New research was presented at ID Week 2018, the combined annual meeting of the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, HIV Medicine Association, and Pediatric Infectious Diseases Society, from October 3 to 7 in San Francisco. The features below highlight some of the studies that emerged from the conference.
Antimicrobial Stewardship for ARVs
Despite the simplicity of currently available antiretroviral (ARV) regimens, evidence suggests that medication errors still occur frequently. To evaluate the impact of an antimicrobial stewardship (ASP) team in identifying and reducing ARV medication errors, researchers assessed the rate of medication errors before and after implementation of an ASP initiative in HIV-positive hospital inpatients. The ASP intervention occurred upon admission and consisted of a comprehensive ARV review to assess for dosing, drug–drug interactions, and completeness of the regimen, all conducted by a PGY2 infectious diseases (ID) pharmacy resident and an ID clinical specialist. Among 199 mediation errors detected during the pre-intervention period, 12 were subsequently corrected, compared with 85 subsequent corrections among the 124 detected errors during the post-intervention period. Of the 39 errors missed by the ASP team, 6 were not detected, 12 occurred post-review, and 21 were not accepted by the primary team.
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Hepatitis A Virus Infection Trends
To assess trends in hepatitis A virus infections in the United States, the CDC recently analyzed National Notifiable Disease Surveillance System (NNDSS) hepatitis A data for 2007 to 2016 and a combination of NNDSS data and cases directly reported to the CDC hepatitis A outbreak response team during 2017. During 2007 to 2011, of 10,619 hepatitis A cases reported, 5% were associated with outbreaks. Of the outbreak-associated cases for whom clinical data were reported, 37% were hospitalized and 0.3% died. Of the outbreak-associated cases for whom risk exposure data were reported, 52% were associated with a common source. Comparatively, during 2012 to 2017, of 11,483 hepatitis A cases reported, 20% were associated with outbreaks. Of the outbreak-associated cases for whom clinical data were reported, 60% were hospitalized and 2% died. Of the outbreak-associated cases for whom risk exposure data were reported, 17% were associated with a common source. The study authors suggest that “decreasing the susceptible population through adherence to childhood vaccination recommendations and targeted vaccination of recommended at-risk groups can prevent future hepatitis A outbreaks of any transmission pattern.”
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Too Few Youth Tested for HCV
Data suggest that hepatitis C virus (HCV) infections have increased, with the current opioid crisis, among Americans aged 15 to 30. While federally qualified health centers (FQHCs) provide comprehensive healthcare to diverse and underserved communities, little is known regarding HCV screening practices among adolescents and young adults seen at FQHCs. To characterize the continuum of HCV testing among this population, researchers used electronic records to create a retrospective cohort of 13 to 21-year-olds who had a least one outpatient visit at any of 98 participating US FQHCs across 19 states from 2012 to 2017. Among nearly 270,000 youth with a mean age of 18.5, only 2.5% were tested for HCV and 2.2% had reactive testing. Of them, 76.5% had confirmatory RNA testing and 55.6% had detectable RNA. Among those with ICD-9 codes for opioid use disorder (OUD) or any ICD-9 code for drug use, 35.0% and 8.9% were tested for HCV, respectively. Of those tested for HCV, only 10.6% were also tested for HIV.
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Stronger Treatment Engagement & Better Outcomes in HIV Patients
While research shows that earlier initiation of antiretroviral therapy (ART) improves desired outcomes, other studies show this can be difficult to achieve. With the help of an early intervention service (EIS) for a local health department, an academic clinic implemented a fast-track linkage and ART process for patients meant to provide services within 10 days of diagnosis. A study team compared the new system with the standard of care. Retention in care, the percentage of patients prescribed ART, viral suppression at one year, and CD4 recovery were better in the intervention group than in the standard of care group. The study authors concluded that implementation of fast-track linkage systems that include EIS “can lead to successful and sustained high rates of viral suppression and improved CD4 recovery,” adding that larger scale studies “could prove to be highly beneficial from a public health perspective.”
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UTI Incidence & Environmental Temperature
Although prior research has suggested that a cause of the 10% greater incidence of urinary tract infections (UTIs) from June to September when compared with other times of the year may be warmer temperatures during summer months, this work has focused on inpatients and used average monthly temperatures. Using data on all UTI cases located in one of 397 metropolitan statistical areas (MSA) in the contiguous United States between 2011 and 2016 and weather data for each MSA and date obtained from the National Centers for Environmental Information, researchers computed the mean temperature during the period 3 to 8 days prior to the service date of outpatient claims for UTI. Temperature was found to have aHo significant effect on UTI risk. Relative to times when the average temperature 3-8 days prior was 40.1-45°F, UTI incidence exhibited a dose-response relationship that persisted after adjustment for seasonal factors.
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CD4 Count Monitoring: Less Is More
Simple lymphocyte panels for monitoring CD4 counts in patients with HIV show absolute and percentage counts only. While complex lymphocyte panels are more comprehensive, data indicate that they are expensive and often do not offer more clinically valuable information. To determine if increasing the rate of simple panel utilization can significantly save costs for the healthcare system without compromising care, a study was conducted to compare panels ordered prior to an intervention that encouraged simple panels with those ordered after. Complex panels represented 99% of tests ordered prior to the intervention, with an average cost of $167.67. The proportion of complex panels fell by 85% during the post-intervention period. The average cost of all post-intervention tests was $55.54, a statistically significant difference from the pre-intervention period. The percentage of simple panels consistently increased month-per-month post-intervention, up to 100% during the last month of the study.
