Background & Aims The high costs of direct-acting antiviral (DAA) agents to treat chronic hepatitis C virus (HCV) infection have resulted in denials of treatment, but it is not clear whether patients’ access to these therapies differs with their type of insurance. Methods We conducted a prospective cohort study among all patients who had a DAA prescription submitted between November 1, 2014 and April 30, 2015 to Burman’s Specialty Pharmacy, which provides HCV pharmacy services to patients in Delaware, Maryland, New Jersey, and Pennsylvania. We determined the incidence of absolute denial of DAA prescription, defined as lack of approval of prescription fill by the insurer, according to type of insurance (US Medicaid, US Medicare, commercial insurance). Multivariable Poisson regression was used to estimate adjusted relative risks (RRs) of absolute denial associated with patient characteristics. Results Among 2321 patients prescribed a DAA regimen (503 covered by Medicaid; 795 by Medicare; 1023 by commercial insurance), 377 (16.2%) received an absolute denial. The most common reasons for absolute denial were insufficient information to assess medical need (134 [35.5%]) and lack of medical necessity (132 [35.0%]). A higher proportion of patients covered by Medicaid received an absolute denial (233 [46.3%]) than those covered by Medicare (40 [5.0%]; P<.001) or commercial insurance (104 [10.2%]; P<.001). Medicaid insurance (adjusted RR, 4.14; 95% confidence interval, 3.38–5.08) and absence of cirrhosis (adjusted RR, 1.96; 95% confidence interval, 1.53–2.50) were associated with absolute denial. Conclusions There are significant disparities in access to DAA-based treatments for HCV infection among patients with different types of insurance. Nearly half of Medicaid beneficiaries in Delaware, Maryland, New Jersey, and Pennsylvania were denied access to these drugs for chronic HCV infection.

SummaryWhat is known and objective: With the advent of antiretroviral therapy and the resultant decrease in mortality among adults living with human immunodeficiency virus (HIV), there is now an increased incidence of obesity and obesity-related comorbidities in these patients. Bariatric surgery is becoming an increasingly common Results: Several case series and case reports have been published which demonstrate minimal risk of complications and maintenance of virologic suppression in the vast majority of patients. Bariatric surgery appears to be an effective mechanism for assistance in controlling obesity in patients infected with HIV; however, numerous factors may impact the safe and effective use of antiretroviral therapy.

Native vertebral osteomyelitis (NVO) is a difficult to treat infection often caused by hematogenous spread of bacteria to the bone, causing pain and inflammation. The Infectious Diseases Society of America recommends vancomycin intravenously as first-line treatment for NVO involving methicillin-resistant Staphylococcus aureus (MRSA) for 6 weeks. Alternatives include daptomycin and linezolid. Oritavancin (Orbactiv) is a lipoglypoglycopeptide, structurally similar to vancomycin approved by the Food and Drug Administration for the treatment of acute bacterial skin and skin structure infections caused by susceptible bacteria including S. aureus (both methicillin sensitive and resistant), Streptocococcus, and Enterococcus species. The clinical features of oritavancin are favorable for outpatient use given its broad spectrum of activity for gram-positive organisms and ease of administration; however, clinical experience with the medication is lacking. In this case report, we describe a patient presentation and the evidence for use of oritavancin for the treatment of NVO caused by MRSA. To our knowledge, this is the first reported case of oritavancin for NVO caused by MRSA, and further clinical studies to evaluate it for other indications should be considered.

Summary Background Automatic stop orders (ASOs) for antimicrobials have been recommended as a component of antimicrobial stewardship programs, but may result in unintentional treatment interruption due to failure of providers to re-order an antimicrobial medication. We examined the impact of a multifaceted intervention designed to reduce the potential harms of interrupting antimicrobial treatment due to ASOs. Methods An intervention was implemented that included pharmacist review of expiring antimicrobials as well as provider education to encourage use of a long-term antimicrobial order set for commonly used prophylactic antimicrobials. Pharmacist interventions and antimicrobial re-ordering was recorded. Percent of missed doses of a commonly used prophylactic antimicrobial, single strength co-trimoxazole, was compared pre- and post-intervention using a chi-squared test. Results From November 1, 2015 to November 30, 2016, there were 401 individual pharmacist interventions for antimicrobial ASOs, resulting in 295 instances of antimicrobial re-ordering. The total percent of presumed missed single strength co-trimoxazole doses was reduced from 8.4% to 6.2% post-intervention ( P <0.001). Conclusions This study found that a targeted intervention was associated with a reduction in unintended antimicrobial treatment interruption related to ASOs.

BackgroundAdverse drug events are associated with an increase in hospital stay and cost. Risks from these events are minimized by adjusting a medication’s dose or frequency, and changes in renal function may necessitate adjustments. Currently, there is no formal procedure for a prospective audit of renal function over the weekend at our institution. This pharmacist-driven initiative will evaluate if a prospective review identified by real-time clinical decision support alerts over the weekend will reduce the time from change in renal function to dose adjustment of select antimicrobials and/or anticoagulants.MethodsThis monitoring initiative is comprised of a pre- and post-cohort population. The pre-cohort population included patients admitted to Penn Presbyterian Medical Center (PPMC) from January to March of 2018 on select antimicrobials and/or anticoagulants, who were identified to have a change in renal function (serum creatinine change of 0.3 mg/dL or greater) over the weekend. The post-cohort population was identified with a clinical decision support system (ILÚM Health Solutions, Kenilworth, NJ) and included patients admitted to PPMC from January to March of 2019. A pharmacy resident reviewed alerts in the clinical decision support system over the weekend and contacted providers with dose adjustment recommendations. The Mann–Whitney U test was used to analyze the primary endpoint while descriptive statistics were used for the secondary endpointsResultsEighteen interventions were completed within the 3-month post-cohort intervention period, with a time to dose adjustment between the pre/post-cohort being reduced by 50 hours (P = 0.0001) resulting in a median time to change of 11 hours in the post-cohort. All pharmacy recommendations were accepted by the provider, and 94% of medication adjustments were antimicrobials.ConclusionThe application of this prospective weekend initiative utilizing a clinical decision support system demonstrated a clinically and statistically significant reduction in the time to dose adjustments for antimicrobials and/or anticoagulants. Implementation of this initiative will further establish a role for pharmacist-led evaluations and could potentially be expanded to other clinical areas.Disclosures All authors: No reported disclosures.