Background There has been an explosion of commentary and discussion about the ethics and utility of using artificial intelligence in medicine, and its practical use in medical education is still being debated. Through qualitative research methods, this study aims to highlight the advantages and pitfalls of using ChatGPT in the development of clinical reasoning cases for medical student education. Methods Five highly experienced faculty in medical education were provided instructions to create unique clinical reasoning cases for three different chief concerns using ChatGPT 3.0. Faculty were then asked to reflect on and review the created cases. Finally, a focus group was conducted to further analyze and describe their experiences with the new technology. Results Overall, faculty found the use of ChatGPT in the development of clinical reasoning cases easy to use but difficult to get to certain objectives and largely incapable of being creative enough to create complexity for student use without heavy editing. The created cases did provide a helpful starting point and were extremely efficient; however, faculty did experience some medical inaccuracies and fact fabrication. Conclusion There is value to using ChatGPT to develop curricular content, especially for clinical reasoning cases, but it needs to be comprehensively reviewed and verified. To efficiently and effectively utilize the tool, educators will need to develop a framework that can be easily translatable into simple prompts that ChatGPT can understand. Future work will need to strongly consider the risks of recirculating biases and misinformation.

The Mpox virus (previously termed monkeypox) was a relatively obscure zoonotic infection mainly confined to West and Central Africa with the notable exception of a 2003 outbreak in the United States associated with exotic pets. In the summer of 2022, however, the United States experienced an unexpected and unprecedented surge in cases with a markedly different clinical presentation. This epidemic appeared to be driven by close/intimate contact and evidenced a more varied clinical presentation easily confused with common sexually transmitted infections.1 While still navigating the COVID-19 pandemic, public health services launched education campaigns designed to raise awareness and mitigate risks of infection, educate the public and medical community on modes of transmission and the new clinical presentations, and minimize stigma. These education campaigns did influence behavior changes in some members of high-risk communities that led to decreased infections.2 The other major intervention was the release of the JYNNEOS vaccine, which has proven to lower the risk of Mpox infection.3 This vaccination campaign was launched at a time of decreased vaccine confidence4 stemming in part from the continued politicization of the COVID-19 vaccination recommendations. The success of the Mpox vaccine campaign is thus even more impressive and deserving of study to potentially provide a roadmap of combating vaccine hesitancy. “Mpox knowledge and vaccine willingness among a representative analysis of adults in Pennsylvania” in the issue uses a broad-ranging survey to examine Pennsylvania residents' knowledge of Mpox, perception of risk, and willingness to accept vaccine. The survey was conducted in September 2022 reflecting a period after the intensive education campaigns began. Less than 15% of the 1039 survey participants reported no knowledge of Mpox symptoms or transmission modalities reflecting wide penetrance of the education initiatives. The knowledge did appear more basic and the authors point out lacing a “nuanced understanding specific to the current outbreak.”5 Although the majority of survey participants considered themselves to be at low or no risk, those who did perceive increased risk were significantly more likely to plan to accept vaccine. Men who have sex with men comprised 7.2% of the respondents, well represented across age groups, and were more likely to have Mpox awareness/knowledge and acceptance of vaccination. These findings are consistent with the Centers for Disease Control and Prevention's Monkeypox State of Vaccine Confidence Report6 and represent a “dose-response” relationship between perception of Mpox risk and acceptance of vaccine.5 A finding that bears more study involves the health disparities in vaccination rates. Black and Hispanic populations were disproportionally affected in this epidemic yet received relatively fewer vaccines, even in high-risk groups such as those with a recent sexually transmitted infection.7–9 Pinto et al showed Black, non-Hispanic respondents were more likely to report wiliness to vaccinate. This argues against vaccine hesitancy as a reason for undervaccination and should be understood as a call to investigate hidden sources of bias decreasing vaccine rates. To date, the United States has experienced 31,010 cases and 55 deaths due to Mpox.10 Although cases have dropped, there remains a risk of resurgence of this infection. The willingness and ability to receive Mpox vaccine will be a significant modifier of future outbreaks. These data may also be generalizable to other instances of vaccine hesitancy and can further the investigations in health disparities.

Introduction: Initiation of broad-spectrum empiric antibiotics is common when infection is suspected in hospitalized adults. The benefits of early utilization of effective antibiotics are well documented. However, the negative effects of inappropriate antibiotic use have led to antimicrobial stewardship mandates. Recent data demonstrate the utility of methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) nasal screening to steward anti-MRSA empiric antibiotics in pneumonia. We hypothesize that MRSA PCR nasal swabs would also be effective to rule out other MRSA infection to effectively limit unnecessary antibiotics for any infectious source.Methods: We performed a single-center retrospective chart review of all adult patient en-counters from October 2019-July 2021 with MRSA PCR nasal testing. We then reviewed all charts to evaluate for the presence of infections based on source cultures results, as the gold standard. Sensitivity, specificity, negative predictive value, and positive predictive value were calculated from 2 x 2 contingency tables.Results: Among all patients with MRSA nasal screening, 1189 patients had any infection. Prevalence of MRSA nasal carriage among patients screened was 12%. Prevalence of MRSA infection among all infections was 7.5%. MRSA nasal swabs demonstrated a negative predictive value of 100% for MRSA urinary tract infection, 97.9% for MRSA bacteremia, 97.8% for MRSA pneumonia, 92.1% for MRSA wound infection, and 96.6% for other MRSA infections. Overall, MRSA PCR nasal swabs had a sensitivity of 68.5%, specificity of 90.1%, positive predictive value of 23.7%, and negative predictive value of 98.5% for any infections.Conclusions: MRSA PCR nasal swabs have a high negative predictive value for all infections. Our data support the use of MRSA PCR nasal swabs to rule out MRSA infection and thereby allow early de-escalation of MRSA coverage in hospitalized patients requiring empiric antibiotics. Implementation of MRSA screening could decrease antibiotic-associated morbidity, resistance, and costs. More studies should be conducted to validate these re-sults and support these findings. 2022 Elsevier Inc. All rights reserved.

Abstract Background Early in the COVID-19 pandemic, tenofovir (TAF/TDF) was identified as a potential agent for SARS-CoV-2 due to binding to RNA-dependent RNA polymerase similarly to remdesivir. This led to the hypothesis that TAF/TDF may be lessening the severity and improving outcomes of COVID-19 infection. COVID-19 Severity COVID-19 Infection Outcomes Methods Patients were identified by searching for HIV infection and SARS-CoV2 PCR testing. Type of antiretroviral therapy (ART), CD4+ cell count, HIV viral load (VL), comorbidities, presenting symptoms, severity of COVID infection, and outcomes were analyzed. COVID disease was classified as mild, moderate, severe, or critical based on World Health Organization criteria. We primarily sought to determine the effect of TAF/TDF on the severity of COVID infection. The secondary endpoint was to determine the effect of low CD4 count and HIV VL on the severity of infection. Results 39 HIV+ patients were tested at least once for SARS-CoV2 by PCR at VA NJ Health Care System. 18 of 39 patients were PCR positive. In those, common presenting symptoms included: fever (15/18), cough (7/18), and lethargy/fatigue (6/18). 16 of the 39 HIV+ patients’ ART included TAF/TDF; 8 of 18 COVID+ and 8 of 21 COVID-. In the COVID- group, 2 patients had CD4 count < 200 cells/mm3, 3 patients had HIV VL >200, and 19 of 21 had at least 1 comorbidity. In the COVID+ group, 3 had CD4 count < 200 cells/mm3, none had detectible HIV viremia, and all but one had comorbidities. Of COVID+ infections, 7 were mild, 3 moderate, 8 severe, and 5 patients died. 4 of the 5 patients that did not survive were in non-TAF/TDF group. All 3 patients with CD4 count < 200 cells/mm3 had severe disease. 6 out of 8 patients developed mild disease in TAF/TDF group vs. 1 out of 10 patients in non-TAF/TDF group. 1 out of 8 and 7 out of 10 patients had severe or critical disease in TAF/TDF vs non-TAF/TDF groups respectively. Conclusion In this sample of 18 HIV+ patients with COVID-19 infection, patients receiving TAF/TDF were more likely to develop mild disease and have full recovery than those who were on TAF/TDF-free regimens (75% vs. 10% and 87.5% vs. 50%, respectively). Patients not on TAF/TDF-based regimens had a higher rate of developing severe and critical COVID-19 disease (40% vs. 0% and 30% vs. 12.5%, respectively). Disclosures All Authors: No reported disclosures

INTRODUCTION:Antibiotic-resistant infections have become increasingly prevalent nowadays. As a result, it is essential to examine the key socioeconomic and political factors which contribute to the rise in the prevalence of antibiotic resistance in developing and developed nations. This study aims to identify the various contributors to the development of antibiotic resistance in each type of nation. METHODS:PUBMED was used to identify primary research, systematic reviews, and narrative reviews published before Jan 2017. Search terms included antibiotic resistance, antimicrobial resistance, superbugs, multidrug-resistant organisms, developing countries, developed countries. Publications from different countries were included to ensure generalizability. Publications were excluded if they didn't mention factors causing resistance, focused on the molecular basis of resistance, or if they were case reports. Publicly available reports from national and international health agencies were used. RESULTS:In developing countries, key contributors identified included: (1) Lack of surveillance of resistance development, (2) poor quality of available antibiotics, (3) clinical misuse, and (4) ease of availability of antibiotics. In developed countries, poor hospital-level regulation and excessive antibiotic use in food-producing animals play a major role in leading to antibiotic resistance. Finally, research on novel antibiotics is slow ing down due to the lack of economic incentives for antibiotic research. CONCLUSION:Overall, multiple factors, which are distinct for developing and developed countries, contribute to the increase in the prevalence of antibiotic resistance globally. The results highlight the need to improve the regulatory framework for antibiotic use and research globally.

To the Editor: A 46-year-old man with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (CD4 unknown at presentation); hepatitis C; cocaine, tobacco, and alcohol use; genital herpes; and recent pulmonary embolism presented to the hospital with 3 months of progressively worsening ataxia and visual changes, with frequent associated falls but no syncopal episodes. He also noted several recent episodes where friends told him that he was speaking oddly, articulating proper words but not making grammatical sense. Lastly, he complained of 3 weeks of dysuria but denied neck stiffness, photophobia, nausea, vomiting, parasthesias, fever, chills, chest pain, or palpitations. A headache was intermittently endorsed and denied by the patient to different members of the primary and consulting teams, but it was not a reason that led to his presentation at the hospital. Human immunodeficiency virus was diagnosed approximately 7 years before presentation, and he was being managed on fixed dose combination of efavirenz/emtricitabine/tenofovir. However, he had not taken the medication for several months. He was alert and oriented to person, place, and time. He was afebrile at 37.1°C with stable vital signs. Mini-Mental Status Examination score was 19/30. He had a slow, wide-based, ataxic gait, difficulty with tandem walk, a positive Romberg sign, impairment in rapid alternating movements, mild dysmetria with heel-to-shin testing, and spasticity of the right leg. Nuchal rigidity was absent. Ophthalmologic examination revealed an old, inactive, left chorioretinal scar but no evidence of HIV retinopathy (eye examination was done by a consult team at a later point during the admission). Laboratory studies were obtained (Table 1).TABLE 1: Relevant Laboratory DataComputed tomography scan found extensive foci of low attenuation in the periventricular and subcortical white matter, as well as in the lentiform nucleus. Magnetic resonance imaging was obtained to further evaluate these findings, revealing extensive nonspecific white matter changes, 3 areas of acute punctate infarction, multiple nodular deposits of contrast along the cortical surface of the cerebrum, and contrast enhancement of the right thalamus that was consistent with a subacute or chronic infarction. Given these nonspecific findings, lumbar puncture was pursued. Opening pressure was 17 cm H2O, and cerebrospinal fluid analysis was consistent with fungal meningitis (Table 1). Cryptococcal antigen titer was 1:512, and cultures grew Cryptococcus neoformans. Induction therapy with liposomal amphotericin B and flucytosine was started, although flucytosine was discontinued owing to worsening thrombocytopenia. He was later transitioned to maintenance therapy with fluconazole. He was doing well postdischarge with improvement of his gait, and he transitioned his care to an outpatient physician. Cryptococcal meningitis is a significant cause of meningitis in populations with a high burden of HIV and is a leading fungal cause of illness and death worldwide.1 It has a significant neurotropism1,2 and classically presents with the neurological findings of altered mental status and headache with associated fever, nausea, and vomiting in a subacute fashion.1,3 However, it can present in various ways given that not all clinical signs are reliably present in those with HIV and diminished inflammatory responses.4 Immune defense against Cryptococcus requires cell-mediated immunity, and the absence of this response allows for dissemination.4 Our patient represents an atypical case in that he was afebrile with a normal opening pressure on lumbar puncture, and his chief complaint centered around chronic worsening ataxia rather than headache and fever. A study of 230 HIV-positive individuals with cryptococcal meningitis showed headache and fever to be presenting signs and symptoms in 91% of patients, whereas ataxia was not noted in any of those patients.5 Elevated opening pressure is commonly seen in patients with cryptococcal meningitis, contributing to the presenting headache and other symptoms of elevated intracranial pressure such as altered mental status, cranial nerve palsies with resulting diplopia, and seizures.1,3 As a result of this elevated intracranial pressure, repeated lumbar punctures are often required.1 Although our patient did note intermittent visual changes, it is notable that lumbar puncture revealed a normal opening pressure. Our initial differential diagnosis was broad, including HIV encephalitis, progressive multifocal leukoencephalopathy, and lymphoma, as well as infectious etiologies such as tuberculosis meningitis and cryptococcal meningitis. A major teaching point to take away from this case is that, in the presence of HIV/acquired immune deficiency syndrome, cryptococcal meningitis should always be considered in a patient presenting with neurological complaints. The threshold for lumbar puncture should be low in these patients, considering the valuable information that it can provide and because classical presentations are not always reliable in patients with significant immunocompromise.4 Thomas A. Di Vitantonio, BARobert Fede, MD Department of Medicine Rutgers New Jersey Medical School Newark, NJ [email protected]David J. Cennimo, MD Department of Medicine Division of Infectious Diseases Rutgers New Jersey Medical School Newark, NJ

We report a fatal case of Lassa fever diagnosed in the United States in a Liberian traveler. We describe infection control protocols and public health response. One contact at high risk became symptomatic, but her samples tested negative for Lassa virus; no secondary cases occurred among health care, family, and community contacts.

Newark, New Jersey, is disproportionally affected by HIV with one of the highest prevalence rates in the United States. Rutgers New Jersey Medical School is a major healthcare provider to Newark's underserved population and has implemented a HIV testing program that can diagnose and link newly diagnosed individuals to care. We conducted a retrospective chart review of all new patients seen in the Infectious Disease Practice from January 1, 2013, to December 31, 2014, to determine the proportion of patients with a missed testing opportunity (MTO) (patients with a new HIV diagnosis with an encounter at the institution in the 1 year prior to their first appointment). 117 newly diagnosed patients were identified. 36 (31%) had at least one MTO. A total of 34 (29%) of newly diagnosed patients had AIDS at presentation and 17% had CD4 counts of 50 cells/μL (p value 0.5). The two most common locations of a missed testing opportunity were the hospital ED (45%) and subspecialty clinics (37%). This study demonstrates that, even in a high prevalence institution with HIV counseling, testing, and referral service, HIV screening is lacking at multiple points of care and patients are missing opportunities for earlier diagnosis and treatment.

BACKGROUND AND OBJECTIVES:Human immunodeficiency virus (HIV) in adolescents is a growing concern. Amid psychosocial challenges, adolescents must successfully transition into adult-centered care; however, little is known about outcome measurements within this period. We assessed the trend in adolescent HIV viral loads (VLs) in a community with a high HIV prevalence, allowing physicians to better recognize the challenges of transitioning adolescents with HIV to adult care. PATIENTS AND METHODS:All HIV RNA VLs from the Molecular Virology Lab at University Hospital in Newark, New Jersey, from 2007 to 2010 were obtained. Patients were divided into pediatric (<13 years of age), adolescent (13-25 years of age), and adult (>25 years of age) age groups. Univariate and multivariate analyses assessed characteristics of patients by age and gender. RESULTS:A minimum of 40 pediatric, 178 adolescent, and 1335 adult patients were identified per year. There was a statistically significant increase in VLs of adolescents when compared to pediatric patients (P < .02). In 3 of the 4 years, there was a statistically significant increase in the rate of male adolescents reaching undetectable VLs compared to female adolescents. The average VL by age demonstrated increasing VLs from age 12 through age 24, while the percentage of patients reaching undetectable VLs peaked at 80% at age 8 and declined through age 24. CONCLUSION:Successful transitional care programs should focus on pediatric needs to address the noticeable decrease in virologic control beginning at 8 years of age and the decreased rate of virologic suppression in females, creating concern for potential gender inequalities and increased risk of vertical transmission.

Since 1993, the Centers for Disease Control recommendations for HIV testing were extended to include persons obtaining care in the emergency department (ED). Situated in Newark, New Jersey, the University Hospital (UH) ED serves a community with a greater than 2% HIV prevalence, and a recent study showed a UH ED HIV seroprevalence of 6.5%, of which 33% were unknown diagnoses. Electronic records for patients seen in the UH ED from October 1st, 2014, to February 28th, 2015, were obtained. Information was collected on demographics, ED diagnosis, triage time, and HIV testing. Random sampling of 500 patients was performed to identify those eligible for screening. Univariate and multivariate analysis was done to assess screening characteristics. Only 9% (8.8-9.3%) of patients eligible for screening were screened in the ED. Sixteen percent (15.7-16.6%) of those in the age group18-25 and 12% (11.6-12.3%) of those in the age group 26-35 were screened, whereas 8% (7.8-8.2%) of those in the age group 35-45 were screened. 19.6% (19-20.1%) of eligible patients in fast track were screened versus 1.7% (1.6-1.8%) in the main ED. Eighty-five percent of patients screened were triaged between 6 a.m. and 8 p.m. with 90% of all screening tests done by the HIV counseling, testing, and referral services. Due to the high prevalence of HIV, urban EDs play an integral public health role in the early identification and linkage to care of patients with HIV. By evaluating our current screening process, we identified opportunities to improve our screening process and reduce missed opportunities for diagnosis.

INTRODUCTION:Clinical reasoning is a fundamental part of a physician's daily workflow. Yet it remains a challenging skill to develop formally, especially in preclerkship-level early learners. Traditionally, medical students learn clinical reasoning informally through experiential opportunities during their clerkship years. This occurs in contrast to the more structured, explicit learning of the basic sciences and physical diagnosis during the preclerkship years. To address this need, we present a flipped classroom case-based approach for developing clinical reasoning skills based on problem representation and the use of a structured illness script worksheet as a model.METHODS:Students were given a short introduction via screencast to introduce clinical reasoning and related terminology such as problem representation and semantic qualifiers. They also received a case vignette and an illness script worksheet to prepare them for in-class discussion. Students used this worksheet to practice clinical reasoning in a small-group session that was held in our last organ system-based second-year course, prior to the start of the clerkships.RESULTS:In comparison to the traditional facilitator-led small-group sessions, where students would sequentially answer a set of defined content-based questions to explore a clinical case, 80% of students preferred the new framework that incorporates problem representation and the illness script worksheets. Faculty facilitators found the structure of the illness script worksheet helpful in leading a clinical reasoning small-group session.DISCUSSION:Based on the results of this pilot, we plan to systematically implement this clinical reasoning framework in our preclerkship curriculum.

What is known and objectiveTuberculosis, an infectious disease caused by the bacteria Mycobacterium tuberculosis, has significant public health implications. Despite the decreasing prevalence of tuberculosis cases and the availability of well-established treatment guidelines, errors with antituberculosis medications remain a concern as clinician experience with the infection has waned and the goal of eradicating tuberculosis has remained unfulfilled. Whereas inappropriate use of other anti-infective classes has been extensively studied, the evaluation of medication errors associated with antituberculosis therapy has been limited to a small number of studies conducted more than two decades ago. This study evaluated the prevalence of inpatient medication errors with antituberculosis therapy in patients with suspected or confirmed tuberculosis disease.MethodsAll admitted patients treated with at least one antituberculosis medication between July 2010 and June 2013 were evaluated for inclusion in the retrospective study. Multidrug antituberculosis regimens were reviewed for medication errors, which were categorized as dosing errors, drug interactions, omission of therapy and inappropriate continuation of therapy in the presence of drug toxicity. Appropriate management was determined in accordance with the national guidelines for the treatment of tuberculosis, as well as guidelines on the use of antiretroviral agents for patients with both human immunodeficiency virus (HIV) infection and tuberculosis disease. The impact of infectious diseases and pulmonary consultation on the prevalence of medication errors was also examined.Results and discussionMore than half of all study patients (44/72, 61%) experienced at least one medication error associated with antituberculosis therapy. Dosing errors were the most common type of medication error identified and were predominantly related to weight-based dosing. Seven dosing errors were related to drug interactions between rifamycins and antiretroviral therapy in HIV-infected patients. Medication error rates were similar between patients receiving consultation from infectious diseases and/or pulmonary specialties and those without consultation. The large majority of antituberculosis medication errors (56/66 errors, 85%) remained uncorrected during the patient's hospital admission.What is new and conclusionMedication errors associated with antituberculosis therapy remain a common occurrence in the current clinical practice setting. Greater vigilance when prescribing medications for tuberculosis disease is needed.

Overall (N = 254) Medicine (Floors) (n = 96) Surgery (Floors) (n = 42) Medical ICU (n = 51) Surgical ICU (n = 31) Orders adherent to policy, n (%) 84 (33.1) 31 (32.3) 18 (42.9) 13 (25.5) 16 (51.6) Time from order entry to order verification, median minutes (range) All orders 11 (0 – 2142) 13 (1 – 2142) 9 (2 – 540) 13 (1 – 919) 31 (1 – 1769) Adherent orders 7 (1 – 213) 5 (1 – 148) 8.5 (2 – 52) 4 (1 – 74) 6.5 (1 – 213) Non-adherent orders 16 (0 – 2142) 22 (1 – 2142) 13 (2 – 540) 19 (1 – 919) 416 (5 – 1769) ID approval not obtained prior to order entry, n (%) 134 (52.8) 58 (60.4) 16 (38.1) 20 (39.2) 13 (41.9)

SESSION TITLE: Lung Cancer Posters SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, October 28, 2015 at 01:30 PM - 02:30 PM PURPOSE: With the introduction of antiretroviral therapies (HAART) the causes of mortality in HIV patients (pts) have changed considerably. The incidence of lung cancer has risen dramatically in these pts, with lung cancer being a major contributor to mortality in HIV-positive pts. Our objective was to determine the characteristics of non-small cell lung cancer (NSCLC) in HIV-positive pts and compare them with HIV-negative NSCLC pts. METHODS: We reviewed the charts of 1440 HIV-positive pts that followed at our institution's infectious disease clinic from 2000 to 2010. Demographics, CD4 counts and NSCLC characteristics were studied. RESULTS: A total of 19 (1.34%) pts with NSCLC were identified; there were more females than males (68%vs 32%). Regarding HIV infection: median (M) age of HIV diagnosis was 43 years (22-66), the most common modes of infection were heterosexual contact (53%) and IV drug use (31%). M CD4 at diagnosis was 71 (12-800). 89.5% of pts had been in HAART therapy, but only 47% were compliant with the regimen. About co-infections: 47% had hepatitis C and 21% hepatitis B. 95% were current or former smokers. In regards to NSCLC, M age at diagnosis was 50 years (43-69), M CD4 count at cancer diagnosis was 252 (13-818), 79% of the pts were stage IV at diagnosis, 84% of the pts were symptomatic at diagnosis with almost half of these pts (47%) having a prior lung infection. Adenocarcinoma was the most prevalent histologic subtype followed by squamous cell. Following cancer diagnosis, only 32% of the pts received a combination of chemotherapy and HAART therapy. Compared with HIV-positive pts, the HIV-negative pts were older at diagnosis (M age 70 years), contained fewer smokers (55%), and had a greater frequency of squamous cell carcinomas (38% vs. 16%), with only 61%of the of pts presenting with stage IV NSCLC. CONCLUSIONS: We observed a higher incidence of NSCLC in HIV-positive young females. Most of the pts presented with advanced disease and almost half of these pts had a prior lung infection. Our HIV-positive pts were 20 years younger at the time of diagnosis compared with the national median age of NSCLC diagnosis (70 years). CLINICAL IMPLICATIONS: NSCLC HIV-positive pts tend to have a worse prognosis than the general population, management can be difficult as many pts present with advanced disease and co-infections. The risk of NSCLC based on gender differences, especially among HIV-positive females requires further investigation at this could impact cancer screening in the HIV-positive population. DISCLOSURE: The following authors have nothing to disclose: Narjust Duma, Jaimie Mittal, Sobia Nizami, Mohleen Kang, David Cennimo No Product/Research Disclosure Information

BACKGROUND:There is a high prevalence of HIV infection in Newark, New Jersey, with University Hospital admitting approximately 600 HIV-infected patients per year. Medication errors involving antiretroviral therapy (ART) could significantly affect treatment outcomes. The goal of this study was to evaluate the effectiveness of various stewardship interventions in reducing the prevalence of prescribing errors involving ART.METHODS:This was a retrospective review of all inpatients receiving ART for HIV treatment during three distinct 6-month intervals over a 3-year period. During the first year, the baseline prevalence of medication errors was determined. During the second year, physician and pharmacist education was provided, and a computerized order entry system with drug information resources and prescribing recommendations was implemented. Prospective audit of ART orders with feedback was conducted in the third year. Analyses and comparisons were made across the three phases of this study.RESULTS:Of the 334 patients with HIV admitted in the first year, 45% had at least one antiretroviral medication error and 38% had uncorrected errors at the time of discharge. After education and computerized order entry, significant reductions in medication error rates were observed compared to baseline rates; 36% of 315 admissions had at least one error and 31% had uncorrected errors at discharge. While the prevalence of antiretroviral errors in year 3 was similar to that of year 2 (37% of 276 admissions), there was a significant decrease in the prevalence of uncorrected errors at discharge (12%) with the use of prospective review and intervention.CONCLUSIONS:Interventions, such as education and guideline development, can aid in reducing ART medication errors, but a committed stewardship program is necessary to elicit the greatest impact.

• Electronic records for patients seen in the UH ED from October 1st 2014 to February 28th 2015 were obtained. • Information for each visit was electronically collected on; age, gender, ED diagnosis ICD9 codes, care location, triage date and time, disposition, and if they were tested for HIV at that visit. • Excluded patients: patients under the age of 18, patients whose charts were entered in error, and patients who walked out prior to being triaged. • Patients who were tested for HIV in the ED and patients with HIV as part of their ICD9 diagnosis were electronically identified. • Patients due for screening were defined as those without a diagnosis of HIV who did not have documented testing in the prior 12 months. • A retrospective chart review was done via random sampling of 500 patients, representing 1200 visits, to determine the estimated percentage of patients with a history of HIV not documented in the ED diagnosis, those screened in the past 12 months, and those patients due for screening. • Univariate and multivariate analyses were done to assess the percentage of eligible patients screened by age, gender, care location, ED diagnosis code, disposition, and time of day. • Since 1993, the Centers for Disease Control (CDC) recommendations for routine HIV counseling and testing were extended to include persons obtaining health care in the Emergency Department (ED). • In 2003 the recommendations were reinforced with the CDC revisions advising opt-out screening for patients in all health care settings. • In 2013 the USPSTF revised their previous recommendations and recommended routine testing for patients age 15-65 years in any health care setting with an A grade. • Additionally the USPTF included a recommended screening interval of one year for patients, “known to be at risk of HIV infection, those who are actively engaged in high risk behaviors, and those who live or receive medical care in a high-prevalence setting.” (seroprevalence of >1%)