161. Assessing Trends in 1,3-β-D Glucan and Aspergillus Galactomannan Antigen Ordering to Improve Use

Background

1,3-β-D Glucan (BDG) and Aspergillus galactomannan antigen (GM) are commonly ordered. Overutilization of these tests increases the incidence of false positive results, potentially leading to unnecessary follow up testing, procedures, and treatment. The aim of this quality improvement (QI) study was to improve our understanding of BDG and GM utilization at our institution.

Methods

The test orders for BDG and GM were modified within our electronic medical record (EMR) to provide education and require selection of ordering reason from a list of criteria. Educational sessions were provided to non-transplant provider groups who order BDG and GM frequently. Total number of tests, test results, patient immunosuppressed status, ordering location, and provider specialty were compared for a 3-month period pre/post intervention. Ordering criteria was collected post-intervention. SPSS software was used for chi square tests comparing groups.

Results

BDG and GM ordering practices were compared in the pre- and post-intervention timeframes (Table 1). There were no significant differences in the total number of tests, immune status of patients, ordering location or test results for BDG or GM. A significant decrease in hospitalist ordering was found (n=79 (pre), n=48 (post), p=0.006). Positive GM tests were rare in both periods (1.96%, 6/306 and 3.34%, 10/299). Ordering criteria for both tests were also evaluated in the post-intervention period (Table 2). The most common ordering criteria selected for BDG and GM were disseminated fungal infection 275/435 (63%) and invasive aspergillosis 241/299 (81%), respectively.

Conclusion

Most BDG and GM tests were ordered utilizing appropriate ordering criteria and were among immunosuppressed patients. However, selection of an appropriate reason does not necessarily correlate to obtaining in the appropriate clinical setting. This QI project improved our understanding of how BDG and GM are utilized, and by whom. In the future, these results will be used to provide more targeted education to specific provider groups. In addition, further EMR order entry modifications will focus on potential false positive results to further optimize BDG and GM test utilization.

Disclosures

All Authors: No reported disclosures.

Effectiveness of a "Suppression Bundle" to improve HIV virologic suppression in an outpatient infectious disease clinic: a pilot implementation study

Despite effectiveness and accessibility of combined anti-retroviral therapy (cART), only 85% of people living with HIV (PLHIV) in the United States are virologically suppressed. Improving suppression is complex. Our objective was to consider unique factors in PLHIV with non-suppressed viral loads in clinic and improve the percentage of suppressed patients by implementing a "Suppression Bundle" consisting of three to five bundled interventions with the goal of improved suppression. Prior to the study, there were 567 HIV-positive patients receiving care in clinic. Of those, 89 had a measurable viral load (>40 copies/mL). In this pilot pre-post implementation, we focused on the 89 non-suppressed patients to (1) determine feasibility of implementing bundles and (2) increase the number of patients with suppressed viral loads pre- to post-intervention. Of non-suppressed patients, 65 were active in care immediately pre-intervention and participated in the pilot. At the completion of the 9-month intervention, 46 had viral loads <40 copies/mL, demonstrating substantial improvement with 70.1% of the previously non-suppressed patients achieving suppression. By considering unique patient factors, an individualized Suppression Bundle is acceptable, feasible, and may increase virally suppressed patients in an outpatient clinic. Next steps include determining whether suppression bundles can be implemented in differing practices.

66. Improving Antimicrobial Stewardship through Allergy Testing Referrals

Background

Penicillins and cephalosporins (PCN/CEPH) are considered first-line antibiotics for numerous infections for their efficacy, tolerability, and cost effectiveness. Unfortunately, their use may be precluded in approximately 10% of the general adult population who self-report ‘allergy’. As a result, suboptimal antimicrobials are substituted which may increase toxicities, length of hospitalizations, and antimicrobial resistance with subsequent expense and morbidity. Multiple organizations endorse beta-lactam allergy skin testing (BLAST) as an essential component of antimicrobial stewardship programs.^.In an attempt to better describe this patient population as well as to protocolize and improve rates of referral to allergy/immunology clinic, a quality initiative was undertaken at our institution.

Methods

Adult inpatients for whom an infectious disease consult was placed over a 6-month period were chart-reviewed for PCN/CEPH allergy. Inappropriately charted allergies were reconciled and patients were recommended referral to allergy/immunology for formal evaluation with BLAST when appropriate. Referrals were placed for agreeable patients who were then evaluated for appropriateness through history and then scheduled for BLAST. Patients who tolerated oral exposures without adverse effects had the allergy removed from their chart and were educated.

Results

322 patients met inclusion criteria for allergy referral. Of those, 103 agreed to further evaluation, and referrals were placed for 100%. Unfortunately, 7 patients died before referrals could be completed, and 88 referred patients did not complete BLAST for other reasons. In total 8 patients completed BLAST, and allergy was de-labeled in 75% (N= 6) of those cases.

Conclusion

Our data indicated similar prevalence of reported PCN/CEPH allergy between our institution and the general population. We achieved our aim of improving allergy referral rates among this population, however there was a high rate of attrition in the transitions of care. Qualitative review of selected patients highlights common thematic barriers including the COVID-19 pandemic, fiscal concerns, and acuity of condition. Future directions should include BLAST at the point of care or making referrals from the primary care setting.

Disclosures

Lisa A. Clough, MD, Merck (Scientific Research Study Investigator)Merck (Research Grant or Support)ViiV (Scientific Research Study Investigator)

Tuberculosis IRIS: Pathogenesis, Presentation, and Management across the Spectrum of Disease

Antiretroviral therapy (ART), while essential in combatting tuberculosis (TB) and HIV coinfection, is often complicated by the TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). Depending on the TB disease site and treatment status at ART initiation, this immune-mediated worsening of TB pathology can take the form of paradoxical TB-IRIS, unmasking TB-IRIS, or CNS TB-IRIS. Each form of TB-IRIS has unique implications for diagnosis and treatment. Recently published studies have emphasized the importance of neutrophils and T cell subtypes in TB-IRIS pathogenesis, alongside the recognized role of CD4 T cells and macrophages. Research has also refined our prognostic understanding, revealing how the disease can impact lung function. While corticosteroids remain the only trial-supported therapy for prevention and management of TB-IRIS, increasing interest has been given to biologic therapies directly targeting the immune pathology. TB-IRIS, especially its unmasking form, remains incompletely described and more data is needed to validate biomarkers for diagnosis. Management strategies remain suboptimal, especially in the highly morbid central nervous system (CNS) form of the disease, and further trials are necessary to refine treatment. In this review we will summarize the current understanding of the immunopathogenesis, the presentation of TB-IRIS and the evidence for management recommendations.

Methods for rapid diagnosis of meningitis etiology in adults

Infectious meningitis can be caused by viral, bacterial or fungal pathogens. Despite widely available treatments, many types of infectious meningitis are still associated with significant morbidity and mortality. Delay in diagnosis contributes to poor outcomes. Cerebrospinal fluid cultures have been used traditionally but are time intensive and sensitivity is decreased by empiric treatment prior to culture. More rapid techniques such as the cryptococcal lateral flow assay (IMMY), GeneXpert MTB/Rif Ultra (Cepheid) and FilmArray multiplex-PCR (Biofire) are three examples that have drastically changed meningitis diagnostics. This review will discuss a holistic approach to diagnosing bacterial, mycobacterial, viral and fungal meningitis.

Re-drawing the Maps for Endemic Mycoses

Endemic mycoses such as histoplasmosis, coccidioidomycosis, blastomycosis, paracoccidioidomycosis, and talaromycosis are well-known causes of focal and systemic disease within specific geographic areas of known endemicity. However, over the past few decades, there have been increasingly frequent reports of infections due to endemic fungi in areas previously thought to be “non-endemic.” There are numerous potential reasons for this shift such as increased use of immune suppressive medications, improved diagnostic tests, increased disease recognition, and global factors such as migration, increased travel, and climate change. Regardless of the causes, it has become evident that our previous understanding of endemic regions for these fungal diseases needs to evolve. The epidemiology of the newly described Emergomyces is incomplete; our understanding of it continues to evolve. This review will focus on the evidence underlying the established areas of endemicity for these mycoses as well as new data and reports from medical literature that support the re-thinking these geographic boundaries. Updating the endemic fungi maps would inform clinical practice and global surveillance of these diseases.

Afatinib-induced Interstitial Lung Disease Successfully Treated with Corticosteroids: Case Report and Review of the Literature

The first-line treatment for advanced epidermal growth factor receptor (EGFR) mutation positive non-small cell lung cancer (NSCLC) includes the use of afatinib and other EGFR tyrosine kinase inhibitors (EGFR-TKIs). While generally well tolerated, a small subset of patients will develop drug-induced interstitial lung disease (ILD) which could lead to drug discontinuation or even death.

A 58-year-old female with stage IV NSCLC treated with afatinib presented with dyspnea and rapidly progressive hypoxemia. Imaging of the lungs demonstrated ground glass opacities. Infectious workup was unrevealing, and since drug-induced ILD was suspected early on presentation, high dose corticosteroids were initiated leading to clinical improvement.

While the incidence of afatinib-induced ILD is rare, the consequences may be serious and potentially fatal. The presentation is often non-specific and may mimic other common respiratory pathologies making the diagnosis challenging. If therapeutic measures such as corticosteroids are initiated promptly, they can be life-saving.