A novel coronavirus causing acute illness with severe symptoms has been isolated in Wuhan, Hubei Province, China. Since its emergence, cases have been found worldwide, reminiscent of severe acute respiratory syndrome and Middle East respiratory syndrome outbreaks over the past 2 decades. Current understanding of this epidemic remains limited due to its rapid development and available data. While occurrence outside mainland China remains low, the likelihood of increasing cases globally continues to rise. Given this potential, it is imperative that emergency clinicians understand the preliminary data behind the dynamics of this disease, recognize possible presentations of patients, and understand proposed treatment modalities.
ImportanceUrgent Care (UC) encounters result in more inappropriate antibiotic prescriptions than other outpatient setting. Few stewardship interventions have focused on UC.ObjectiveTo evaluate the effectiveness of an antibiotic stewardship initiative to reduce antibiotic prescribing for respiratory conditions in a UC network.Design, Setting, and ParticipantsThis quality improvement study conducted in a UC network with 38 UC clinics and 1 telemedicine clinic included 493 724 total UC encounters. The study compared the antibiotic prescribing rates of all UC clinicians who encountered respiratory conditions for a 12-month baseline period (July 1, 2018, through June 30, 2019) with an intervention period (July 1, 2019, through June 30, 2020). A sustainability period (July 1, 2020, through June 30, 2021) was added post hoc.InterventionsStewardship interventions included (1) education for clinicians and patients, (2) electronic health record (EHR) tools, (3) a transparent clinician benchmarking dashboard, and (4) media. Occurring independently but concurrent with the interventions, a stewardship measure was introduced by UC leadership into the quality measures, including a financial incentive.Main Outcomes and MeasuresThe primary outcome was the percentage of UC encounters with an antibiotic prescription for a respiratory condition. Secondary outcomes included antibiotic prescribing when antibiotics were not indicated (tier 3 encounters) and first-line antibiotics for acute otitis media, sinusitis, and pharyngitis. Interrupted time series with binomial generalized estimating equations were used to compare periods.ResultsThe baseline period included 207 047 UC encounters for respiratory conditions (56.8% female; mean [SD] age, 30.0 [21.4] years; 92.0% White race); the intervention period included 183 893 UC encounters (56.4% female; mean [SD] age, 30.7 [20.8] years; 91.2% White race). Antibiotic prescribing for respiratory conditions decreased from 47.8% (baseline) to 33.3% (intervention). During the initial intervention month, a 22% reduction in antibiotic prescribing occurred (odds ratio [OR], 0.78; 95% CI, 0.71-0.86). Antibiotic prescriptions decreased by 5% monthly during the intervention (OR, 0.95; 95% CI, 0.94-0.96). Antibiotic prescribing for tier 3 encounters decreased by 47% (OR, 0.53; 95% CI, 0.44-63), and first-line antibiotic prescriptions increased by 18% (OR, 1.18; 95% CI, 1.09-1.29) during the initial intervention month. Antibiotic prescriptions for tier 3 encounters decreased by an additional 4% each month (OR, 0.96; 95% CI, 0.94-0.98), whereas first-line antibiotic prescriptions did not change (OR, 1.00; 95% CI, 0.99-1.01). Antibiotic prescribing for respiratory conditions remained stable in the sustainability period.Conclusions and relevanceThe findings of this quality improvement study indicated that a UC antibiotic stewardship initiative was associated with decreased antibiotic prescribing for respiratory conditions. This study provides a model for UC antibiotic stewardship.
Healthcare disparities and inequities exist in a variety of environments and manifest in diagnostic and therapeutic measures. In this commentary, we highlight our experience examining our organization’s urgent care respiratory encounter antibiotic prescribing practices. We identified differences in prescribing based on several individual characteristics including patient age, race, ethnicity, preferred language, and patient and/or clinician gender. Our approach can serve as an electronic health record (EHR)–based methodology for disparity and inequity audits in other systems and for other conditions.
Solid organ transplant recipients (SOTRs) remain at high risk for infection throughout their post‐transplant course. Dosing of immunosuppressive medications, strategies that prevent infection, and choice of empiric antimicrobial treatment could be optimized by a better understanding of an individual patient's risk for infectious complications. Diagnostic tests that qualitatively or quantitatively measure the function of the immune system and/or its response to infection may be useful for individualized management decisions. Numerous studies have identified an association between infectious outcomes after solid organ transplantation (SOT) and the results of a variety of non‐pathogen‐specific or “pathogen‐agnostic” immune monitoring tests. These biomarkers include humoral immune markers, functional or quantitative assessments of cellular immunity, transcriptomic‐based diagnostics, and replication of viruses within the human virome, which have been used to predict or diagnose a variety of different infectious diseases complicating SOT. In this narrative review, we discuss several host‐derived immune biomarkers that show promise for either predicting or diagnosing infection among SOTRs. However, additional studies are needed to determine the optimal use of immune response testing. Whether immune biomarkers contribute added benefits to current standard clinical care has not yet been determined. Testing must be validated across a range of clinical scenarios, including surveillance to predict infection risk and diagnosis of active infection at various time points post transplant.
Tenosynovial giant cell tumors (TGCT) are a rare class of benign proliferative tumors that are classified according to their presentation: localized-type (L-TGCT) or diffuse-type (D-TGCT). TGCT is synonymous with pigmented villonodular synovitis (PVNS). We describe the unique case of a 56-year-old obese male with type 2 diabetes who had polymicrobial septic arthritis of his left knee joint with concurrent D-TGCT in the same knee. While on a vacation, he noticed spontaneous left knee pain and swelling with an acute onset of fever. He was diagnosed with septic arthritis that was attributed to hematogenous spread from a leg laceration. The septic arthritis was treated with arthroscopic lavage and debridement, including simultaneous excision of the D-TGCT lesions, followed by intravenous ceftriaxone. Cultures of the synovial tissue that were obtained during arthroscopy grew Klebsiella oxytoca and beta-hemolytic (group B) Streptococcus agalactiae. We were not able to find another reported case of any joint with (1) a polymicrobial bacterial infection that included Klebsiella oxytoca and (2) concurrent bacterial septic arthritis and TGCT.
Background Sexually transmitted infections (STIs) continue to increase in the United States. Syphilis management may challenge busy outpatient clinicians and diagnostic delays have been described. To better understand syphilis treatment practices and identify targets for improvement in our organization, we characterized outpatient encounters associated with a positive syphilis test. Methods Intermountain Healthcare (IH) is an integrated healthcare system with 23 emergency departments (ED), 34 urgent care (UC), and >100 primary care (PC) clinics. Protocols favor treponemal testing as the initial screening test. All positive treponemal tests associated with a positive non-treponemal test in the ambulatory setting were routed to an electronic inbox within the electronic health record (EHR) and reviewed by a team of Infectious Disease (ID) clinicians from May 1st 2021 – January 31st, 2022. Positive results originating from ID or HIV-trained primary care clinicians were excluded. Each encounter was assessed for staging and treatment plans based on CDC guidelines as well as HIV pre-exposure prophylaxis (PrEP) and HIV treatment eligibility. Results 119 encounters were reviewed. Patients 30-44 years old were most likely to have a positive test (50, 42.0%). PC (63, 52.9%) and UC (24, 20.2%) accounted for the most positive tests. 102 (85.7%) positive tests were from white patients, consistent with racial demographics of Utah. Only 40 (33.6%) encounters could be clinically staged after chart review by an ID clinician. Of these, 17 (42.5%) were determined to be staged and treated inappropriately by the treating provider. 54 (45.4%) encounters could not be staged and required further testing or more clinical history to determine the significance of positive test. 18 (15.1%) patients could possibly have benefitted from PrEP evaluation and one new HIV diagnosis was referred to ID clinic. Conclusion Our exploratory analysis revealed many syphilis cases unable to be staged on chart review and opportunities to improve care. Strategies such as prospective audit and feedback or eConsults may be insufficient and clinical evaluation may be necessary to stage syphilis infection. Syphilis care improvements in our system may be a future target for ID physician engagement and novel stewardship strategies. Disclosures All Authors: No reported disclosures.
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