Abstract Background Per the Centers for Disease Control and Prevention, 2.4 million Americans have the hepatitis C virus (HCV). New cases increased by 14% from 2014 to 2016 in California with 400,000 infections, 4,000 infections in the Coachella Valley and about 50% unaware of their diagnosis. A barrier to elimination is the lack of rapid screenings and linkage to care (LTC) of infected individuals into an integrated system. Thus, we developed a program at the Hepatitis Center of Excellence (HCE) where pharmacists in a managed care organization (MCO) provide opportunities to overcome these boundaries. The partnership of the MCO and federally qualified health center (FQHC) was established in 2017 to expand access to care to the HCV community. We anticipate that our program will eliminate HCV in the Coachella Valley by modeling past success in human immunodeficiency virus (HIV) testing and LTC at the FQHC through an interdisciplinary approach. Methods A single-center, retrospective analysis from January 2017 to December 2018 of HCV individuals was conducted at the pharmacist-led HCE in Palm Springs, California. The LTC team approached barriers through prompt free screenings and major advocacy. Pharmacists and specialty physicians collaborated to ensure rapid assessment, treatment initiation and completion, and sustained virologic response (SVR). The HCE has adapted the HIV testing and LTC model in hopes of achieving similar feats. From 2014 to 2018, 92,947 total HIV tests were performed with 90.2% of HIV-positive patients linked to care. HCV testing was then added to HIV screening and expanded to other testing sites. Results The first visit with a clinical pharmacist consists of education, reviewing lab tests, cost assistance, and providing treatment options. From 2017 to 2018, 169 of 172 HCV positive individuals (98.2%) achieved SVR by treatment completion. The HCV LTC program demonstrated a 3.8% increase in HCV testing from 2017 to 2018. Conclusion Pharmacist-led care for a large volume of HCV patients allows time for specialty physicians to manage more complex cases. The collaboration between the FQHC, MCO, and LTC team showed HCV elimination is possible based on high SVR rates. HCE is projecting successful linkages to care and continuous campaigning for individuals to be treated for HCV in the Coachella Valley. Disclosures All authors: No reported disclosures.

Ceftolozane/tazobactam is a combination intravenous antibiotic with potentially important activity against drug-resistant Gram-negative organisms. Ceftolozane/tazobactam's in vitro activity was evaluated in 30 samples collected from 23 adult cystic fibrosis patients with extended and pan-resistant Pseudomonas aeruginosa in 2015. Testing results demonstrated that 30% of the isolates were susceptible,13% were intermediate, and 57% were resistant. This suggests that ceftolozane/tazobactam may be a useful antibiotic in carefully selected, multidrug-resistant Pseudomonas isolates.

Patients with increasingly complex conditions are being discharged from hospitals with increasingly complex care plans. Those plans often include a daunting array of medications, some new, some old, some with adjusted doses, and often some that interact with what the patient may already have at home. Not surprisingly, patients are sometimes quickly readmitted, and nonadherence to their medication regimens is frequently cited as a contributing factor. Delivery of postdischarge medications to patients before they leave the hospital (meds-to-beds) is an innovation with the goal of reducing readmissions and their associated morbidity and mortality. In 1 recent study, a meds-to-beds program reduced readmissions by about 50%, but will these programs alone be enough? –Donald Gardenier Jade LeJade Le, PharmD, BCACP, is a clinical pharmacist at Desert Oasis Healthcare in Palm Springs, CA, where her clinical focus is in ambulatory care. She studied at the Loma Linda University School of Pharmacy in Loma Linda, CA, and completed her pharmacy residency at Desert Regional Medical Center in Palm Springs, CA. Jade Le, PharmD, BCACP, is a clinical pharmacist at Desert Oasis Healthcare in Palm Springs, CA, where her clinical focus is in ambulatory care. She studied at the Loma Linda University School of Pharmacy in Loma Linda, CA, and completed her pharmacy residency at Desert Regional Medical Center in Palm Springs, CA. Data indicate that 15% to 25% of readmissions within 30 days are caused by medication nonadherence, medication misuse, and missed refills. In addition, only about 40% of patients fill their prescriptions on their day of discharge. One strategy to help reverse this trend is meds-to-beds; home medications are delivered to the patient before they are discharged from the hospital. Meds-to-beds provides opportunities for the inpatient team to ensure proper medication education and counseling, including interactions with over-the-counter and herbal medications. Other potential adherence barriers may also be uncovered in this process, including high copayments, lack of transportation, and low literacy. Delivering medications in the hospital can alleviate many of these barriers. This is a key component of meds-to-beds (ie, identifying patients who are at higher risk for nonadherence). By delivering medications to the patient’s bedside, the health care team can build relationships, assist with any issues, and empower the patient to participate in the management of their health. Medication questions could be answered at the bedside before being discharged home. Cost is another barrier to adherence. Meds-to-beds gives the inpatient team an opportunity to work with patients who are not able to afford their medications. Using generics first and explaining the rationale to patients is 1 way to reduce costs. The team can also refer to social services to assist with social hindrances that could be preventing patients from affording their medications. Another obstacle is when a medication is not on formulary or needs prior authorization. With meds-to-beds, the inpatient team has an opportunity to identify these issues, obtain approval, and/or to adjust medications accordingly. By implementing meds-to-beds programs, the goal is to improve patient engagement and ease the transition home from the hospital by encouraging adherence to medications. Meds-to-beds programs will improve adherence and will therefore also reduce morbidity, cost, and readmissions. Point/Counterpoint offers thought-provoking topics relevant to nurse practitioners in every issue of JNP. Two authors present thoughtful but opposing viewpoints on current subjects, from scope of practice and regulations to work ethics and care practices. Your opinion on these matters is also important, so go to www.npjournal.org or scan the QR code here to register your vote for either side of each topic. Comments or suggestions for future columns should be sent to Department Editor Donald Gardenier at [email protected] Madeeha BakerMadeeha Baker, PharmD, is a clinical pharmacist at Desert Oasis Healthcare in Palm Springs, CA. She studied pharmacy at California Northstate University College of Pharmacy in Elk Grove, CA. She completed her acute care residency at Eisenhower Medical Center in Rancho Mirage, CA. Dr Baker’s current clinical focus is in ambulatory care, managing patients with diabetes and coronary artery disease. Madeeha Baker, PharmD, is a clinical pharmacist at Desert Oasis Healthcare in Palm Springs, CA. She studied pharmacy at California Northstate University College of Pharmacy in Elk Grove, CA. She completed her acute care residency at Eisenhower Medical Center in Rancho Mirage, CA. Dr Baker’s current clinical focus is in ambulatory care, managing patients with diabetes and coronary artery disease. Nearly 20% of Medicare patients are readmitted within 30 days of hospital discharge. Finding ways to minimize readmissions has become a priority for many institutions. Unfortunately, the new meds-to-beds programs have yet to be successful in reducing hospital readmissions. Many of the medications prescribed at discharge are inappropriate dosages or duplications or may not be safe for the patient if a thorough medical history was not completed. Let’s say, for example, a 79-year-old man is admitted to the hospital for chronic obstructive pulmonary disease exacerbation. He doesn’t remember all his medications but knows he takes something for his blood pressure and uses insulin for his diabetes. Upon discharge, he is given 30-day supplies of glargine 10 U and lisinopril 40 mg and a course of ciprofloxacin 500 mg for his chronic obstructive pulmonary disease exacerbation, but he has no scheduled follow-up with his primary care provider. He starts the new medications but also resumes his old regimen (ie, losartan 100 mg daily and 20 U 75/25 insulin twice daily). He is now taking 2 long-acting insulins, putting him at high risk for a hypoglycemic event, as well as maximum doses of lisinopril and losartan, likely causing hypotension and putting him at high risk for a fall. Unfortunately, scenarios like this are not uncommon. Supplying medications is all well and good, but without appropriate transitions of care, patients could be at increased risk. This is especially true for patients with low health literacy, those prescribed high-risk or complex medication regimens, those with dementia, and those without a caregiver. The meds-to-beds programs are a great initiative, but they cannot by themselves reduce hospital readmissions and could cause harm. However, they can contribute successfully to reducing readmissions if done appropriately in collaboration with a multidisciplinary team that includes the primary care provider and appropriate follow-up care.

Epstein–Barr virus (EBV) is a gamma herpesvirus associated with diseases ranging from asymptomatic viremia to post-transplant malignancies in kidney transplant recipients. EBV specifically is associated with post-transplantation lymphoproliferative disorder (PTLD), in kidney transplant recipients, with increased risk in EBV seronegative patients with EBV seropositive donors on intensified immunosuppression. The diagnosis of PTLD relies on clinical suspicion plus tissue biopsy with polymerase chain reaction (PCR) testing of blood currently used for risk determination in high-risk recipients. Therapeutic strategies for PTLD include reduction of immunosuppression, chemotherapy and rituximab, and consideration of sirolimus-based immunosuppression. Antivirals such as ganciclovir are used to prevent reactivation of cytomegalovirus and other herpes viruses but are not onco-therapeutic. Radiation therapy or surgery is indicated for bulky, disseminated or recalcitrant disease. Prognosis varies depending on the type of malignancy identified and stage of disease.

Abstract Background We created a retrospective and prospective database of SOT recipients using innovative data mining tools. This study describing the epidemiology of BSI in SOT serves as a proof of concept of such techniques in clinical research. Methods The design of the study was a retrospective, single-center, cohort study. Data mining tools were used to extract information from the electronic medical record and merged it with data from the SRTR (Figure 1). First SOT from January 1, 2010 to December 31, 2015 were included. Charts of subjects with positive blood cultures were manually reviewed and adjudicated using CDC/NHSN and SCCM/ESICM criteria. The 1-year cumulative incidence was calculated using the Kaplan–Meier method. Cox proportional hazards models were used to identify risk factors for BSI and 1-year mortality. BSI was analyzed as a time-dependent covariate in the mortality model. Fisher’s exact test and chi-square were used to identify risk factors for 30-day mortality and MDRO. Results A total of 917 SOT recipients met inclusion criteria. Seventy-five patients experienced at least one BSI. The cumulative incidence was 8.4% (95% CI 6.8–10.4) (Figure 2). The onset of the first BSI episode was: 30 episodes (40%) <1 month, 33 (44%) 1–6 months, and 12 (16%) >6 months. The most common pathogens were Klebsiella sp. (16%), Vancomycin-resistant E. faecium (12%), E. coli (12%), CoNS (12%), and Candida sp. (9.3%). Nineteen isolates (25%) were identified as MDRO; the risk of MDRO was highest <1 month compared with 1–6 and >6 months (44.8 vs. 12.1 vs. 16.7; P = 0.01). The most common source of BSI was CLABSI (29%) (Figure 3). In multivariable analysis, the risk of BSI was associated with organ type (HR [95% CI] = Multiorgan 3.5 [1.1–11.6], liver 2.5 [1.1–5.4], heart 2.4 [1.1–5.1]) and acquisition of a BSI was associated with a higher 1-year mortality (HR = 8.7 [5.1–14.7]). In univariable analysis, a polymicrobial BSI (14.7 vs. 57.1%; P = 0.02), qSOFA ≥ 2 (0.0 vs. 25.5%; P = 0.02) and septic shock (3.9 vs. 52.2%; P < 0.001) were associated with an increased risk of death at 30 days. Conclusion A BSI significantly affects the 1-year survival of SOT recipients. A qSOFA ≥ 2 can be used to identify patients at risk for death. Additionally, this study illustrates the potential of data mining tools to study infectious complications. Disclosures All authors: No reported disclosures.

We conducted this study to determine the risk of transmission of Q fever to health care workers (HCWs) during perioperative exposure to Coxiella burnetii-infected thoracic endovascular aneurysm stent graft. Pre-operative and 6-week post-operative phase I and II IgG Q fever antibody titers were determined in 14 staff members of an operation room. The room had a negative pressure and all the members of the surgical team wore either a fitted N-95 mask or a powered purified air respirator. Phase I and II IgG antibody titers were < 1: 16 for 11 of the 14 studied HCWs; 2 HCWs did not follow up at 6 weeks and 1 had a pre-exposure phase II IgG titer of 1: 128 with no change 6 weeks later. We concluded that risk of transmission of C. burnetii in the operating room from infected patient to HCWs who wore appropriate personal protective equipment is low.

Characteristics of cirrhosis-associated cryptococcosis first diagnosed after death are not fully known. In a multicenter study, data generated as standard of care was systematically collected in 113 consecutive patients with cirrhosis and cryptococcosis followed for 80 patient-years. The diagnosis of cryptococcosis was first established after death in 15.9% (18/113) of the patients. Compared to cases diagnosed while alive, these patients had higher MELD score (33 vs. 22, P = .029) and higher rate of cryptococcemia (75.0% vs. 41.9%, P = .027). Cases diagnosed after death, in comparison to those diagnosed during life were more likely to present with shock (OR 3.42, 95% CI 1.18-9.90, P = .023), require mechanical ventilation at admission (OR 8.5, 95% CI 2.74-26.38, P = .001), less likely to undergo testing for serum cryptococcal antigen (OR 0.07, 95% CI 0.02-0.21, P < .001) and have positive antigen when the test was performed (OR 0.07, 95% CI 0.01-0.60, P = .016). In a subset of cirrhotic patients with advanced liver disease cryptococcosis was first recognized after death. These patients had the characteristics of presenting with fulminant fungemia, were less likely to have positive serum cryptococcal antigen and posed a diagnostic challenge for care providers.

Epstein-Barr virus (EBV) and human herpesvirus-8 (HHV-8) are γ herpesviruses associated with post-transplant malignancies in kidney transplant recipients. EBV is associated with post-transplantation lymphoproliferative disorder (PTLD), with increased risk in EBV-seronegative patients on intensified immunosuppression. Human herpesvirus-8 is associated with Kaposi’s sarcoma (KS), with an increased risk in certain patient populations. Diagnosis of PTLD and KS relies on tissue biopsy. The mainstay of therapy for both PTLD and Kaposi’s sarcoma is a reduction of immunosuppression, and in the case of PTLD, consideration of rituximab. Chemotherapy, radiation therapy, or surgery is provided for disseminated or recalcitrant disease. The prognoses vary depending on the type of malignancy identified and stage of disease.

BACKGROUND:The outcomes and optimal management of cirrhotic patients who develop cryptococcosis before transplantation are not fully known.METHODS:We conducted a multicenter study involving consecutive patients with cirrhosis and cryptococcosis between January 2000 and March 2014. Data collected were generated as standard of care.RESULTS:In all, 112 patients were followed until death or up to 9 years. Disseminated disease and fungemia were present in 76.8% (86/112) and 90-day mortality was 57.1% (64/112). Of the 39 patients listed for transplant, 20.5% (8) underwent liver transplantation, including 2 with active but unrecognized disease before transplantation. Median duration of pretransplant antifungal therapy and posttransplant therapy was 43 days (interquartile range, 8-130 days) and 272 days (interquartile range, 180-630 days), respectively. Transplantation was associated with lower mortality (P = 0.002). None of the transplant recipients developed disease progression during the median follow-up of 3.5 years with a survival rate of 87.5%.CONCLUSIONS:Cryptococcosis in patients with cirrhosis has grave prognosis. Our findings suggest that transplantation after recent cryptococcal disease may not be a categorical exclusion and may be cautiously undertaken in liver transplant candidates who are otherwise deemed clinically stable.

In 2012, Texas has reported the highest number of West Nile virus (WNV) cases in the United States to the Centers for Disease Control and Prevention. In this report, we conducted a retrospective chart review of 57 patients with WNV disease and analyzed the clinical features of these patients. Our results revealed that 25 (44%) patients were diagnosed with West Nile fever and 32 (56%) with West Nile neuroinvasive disease (WNND). The median age for patients with WNND was 54.5 years, and those with encephalitis were more likely to be >60 years old. Pre-existing conditions such as hypertension and diabetes were more frequent in patients with WNND. Testing both serum and cerebrospinal fluid (CSF) for antibodies diagnosed more cases of WNND than just testing serum or CSF alone. The increasing number of WNV cases during this epidemic highlights the need to increase efforts to control mosquito populations and educate the general public.