Therapeutic plasma apheresis is an invasive medical intervention that should be reserved for treatment of children and adolescents who are severely affected by PANDAS. In such patients, it appears to be a safe, well-tolerated, and beneficial treatment option.
Majocchi's granuloma is a rare condition in which a dermatophyte invades the deeper layers of the dermis and subcutaneous tissue and can often be misidentified and treated as eczema. It has a variable presentation ranging from cutaneous lesions to deeper infections in immunocompromised patients. No prior cases have described the formation of Majocchi's granuloma with the deuteromycetes, Malabranchea.
BackgroundHepatitis B virus (HBV) reactivation is a common complication in the treatment of oncology patients when using anti-CD20 monoclonal antibodies (MABs) such as rituximab, obinituzumab, and ofatumumab. In such patients, the reaction of HBV is seen in up to 70% who are HBV DNA positive. Antiviral therapy in high-risk patients has been shown to improve outcomes.MethodsThis retrospective review evaluated patients at Thomas Jefferson University Hospital who received rituximab, obinituzumab, or ofatumumab as a component of hematologic malignancy therapy between 2013 and 2016. We determined the number of patients who had appropriate HBV testing prior to therapy, the number who received appropriate antiviral therapy, and the number who developed reactivation of HBV and their outcomes.Results402 patients received one of the above anti-CD20 MABs between November 2013 and December 2016. Of these 402 patients, 52 (13.4%) did not have either HBsAg or HBcAb performed prior to anti-CD20 therapy. 39 (9.7%) patients had positive HBsAg or HBcAb prior to therapy. Of these 39 highrisk patients, only 16/39 (41.3%) were placed on appropriate antiviral therapy. Two of the 39 high-risk patients (5.1%), who were not started on antiviral therapy, developed HBV reactivation as a complication of anti-CD20 MAB therapy.ConclusionA significant number of patients were not appropriately screened with HBV markers prior to anti-CD20 therapy for hematologic malignancies at our institution. In addition, less than half of highrisk HBV patients received appropriate antiviral therapy. System-wide changes are anticipated to improve this process at our institution.Disclosures
All authors: No reported disclosures.
Background
C. difficile (CD) testing is frequently ordered inappropriately. Highly sensitive polymerase chain reaction (PCR) tests can detect CD colonization leading to misdiagnosis. Providers often overlook other causes of diarrhea, notably laxatives. To improve diagnostic stewardship, our hospital introduced an electronic medical record (EMR)-based order set (OS).
Methods
In a 926-bed, teaching hospital, we conducted a 3-step intervention to improve CD diagnostic stewardship. (1) A retrospective analysis of CD orders before and after OS implementation was done to assess its impact on inappropriate orders. The OS included two questions: (a) Did patient have ≥ 3 loose bowel movements in past 24 hours? and (b) No laxatives in past 24 hours? An appropriate order was defined if “yes” to both questions. It was still appropriate if “no” to either question but ≥ 2 unexplained following features: fever > 100.4 F, abdominal pain, megacolon, ileus or leukocytosis > 11,000 cells/mm3 in prior day. (2) After implementation of OS, house staff compliance with OS was surveyed via email. (3) Rationale for inappropriate orders was discussed with providers.
Results
Of 238 patients in retrospective analysis, 44% were ≥ 65 years and 37% had other potential causes of diarrhea. Common clinical features were leukocytosis (40%) and fever (31%). There was no significant difference in inappropriate testing: pre-OS 27/99 (27%) vs post-OS 44/139 (32%) (p=0.47). Of 43 house officers who participated in the survey, 75% indicated they over rode the OS. When asked to provide rationale of inappropriate CD testing, providers acknowledged inappropriate ordering but did not want to miss a CD diagnosis and frequently overlooked other causes of diarrhea.
Conclusion
Appropriate CD testing relies on providers’ appreciation of a clinical picture consistent with CD infection, confirmation of clinically significant diarrhea, and consideration of other causes of diarrhea. Providers order inappropriate tests, not due to lack of knowledge, but likely fear of missing diagnosis and overlooking other causes of diarrhea.
Disclosures
All Authors: No reported disclosures
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