Evaluating electronic medical record based screening protocol on hepatitis c screening and linkage to care

Background and Objectives: The Emergency Department (ED) is potentially a high-yield site in health care to reach patients at risk for the hepatitis C virus (HCV) infection, the most common chronic bloodborne pathogen in the United States. Of the 71 million HCV-infected individuals globally in 2017, only an estimated 19% were aware of their positive HCV status. If EDs can identify the infected patients, this is a step toward reducing new hepatitis infections and death due to HCV, goals set by the World Health Organization to be reached by 2030. The primary aim of this project is to determine the effectiveness of upgrading the laboratory infrastructure to enable routine HCV ribonucleic acid (RNA) reflex testing and determine its effect on linking patients to care. Methods: An automated HCV screening protocol was implemented into the EPIC electronic medical record (EMR). The system screens patients born from 1945 through 1965 and/or those with a history of intravenous drug use, two identified risk factors for HCV set by the Center for Disease Control and Prevention. A best practice advisory (BPA) notifies providers to order an HCV antibody (Ab) test for patients with an ordered complete blood count with at least one risk factor. Positive HCV Ab test triggers a second BPA, prompting a HCV RNA test. In January 2019, HCV RNA reflex testing began where the RNA test would be automatically ordered after a positive Ab result. Linkage to care team followed up with patients until they attended their first visit with a qualified provider. The data analysis is inclusive of data obtained between August 2018 and November 2019. Results: HCV Ab tests were performed on 9,704 patients. Prior to RNA reflex implementation, out of the 445 patients who tested positive for HCV Ab, 220 had HCV RNA test performed (49.4%). After the revised protocol, out of 671 patients who tested positive for HCV Ab, 601 had RNA test performed (90%). Before RNA reflex testing was initiated, 66 patients were linked to care versus 126 patients were linked to care after the implementation, an increase of 66%. Conclusion: A significantly higher percentage of patients with positive HCV Ab testing had HCV RNA tests completed after the implementation of routine HCV RNA reflex testing. Connection to care rates also increased. Overall, the utilization of BPA capability of an EMR system may be an invaluable tool in efforts to reduce the prevalence of HCV

Monotherapy with Vancomycin or Daptomycin versus Combination Therapy with β-Lactams in the Treatment of Methicillin-Resistant Staphylococcus Aureus Bloodstream Infections: A Retrospective Cohort Analysis

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections (BSI) are associated with high morbidity and mortality. More in vitro, in vivo, and clinical data suggest that vancomycin (VAN) or daptomycin (DAP) combination therapy with β-lactams (BL) improves outcomes of MRSA infections. We hypothesize that BL combination with VAN or DAP would reduce the odds of clinical failure compared to VAN or DAP monotherapy. METHODS: A retrospective cohort study of adult patients ≥ 18 years treated with VAN or DAP for MRSA BSI from 2006 to 2019 at Detroit Medical Center. Combination therapy (CT) was defined as VAN or DAP plus any BL for ≥ 24 h within 72 h of index culture. Monotherapy (MT) was defined as ≥ 72 h VAN or DAP within 72 h of index culture and no BL for ≥ 24 h up to 7 days following VAN/DAP initiation. Primary outcome was composite endpoint of clinical failure defined as: (1) 30-day mortality, (2) 60-day recurrence, or (3) persistent bacteremia (PB). PB was defined as bacteremia \u3e 5 days. Multivariable logistic regression was used to evaluate the association between CT and the primary outcome. RESULTS: Overall, 597 patients were included in this analysis, 153 in the MT group and 444 in the CT group. CT was independently associated with reduced odds of clinical failure (adjusted odds ratio, 0.523; 95% confidence interval, 0.348-0.787). The composite endpoint was driven by 60-day recurrence and PB but not 30-day mortality. There were no difference in adverse events including nephrotoxicity between the two study arms. CONCLUSIONS: In hospitalized adults with MRSA BSI, CT with any BL was independently associated with improved clinical outcomes and may ultimately be selected as preferred therapy

Multicenter Observational Study of Ceftaroline Fosamil for Methicillin-Resistant Staphylococcus aureus Bloodstream Infections

Novel therapies for methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infection (BSI) are needed in the setting of reduced antibiotic susceptibilities and therapeutic failure. Ceftaroline is a cephalosporin antibiotic with MRSA activity. Although not FDA approved for MRSA BSI, ceftaroline has generated much interest as a potential treatment option. However, detailed descriptions of its use in this setting remain limited. To address this, we conducted a retrospective, multicenter, observational study of adult patients with MRSA BSI treated with at least 72 h of ceftaroline from 2011 to 2015. Safety outcomes were examined in the overall cohort, while efficacy outcomes were examined among patients who had not cleared their BSI prior to ceftaroline initiation. Data were also stratified by ceftaroline monotherapy or combination therapy. Predictors of clinical failure on ceftaroline treatment were also sought. Overall, 211 patients were included in the safety population; Clostridium difficile infection, rash, and neutropenia occurred in 6 patients (2.8%), 7 patients (3.3%), and 3 patients (1.4%), respectively. Clinical success was observed in 86 (68.3%) of the 126 patients included in the efficacy population. The monotherapy and combination therapy subgroups had similar proportions of patients experiencing success (69.7 and 64.9%, respectively). The median BSI durations post-ceftaroline treatment were 2 days (interquartile range, 1 to 4 days) for monotherapy and 3 days (interquartile range, 1.5 to 5 days) for combination therapy. Higher acute physiology and chronic health evaluation II scores and comorbid malignancy independently predicted treatment failure. Ceftaroline appears effective for MRSA BSI as both monotherapy and combination therapy. However, comparative studies are needed to further delineate the role of ceftaroline in MRSA BSI treatment

Daptomycin plus beta-lactam combination therapy for methicillin-resistant Staphylococcus aureus bloodstream infections: a retrospective, comparative cohort study

BACKGROUND: Mounting evidence suggests the addition of a beta-lactam (BL) to daptomycin (DAP) results in synergistic in vitro activity against methicillin-resistant Staphylococcus aureus (MRSA) and bolsters the innate immune response to infection. The objective of this study was to provide clinical translation to this experimental data and determine if DAP+BL combination therapy results in improved clinical outcomes compared to treatment with DAP alone in patients with MRSA bloodstream infections (BSI). METHODS: This was a retrospective, comparative cohort study conducted at two academic medical centers between 2008 and 2018. Adults with MRSA BSI treated with DAP for ≥72 hours and initiated within five days of culture collection were included. Patients who received a BL for ≥24 hours and initiated within 24 hours of DAP comprised the DAP+BL group. The primary outcome was composite clinical failure (60-day all-cause mortality and/or 60-day recurrence). Analyses were adjusted for confounding using inverse probability of treatment weighting (IPTW). RESULTS: A total of 229 patients were included (72 DAP+BL and 157 DAP). In unadjusted and IPTW-adjusted analyses, DAP+BL was associated with significantly reduced odds of clinical failure (OR 0.362, 95% CI 0.164, 0.801; aOR 0.386, 95% CI 0.175, 0.853). Adjusted analyses restricted to pre-specified subgroups based on infection complexity and baseline health status, were consistent with the main analysis. CONCLUSIONS: The addition of a BL to DAP was associated with improved clinical outcomes in patients with MRSA BSI. This study provides support to ongoing and future studies evaluating the impact of combination therapy for invasive MRSA infections

Hepatitis C Virus Reflex Testing Protocol in an Emergency Department

Introduction: Our aim was to measure hepatitis C virus (HCV) screening and linkage-to-care rates in an urban emergency department (ED) before and after implementing an HCV viral RNA (vRNA) reflex testing protocol within a HCV screening program for at-risk patients. Our hypothesis was that using a reflex testing protocol would increase HCV testing rates of at-risk patients in the ED, which would increase the linkage-to-care rate. Methods: In August 2018, our institution implemented an automated, electronic health record-based HCV screening protocol in the ED for at-risk patients. In January 2019, we implemented an HCV vRNA reflex testing protocol (reflex testing) for all positive HCV antibody (Ab) tests that were initiated through the screening protocol. We compared completion rates of HCV vRNA testing and the rate of linkage to care for patients with positive HCV Ab test results before and after implementation of reflex testing (five months per study period). Results: Prior to reflex testing implementation, 233/425 (55%) patients with a positive HCV Ab test had an HCV vRNA test performed, whereas 270/323 (84%) patients with a positive HCV Ab test result had vRNA testing after reflex testing implementation (odds ratio [OR], 4.2; 95% confidence interval (CI): 3.0-6.0; P < 0.001). Of the eligible patients with positive HCV Ab test results who could be linked to care, 45 (10.6%) were linked to care before HCV reflex implementation and 46 (14.2%) were linked to care with reflex testing (OR, 1.4; 95% CI: 0.9-2.2; P = 0.13). Conclusion: Implementing a reflex testing initiative into an HCV screening program in the ED can result in an increase of the percentage of patients who receive an HCV vRNA test after having had a positive HCV Ab. Hepatitis C virus vRNA reflex testing was not associated with a statistically significant increase in linkage-to-care rates for HCV Ab-positive patients; however, further studies are required