Melissa Gaitanis

A review of the case for hepatitis B vaccination of high-risk adults☆

The sequelae of hepatitis B virus infection include fulminant liver failure, chronic liver disease, hepatocellular carcinoma, and death. The hepatitis B vaccine is efficacious, safe, and cost-effective, but has been consistently underutilized in high-risk adults despite long-standing recommendations. Instituting routine hepatitis B vaccination for high-risk adults in settings such as prisons and jails, sexually transmitted disease clinics, drug treatment centers, and needle exchange programs could prevent up to 800 cases of hepatitis, and 10 deaths from hepatitis, per 10,000 vaccinations, with an overall cost savings. Low rates of completion of the three-dose series and lack of funding for adult immunizations have always been challenges to offering hepatitis B vaccines to high-risk adults. However, there is benefit to an incomplete vaccination series, and high-risk populations are accessible for follow-up vaccination outside of traditional medical settings. A clear national objective and federal funding for vaccinating high-risk adults are needed.

Impact of a Prospective Audit and Feedback Antimicrobial Stewardship Program at a Veterans Affairs Medical Center: A Six-Point Assessment.

Background Prospective audit and feedback is a core antimicrobial stewardship program (ASP) strategy; however its impact is difficult to measure. Methods Our quasi-experimental study measured the effect of an ASP on clinical outcomes, antimicrobial use, resistance, costs, patient safety (adverse drug events [ADE] and Clostridium difficile infection [CDI]), and process metrics pre- (9/10–10/11) and post-ASP (9/12–10/13) using propensity adjusted and matched Cox proportional-hazards regression models and interrupted time series (ITS) methods. Results Among our 2,696 patients, median length of stay was 1 day shorter post-ASP (5, interquartile range [IQR] 3–8 vs. 4, IQR 2–7 days, p<0.001). Mortality was similar in both periods. Mean broad-spectrum (-11.3%), fluoroquinolone (-27.0%), and anti-pseudomonal (-15.6%) use decreased significantly (p<0.05). ITS analyses demonstrated a significant increase in monthly carbapenem use post-ASP (trend: +1.5 days of therapy/1,000 patient days [1000PD] per month; 95% CI 0.1–3.0). Total antimicrobial costs decreased 14%. Resistance rates did not change in the one-year post-ASP period. Mean CDI rates/10,000PD were low pre- and post-ASP (14.2 ± 10.4 vs. 13.8 ± 10.0, p = 0.94). Fewer patients experienced ADEs post-ASP (6.0% vs. 4.4%, p = 0.06). Conclusions Prospective audit and feedback has the potential to improve antimicrobial use and outcomes, and contain bacterial resistance. Our program demonstrated a trend towards decreased length of stay, broad-spectrum antimicrobial use, antimicrobial costs, and adverse events.

Assessments of Opportunities to Improve Antibiotic Prescribing in an Emergency Department: A Period Prevalence Survey

IntroductionApproximately 30% of all outpatient antimicrobials are inappropriately prescribed. Currently, antimicrobial prescribing patterns in emergency departments (ED) are not well described. Determining inappropriate antimicrobial prescribing patterns and opportunities for interventions by antimicrobial stewardship programs (ASP) are needed.MethodsA retrospective chart review was performed among a random sample of non-admitted, adult patients who received an antimicrobial prescription in the ED from January 1 to December 31, 2015. Appropriateness was measured using the Medication Appropriateness Index, and was based on provider adherence to local guidelines. Additional information collected included patient characteristics, initial diagnoses, and other chronic medication use.ResultsOf 1579 ED antibiotic prescriptions in 2015, we reviewed a total of 159 (10.1%) prescription records. The most frequently prescribed antimicrobial classes included penicillins (22.6%), macrolides (20.8%), cephalosporins (17.6%), and fluoroquinolones (17.0%). The most common indications for antibiotics were bronchitis or upper respiratory tract infection (URTI) (35.1%), followed by skin and soft tissue infection (SSTI) (25.0%), both of which were the most common reason for unnecessary prescribing (28.9% of bronchitis/URTIs, 25.6% of SSTIs). Of the antimicrobial prescriptions reviewed, 39% met criteria for inappropriateness. Among 78 prescriptions with a consensus on appropriate indications, 13.8% had inappropriate dosing, duration, or expense.ConclusionConsistent with national outpatient prescribing, inappropriate antibiotic prescribing in the ED occurred in 39% of cases with the highest rates observed among patients with bronchitis, URTI, and SSTI. Antimicrobial stewardship programs may benefit by focusing on initiatives for these conditions among ED patients. Moreover, creation of local guideline pocketbooks for these and other conditions may serve to improve prescribing practices and meet the Core Elements of Outpatient Stewardship recommended by the Centers for Disease Control and Prevention.

Commentary: A Call for Routine HIV Testing Among Patients with Hepatitis C Virus Infection

In February 2010, Mr. R, a 49-year-old male with wellcontrolled HIV infection on highly active antiretroviral therapy (HAART), was referred to our HIV/viral hepatitis coinfection clinic for evaluation of chronic hepatitis C virus (HCV) infection. While he was worried about the degree of damage to his liver and whether HCV treatment was indicated, his greatest concern was for his wife. The couple had been having unprotected intercourse since they were teenagers, and Mr. R feared that his 47-year-old wife was infected with HIV. Mrs. R was diagnosed with chronic HCV years earlier and was under the care of a highly regarded gastroenterologist. This physician recommended liver biopsy with pharmacotherapy for HCV but had not tested Mrs. R for HIV.

A Call for Routine HIV Testing Among Patients with Hepatitis C Virus Infection

In February 2010, Mr. R, a 49-year-old male with wellcontrolled HIV infection on highly active antiretroviral therapy (HAART), was referred to our HIV/viral hepatitis coinfection clinic for evaluation of chronic hepatitis C virus (HCV) infection. While he was worried about the degree of damage to his liver and whether HCV treatment was indicated, his greatest concern was for his wife. The couple had been having unprotected intercourse since they were teenagers, and Mr. R feared that his 47-year-old wife was infected with HIV. Mrs. R was diagnosed with chronic HCV years earlier and was under the care of a highly regarded gastroenterologist. This physician recommended liver biopsy with pharmacotherapy for HCV but had not tested Mrs. R for HIV.

Infections of the Central Nervous System

Infections of the central nervous system (CNS) may be acute (days) or chronic (months to years). The CNS is sequestered from the rest of the body. The blood brain barrier (BBB) excludes most microorganisms and also vital immune cells including phagocytes, antibodies, and complement. Once this barrier is breached, pathogens in the subarachnoid space may grow logarithmically. In this chapter, we discuss the immune response and clinical manifestations of common bacterial, viral, fungal, and parasitic infections of the CNS.