Table 1.

Studies Demonstrating Effects on Antimicrobial Prescribing in Coccidioidomycosis-Endemic Areas

Publication	Study Design	Effects on Antimicrobial Prescribing	Take-Home Points
Donovan et al [25]	Retrospective study of patients at Banner University Medical Center–Tucson (1 Jan 2015–18 Sep 2017) with selected ICD-9/10 codes. This information was used to determine initial symptom presentation date and official CM diagnosis date to quantify the delay in diagnosis. Antibacterial prescriptions were characterized as antibacterial medication orders submitted prior to CM diagnosis date.	Antibacterial prescriptions ordered prior to CM diagnosis (N = 276 patients): 1103 antibacterial prescriptions ordered prior to diagnosis. Vancomycin and daptomycin responsible for 22% of the orders.	Single-center retrospective analysis demonstrating that 43% of 276 patients with CM had a delay in diagnosis >1 mo Median delays in diagnosis ranged between 17 and 54 d 1103 antibacterial prescriptions orders submitted prior to diagnosis of CM
Pu et al [27]	Retrospective study analyzing CM practice patterns in a large Arizona-based health system over 3 y (2017–2019). This included data from 15 hospitals, 53 primary care sites, and 48 urgent care sites. Patients identified with CM ICD-10 code and ordered CM antibodies.	Quantification of antibacterial prescriptions: For 95.4% of 1491 hospital-diagnosed patients: 13 135 antibacterial prescriptions ordered in 2017, 16 755 antibacterial prescriptions ordered in 2018, and 23 355 antibacterial prescriptions ordered in 2019. Median number of antibacterial prescription orders per patient: Not requiring ICU care or a procedure during admission: 14 orders per patient; ICU care but no procedure during admission: 21 orders per patient; procedure but no ICU care during admission: 21 orders per patient; ICU care and procedure during admission: 41 orders per patient. Overall—19 orders per patient.	Large amount of CM diagnoses made only after hospital admission Large amount of antibacterial prescribing occurred during these hospitalizations Study demonstrates a practice pattern of not considering the diagnosis of CM in ambulatory settings
Tartof et al [17]	Cohort study of all patients in a large health system who were both diagnosed with CAP and received outpatient treatment. The study evaluated for CAP diagnoses from all care settings and documentation of a CM ICD-9 code from 1 wk prior to 1 wk after sample collection date for confirmed CM cases.	Having antibacterial agents prescribed ≥2 times from 1 wk prior to CAP visit to first CM test: Associated with increased odds of positive CM testing (aOR, 4.57 [95% CI, 1.29–16.12]). Total number of times prescribed additional antibacterials before/on follow-up CAP visits to 1 y after CAP diagnosis with or without CM testing (N = 33 756 patients): 0 prescriptions: 29 248 patients 1 prescription: 3607 patients 2 prescriptions: 669 patients 3 prescriptions: 161 patients ≥4 prescriptions: 71 patients	Study highlights opportunities to reduce antibacterial prescribing in endemic regions for CM by increasing awareness to test for CM in patients presenting with CAP Patients with confirmed cases of CM were more likely to receive multiple courses of antibacterials
Chi et al [28]	Retrospective study that investigated CM testing and treatment patterns through use of EHR in a large integrated health network.	Antibacterial patterns (N = 530 patients): 70% of patients received antibacterials 3 mo prior to first positive CM test; 36% of patients received antibacterials 3 mo after first positive CM test. Median antibacterial prescriptions: Patients who received antibacterials had a median of 3 prescriptions (IQR, 2–7). Antifungal patterns (N = 530 patients): 14% received antifungals the year prior to first positive CM test; 79% patients received antifungals after first positive CM test. Median time from first positive CM test to antifungal prescription: 7 d (IQR, 2–13). Event sequence: Most common event sequence was (1) antibacterial prescription, (2) positive CM testing, (3) antifungal prescription.	In this study, most patients received antibacterials prior to first positive CM test After positive CM testing, most patients received antifungal prescriptions, while antibacterial prescribing decreased Awareness for testing in patients with CAP could reduce antibacterial prescribing

Abbreviations: aOR, adjusted odds ratio; CAP, community-acquired pneumonia; CI, confidence interval; CM, coccidioidomycosis; EHR, electronic health record; ICD-9, International Classification of Diseases, Ninth Revision; ICD-10, International Classification of Diseases, Tenth Revision; ICU, intensive care unit; IQR, interquartile range.