CDC Recommendations Research Articles

Closing the Gaps: Testing the Efficacy of Carbapenem and Cephalosporin Treatments of Late-Stage Anthrax in Rabbits

Anthrax is a fatal zoonotic disease caused by exposure to Bacillus anthracis spores. The CDC’s guidelines divide anthrax treatment into three categories according to disease progression: post-exposure prophylaxis (PEP), systemic, and systemic with a suspicion of CNS infection. While the prognosis for PEP or the early treatment of systemic anthrax is very good, ingress of the bacteria into the CNS poses a substantial clinical challenge. Here, we use rabbits to test the efficacy of a combined treatment of meropenem and doxycycline, which is the first choice in the CDC recommendations for treating systemic patients with an indication of CNS infection. In addition, we test the efficacy of the first-generation cephalosporin, cefazolin, in treating different stages of the disease. We found that the combination of doxycycline and meropenem is highly effective in treating rabbits in our inhalation model. Cefazolin was efficient only for PEP or systemic-stage treatment and not for CNS-infected animals. Our findings support the CDC recommendation of using a combination of doxycycline and meropenem for systemic patients with or without indications of CNS infection. We found that cefazolin is a decent choice for PEP or early-stage systemic disease but recommend considering using this antibiotic only if all other options are not available.

Primary care physicians' perspectives on adults with diabetes and the recommended hepatitis B vaccine: A qualitative study.

People with diabetes are at an increased risk of contracting the hepatitis B virus (HBV). However, hepatitis B (HepB) vaccination rates among adults with diabetes are low. Factors influencing HepB vaccination have not been adequately explored. The study aims to identify and understand the barriers adults with diabetes have in receiving the recommended HepB vaccine from the physicians' perspective. This study used semi-structured interviews to ascertain the perspective of 11 primary care physicians (PCPs) in a large academic medical group about HepB vaccination among their patients with Type 1 and 2 diabetes. Thematic analysis yielded descriptions of barriers and strategies that could potentially impact HepB vaccination among adults with diabetes. Physician responses related to four themes: (1) Conflicting perceptions about HBV risk and the CDC recommendation for adults with diabetes; (2) PCPs don't perceive HepB vaccination as important as other adult vaccines and prioritize vaccination based on risk exposure; (3) PCPs' perceived barriers to HepB vaccination among adults with diabetes; and (4) Physician recommended strategies to increase HepB vaccination among adults with diabetes. Our findings indicate that physicians are generally aware of the existence of the CDC guidelines, but not all physicians recommend the HepB vaccine to adults with diabetes. This is because of a wide variation in treatment concerning glucose monitoring or insulin injection due to varying opinions about actual risk. We also identified barriers adults with diabetes have in receiving the HepB vaccine and strategies to increase HepB vaccination.

Association between depression severity and trouble sleeping: A population-based study.

This study investigates the association between insomnia and depression severity, exploring sleep disturbances in individuals with depression. The aim is to establish a new foundation for managing patients with co-occurring depression and insomnia, using 2015 to 2016 National Health and Nutrition Examination Survey (NHANES) data. We employed a cross-sectional design, using NHANES data from 2015 to 2018. The study included 11,261 participants after excluding incomplete data. Depression severity, assessed using Patient Health Questionnaire-9 (PHQ-9) scores, served as the exposure variable. We considered various demographic and lifestyle factors as covariates in the multivariate adjustment model. Statistical analyses adhered to CDC recommendations, with sample weights incorporated to account for NHANES' complex sample design. Our study, encompassing 19,225 participants, revealed that higher PHQ-9 scores correlated with an increased likelihood of sleep disorders. In the fully adjusted model, a positive association emerged between PHQ-9 scores and trouble sleeping (OR = 3.95, 95% CI: 3.35-4.66, P < .0001). This relationship displayed an inverted U-shaped curve, with an inflection point at 28. Subgroup analysis and interaction tests indicated no reliance on factors such as gender, age, marital status, or BMI for the connection between depression severity and trouble sleeping (all P for interaction > .05). We identified a significant inverted U-shaped correlation between sleep disturbances and depression severity. This underscores the crucial importance of assessing sleep disorder risks in individuals with varying degrees of depression severity, facilitating personalized therapeutic interventions.

Adopting the 2023 CDC Early Testing for Perinatal Hepatitis C: Call to Action for Pediatric Primary Care Providers.

In the US, the burden of hepatitis C virus (HCV) infection is disproportionately high among young adults including pregnant persons, resulting in increased infections among children as perinatal transmission remains the main route of HCV infection in children. Hence, in 2020, the Centers for Disease Control and Prevention (CDC) recommended universal HCV screening during each pregnancy. HCV infection in infancy is usually asymptomatic, so the diagnosis entirely relies on testing of perinatally-exposed infants which, historically, included anti-HCV antibody testing at ≥ 18 months of age. However, nation-wide perinatal HCV testing rates have been suboptimal with significant loss to follow up. To address this problem, in 2023, the CDC introduced early single HCV RNA testing at 2-6 months of age with an alternative for HCV RNA testing up to 17 months of age if not previously tested. The high sensitivity and specificity of the HCV real-time PCR laid the grounds for this policy shift. In this review we highlight how these new CDC recommendations will enhance testing of infants and children and ultimately contribute to overall HCV elimination efforts. We also emphasize the role of all pediatric providers and obstetricians in implementing these new guidelines. Additionally, we offer our perspective and practical advice for testing of perinatally exposed infants and children. Currently, curative oral antivirals for HCV-infection treatment are approved for children ≥ 3 years of age. As pediatricians, advocating for children's wellness, it is our utmost duty to ensure that every child exposed to perinatal hepatitis C has been tested, diagnosed, linked to care, treated, and achieved cure.

Multifaceted Implementation Strategy to Improve the Comprehensive Assessment of Penicillin Allergies in Perioperative Patient

Background: The CDC recommends that nurses improve the evaluation of penicillin allergies as part of antimicrobial stewardship programs. We evaluated the feasibility of a multifaceted implementation strategy to improve nurses’ documentation of penicillin allergy histories and to encourage nurses to notify prescribers of patients with low-risk symptoms of reported penicillin allergy. The implementation strategy was guided by the COM-B model of behavior change and addressed nurses’ capability, opportunity, and motivation to implement practices (Figure 1). The implementation strategy included education on the STORY mnemonic that details the questions of a penicillin allergy history, education on low-risk symptoms of penicillin allergy, dot phrases in EPIC to facilitate nurses’ documentation of STORY and communication of patients with low-risk penicillin allergy symptoms, and educational pocket cards and flyers. We define feasibility as the implementation and acceptability of practices. Methods: This was a six-month feasibility study conducted in an outpatient perioperative area. We compared penicillin allergy documentation pre- and post- implementation strategy and report on nurses’ notification of prescribers regarding patients with low-risk penicillin allergies in the post-implementation period. We engaged nurses in a focus group to assess factors that facilitated or hindered practice adoption. Results: A total of 426 unique patients with 482 penicillin allergy records were included in our study (n= 207 records pre-implementation, n = 275 records post-implementation). We found little to no change in the percentage of records that included symptom information post vs. pre-implementation (88.36% vs 88.41%). A greater percentage of allergy records in the post vs. pre-implementation periods included information on: timing/years since reaction (25.6% vs. 8.2%), onset of reaction (20.7% vs. 0%), resolution of symptoms (20.4% vs. 0%), and penicillin re-exposure (21.1% vs. 2.4%). There were 24 documented instances of nurses’ notifying prescribers of patients with a low-risk penicillin allergy. Focus group data revealed nurses perceived their comprehensive documentation of penicillin allergies highly acceptable and likely to improve patient care and outcomes. Whereas nurses’ notification of prescribers concerning patients meeting low-risk penicillin allergy criteria had little appeal. Nurses described the STORY mnemonic, pocket cards describing the penicillin allergy assessment mnemonic, and the associated dot phrase in EPIC as particularly helpful. Conclusions: A multifaceted implementation strategy showed promise in improving the comprehensive documentation of penicillin allergy histories. Future studies are needed to determine the efficacy of the multifaceted implementation strategy on penicillin allergy documentation, the selection of antibiotic prophylactic treatment, and clinical outcomes among surgical patients.

Septic Arthritis of the Hip Joint Secondary to Haemophilus Influenza in Immunized Teenager: A Case Report

Septic arthritis is an infection to one joint or more that mainly happens after a hematogenous spread of an infection causing inflammation to the joint. Large joints such as hip and knee are more commonly affected, however, septic arthritis can happen in any other joints such as shoulders and ankles. Staphylococcus aureus is the most frequently isolated pathogen in this condition; however, other bacteria, viruses, fungi, and mycobacterium can also cause septic arthritis. Haemophilus influenzae type b (Hib) is the most common subtype of Haemophilus influenza and is primarily affecting children and those with compromised immune systems. Haemophilus influenza usually causes lower respiratory tract infections, including pneumonia. In addition, they can induce numerous other severe infections, such as bacteremia, empyema, meningitis, cellulitis, and septic arthritis. The Hib conjugate vaccine has significantly reduced the incidence of Hib infections and is effective in protecting against capsular polysaccharide type b. the CDC recommends administering a conjugate Hib vaccine series beginning at age 2 months, or 6 weeks followed by boosters at age of12 to 15 months. In this article, we are reporting a unique case of hip septic joint in a fully vaccinated teenager, and it is the first case reported in the literature to our knowledge.

CDC Clinical Guidelines on the Use of Doxycycline Postexposure Prophylaxis for Bacterial Sexually Transmitted Infection Prevention, United States, 2024.

No vaccines and few chemoprophylaxis options exist for the prevention of bacterial sexually transmitted infections (STIs) (specifically syphilis, chlamydia, and gonorrhea). These infections have increased in the United States and disproportionately affect gay, bisexual, and other men who have sex with men (MSM) and transgender women (TGW). In three large randomized controlled trials, 200 mg of doxycycline taken within 72 hours after sex has been shown to reduce syphilis and chlamydia infections by >70% and gonococcal infections by approximately 50%. This report outlines CDC's recommendation for the use of doxycycline postexposure prophylaxis (doxy PEP), a novel, ongoing, patient-managed biomedical STI prevention strategy for a selected population. CDC recommends that MSM and TGW who have had a bacterial STI (specifically syphilis, chlamydia, or gonorrhea) diagnosed in the past 12 months should receive counseling that doxy PEP can be used as postexposure prophylaxis to prevent these infections. Following shared decision-making with their provider, CDC recommends that providers offer persons in this group a prescription for doxy PEP to be self-administered within 72 hours after having oral, vaginal, or anal sex. The recommended dose of doxy PEP is 200 mg and should not exceed a maximum dose of 200 mg every 24 hours.Doxy PEP, when offered, should be implemented in the context of a comprehensive sexual health approach, including risk reduction counseling, STI screening and treatment, recommended vaccination and linkage to HIV PrEP, HIV care, or other services as appropriate. Persons who are prescribed doxy PEP should undergo bacterial STI testing at anatomic sites of exposure at baseline and every 3-6 months thereafter. Ongoing need for doxy PEP should be assessed every 3-6 months as well. HIV screening should be performed for HIV-negative MSM and TGW according to current recommendations.

Using the health belief model to understand intention to vaccinate for Lyme disease in the United States.

A growing number of Lyme disease (LD) cases in the U.S. are reported in states neighbouring those with high-incidence (>10 cases per 100,000 population) rates. Considering the evolving epidemiology, high-incidence counties in many of these "neighbouring states," and the forthcoming vaccines, understanding the drivers of vaccination intention is critical, particularly how drivers of intention in neighbouring states vary relative to regions currently classified as high incidence. This study uses the Health Belief Model (HBM) to determine the key drivers associated with vaccine intention for U.S. adults and caregivers of children residing in neighbouring states. Using an established panel with quotas for age, sex, race/ethnicity and urbanity, we surveyed 887 adults and 822 caregivers of children residing in U.S. neighbouring states. Survey items included measures of intention and HBM constructs, all of which were assessed using 5-point Likert scales. We subsequently used structural equation modelling to understand the influence of the HBM constructs on LD vaccine intention. Estimates from structural equation modelling show that the HBM constructs explain much of the variation in intention to vaccinate against LD. Intentions to vaccinate for both adults and caregivers are positively influenced by cues to action, perceived susceptibility of LD, and perceived benefits to vaccination. Both are also negatively influenced by perceived barriers to vaccination. The caregiver's intention to vaccinate is also positively influenced by the perceived severity of LD. The intention to vaccinate for respondents residing in LD neighbouring states is strongly influenced by recommendations from healthcare providers or the Centers for Disease Control and Prevention (CDC). As incidence rises in neighbouring states and the need to prevent disease becomes more overt, public health officials should strongly recognize the influence of healthcare providers and CDC recommendations on intention to vaccinate against LD.

Durability of Original Monovalent mRNA Vaccine Effectiveness Against COVID-19 Omicron-Associated Hospitalization in Children and Adolescents - United States, 2021-2023.

Pediatric COVID-19 vaccination is effective in preventing COVID-19-related hospitalization, but duration of protection of the original monovalent vaccine during SARS-CoV-2 Omicron predominance merits evaluation, particularly given low coverage with updated COVID-19 vaccines. During December 19, 2021-October 29, 2023, the Overcoming COVID-19 Network evaluated vaccine effectiveness (VE) of ≥2 original monovalent COVID-19 mRNA vaccine doses against COVID-19-related hospitalization and critical illness among U.S. children and adolescents aged 5-18 years, using a case-control design. Too few children and adolescents received bivalent or updated monovalent vaccines to separately evaluate their effectiveness. Most case-patients (persons with a positive SARS-CoV-2 test result) were unvaccinated, despite the high frequency of reported underlying conditions associated with severe COVID-19. VE of the original monovalent vaccine against COVID-19-related hospitalizations was 52% (95% CI=33%-66%) when the most recent dose was administered <120 days before hospitalization and 19% (95% CI=2%-32%) if the interval was 120-364 days. VE of the original monovalent vaccine against COVID-19-related hospitalization was 31% (95% CI=18%-43%) if the last dose was received any time within the previous year. VE against critical COVID-19-related illness, defined as receipt of noninvasive or invasive mechanical ventilation, vasoactive infusions, extracorporeal membrane oxygenation, and illness resulting in death, was 57% (95% CI=21%-76%) when the most recent dose was received <120 days before hospitalization, 25% (95% CI=-9% to 49%) if it was received 120-364 days before hospitalization, and 38% (95% CI=15%-55%) if the last dose was received any time within the previous year. VE was similar after excluding children and adolescents with documented immunocompromising conditions. Because of the low frequency of children who received updated COVID-19 vaccines and waning effectiveness of original monovalent doses, these data support CDC recommendations that all children and adolescents receive updated COVID-19 vaccines to protect against severe COVID-19.

Potential impact of annual vaccination with reformulated COVID-19 vaccines: Lessons from the US COVID-19 scenario modeling hub.

Coronavirus Disease 2019 (COVID-19) continues to cause significant hospitalizations and deaths in the United States. Its continued burden and the impact of annually reformulated vaccines remain unclear. Here, we present projections of COVID-19 hospitalizations and deaths in the United States for the next 2 years under 2 plausible assumptions about immune escape (20% per year and 50% per year) and 3 possible CDC recommendations for the use of annually reformulated vaccines (no recommendation, vaccination for those aged 65 years and over, vaccination for all eligible age groups based on FDA approval). The COVID-19 Scenario Modeling Hub solicited projections of COVID-19 hospitalization and deaths between April 15, 2023 and April 15, 2025 under 6 scenarios representing the intersection of considered levels of immune escape and vaccination. Annually reformulated vaccines are assumed to be 65% effective against symptomatic infection with strains circulating on June 15 of each year and to become available on September 1. Age- and state-specific coverage in recommended groups was assumed to match that seen for the first (fall 2021) COVID-19 booster. State and national projections from 8 modeling teams were ensembled to produce projections for each scenario and expected reductions in disease outcomes due to vaccination over the projection period. From April 15, 2023 to April 15, 2025, COVID-19 is projected to cause annual epidemics peaking November to January. In the most pessimistic scenario (high immune escape, no vaccination recommendation), we project 2.1 million (90% projection interval (PI) [1,438,000, 4,270,000]) hospitalizations and 209,000 (90% PI [139,000, 461,000]) deaths, exceeding pre-pandemic mortality of influenza and pneumonia. In high immune escape scenarios, vaccination of those aged 65+ results in 230,000 (95% confidence interval (CI) [104,000, 355,000]) fewer hospitalizations and 33,000 (95% CI [12,000, 54,000]) fewer deaths, while vaccination of all eligible individuals results in 431,000 (95% CI: 264,000-598,000) fewer hospitalizations and 49,000 (95% CI [29,000, 69,000]) fewer deaths. COVID-19 is projected to be a significant public health threat over the coming 2 years. Broad vaccination has the potential to substantially reduce the burden of this disease, saving tens of thousands of lives each year.

Adherence to doxycycline for uncomplicated genitourinary chlamydia: A prospective observational study.

Since 2020, the Center for Disease Control and Prevention (CDC) no longer recommends single-dose azithromycin as first-line therapy for uncomplicated genitourinary chlamydia, advising instead a 7-day course of doxycycline. Our study investigates self-reported adherence to the new regimen, reasons for nonadherence, and the impact of dispensing the regimen on-site compared to prescribing it. We performed a prospective observational study of adult patients treated for suspected or laboratory-confirmed uncomplicated genitourinary chlamydia at three urban emergency departments (EDs), where patients receive a prescription for doxycycline, and in a sexually transmitted infection (STI) clinic, where the 14 doxycycline pills are dispensed on-site. Clinical data were extracted from electronic medical records and patients were interviewed regarding adherence via telephone 2-4weeks after their index visit. We enrolled 127 STI clinics and 201 ED patients. Therapeutic adherence was reported by 85% of STI clinic patients and 77% of ED patients. In the ED setting, younger age and female sex were associated with nonadherence, with only 67% of female patients reporting adherence. Reported reasons for nonadherence included medication adverse effects, financial and transportation barriers, skepticism of the need for therapy, and misunderstanding of discharge instructions, among others. A considerable portion of patients treated for uncomplicated genitourinary chlamydia in urban EDs and STI Clinics report nonadherence to the 7-day doxycycline regimen. The CDC recommendation to consider azithromycin when nonadherence is a "substantial concern" should be applied broadly in these settings by routinely discussing barriers to adherence when selecting the optimal antimicrobial regimen. The benefit of dispensing the doxycycline regimen on-site compared to prescribing it could not be determined given differences in baseline characteristics between the two groups.

Interim Estimates of 2023-24 Seasonal Influenza Vaccine Effectiveness - United States.

In the United States, annual influenza vaccination is recommended for all persons aged ≥6 months. Using data from four vaccine effectiveness (VE) networks during the 2023-24 influenza season, interim influenza VE was estimated among patients aged ≥6 months with acute respiratory illness-associated medical encounters using a test-negative case-control study design. Among children and adolescents aged 6 months-17 years, VE against influenza-associated outpatient visits ranged from 59% to 67% and against influenza-associated hospitalization ranged from 52% to 61%. Among adults aged ≥18 years, VE against influenza-associated outpatient visits ranged from 33% to 49% and against hospitalization from 41% to 44%. VE against influenza A ranged from 46% to 59% for children and adolescents and from 27% to 46% for adults across settings. VE against influenza B ranged from 64% to 89% for pediatric patients in outpatient settings and from 60% to 78% for all adults across settings. These findings demonstrate that the 2023-24 seasonal influenza vaccine is effective at reducing the risk for medically attended influenza virus infection. CDC recommends that all persons aged ≥6 months who have not yet been vaccinated this season get vaccinated while influenza circulates locally.

Interim Effectiveness of Updated 2023-2024 (Monovalent XBB.1.5) COVID-19 Vaccines Against COVID-19-Associated Emergency Department and Urgent Care Encounters and Hospitalization Among Immunocompetent Adults Aged ≥18 Years - VISION and IVY Networks, September 2023-January 2024.

In September 2023, CDC's Advisory Committee on Immunization Practices recommended updated 2023-2024 (monovalent XBB.1.5) COVID-19 vaccination for all persons aged ≥6 months to prevent COVID-19, including severe disease. However, few estimates of updated vaccine effectiveness (VE) against medically attended illness are available. This analysis evaluated VE of an updated COVID-19 vaccine dose against COVID-19-associated emergency department (ED) or urgent care (UC) encounters and hospitalization among immunocompetent adults aged ≥18 years during September 2023-January 2024 using a test-negative, case-control design with data from two CDC VE networks. VE against COVID-19-associated ED/UC encounters was 51% (95% CI = 47%-54%) during the first 7-59 days after an updated dose and 39% (95% CI = 33%-45%) during the 60-119 days after an updated dose. VE estimates against COVID-19-associated hospitalization from two CDC VE networks were 52% (95% CI = 47%-57%) and 43% (95% CI = 27%-56%), with a median interval from updated dose of 42 and 47 days, respectively. Updated COVID-19 vaccine provided increased protection against COVID-19-associated ED/UC encounters and hospitalization among immunocompetent adults. These results support CDC recommendations for updated 2023-2024 COVID-19 vaccination. All persons aged ≥6 months should receive updated 2023-2024 COVID-19 vaccine.

Adjuvant Human Papillomavirus Vaccination in Recurrent Respiratory Papilloma Patients Older than 45.

The primary objective was to examine the intersurgical interval (ISI) of recurrent respiratory papillomatosis (RRP) in patients older than 45 years before and after a Gardasil vaccination series. We conducted a retrospective chart review of adult patients >45 years of age diagnosed with RRP from 2012 to 2022. Patients were excluded if they did not receive at least two doses of the Gardasil vaccine series or if they underwent two or fewer surgeries during the study period. Thirteen patients met the inclusion criteria, 11 males and two females. The age at initial diagnosis ranged from 46 to 80 years, with a mean of 59 years. There was a significant increase in the average ISI, from 126 ± 87 days pre-vaccination compared to 494 ± 588 days post-vaccination (p < 0.01). The average number of surgeries per patient was 6.8 ± 2.4 over an average follow-up of 49.7 ± 30.3 months. Adjuvant Gardasil use in RRP patients older than 45 years significantly increases the ISI. Current CDC recommendations include only patients ages 9 to 45, but this study provides evidence that RRP patients outside this age range may benefit from adjuvant HPV vaccination. 4 Laryngoscope, 134:3226-3229, 2024.

CDC Laboratory Recommendations for Syphilis Testing, United States, 2024.

This report provides new CDC recommendations for tests that can support a diagnosis of syphilis, including serologic testing and methods for the identification of the causative agent Treponema pallidum. These comprehensive recommendations are the first published by CDC on laboratory testing for syphilis, which has traditionally been based on serologic algorithms to detect a humoral immune response to T. pallidum. These tests can be divided into nontreponemal and treponemal tests depending on whether they detect antibodies that are broadly reactive to lipoidal antigens shared by both host and T. pallidum or antibodies specific to T. pallidum, respectively. Both types of tests must be used in conjunction to help distinguish between an untreated infection or a past infection that has been successfully treated. Newer serologic tests allow for laboratory automation but must be used in an algorithm, which also can involve older manual serologic tests. Direct detection of T. pallidum continues to evolve from microscopic examination of material from lesions for visualization of T. pallidum to molecular detection of the organism. Limited point-of-care tests for syphilis are available in the United States; increased availability of point-of-care tests that are sensitive and specific could facilitate expansion of screening programs and reduce the time from test result to treatment. These recommendations are intended for use by clinical laboratory directors, laboratory staff, clinicians, and disease control personnel who must choose among the multiple available testing methods, establish standard operating procedures for collecting and processing specimens, interpret test results for laboratory reporting, and counsel and treat patients. Future revisions to these recommendations will be based on new research or technologic advancements for syphilis clinical laboratory science.

Characteristics Associated with Pre-Exposure Prophylaxis Discussion and Use Among Transgender Women Without HIV Infection - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020.

CDC recommends pre-exposure prophylaxis (PrEP) for transgender women who have sex with men and who report sexual behaviors that place them at substantial ongoing risk for HIV exposure, including those who engage in nonsterile syringe sharing. Providing transgender women with access to PrEP is a critical strategy for reducing HIV acquisition and ending the HIV epidemic. Survey results from the National HIV Behavioral Surveillance Among Transgender Women were used to assess characteristics associated with past-year discussions of PrEP with a health care provider and PrEP use. Bivariate analyses were conducted to assess the association between covariates (sociodemographic, HIV-associated characteristics, and gender-affirming care) and each outcome, accounting for sampling design. All covariates that were statistically significant at p<0.05 in the bivariate analyses were included in multivariate models, and manual backward elimination was used to obtain final models that retained statistically significant covariates. Among 902 transgender women from seven urban areas in the United States without HIV infection in the analyses, 57% had recently discussed PrEP with a health care provider, and 32% recently had used PrEP. In the final multivariate model, the following subgroups of transgender women were more likely to report recent PrEP use: those who identified as Black or African American or Hispanic or Latina, had two or more sex partners in the past 12 months, had condomless sex in the past 12 months, reported their last sex partner was infected with HIV, had condomless sex with their last sex partner whose HIV status was positive or unknown, ever had transgender-specific health care, and currently had transgender-specific health insurance coverage. Participants who were less likely to have recently used PrEP were those who wanted to but were not currently taking hormones and those aged <40 years. Providing increased access to gender-affirming care and training health care providers who serve transgender women to incorporate PrEP into existing services might increase PrEP use among transgender women.

Comparison of two testing strategies for Mycoplasma genitalium in emergency department patients across a statewide health system

PurposeMycoplasma genitalium (Mgen) is a sexually transmitted infection (STI) that has an estimated prevalence in the general population of 2.3% in women and 1.1% in men aged 21–23 years. (Hilbert and Reno, 2018) A cross-sectional study conducted in a community emergency department (ED) determined that the prevalence of Mgen was 14.8% in asymptomatic female patients. (Centers for Disease Control and Prevention (CDC). Sexually Transmitted Infections Treatment Guidelines, 2021) The Centers for Disease Control and Prevention (CDC) 2021 STI Treatment Guidelines recommend testing for Mgen in select circumstances. This study aims to determine what testing strategy in ED patients results in the most appropriate treatment of Mgen based on CDC recommendations. MethodsThis multicenter, retrospective, pre- and post-intervention cohort study assessed adherence to CDC recommendations for appropriate management of Mgen in ED patients. Inclusion criteria were patients at least 18 years of age discharged from one of the 15 ED sites within the health system studied who were tested for Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis (T. vaginalis), and Mgen. Subjects were excluded if they were pregnant, sexually assaulted, or had indeterminate STI results. For cohort 1, which included patients evaluated from May 2022 through July 2022, Mgen was incorporated into the standard STI testing panel. Cohort 2 consisted of patients evaluated from September 2022 through November 2022; testing for Mgen in cohort 2 was optional, and a testing algorithm based on CDC recommendations was disseminated to ED sites. The primary endpoint was the number of subjects treated appropriately for Mgen in accordance with CDC recommendations. Cohort 1 secondary endpoints included overall prevalence of Mgen in patients who presented to ED sites for STI testing and prevalence in ICD-10 code diagnosed PID. Secondary endpoints for both cohorts included baseline characteristics of patients who tested positive for Mgen. ResultsPercent appropriate treatment did not differ significantly between cohort 1 (21%) and cohort 2 (20%), (p > 0.9). However, greater than three times as many subjects were inappropriately treated for Mgen in cohort 1 when the health system studied did not adhere to current CDC Mgen testing recommendations. The overall prevalence of Mgen in ED patients who were tested for STIs was 13.1%. The prevalence of PID ICD-10 diagnosis code in patients positive for Mgen was 2.9%. Based on results of a risk factor analysis to determine if certain baseline characteristics are indicators for a positive infection with Mgen, a positive Mgen result was significantly associated with a positive result for T. vaginalis (p = 0.042). ConclusionsEvidence regarding the preferred testing strategy for Mgen is currently limited. This study demonstrates that testing all STI presenting patients for Mgen results in antibiotic overuse, so adhering to CDC testing recommendations is important. Prevalence of positive Mgen result in ED patients tested for STIs was similar to results of previously published literature. Risk factor analysis results could be used as a screening method to determine what patients should be considered for Mgen testing. Based on the results of this study, we recommend against including Mgen on the standard ED STI testing panel at this time.

Obesity after Induction Is Associated with Poor Overall Survival in Adults with Acute Lymphoblastic Leukemia: Results from a Peruvian Adaptation of the CALGB10403 Protocol

Background:Acute lymphoblastic leukemia (ALL) is a lymphoid malignancy with wide racial disparities. Indeed, ALL is more frequently diagnosed among the Latino population who classically achieve lower remission rates and experience worse survival than other racial and ethnic groups. Several high-risk features including genetic polymorphisms and metabolic issues have been implicated in Latino ethnicity, including obesity. A high body mass index (BMI) at different stages of treatment represents a well-known risk factor in several prospective studies mainly based on white populations. It is unclear whether these findings are consistent in other racial and ethnic unrepresentative groups. We aimed to evaluate the effect of BMI at the end of induction on the overall survival (OS) of Latino adults with ALL. Methods:We conducted a retrospective cohort study among adult patients diagnosed with ALL in an academic cancer center (Instituto Nacional de Enfermedades Neoplasicas - INEN) from 2017 to 2019, with follow-up through July 2023. The INEN is a national tertiary referral center in Lima-Peru that provides leukemia treatment for approximately 85% of the insured population in Peru. Patients aged 20-65 who successfully achieved complete remission after 4 weeks of intensive induction treatment were included. Patient data were manually abstracted from the medical records. BMI was classified as underweight, healthy weight, overweight and obese according to the CDC and WHO recommendations. Vital status was ascertained with the National Vital Registry. The Kaplan-Meier method and the Log-rank test were used to estimate OS probabilities. Multivariable Cox regression was used to evaluate the effect of BMI on OS, adjusting for sex, age, risk, and immunophenotype. Results: Of 784 patients identified in the electronic records of the INEN, we excluded 578 because they didn't achieve complete remission, yielding 206 patients for analysis. The median age at diagnosis was 33 years, most were aged 20-40 years old (68%), and female (54%). 160 (78%) were ALL-B Ph- and 126 (61%) corresponded to the high-risk stratification. At the end of the induction, 119 patients presented a healthy weight (58%), 49 (24%) overweight, 26 (13%) obese, and 12 (6%) underweight (Table 1). With a median follow-up of 55 months, the median OS was 18 months (95% CI: 16-23), and the 5-year OS was 23% for all patients. The 5-year OS was lower in patients with obesity (12%), followed by patients with overweight (20%), healthy weight (26%), and underweight (33%), as evidenced by the Kaplan-Meier curve (Figure 1, p=0.036). In the multivariable analysis, obesity (p-value=0.006) was associated with an increased risk of all-cause mortality (adjusted Hazard Ratio [aHR]: 1.93; 95% CI: 1.21-3.08). A very high-risk disease was also associated with poor OS (aHR:2.69; 95% CI: 1.15-6.26) (Table 1). Conclusion: This study identified that obesity at the end of induction is associated with inferior OS among Peruvian patients who achieved complete remission. Our real-world findings should be validated in prospective studies including other Latino populations to recommend the feasibility of weight reduction strategies.

A multimethods randomized trial found that plain language versions improved adults understanding of health recommendations

ObjectivesTo make informed decisions, the general population should have access to accessible and understandable health recommendations. To compare understanding, accessibility, usability, satisfaction, intention to implement, and preference of adults provided with a digital “Plain Language Recommendation” (PLR) format vs. the original “Standard Language Version” (SLV). Study Design and SettingAn allocation-concealed, blinded, controlled superiority trial and a qualitative study to understand participant preferences. An international on-line survey. 488 adults with some English proficiency. 67.8% of participants identified as female, 62.3% were from the Americas, 70.1% identified as white, 32.2% had a bachelor's degree as their highest completed education, and 42% said they were very comfortable reading health information. In collaboration with patient partners, advisors, and the Cochrane Consumer Network, we developed a plain language format of guideline recommendations (PLRs) to compare their effectiveness vs. the original standard language versions (SLVs) as published in the source guideline. We selected two recommendations about COVID-19 vaccine, similar in their content, to compare our versions, one from the World Health Organization (WHO) and one from Centers for Disease Control and Prevention (CDC). The primary outcome was understanding, measured as the proportion of correct responses to seven comprehension questions. Secondary outcomes were accessibility, usability, satisfaction, preference, and intended behavior, measured on a 1-7 scale. ResultsParticipants randomized to the PLR group had a higher proportion of correct responses to the understanding questions for the WHO recommendation (mean difference [MD] of 19.8%, 95% confidence interval [CI] 14.7–24.9%; P < 0.001) but this difference was smaller and not statistically significant for the CDC recommendation (MD of 3.9%, 95% CI −0.7% to 8.3%; P = 0.096). However, regardless of the recommendation, participants found the PLRs more accessible, (MD of 1.2 on the seven-point scale, 95% CI 0.9–1.4%; P < 0.001) and more satisfying (MD of 1.2, 95% CI 0.9–1.4%; P < 0.001). They were also more likely to follow the recommendation if they had not already followed it (MD of 1.2, 95% CI 0.7–1.8%; P < 0.001) and share it with other people they know (MD of 1.9, 95% CI 0.5–1.2%; P < 0.001). There was no significant difference in the preference between the two formats (MD of −0.3, 95% CI −0.5% to 0.03%; P = 0.078). The qualitative interviews supported and contextualized these findings. ConclusionHealth information provided in a PLR format improved understanding, accessibility, usability, and satisfaction and thereby has the potential to shape public decision-making behavior.

Analysis of Patient Adherence to Filling Emergency Department Discharge Prescriptions for Empiric Treatment of Chlamydia

PurposeSexually transmitted infections (STIs) represent an enormous public health burden in the United States. Emergency departments (EDs) are a significant source of medical care, particularly for vulnerable patient populations. Guidelines for the treatment of Chlamydia trachomatis have evolved and now recommend doxycycline 100 mg orally twice daily for 7 days as the primary regimen for adults. However, the single-dose azithromycin regimen can be given during the ED visit, while the new regimen has nonadherence hurdles. The purpose of this study will be determining the rate of ED discharge prescription pick ups of doxycycline for Chlamydia trachomatis infection at two discharge pharmacies. MethodsThis is a retrospective chart review of information contained in the electronic medical record (EMR) from August 1st, 2021 – July 31st, 2022. Adult patients who present to the two EDs in the healthcare system and those who received empiric antibiotic treatment for Chlamydia trachomatis infection prior to, or at, ED discharge will be included. Patients who are pregnant, less than 18 years old, those without a Chlamydia trachomatis nucleic acid amplification test during their ED visit, or patients whose antibiotic treatment prescription was sent to a pharmacy other than the two primary discharge pharmacies at the respective medical centers will be excluded. The primary outcome of this study will be determining the rate of emergency department (ED) discharge prescription pick ups of doxycycline for empiric treatment of Chlamydia trachomatis infection at two discharge pharmacies. The secondary outcomes will include the incidence of repeat positive tests between four weeks and 90 days, risk of repeat positive tests in those who do not fill doxycycline, number of positive and negative test results, rate of prescribing adherence to 2021 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Infections Treatment Guidelines regimens for empiric treatment, and insurance status at the time of discharge fill. ResultsSeven hundred and thirty patients were pulled from the EMR. One hundred of the patients were excluded from the study as they did not receive empiric antibiotic treatment for Chlamydia trachomatis infection prior to, or at, ED discharge leaving 630 participants. Among this group, 369 patients were excluded as their discharge prescription was not sent to the discharge pharmacies within the medical system, leaving 261 individuals in the study. Per chart review, 215 of the patients picked up their doxycycline prescription (82.4%) and 46 (17.6%) patients failed to pick up their prescription. Additionally, 43 (16.5) of the patients who were prescribed empiric therapy had a positive chlamydia trachomatis test, while 209 (83.5%) of those had a negative test. This study also showed 188 (72%) patients received treatment according to the current CDC recommendations. ConclusionMajority of patients who received prescriptions from the in-hospital discharge pharmacy picked up their prescriptions.