentage of participants who achieved at least 10% total body weight loss, was a prioritized outcome, but data were insufficient for network meta-analysis and were not rated with GRADE. AUDIENCE AND PATIENT POPULATION:The audience for this clinical guideline is physicians and other clinicians. The population is nonpregnant adults with type 2 diabetes. RECOMMENDATION 1:ACP recommends adding a sodium-glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control (strong recommendation; high-certainty evidence). • Use an SGLT-2 inhibitor to reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to congestive heart failure. • Use a GLP-1 agonist to reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke. RECOMMENDATION 2:ACP recommends against adding a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control to reduce morbidity and all-cause mortality (strong recommendation; high-certainty evidence).

Background. In 2022-2023, 15- and 20-valent pneumococcal conjugate vaccines (PCV15/PCV20) were recommended for infants. We aimed to estimate the incidence of outpatient visits and antibiotic prescriptions in US children (<= 17 years) from 2016-2019 for acute otitis media, pneumonia, and sinusitis associated with PCV15- and PCV20-additional (non-PCV13) serotypes to quantify PCV15/20 potential impacts. Methods. We estimated the incidence of PCV15/20-additional serotype-attributable visits and antibiotic prescriptions as the product of all-cause incidence rates, derived from national health care surveys and MarketScan databases, and PCV15/20-additional serotype-attributable fractions. We estimated serotype-specific attributable fractions using modified vaccine-probe approaches incorporating incidence changes post-PCV13 and ratios of PCV13 versus PCV15/20 serotype frequencies, estimated through meta-analyses. Results. Per 1000 children annually, PCV15-additional serotypes accounted for an estimated 2.7 (95% confidence interval, 1.8-3.9) visits and 2.4 (95% CI, 1.6-3.4) antibiotic prescriptions. PCV20-additional serotypes resulted in 15.0 (95% CI, 11.2-20.4) visits and 13.2 (95% CI, 9.9-18.0) antibiotic prescriptions annually per 1000 children. PCV15/20-additional serotypes account for 0.4% (95% CI, 0.2%-0.6%) and 2.1% (95% CI, 1.5%-3.0%) of pediatric outpatient antibiotic use. Conclusions. Compared with PCV15-additional serotypes, PCV20-additional serotypes account for > 5 times the burden of visits and antibiotic prescriptions. Higher-valency PCVs, especially PCV20, may contribute to preventing pediatric pneumococcal respiratory infections and antibiotic use.

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.

Background/Purpose: The burden and epidemiology of Mycoplasma pneumoniae (Mp) community-acquired pneumonia (CAP) among hospitalized U. S. adults (>= 18 years) are poorly understood. Methods: In the Etiology of Pneumonia in the Community (EPIC) study, we prospectively enrolled 2272 adults hospitalized with radiographically-confirmed pneumonia between January 2010-June 2012 and tested nasopharyngeal/oropharyngeal swabs for Mp by real-time polymerase chain reaction (PCR). Clinical and epidemiological features of Mp-PCR-positive and -negative adults were compared using logistic regression. Macrolide susceptibility was assessed by genotyping isolates. Results: Among 2272 adults, 43 (1.8%) were Mp-PCR-positive (median age: 45 years); 52% were male, and 56% were non-Hispanic white. Only one patient had Mp macrolide resistance. Four (9%) were admitted to the intensive care unit (ICU). No in-hospital deaths were reported. Of the 9 (21%) who received an outpatient antibiotic <= 5 days pre-admission, 2 (22%) received an antibiotic with Mp activity. Variables significantly associated with higher odds of Mp detection included age {18-29 years [(adjusted odds ratio (aOR): 11.7 (95% confidence interval (CI): 5.1- 26.6) versus >= 50 years]} and radiographic lymphadenopathy [aOR: 3.5 (95% CI: 1.2- 9.3)]. Conclusions: M. pneumoniae, commonly known to cause "walking pneumonia", was detected among hospitalized adults, with the highest prevalence among young adults. Although associated with clinically non-specific symptoms, approximately one out of every ten patients were admitted to the ICU. Increasing access to M. pneumoniae point-of-care testing could facilitate targeted treatment and avoid hospitalization.

In recognition of accelerating health care spending and alignment with the American College of Physicians (ACP) principles of promoting high-value care, the ACP Clinical Guidelines Committee (CGC) developed a framework to standardize its approach to identifying, appraising, and considering economic evidence in the development of ACP clinical guidelines. This article presents the CGC's process for incorporating economic evidence, which encompasses cost-effectiveness analyses, economic outcomes in randomized controlled trials, and resource utilization (intervention cost) data. Economic evidence is one component of ACP recommendations. The CGC first and foremost assesses the certainty of evidence for clinical net benefit of interventions; it then considers patient values and preferences, and only then considers economic evidence to develop recommendations.

ImportanceMultiplex molecular syndromic panels for diagnosis of urinary tract infection (UTI) lack clinical data supporting their use in routine clinical care. They also have the potential to exacerbate inappropriate antibiotic prescribing.ObjectiveTo describe the frequency of unspecified multiplex testing in administrative claims with a primary diagnosis of UTI in the Medicare population over time, to assess costs, and to characterize the health care professionals (eg, clinicians, laboratories, physician assistants, and nurse practitioners) and patient populations using these tests.Design, Setting, and ParticipantsThis cohort study used Centers for Medicare & Medicaid Services (CMS) claims data for Medicare beneficiaries. The study included older community-dwelling adults and nursing home residents with fee-for-service Medicare Part A and Part B benefits from January 1, 2016, to December 31, 2023.Main Outcomes and MeasuresMultiplex syndromic panels were identified using carrier claims (ie, claims for clinician office or laboratory services). The annual rate of claims was measured for multiplex syndromic panels with a primary diagnosis of UTI per 10 000 eligible Medicare beneficiaries. The performing and referring specialties of health care professionals listed on claims of interest and the proportion of claims that occurred among beneficiaries residing in a nursing home were described.ResultsBetween 31 110 656 and 36 175 559 Medicare beneficiaries with fee-for-service coverage annually (2016-2023) were included in this study. In this period, 1 679 328 claims for UTI multiplex testing were identified. The median age of beneficiaries was 77 (IQR, 70-84) years; 34% of claims were from male beneficiaries and 66% were from female beneficiaries. From 2016 to 2023, the observed rate of UTI multiplex testing increased from 2.4 to 148.1 claims per 10 000 fee-for-service beneficiaries annually, and the proportion of claims that occurred among beneficiaries residing in a nursing home ranged from 1% in 2016 to 12% in 2020. In addition to laboratories or pathologists, urology was the most common clinician specialty conducting this testing. The CMS-assigned referring clinician specialty was most frequently urology or advanced practice clinician for claims among community-dwelling beneficiaries compared with internal medicine or family medicine for claims among nursing home residents. In 2023, the median cost of a multiplex test in the US was $585 (IQR, $516-$695 for Q1-Q3), which was more than 70 times higher than the median cost of $8 for a urine culture (IQR, $8-$16 for Q1-Q3).Conclusions and RelevanceThis cohort study of Medicare beneficiaries with fee-for-service coverage from 2016 to 2023 found increasing use of emerging multiplex testing for UTI coupled with high costs to the Medicare program. Monitoring and research are needed to determine the effects of multiplex testing on antimicrobial use and whether there are clinical situations in which this testing may benefit patients.