Perspectives on Diagnosis and Management of All-Cause Encephalitis: A National Survey of Adult Infectious Diseases Physicians

Background

Encephalitis is widely recognized as a challenging condition to diagnose and manage. The care of patients with encephalitis typically involves multiple disciplines, including neurologists and infectious disease (ID) physicians. Our objective was to describe the perspectives and needs of ID physicians regarding encephalitis, using a cross-sectional questionnaire survey.

Methods

We performed a survey among physician members of the Infectious Diseases Society of America's (IDSA) Emerging Infections Network (EIN).

Results

Response rate was 33% (480 among 1472 active EIN physician members). More than 75% of respondents reported caring for patients with suspected encephalitis. Although one-third were involved in the care of multiple patients with autoimmune encephalitis (AE) annually, comfort in diagnosing and managing encephalitis, and in particular AE, was low. Experience with advanced diagnostic tools was variable, as were approaches toward deployment of such tools. Respondents noted that training could be improved by incorporating a multidisciplinary approach taking advantage of online and virtual platforms. ID physicians report a heavy reliance on the 2008 IDSA guidelines for the management of encephalitis, and indicated strong support for a formal update.

Conclusions

ID physicians play an important role in the diagnosis and management of all-cause encephalitis. Despite exposure to AE, few ID physicians are comfortable in recognizing, diagnosing, and treating AE. Moreover, comfort with and use of advanced diagnostic tools for infectious encephalitis was highly variable. Training in encephalitis should include a focus on use and stewardship of advanced diagnostic tools and on collaborative approaches with neurologists and other practitioners on mechanisms and clinical presentations of AE. There is a need for a formal update of 2008 guidelines on the management of encephalitis.

Assessing Pathogen Transmission Opportunities: Variation in Nursing Home Staff-Resident Interactions

OBJECTIVES

The Centers for Disease Control and Prevention (CDC) recommends implementing Enhanced Barrier Precautions (EBP) for all nursing home (NH) residents known to be colonized with targeted multidrug-resistant organisms (MDROs), wounds, or medical devices. Differences in health care personnel (HCP) and resident interactions between units may affect risk of acquiring and transmitting MDROs, affecting EBP implementation. We studied HCP-resident interactions across a variety of NHs to characterize MDRO transmission opportunities.

DESIGN

2 cross-sectional visits.

SETTING AND PARTICIPANTS

Four CDC Epicenter sites and CDC Emerging Infection Program sites in 7 states recruited NHs with a mix of unit care types (≥30 beds or ≥2 units). HCP were observed providing resident care.

METHODS

Room-based observations and HCP interviews assessed HCP-resident interactions, care type provided, and equipment use. Observations and interviews were conducted for 7-8 hours in 3-6-month intervals per unit. Chart reviews collected deidentified resident demographics and MDRO risk factors (eg, indwelling devices, pressure injuries, and antibiotic use).

RESULTS

We recruited 25 NHs (49 units) with no loss to follow-up, conducted 2540 room-based observations (total duration: 405 hours), and 924 HCP interviews. HCP averaged 2.5 interactions per resident per hour (long-term care units) to 3.4 per resident per hour (ventilator care units). Nurses provided care to more residents (n = 12) than certified nursing assistants (CNAs) and respiratory therapists (RTs) (CNA: 9.8 and RT: 9) but nurses performed significantly fewer task types per interaction compared to CNAs (incidence rate ratio (IRR): 0.61, P < .05). Short-stay (IRR: 0.89) and ventilator-capable (IRR: 0.94) units had less varied care compared with long-term care units (P < .05), although HCP visited residents in these units at similar rates.

CONCLUSIONS AND IMPLICATIONS

Resident-HCP interaction rates are similar across NH unit types, differing primarily in types of care provided. Current and future interventions such as EBP, care bundling, or targeted infection prevention education should consider unit-specific HCP-resident interaction patterns.

Abstract P301: The Proportion Of Physician Notes Addressing Elevated Blood Pressures Varies Dramatically Across Internal Medicine Specialties

Introduction: Approximately 20% of U.S. adults are unaware that they have a diagnosis of hypertension (HTN). Of those diagnosed, almost half are uncontrolled. This study provides a potential explanation of these care gaps: providers whose specialization does not include cardiovascular disease rarely document HTN, even when the patient has markedly elevated blood pressures (BPs) during their visit.

Methods: We randomly sampled ten thousand patients with clinic visits after Jan 1, 2017.We then selected notes from only these visits with patient BPs above 140/90. The assessment and plans (A/Ps) of these notes were searched for words related to elevated BP or HTN. A/Ps with no mention of BP or HTN were considered not to have addressed hypertension. Results were grouped by the specialties listed in the figure.

Results: We found 5674 clinic visits with associated BPs above 140/90. A/Ps from nephrology, cardiology, and general internal medicine visits mentioned elevated BP at least 50% of the time (in 55 of 77, 206 of 366, and 251 of 438 encounters, respectively). In contrast, A/Ps from encounters with allergy/immunology, endocrinology, and rheumatology specialists referenced the patient’s BP less than 10% of the time (in 3 of 52, 0 of 15, and 10 of 124 encounters, respectively. See figure).

Discussion: Our results suggest specialties focused on the management of HTN are substantially more likely to address elevated BP in their documentation. However, there appears to be room for improvements in documentation across all specialties. Future studies will measure the impact of these missed opportunities on the diagnosis and management of HTN.

Positive Predictive Values of 2 Algorithms for Identifying Patients with Intravenous Drug Use-Associated Endocarditis Using Administrative Data

Background

Prior studies have used International Classification of Disease (ICD) diagnosis codes in administrative data to identify patients with infective endocarditis (IE) associated with intravenous drug use (IVDU). Little is known about the accuracy of ICD codes for IVDU-IE.

Methods

We used 2 previously described algorithms to identify patients with potential IVDU-IE admitted to 125 Veterans Administration hospitals from January 2010 through December 2018. Algorithm A identified patients with concurrent ICD-9/10 codes for IE and drug use during the same admission. Algorithm B identified patients with drug use coded either during the IE admission or during outpatient or other visits within 6 months of admission. We reviewed 400 randomly selected patient charts to determine the positive predictive value (PPV) of each algorithm for clinical documentation of IE, any drug use, IVDU, and IVDU-IE, respectively.

Results

Algorithm A identified 788 patients, and B identified 1314 patients, a 68% increase. PPVs were high for clinical documentation of diagnoses of IE (86.5% for A and 82.6% for B) and any drug use (99.0% and 96.3%). PPVs were lower for documented IVDU (74.5% and 64.1%) and combined diagnoses of IVDU-IE (65.0% and 55.2%), partly because of a lack of ICD codes specific to IVDU. Among patients identified by algorithm B but not A, 72% had clinical documentation of drug use during the IE admission, indicating a failure of algorithm A to capture cases due to incomplete recording of inpatient ICD codes for drug use.

Conclusions

There is need for improved algorithms for IVDU-IE surveillance during the ongoing opioid epidemic.

Prevalence and Characteristics of Neuroinfectious Disease Inquiries Within the Emerging Infections Network: A 22-Year Retrospective Study

Background

To monitor emerging infectious diseases, the Centers for Disease Control and Prevention and the Infectious Disease Society of America established the Emerging Infections Network (EIN), allowing infectious disease specialists to post inquiries about clinical cases. We describe the frequency and characteristics of neuroinfectious disease-related inquiries.

Methods

The EIN listserv was retrospectively reviewed from February 1997 to December 2019 using search terms associated with neurologic diseases. We recorded case summaries, disease type (ie, meningitis, encephalitis), inquiry type (diagnostic approach, result interpretation, management decisions), unique patient populations, exposures, pathogens, ultimate diagnosis, and change in clinical care based on responses.

Results

Of 2348 total inquiries, 285 (12.1%) related to neuroinfectious diseases. The majority involved meningitis (99, 34.7%) or encephalitis (56, 19.6%). One hundred fifteen inquiries (40%) related to management, 34 (12%) related to diagnostic workup, and 22 (8%) related to result interpretation. Eight (2.8%) specifically involved results of cerebrospinal fluid polymerase chain reaction testing. Sixty-three (22.1%) involved immunosuppressed patients (29 human immunodeficiency virus-positive cases [46%]). The most common pathogens were Treponema pallidum (19, 6.7%) and Cryptococcus neoformans (18, 6.3%). In 74 (25%) inquiries, patients had neurologic symptoms without a clear infection, 38 (51.3%) of which included noninfectious neurologic etiologies in the differential diagnosis.

Conclusions

This study demonstrates the significant challenges of diagnosis and management of neuroinfectious diseases within the field of infectious diseases. It also highlights the importance of curated forums to guide the approach of difficult cases, in particular instances that mimic infectious diseases. Finally, the EIN listserv may assist in identifying areas for research and training to address these complexities.

Diagnosis and Management of Pediatric Influenza in the Era of Rapid Diagnostics

Influenza is a significant cause of childhood morbidity and death; it contributes to up to 16% of hospitalizations for respiratory illnesses worldwide. Novel rapid viral diagnostic tests, including molecular diagnostic tests, have the potential to significantly affect both time to diagnosis and selection of optimal anti-infective therapy. However, little is known about current treatment algorithms used in US hospitals. In this study, for hospitalized children in the United States, we aimed to define the current approaches to influenza diagnosis and treatment and to explore reasons for their potential variation. In this study, we aimed to define the current approaches to pediatric influenza diagnosis and treatment in US hospitals, and to explore reasons for their potential variation. Our results suggest a rise in the availability and use of rapid molecular diagnostic testing in addition to continued variability in anti-infective management, particularly with regard to antiviral use.

Practice Patterns of Providers for the Management of Staphylococcus aureus Bacteremia in Children: Results of an Emerging Infections Network Survey

We conducted a survey of pediatric infectious diseases providers in the Emerging Infections Network regarding the workup and treatment of children with Staphylococcus aureus bacteremia (SAB). We found significant practice variation in the management of children with SAB. These findings emphasize the need for further research to guide best practices.

The Association Between Technology Use and Health Status in a Chronic Obstructive Pulmonary Disease Cohort: Multi-Method Study

Background

Telemedicine and electronic health (eHealth) interventions have been proposed to improve management of chronic obstructive pulmonary disease (COPD) for patients between traditional clinic and hospital visits to reduce complications. However, the effectiveness of such interventions may depend on patients’ comfort with technology.

Objective

The aim was to describe the relationship between patient demographics and COPD disease severity and the use of communication-related technology.

Methods

We administered a structured survey about the use of communication technologies to a cohort of persons in the COPDGene study at one midwestern hospital in the United States. Survey results were combined with clinical and demographic data previously collected as part of the cohort study. A subsample of patients also completed eHealth simulation tasks. We used logistic or linear regression to determine the relationship between patient demographics and COPD disease severity and reported use of communication-related technology and the results from our simulated eHealth-related tasks.

Results

A total of 686 patients completed the survey and 100 participated in the eHealth simulation. Overall, those who reported using communication technology were younger (P=.005) and had higher incomes (P=.03). Men appeared less likely to engage in text messaging (P<.001) than women. Patients who spent more time on tasks in the eHealth simulation had greater odds of a COPD Assessment Test score >10 (P=.02) and walked shorter distances in their 6-minute walk tests (P=.003) than those who took less time.

Conclusions

Older patients, patients with lower incomes, and less healthy patients were less likely to report using communication technology, and they did not perform as well on our simulated eHealth tasks. Thus, eHealth-based interventions may not be as effective in these populations, and additional training in communication technology may be needed.

Survey of diagnostic testing for respiratory syncytial virus (RSV) in adults: Infectious disease physician practices and implications for burden estimates

Respiratory syncytial virus (RSV) often causes respiratory illness in adults. Over 40 RSV vaccine and monoclonal antibody products are currently in preclinical development or clinical trials. Because RSV diagnostic practices may impact disease burden estimates, we investigated infectious disease physicians' RSV diagnostic practices among their adult patients.

Social media engagement analysis of U.S. Federal health agencies on Facebook

BACKGROUND

It is becoming increasingly common for individuals and organizations to use social media platforms such as Facebook. These are being used for a wide variety of purposes including disseminating, discussing and seeking health related information. U.S. Federal health agencies are leveraging these platforms to 'engage' social media users to read, spread, promote and encourage health related discussions. However, different agencies and their communications get varying levels of engagement. In this study we use statistical models to identify factors that associate with engagement.

METHODS

We analyze over 45,000 Facebook posts from 72 Facebook accounts belonging to 24 health agencies. Account usage, user activity, sentiment and content of these posts are studied. We use the hurdle regression model to identify factors associated with the level of engagement and Cox proportional hazards model to identify factors associated with duration of engagement.

RESULTS

In our analysis we find that agencies and accounts vary widely in their usage of social media and activity they generate. Statistical analysis shows, for instance, that Facebook posts with more visual cues such as photos or videos or those which express positive sentiment generate more engagement. We further find that posts on certain topics such as occupation or organizations negatively affect the duration of engagement.

CONCLUSIONS

We present the first comprehensive analyses of engagement with U.S. Federal health agencies on Facebook. In addition, we briefly compare and contrast findings from this study to our earlier study with similar focus but on Twitter to show the robustness of our methods.

Opportunistic infections and biologic therapies in immune-mediated inflammatory diseases: consensus recommendations for infection reporting during clinical trials and postmarketing surveillance

No consensus has previously been formed regarding the types and presentations of infectious pathogens to be considered as ‘opportunistic infections’ (OIs) within the setting of biologic therapy. We systematically reviewed published literature reporting OIs in the setting of biologic therapy for inflammatory diseases. The review sought to describe the OI definitions used within these studies and the types of OIs reported. These findings informed a consensus committee (infectious diseases and rheumatology specialists) in deliberations regarding the development of a candidate list of infections that should be considered as OIs in the setting of biologic therapy. We reviewed 368 clinical trials (randomised controlled/long-term extension), 195 observational studies and numerous case reports/series. Only 11 observational studies defined OIs within their methods; no consistent OI definition was identified across studies. Across all study formats, the most numerous OIs reported were granulomatous infections. The consensus group developed a working definition for OIs as ‘indicator’ infections, defined as specific pathogens or presentations of pathogens that ‘indicate’ the likelihood of an alteration in host immunity in the setting of biologic therapy. Using this framework, consensus was reached upon a list of OIs and case-definitions for their reporting during clinical trials and other studies. Prior studies of OIs in the setting of biologic therapy have used inconsistent definitions. The consensus committee reached agreement upon an OI definition, developed case definitions for reporting of each pathogen, and recommended these be used in future studies to facilitate comparison of infection risk between biologic therapies.

Network position and health care worker infections

We use a newly collected data set coupled with an agent-based model to study the spread of infectious disease in hospitals. We estimate the average and marginal infections created by various worker groups in a hospital as a function of their network position in order to identify groups most crucial in a hospital-based epidemic. Surprisingly, we find that many groups with primary patient care responsibilities play a small role in spreading an infectious disease within our hospital data set. We also demonstrate that the effect of different network positions can be as important as the effect of different transmission rates for some categories of workers.

CaseFinder: A Flexible Real-time Online Surveillance Registry for Infectious Disease Physicians to Report Cases of Carbapenem-resistant Enterobacteriaceae (CRE)

Objective

To create a flexible online surveillance system for infectious disease experts to report cases of emerging infectious diseases.

Introduction

The Infectious Disease Society of America’s Emerging Infections Network (EIN) is a sentinel network of over 1,200 practicing infectious disease physicians, supported by the Centers for Disease Control and Prevention (CDC). In January 2012, the EIN listserv fielded a member inquiry about treatment recommendations for a complicated polymicrobial wound infection in a traveler returning to the United States from India. The posting led to a member-to-member communication that resulted in shipment of clinical microbiology isolates from one member’s hospital to another’s research laboratory. Molecular evaluation of the clinical isolates uncovered previously undetected carriage of the emerging NDM-1 enzyme in 2 of the Enterobacteriaceae species. Based on this interaction, we built a flexible online surveillance registry (CaseFinder) for infectious disease physicians to report cases of CRE.

Methods

To ascertain the frequency and nature of CRE infections treated by EIN members, a survey was sent to EIN members in July 2012 that elicited risk factors and clinical features associated with CRE. Survey opt-out items also allowed respondents to specify that they had not treated any CRE infections. Concurrently, we developed a formal relational data model for CRE infection survey data, allowing for analysis and visualization. The data model was implemented in Python using the Object-Relational Mapping provided by the Django web framework, which we used to implement the backend server component to the online registry. An interactive front-end web application, written in Javascript using the jQuery library, retrieves data via the AJAX web protocol. Geolocated data is visualized using the OpenLayers library to render map tiles and provide interactive controls such as panning and zooming.

Results

The crowd-sourced online registry for infectious disease experts to report CRE infections, called CaseFinder (http://casefinder.org/), was developed, released, and seeded with data from the EIN survey. To date, a total of 69 cases have been submitted, describing 53 infections with Klebsiella pneumoniae, 7 with Escherichia coli and 9 with other Enterobacteriaceae, representing 7 of 9 US Census divisions. Another 214 members have indicated that they have not seen any cases to date. CaseFinder includes: an online data entry component (to supplant the original EIN listserv survey); real-time filtering of data; and interactive maps that geolocate survey responses using the first 2 digits of the treating facility’s zip code. Users can filter data based on species, clinical features (age, gender), resistance profile, or 2-digit zip code. CaseFinder can also display clinical case data in an exportable line-item format.

Conclusions

We have created a web-based data registry for CRE infections in the US. Populated by EIN survey responses, the registry already has a collection 283 data points—69 cases of CRE and 214 reports indicating the absence of cases—and is open for ongoing submission of data represented in real time. This system can serve as a de facto national surveillance system for CRE infections - an important but not yet universally reportable condition. Our platform can be expanded to map and track other emerging infections seen by infectious diseases physicians. We are currently working to incorporate molecular fingerprinting and typing information into the data model. The site will also provide incentives for infectious disease experts to submit cases in underrepresented geographic areas. In future efforts we will incorporate “machine learning” techniques to leverage knowledge from infectious disease experts on existing cases and provide features such as an intelligent automated alert system.

Evaluation of the knowledge-sharing social network of hospital-based infection preventionists in Kentucky

BACKGROUND

The role of the infection preventionist (IP) has become increasingly complex, underscoring the need for rapid mechanisms of knowledge acquisition. One mechanism for knowledge acquisition is knowledge-sharing through social networks. In a state such as Kentucky with predominantly rural health care facilities, an optimal knowledge-sharing network is critical; however, descriptions of these networks are absent from the literature. The objective of this study was to evaluate the knowledge-sharing networks of hospital-based IPs in Kentucky.

METHODS

A survey was sent to all hospital-based IPs in Kentucky in November 2010. Density and component analyses were used to evaluate network cohesion, and centrality statistics and key player algorithms were used to identify IPs important to the network.

RESULTS

A total of 75 (58%) IPs completed the survey. The network density was 1.8%. Three components were identified. The median (range) centrality measures were as follows: in-degree, 2 (0-11); out-degree, 0.5 (0-5); betweenness, 0 (0-567); and eigenvector 0.02 (0-0.45). Three key players were identified.

CONCLUSIONS

Low network statistics indicate that the knowledge-sharing network of hospital-based IPs might not be adequate for efficient knowledge-sharing. Interventions to increase the density of the network and reduce the number of components are needed.

Current practice in Staphylococcus aureus screening and decolonization

We surveyed infectious disease physicians to determine their preoperative Staphylococcus aureus screening and decolonization practices. Sixty percent reported preoperative screening for S. aureus. However, specific screening and decolonization practices are highly variable, are focused almost exclusively on methicillin-resistant S. aureus, and do not include testing for mupirocin or chlorhexidine resistance.