Role of ID Consultation in Candidemia

"Candida bloodstream infections affect many patients across the U.S. Their mortality rate is approximately 25% to 35% according to surveillance data1,2. Candidemia is associated with immune suppression, hematologic malignancy, the presence of a central line, the use of parenteral nutrition, and exposure to broad spectrum antibiotics. The timing and appropriateness of antifungal therapy can improve outcomes. Further, patients should undergo investigations to identify the source of their infection and possible metastatic complications, such as endocarditis, endophthalmitis and invasive organ disease. The Infectious Disease Society of America has created evidence-based guidelines for the management of invasive candidiasis 3."Nathanial S. Nolan (Department of Infectious Diseases, Washington University School of Medicine)Includes bibliographical reference

Bictegravir-based antiretroviral therapy-associated accelerated hyperglycemia and diabetes mellitus

Integrase strand transfer inhibitor (INSTI)-based antiretroviral therapy (ART) is first line for treatment of people with human immunodeficiency virus (PWH). Emerging data suggest the possibility of adverse metabolic effects of these medications. We describe 3 cases in which PWH developed hyperglycemia and ketoacidosis within months of being switched to bictegravir-based ART

Online learning for infectious disease fellows-A needs assessment

BACKGROUND: Online resources and social media have become increasingly ubiquitous in medical education. Little is known about the need for educational resources aimed at infectious disease (ID) fellows. METHODS: We conducted an educational needs assessment through a survey that aimed to describe ID fellows\u27 current use of online and social media tools, assess the value of online learning, and identify the educational content preferred by ID fellows. We subsequently convened focus groups with ID fellows to explore how digital tools contribute to fellow learning. RESULTS: A total of 110 ID fellows responded to the survey. Over half were second-year fellows (61, 55%). Although many respondents were satisfied with the educational resources provided by their fellowship program (70, 64%), the majority were interested in an online collaborative educational resource (97, 88%). Twitter was the most popular social media platform for education and the most valued online resource for learning. Focus groups identified several themes regarding social medial learning: broadened community, low barrier to learning, technology-enhanced learning, and limitations of current tools. Overall, the focus groups suggest that fellows value social media and online learning. CONCLUSIONS: ID fellows are currently using online and social media resources, which they view as valuable educational tools. Fellowship programs should consider these resources as complementary to traditional teaching and as a means to augment ID fellow education

Get privacy trending: Best practices for the social media educator

Social media is an increasingly popular forum for medical education. Many educators, including those in infectious diseases, are now creating and sharing unique and educational patient cases online. Unfortunately, some educators unknowingly threaten patient privacy and open themselves to legal liability. Further, the use of published figures or tables creates risk of copyright infringement. As more and more infectious diseases physicians engage in social media, it is imperative to create best practices to protect both patients and physicians. This summary will define the legal requirements of patient de-identification as well as other practical recommendations as they relate to use of clinical case information, patient images, and attribution of primary references on social media

Low knowledge of HIV PrEP within a midwestern US cohort of persons who inject drugs

We interviewed persons who inject drugs (PWID) to understand perceptions of pre-exposure prophylaxis (PrEP) to prevent HIV infection. Knowledge of PrEP was poor. Patients felt that PrEP was for sexual intercourse rather than injection drug use, and PWID managed on medications for opioid use disorder felt that they had no need for PrEP

Experiences using a multidisciplinary model for treating injection drug use associated infections: A qualitative study

Background: Over the past two decades, the United States has experienced a dramatic increase in the rate of injection drug use, injection associated infections, and overdose mortality. A hospital-based program for treating opioid use disorder in people who inject drugs presenting with invasive infections was initiated at an academic tertiary care center in 2020. The goal of this program was to improve care outcomes, enhance patient experiences, and facilitate transition from the hospital to longer term addiction care. The purpose of this study was to interview two cohorts of patients, those admitted before vs. after initiation of this program, to understand the program\u27s impact on care from the patient\u27s perspective and explore ways in which the program could be improved. Methods: Thirty patients admitted to the hospital with infectious complications of injection drug use were interviewed using a semi-structured format. Interviews were transcribed and coded. Emergent themes were reported. Limited descriptive statistics were reported based on chart review. Results: Thirty interviews were completed; 16 participants were part of the program (admitted after program implementation) while 14 were not participants (admitted prior to implementation). Common themes associated with hospitalization included inadequate pain control, access to medications for opioid use disorder (MOUD), loss of freedom, stigma from healthcare personnel, and benefits of having an interprofessional team. Participants in the program were more likely to report adequate pain control and access to MOUD and many cited benefits from receiving care from an interprofessional team. Conclusions: Patients with opioid use disorder admitted with injection related infections reported improved experiences when receiving care from an interprofessional team focused on their addiction. However, perceived stigma from healthcare personnel and loss of freedom related to hospitalization were continued barriers to care before and after implementation of this program

Use of ICD-10 codes for identification of injection drug use-associated infective endocarditis is nonspecific and obscures critical findings on impact of medications for opioid use disorder

Background: No International Classification of Diseases, 10th revision (ICD-10), diagnosis code exists for injection drug use-associated infective endocarditis (IDU-IE). Instead, public health researchers regularly use combinations of nonspecific ICD-10 codes to identify IDU-IE; however, the accuracy of these codes has not been evaluated. Methods: We compared commonly used ICD-10 diagnosis codes for IDU-IE with a prospectively collected patient cohort diagnosed with IDU-IE at Barnes-Jewish Hospital to determine the accuracy of ICD-10 diagnosis codes used in IDU-IE research. Results: ICD-10 diagnosis codes historically used to identify IDU-IE were inaccurate, missing 36.0% and misclassifying 56.4% of patients prospectively identified in this cohort. Use of these nonspecific ICD-10 diagnosis codes resulted in substantial biases against the benefit of medications for opioid use disorder (MOUD) with relation to both AMA discharge and all-cause mortality. Specifically, when data from all patients with ICD-10 code combinations suggestive of IDU-IE were used, MOUD was associated with an increased risk of AMA discharge (relative risk [RR], 1.12; 95% CI, 0.48-2.64). In contrast, when only patients confirmed by chart review as having IDU-IE were analyzed, MOUD was protective (RR, 0.49; 95% CI, 0.19-1.22). Use of MOUD was associated with a protective effect in time to all-cause mortality in Kaplan-Meier analysis only when confirmed IDU-IE cases were analyzed ( Conclusions: Studies using nonspecific ICD-10 diagnosis codes for IDU-IE should be interpreted with caution. In the setting of an ongoing overdose crisis and a syndemic of infectious complications, a specific ICD-10 diagnosis code for IDU-IE is urgently needed

Value of packaged testing for sexually transmitted infections for persons who inject drugs hospitalized with serious injection-related infections

Background: Persons who inject drugs (PWID) are frequently admitted for serious injection-related infections (SIRIs). PWID are also at risk for sexually transmitted infections (STIs). Methods: We conducted a multicenter quality improvement project at 3 hospitals in Missouri. PWID with SIRI who received an infectious diseases consultation were prospectively identified and placed into an electronic database as part of a Centers for Disease Control and Prevention-funded quality improvement project. Baseline data were collected from 8/1/2019 to 1/30/2020. During the intervention period (2/1/2020-2/28/2021), infectious diseases physicians caring for patients received 2 interventions: (1) email reminders of best practice screening for HIV, viral hepatitis, and STIs; (2) access to a customized EPIC SmartPhrase that included checkboxes of orders to include in assessment and plan of consultation notes. STI screening rates were compared before and after the intervention. We then calculated odds ratios to evaluate for risk factors for STIs in the cohort. Results: Three hundred ninety-four unique patients were included in the cohort. Initial screening rates were highest for hepatitis C (88%), followed by HIV (86%). The bundled intervention improved screening rates for all conditions and substantially improved screening rates for gonorrhea, chlamydia, and syphilis (30% vs 51%, 30% vs 51%, and 39 vs 60%, respectively; Conclusions: PWID admitted for SIRI frequently have unrecognized STIs. Our bundled intervention improved STI screening rates, but additional interventions are needed to optimize screening

Patients with serious injection drug use-related infections who experience patient-directed discharges on oral antibiotics have high rates of antibiotic adherence but require multidisciplinary outpatient support for retention in care

Background: Persons who inject drugs (PWID) are frequently admitted for serious injection-related infections (SIRIs). Outcomes and adherence to oral antibiotics for PWID with patient-directed discharge (PDD) remain understudied. Methods: We conducted a prospective multicenter bundled quality improvement project of PWID with SIRI at 3 hospitals in Missouri. All PWID with SIRI were offered multidisciplinary care while inpatient, including the option of addiction medicine consultation and medications for opioid use disorder (MOUD). All patients were offered oral antibiotics in the event of a PDD either at discharge or immediately after discharge through an infectious diseases telemedicine clinic. Additional support services included health coaches, a therapist, a case manager, free clinic follow-up, and medications in an outpatient bridge program. Patient demographics, comorbidities, 90-day readmissions, and substance use disorder clinic follow-up were compared between PWID with PDD on oral antibiotics and those who completed intravenous (IV) antibiotics using an as-treated approach. Results: Of 166 PWID with SIRI, 61 completed IV antibiotics inpatient (37%), while 105 had a PDD on oral antibiotics (63%). There was no significant difference in 90-day readmission rates between groups ( Conclusions: PWID with SIRI who experience a PDD should be provided with oral antibiotics. Multidisciplinary outpatient support services are needed for PWID with PDD on oral antibiotics

Harm reduction: A missing piece to the holistic care of patients who inject drugs

BACKGROUND: The rise in injection drug use (IDU) has led to an increase in drug-related infections. Harm reduction is an important strategy for preventing infections among people who inject drugs (PWID). We attempted to evaluate the harm reduction counseling that infectious diseases physicians provide to PWID presenting with infections. METHODS: An electronic survey was distributed to physician members of the Emerging Infections Network to inquire about practices used when caring for patients with IDU-related infections. RESULTS: In total, 534 ID physicians responded to the survey. Of those, 375 (70%) reported routinely caring for PWID. Most respondents report screening for human immunodeficiency virus (HIV) and viral hepatitis (98%) and discussing the risk of these infections (87%); 63% prescribe immunization against viral hepatitis, and 45% discuss HIV preexposure prophylaxis (PrEP). However, 55% of respondents (n = 205) reported not counseling patients on safer injection strategies. Common reasons for not counseling included limited time and a desire to emphasize antibiotic therapy/medical issues (62%), lack of training (55%), and believing that it would be better addressed by other services (47%). Among respondents who reported counseling PWID, most recommended abstinence from IDU (72%), handwashing and skin cleansing before injection (62%), and safe disposal of needles/drug equipment used before admission (54%). CONCLUSIONS: Almost all ID physicians report screening PWID for HIV and viral hepatitis and discussing the risks of these infections. Despite frequently encountering PWID, fewer than half of ID physicians provide safer injection advice. Opportunities exist to standardize harm reduction education, emphasizing safer injection practices in conjunction with other strategies to prevent infections (eg, HIV PrEP or hepatitis A virus/hepatitis B virus vaccination)