National HIV prevention goals call for interventions that address Continuum of HIV Care (CoC) for persons living with HIV. Electronic health (eHealth) can leverage technology to rapidly develop and disseminate such interventions. We conducted a qualitative review to synthesize (a) technology types, (b) CoC outcomes, (c) theoretical frameworks, and (d) behavior change mechanisms. This rapid review of eHealth, HIV-related articles (2007–2017) focused on technology-based interventions that reported CoC-related outcomes. Forty-five studies met inclusion criteria. Mobile texting was the most commonly reported technology (44.4%, k = 20). About 75% (k = 34) of studies showed proven or preliminary efficacy for improving CoC-related outcomes. Most studies (60%, k = 27) focused on medication adherence; 20% (k = 9) measured virologic suppression. Many eHealth interventions with preliminary or proven efficacy relied on mobile technology and integrated knowledge/cognition as behavior change mechanisms. This review identified gaps in development and application of eHealth interventions regarding CoC.
Recent emergence of a virulent strain of Clostridium difficile demonstrates the importance of tracking C. difficile incidence locally. Our survey of New Jersey hospitals documented increases in the rates of C. difficile disease (by 2-fold), C. difficile –associated complications (by 7-fold), and C. difficile outbreaks (by 12-fold) during 2000–2004.
Background This article summarizes the results from systematic reviews of human immunodeficiency virus (HIV) prevention interventions for people who use drugs (PWUD). We performed an overview of reviews, meta-analysis, meta-epidemiology, and PROSPERO Registration CRD42017070117. Methods We conducted a comprehensive systematic literature search using the Centers for Disease Control and Prevention HIV/AIDS Prevention Research Synthesis Project database to identify quantitative systematic reviews of HIV public heath interventions with PWUD published during 2002–2017. We recombined results of US studies across reviews to quantify effects on HIV infections, continuum of HIV care, sexual risk, and 5 drug-related outcomes (sharing injection equipment, injection frequency, opioid use, general drug use, and participation in drug treatment). We conducted summary meta-analyses separately for reviews of randomized controlled trials (RCTs) and quasi-experiments. We stratified effects by 5 intervention types: behavioral-psychosocial (BPS), syringe service programs (SSP), opioid agonist therapy (OAT), financial and scheduling incentives (FSI), and case management (CM). Results We identified 16 eligible reviews including >140 US studies with >55 000 participants. Summary effects among US studies were significant and favorable for 4 of 5 outcomes measured under RCT (eg, reduced opioid use; odds ratio [OR] = 0.70, confidence interval [CI] = 0.56–0.89) and all 6 outcomes under quasi-experiments (eg, reduced HIV infection [OR = 0.42, CI = 0.27–0.63]; favorable continuum of HIV care [OR = 0.68, CI = 0.53–0.88]). Each intervention type showed effectiveness on 1–6 outcomes. Heterogeneity was moderate to none for RCT but moderate to high for quasi-experiments. Conclusions Behavioral-psychosocial, SSP, OAT, FSI, and CM interventions are effective in reducing risk of HIV and sequelae of injection and other drug use, and they have a continuing role in addressing the opioid crisis and Ending the HIV Epidemic.
In the United States, men who have sex with men (MSM) are disproportionately affected by HIV. To identify research gaps and inform HIV prevention for MSM, we conducted a scoping review of systematic reviews using CDC's Prevention Research Synthesis database. Eligibility criteria comprised English-language systematic reviews focused on HIV prevention for MSM, published during 1988-2017, and included at least one U.S. primary study. We coded data type, subpopulations, topics, and key findings. To assess study quality, we used the Assessment of Multiple Systematic Reviews (AMSTAR). Among 129 relevant systematic reviews, study quality was high or moderate for 63%. Most common topics were sexual behavior and disease vulnerability. The most frequently mentioned MSM subgroups were HIV-positive, Black or African American, and young. Research gaps include Hispanic/Latino MSM, pre-exposure prophylaxis (PrEP), treatment as prevention, social determinants of health, health disparities, syndemics, and protective factors for sexual health.
In September 2009, federal funding for health care-associated infection (HAI) program development was dispersed through a cooperative agreement to 51 state and territorial health departments. From July to September 2011, 69 stakeholders from six states-including state health department employees, representatives from partner organizations, and health care facility employees-were interviewed to assess state HAI program achievements, implementation barriers, and strategies for sustainability. Respondents most frequently cited enhanced HAI surveillance as a program achievement and resource constraints as an implementation barrier. To sustain programs, respondents recommended ongoing support for HAI prevention activities, improved surveillance processes, and maintenance of partnerships. Findings suggest that state-level HAI program growth was achieved during the cooperative agreement but that maintenance of programs faces challenges.
Background Interventions to reduce community-onset (CO) Clostridioides difficile Infection (CDI) are not usually hospital-based due to the perception that they are often acquired outside the hospital. We determined the proportion of admitted CO CDI that might be associated with previous hospitalization. Methods The CDC’s Emerging Infections Program conducts population-based CDI surveillance in 10 US sites. We defined an incident case as a C. difficile-positive stool collected in 2017 from a person aged ≥ 1 year admitted to a hospital with no positive tests in the prior 8 weeks. Cases were defined as CO if stool was collected within 3 days of hospitalization. CO cases were classified into four categories: long-term care facility (LTCF)-onset if patient was admitted from an LTCF; long-term acute care hospital (LTACH)-onset if patient was admitted from an LTACH; CO-healthcare-facility associated (CO-HCFA) if patient was admitted from a private residence but had a prior healthcare-facility admission in the past 12 weeks; or community-associated (CA) if there was no admission to a healthcare facility in the prior 12 weeks. We excluded hospitals with < 10 cases among admitted catchment-area residents. Results Of 4724 cases in 86 hospitals, 2984 (63.2%) were CO (median per hospital: 65.8%; interquartile range [IQR]: 58.3%-70.7%). Among the CO cases, 1424 (47.7%) were CA (median per hospital: 48.1%; IQR: 40.3%-57.7%), 1201 (40.3%) were CO-HCFA (median per hospital: 41.0%; IQR: 32.9%-47.8%), 350 (11.7%) were LTCF-onset (median per hospital: 10.0%; IQR: 0.6%-14.4%), and 9 (0.3%) were LTACH-onset. Of 1201 CO-HCFA cases, 1174 (97.8%) had a prior hospitalization; among these, 978 (83.3%) (median per hospital: 83.3%; IQR: 69.2%-90.6%), which consists of 32.8% of all hospitalized CO cases, had been discharged from the same hospital (Figure), and 84.4% of the 978 cases (median per hospital: 88.2%: IQR: 76.5%-100.0%) had received antibiotics sometime in the prior 12 weeks. Figure. Frequency of Cases Discharged in the 12 Weeks Prior to Readmission with Clostridioides difficile Infection (N=1138*) Conclusion A third of hospitalized CO CDI had been recently discharged from the same hospital, and most had received antibiotics during or soon after the last admission. Hospital-based and post-discharge antibiotic stewardship interventions could help reduce subsequent CDI hospitalizations. Disclosures Ghinwa Dumyati, MD, Roche Diagnostics (Consultant)
Background While discharge antibiotic prescriptions from emergency department (ED) visits have been reported, systemic antibiotic use during ED and hospital observation (OBS) visits have not been well assessed. We conducted a descriptive analysis of antibiotic use in these settings. Methods We identified ED and OBS visits not resulting in hospitalization, and systemic antibiotics administration charges during these visits from January 2012-December 2018 using the Premier Healthcare Database, representing at least 600 hospitals annually. Antibiotics prescribed after discharge were excluded. We reported the proportion of visits with antibiotic use, and described antibiotic use by class, agent and route stratified by location. We also examined trends in antibiotic use over time using a multivariable logistic model. Results We assessed 161,291,011 ED visits and 15,660,062 OBS visits from 2012–2018. Systemic antibiotics were identified in 9.0% of ED visits and 25.2% of OBS visits. Parenteral (IV) antibiotics were received in a high proportion of ED and OBS visits in which a systemic antibiotic was received (52.6% and 87.6% respectively). In the ED, 3rd/4th generation cephalosporins were the most commonly identified (32.7%) while in the OBS, 1st/2nd generation cephalosporins were most commonly identified (38.9%), Fig. 1. The most common agents in the ED were ceftriaxone, azithromycin, and cephalexin while the most common agents in the OBS were cefazolin, ceftriaxone, and levofloxacin. Any systemic antibiotic use in EDs declined slightly from 2012–2018 (9.2%-8.9%, p< 0.0001) while use in OBS settings saw the largest increase from 2017- 2018 (25.4%-30.4%, p< 0.0001), Fig. 2. Fluoroquinolone use decreased in both ED (41.3%) and OBS (31.2%) (both p< 0.0001) beginning in years 2012 and 2016 respectively. Figure 1: Antibiotic use in emergency departments and observation settings by antibiotic class, Premier Healthcare Database Hospitals, 2012–2018 Figure 2: Overall antibiotic use in emergency departments and observation settings by year, Premier Healthcare Database Hospitals, 2012–2018 Conclusion Hospital ED and OBS settings are uniquely positioned to improve appropriate antibiotic use across the spectrum of healthcare. Frequent use of IV antibiotics and recent increases in antibiotic use in observation settings call for evaluation of appropriateness of their use and presence of transition-of-care process. Further evaluation of diagnoses to evaluate the appropriateness of IV administration may highlight additional opportunities for optimizing prescribing practices. Disclosures All Authors: No reported disclosures
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