Journal Club

In this feature, a panel of IDSA members identifies and critiques important new studies in the current literature that have a significant impact on the practice of infectious diseases medicine

• Just What the C-Suite Ordered: An FTE-to-Bed Ratio to Guide ASP Discussions
• Addiction Medicine Consultation for Patients with Opioid Use Disorder Admitted for Infections
• Should Routine HIV PrEP Follow-Up Include HCV Screening?

Click here for the previous edition of Journal Club. For a review of other recent research in the infectious diseases literature, see “In the Literature,”  by Stanley Deresinski, MD, FIDSA, in each issue of Clinical Infectious Diseases.

Just What the C-Suite Ordered: An FTE-to-Bed Ratio to Guide ASP Discussions

Reviewed by Erica Kaufman West, MD

Given the risk of antibiotic resistance, the Centers for Disease Control and Prevention and the Joint Commission have recognized the benefit of antimicrobial stewardship programs (ASPs) and recommend all acute care facilities have one.  However, they do not provide guidelines for how much physician or pharmacist time is needed for a successful program. Interestingly, European guidelines provide concrete full-time equivalent (FTE)-to-bed ratios; direct translation to the U.S. system is difficult. An article published in Clinical Infectious Diseases, drawing on the experiences of U.S. stewardship programs, may help address this issue.

Representatives from IDSA, the Society for Healthcare Epidemiology of America, and the Pediatric Infectious Diseases Society created a survey and distributed it to members of their societies who met certain criteria. They chose only one representative, typically a physician or pharmacist, from each facility. Of 244 respondents, 46 percent practiced stewardship at an academically affiliated hospital and 21 percent did so at major academic centers. A nearly equal number of physicians worked in private practice (29 percent) and academia (28 percent), with 68 percent as employees of health care systems. The more dedicated FTEs a facility had, the more likely they were to offer performance audit and feedback (PAF). The article authors found that PAF was the strongest mediator of ASP success. Two hundred eight programs (85 percent) were able to demonstrate some measure of effectiveness in the last 2 years: 67 percent showed cost savings, 69 percent showed decreased antibiotic utilization, and 20 percent showed a decrease in rates of drug-resistant organisms.

The authors used a multivariate model to show that there was a consistent dose-response relationship between combined FTE and ability to demonstrate effectiveness in any domain. They further recommended concrete numbers for both pharmacist and physician FTE based on hospital bed number. It is helpful to finally have numbers like these to bring to the C-suite table for discussions with executive leadership about resources needed for a successful ASP.

(Doernberg et al. Clin Infect Dis. 2018;67(8):1168–1174.)

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Addiction Medicine Consultation for Patients with Opioid Use Disorder Admitted for Infections

Reviewed by Christopher J. Graber, MD, MPH, FIDSA

The inpatient care of patients with opioid use disorder (OUD) who are admitted for infections often associated with their OUD (e.g., infective endocarditis, osteomyelitis, skin and soft tissue infection) can often be challenging for both patients and providers, particularly when intravenous antibiotic therapy is deemed necessary.  Patients’ opioid cravings and withdrawal symptoms often lead them to leave the inpatient setting against medical advice (AMA). Decisions on intravenous access can be complex, as provision of long-term access has the potential for abuse. As a result, an adversarial relationship between the patient and the treatment team often unfortunately develops.

The development of strategies to manage OUD acutely, particularly medication-assisted therapy (MAT) involving buprenorphine, has been advocated for patients with OUD admitted for infection, but evidence for success in improving infection-related outcomes has been limited.

A brief report recently published in Clinical Infectious Diseases documents outcomes associated with involvement of addiction medicine consultation for patients with OUD admitted for infections at a large academic medical center for whom at least 2 weeks of parenteral antimicrobial therapy was recommended for completion as an inpatient. Thirty-eight of 125 patients received addiction medicine consultation and were similar demographically and clinically from those not receiving addiction medicine consultation except for a higher rate of hepatitis C infection. Patients receiving addiction medicine consultation were 32 times more likely to receive MAT (95 percent confidence interval [CI] 10-81), 5.6 times more likely to complete their course of parenteral antibiotics (95 percent CI 2.3-13), 5.3 times less likely to be discharged AMA or elope (95 percent CI 2.1-13), and 2.6 times less likely to be readmitted within 90 days of discharge (95 percent CI 1.45-4.8).

While these single-center findings deserve confirmation in other care settings, they nonetheless strongly support a holistic multidisciplinary approach that includes the involvement of physicians trained in addiction medicine in the care of patients with OUD admitted for infection.

(Marks et al. Clin Infect Dis. Published online: October 23, 2018.)

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Should Routine HIV PrEP Follow-Up Include HCV Screening?

Reviewed by Manie Beheshti, MD

Recommended hepatitis C virus (HCV) screening practices for patients on preexposure prophylaxis (PrEP) to prevent HIV infection differ slightly. The Centers for Disease Control and Prevention recommends baseline HCV screening and further screening as dictated by HCV risk factors. Guidance from the American Association for the Study of Liver Diseases and IDSA recommends at least annual screening for men who have sex with men (MSM). Classically, sexual transmission of HCV is considered rare. However, since the advent of PrEP, sexual acquisition of HCV in MSM on PrEP has been increasingly noted in the literature.

A recent study published in The Journal of Infectious Diseases reported on the largest number of HCV acquisitions among HIV PrEP users to date. Researchers in New York and San Francisco noted 15 HCV infections (14 primary infections; one re-infection) among HIV-uninfected patients on PrEP. All engaged in receptive anal intercourse and half reported an increase in HCV risk factors, most commonly decreased condom use and an increase in sexual partners. All except two were asymptomatic and were diagnosed during routine laboratory screening: abnormal alanine transaminase or HCV testing.

Though this study is limited by its inability to determine an incidence rate of HCV infection, the possibility of sampling error, and the lack of phylogenetic testing, it adds to the mounting evidence that sexual acquisition of HCV in HIV-uninfected MSM on PrEP is on the rise. The authors strongly recommend that quarterly testing for those on PrEP include HCV screening. While this may not be routine practice, it could be an important addition to our understanding of how to best care for MSM on PrEP to prevent HIV.

(Price et al. J Infect Dis. Published online: November 20, 2018.)

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