Infectious Disease Physicians Research Articles

A review of transplant infectious diseases and pediatric transplant infectious diseases curriculum.

As the volume and complexity of solid organ and hematopoietic stem cell transplantation continue to see rapid growth, the training of a specialized transplant infectious diseases physician workforce is of increasing interest and importance. This review provides an overview of the evolution of transplant infectious diseases training programs, essential elements of training, as well as future needs. Despite the first publication of a transplant infectious diseases curriculum in 2010, more recent surveys of infectious diseases trainees have identified gaps in didactic curriculum, donor and recipient assessment, and safe living practices. This review of transplant infectious diseases training summarizes growth through the decades, the current landscape of recommend training elements, suggested areas for continued development and expansion in training as well as novel methodologies to reach a modern trainee audience.

Using Active Surveillance to Identify Monoclonal Antibody Candidates Among COVID-19-Positive Veterans in the Atlanta VA Health Care System.

Strategies for optimizing identification and outreach to potential candidates for monoclonal antibody (Mab) therapy for COVID-19 are not clear. Using a centralized, active surveillance system, the Atlanta Veterans Affairs Health Care System (AVAHCS) infectious disease (ID) team identified candidates for Mab infusion and provided treatment. As part of a quality improvement project from December 28, 2020, to August 31, 2021, a clinical team consisting of ID pharmacists and physicians reviewed each outpatient with a positive COVID-19 polymerase chain reaction test daily at the AVAHCS. The clinical team used Emergency Use Authorization (EUA) criteria to determine eligibility. Eligible patients were contacted on the same day of review via telephone to confirm eligibility and obtain verbal consent. Telehealth follow-up occurred on day 1 and day 7 postinfusion to assess for adverse events. In total, 2028 patients with COVID-19 were identified; 289 patients (14%) were eligible, and 132 (46%) received Mab therapy. Similar to AVAHCS demographics, a majority of those who received Mab therapy were non-Hispanic Black patients (65%). The most common comorbidities were hypertension (59%) and diabetes (37%). The median time from symptom onset to positive COVID-19 polymerase chain reaction (PCR) test result was 6 days (range, 0-9), and the median time from positive COVID-19 PCR test result to Mab infusion was 2 days (range, 0-8). Twelve patients (9%) required hospitalization for worsening COVID-19 symptoms postinfusion. No deaths occurred. Combining laboratory surveillance and active screening led to high uptake of Mab therapy and minimized delay from symptom onset to Mab infusion, thereby optimizing outpatient treatment of COVID-19. This approach also successfully screened and treated Black patients in the AVAHCS population.

Harm Reduction: A Missing Piece to the Holistic Care of Patients Who Inject Drugs.

The rise in injection drug use (IDU) has led to an increase in drug-related infections. Harm reduction is an important strategy for preventing infections among people who inject drugs (PWID). We attempted to evaluate the harm reduction counseling that infectious diseases physicians provide to PWID presenting with infections. An electronic survey was distributed to physician members of the Emerging Infections Network to inquire about practices used when caring for patients with IDU-related infections. In total, 534 ID physicians responded to the survey. Of those, 375 (70%) reported routinely caring for PWID. Most respondents report screening for human immunodeficiency virus (HIV) and viral hepatitis (98%) and discussing the risk of these infections (87%); 63% prescribe immunization against viral hepatitis, and 45% discuss HIV preexposure prophylaxis (PrEP). However, 55% of respondents (n = 205) reported not counseling patients on safer injection strategies. Common reasons for not counseling included limited time and a desire to emphasize antibiotic therapy/medical issues (62%), lack of training (55%), and believing that it would be better addressed by other services (47%). Among respondents who reported counseling PWID, most recommended abstinence from IDU (72%), handwashing and skin cleansing before injection (62%), and safe disposal of needles/drug equipment used before admission (54%). Almost all ID physicians report screening PWID for HIV and viral hepatitis and discussing the risks of these infections. Despite frequently encountering PWID, fewer than half of ID physicians provide safer injection advice. Opportunities exist to standardize harm reduction education, emphasizing safer injection practices in conjunction with other strategies to prevent infections (eg, HIV PrEP or hepatitis A virus/hepatitis B virus vaccination).

Updates in hematopoietic cell transplant and cellular therapies that enhance the risk for opportunistic infections.

Infectious disease physicians may be asked to evaluate and manage a variety of infections in immunocompromised hosts undergoing hematopoietic cell transplant (HCT) and cellular therapies. Over the last decade, several advances in cellular therapy have occurred, with implications for the types of infectious complications that may be seen. The purpose of this review is to update the infectious disease physician on newer advances in HCT and cellular therapy, including haploidentical transplant, expanding indications for transplant in older individuals and children, and chimeric antigen receptor T-cells. We will review how these advances might influence infectious disease complications following HCT. We will also provide a perspective that infectious disease physicians can use to evaluate the degree of immune suppression in an individual patient to help determine the type of infections that may be encountered.

Preserving the Future of Infectious Diseases: Why We Must Address the Decline in Compensation for Clinicians and Researchers.

Infectious diseases (ID) physicians play a pivotal role in patient care and public health, yet concerns are mounting about their under-compensation compared with other medical specialties. This trend sees ID physicians, including new graduates, receiving lower remuneration than their general and hospital medicine peers, despite their significant contributions. The persistent disparity in compensation has been identified as a key factor behind the declining interest in the ID specialty among medical students and residents, potentially threatening patient care quality, research advancement, and diversity within the ID workforce. This viewpoint underscores the urgent need for the ID community to rally behind the Infectious Diseases Society of America in advocating for fair compensation for ID physicians and researchers. While focusing on wellness and work-life balance is vital, it is critical to address compensation, a significant source of distress for physicians. Failure to confront the issue of under-compensation promptly may jeopardize the future growth and sustainability of the ID specialty.

Fixed versus individualized treatment for five common bacterial infectious syndromes: a survey of the perspectives and practices of clinicians.

Traditionally, bacterial infections have been treated with fixed-duration antibiotic courses; however, some have advocated for individualized durations. It is not known which approach currently predominates. We conducted a multinational clinical practice survey asking prescribers their approach to treating skin and soft tissue infection (SSTI), community-acquired pneumonia (CAP), pyelonephritis, cholangitis and bloodstream infection (BSI) of an unknown source. The primary outcome was self-reported treatment approach as being fully fixed duration, fixed minimum, fixed maximum, fixed minimum and maximum, or fully individualized durations. Secondary questions explored factors influencing duration of therapy. Multivariable logistic regression with generalized estimating equations was used to examine predictors of use of fully fixed durations. Among 221 respondents, 170 (76.9%) completed the full survey; infectious diseases physicians accounted for 60.6%. Use of a fully fixed duration was least common for SSTI (8.5%) and more common for CAP (28.3%), BSI (29.9%), cholangitis (35.7%) and pyelonephritis (36.3%). Fully individualized therapy, with no fixed minimum or maximum, was used by only a minority: CAP (4.9%), pyelonephritis (5.0%), cholangitis (9.9%), BSI (13.6%) and SSTI (19.5%). In multivariable analyses, a fully fixed duration approach was more common among Canadian respondents [adjusted OR (aOR) 1.76 (95% CI 1.12-2.76)] and for CAP (aOR 4.25, 95% CI 2.53-7.13), cholangitis (aOR 6.01, 95% CI 3.49-10.36), pyelonephritis (aOR 6.08, 95% CI 3.56-10.39) and BSI (aOR 4.49, 95% CI 2.50-8.09) compared with SSTI. There is extensive practice heterogeneity in fixed versus individualized treatment; clinical trials would be helpful to compare these approaches.

Evaluation of Systemic Antifungal Use in a Latin American General Care Hospital: A Retrospective Study.

Invasive fungal infections significantly contribute to mortality and morbidity rates. Despite the presence of all four major classes of antifungal medications, it is estimated that these infections result in the death of 1.5 million people each year, and death rates are increasing at an alarming rate. With increasing concerns about the emergence of antifungal resistance, there is a growing consideration in many countries to incorporate antifungal stewardship into existing antimicrobial stewardship programs. This approach aims to address issues hindering the appropriate use of antifungal drugs and to optimize their utilization. An analytical retrospective study of 48 hospitalized patients was conducted to assess factors related to the use of systemic antifungals and develop and implement an internal protocol to improve its use. All patients with severe comorbidity had SOFA scores linked with a mortality risk of more than 10%. Based on 48 evaluations of antifungal orders, 62.5% were considered appropriate, 14.6% were considered debatable, and 22.9% were considered inappropriate. Infectious disease physicians made most of the prescriptions considered appropriate in this study. Comorbidities and risk factors in patients receiving systemic antifungals can be associated with the development of more serious fungal infections; hence, the implementation of antifungal stewardship as a complement to antimicrobial stewardship programs can help facilitate decision-making when dealing with a suspected case of fungal infection.

Healthcare providers consistently overestimate the diagnostic probability of ventilator-associated pneumonia.

To assess the accuracy of provider estimates of ventilator-associated pneumonia (VAP) diagnostic probability in various clinical scenarios. We conducted a clinical vignette-based survey of intensive care unit (ICU) physicians to evaluate provider estimates of VAP diagnostic probability before and after isolated cardinal VAP clinical changes and VAP diagnostic test results. Responses were used to calculate imputed diagnostic likelihood ratios (LRs), which were compared to evidence-based LRs. Michigan Medicine University Hospital, a tertiary-care center. This study included 133 ICU clinical faculty and house staff. Provider estimates of VAP diagnostic probability were consistently higher than evidence-based diagnostic probabilities. Similarly, imputed LRs from provider-estimated diagnostic probabilities were consistently higher than evidence-based LRs. These differences were most notable for positive bronchoalveolar lavage culture (provider-estimated LR 5.7 vs evidence-based LR 1.4; P < .01), chest radiograph with air bronchogram (provider-estimated LR 6.0 vs evidence-based LR 3.6; P < .01), and isolated purulent endotracheal secretions (provider-estimated LR 1.6 vs evidence-based LR 0.8; P < .01). Attending physicians and infectious disease physicians were more accurate in their LR estimates than trainees (P = .04) and non-ID physicians (P = .03). Physicians routinely overestimated the diagnostic probability of VAP as well as the positive LRs of isolated cardinal VAP clinical changes and VAP diagnostic test results. Diagnostic stewardship initiatives, including educational outreach and clinical decision support systems, may be useful adjuncts in minimizing VAP overdiagnosis and ICU antibiotic overuse.

The use of telehealth-supported stewardship activities in acute-care and long-term care settings: An implementation effectiveness trial.

We assessed the implementation of telehealth-supported stewardship activities in acute-care units and long-term care (LTC) units in Veterans' Administration medical centers (VAMCs). Before-and-after, quasi-experimental implementation effectiveness study with a baseline period (2019-2020) and an intervention period (2021). The study was conducted in 3 VAMCs without onsite infectious disease (ID) support. The study included inpatient providers at participating sites who prescribe antibiotics. During 2021, an ID physician met virtually 3 times per week with the stewardship pharmacist at each participating VAMC to review patients on antibiotics in acute-care units and LTC units. Real-time feedback on prescribing antibiotics was given to providers. Additional implementation strategies included stakeholder engagement, education, and quality monitoring. The reach-effectiveness-adoption-implementation-maintenance (RE-AIM) framework was used for program evaluation. The primary outcome of effectiveness was antibiotic days of therapy (DOT) per 1,000 days present aggregated across all 3 sites. An interrupted time-series analysis was performed to compare this rate during the intervention and baseline periods. Electronic surveys, periodic reflections, and semistructured interviews were used to assess other RE-AIM outcomes. The telehealth program reviewed 502 unique patients and made 681 recommendations to 24 providers; 77% of recommendations were accepted. After program initiation, antibiotic DOT immediately decreased in the LTC units (-30%; P < .01) without a significant immediate change in the acute-care units (+16%; P = .22); thereafter DOT remained stable in both settings. Providers generally appreciated feedback and collaborative discussions. The implementation of our telehealth program was associated with reductions in antibiotic use in the LTC units but not in the smaller acute-care units. Overall, providers perceived the intervention as acceptable. Wider implementation of telehealth-supported stewardship activities may achieve reductions in antibiotic use.

An Apple a Day

In this narrative medicine essay, an infectious diseases physician compares her past near bucolic experience in the emergency department when treated for anaphylactic with the now perpetually chaotic and crowded scene ushered in by COVID-19.

A Retrospective Study of Staphylococcus aureus Bacteremia in a Tertiary Hospital and Factors Associated with Mortality.

Staphylococcus aureus bacteremia (SAB) is a severe infection frequently associated with significant morbidity and mortality. Recent studies have shown that SAB mortality has decreased during the last decades. However, about 25% of patients suffering from the disease will ultimately die. Hence, there is an urgent need for more timely and efficient treatment of patients with SAB. The aim of the present study was to retrospectively evaluate a cohort of SAB patients hospitalized in a tertiary hospital and to identify factors independently associated with mortality. All 256 SAB patients hospitalized from January 2005 to December 2021 in the University Hospital of Heraklion, Greece, were evaluated. Their median age was 72 years, while 101 (39.5%) were female. Most SAB patients were cared for in medical wards (80.5%). The infection was community-acquired in 49.5%. Among all strains 37.9% were methicillin-resistant S. aureus (MRSA), however, definite treatment with an antistaphylococcal penicillin was given only in 22% of patients. Only 14.4% of patients had a repeat blood culture after the initiation of antimicrobial treatment. Infective endocarditis was present in 8%. In-hospital mortality has reached 15.9%. Female gender, older age, higher McCabe score, previous antimicrobial use, presence of a central venous catheter, neutropenia, severe sepsis, septic shock, and MRSA SAB were positively associated with in-hospital mortality, while monomicrobial bacteremia was negatively associated. The multivariate logistic regression model identified only severe sepsis (p = 0.05, odds ratio = 12.294) and septic shock (p = 0.007, odds ratio 57.18) to be independently positively associated with in-hospital mortality. The evaluation revealed high rates of inappropriate empirical antimicrobial treatment and non-adherence to guidelines, as shown, by the lack of repeat blood cultures. These data underline the urgent need for interventions with antimicrobial stewardship, increased involvement of infectious diseases physicians, educational sessions, and creation and implementation of local guidelines for improvement of the necessary steps for timely and efficient SAB treatment. Optimization of diagnostic techniques is needed to overcome challenges such as heteroresistance that may affect treatment. Clinicians should be aware of the factors associated with mortality in patients with SAB to identify those who are at a higher risk and optimize medical management.

Social media as a catalyst to improve (personal) health.

Social media as a catalyst to improve (personal) health.

Qdenga® - A promising dengue fever vaccine; can it be recommended to non-immune travelers?

Qdenga® has been approved by the European Medicines Agency (EMA) for individuals > 4 years of age and for use according to national recommendations. The vaccine shows high efficacy against virologically confirmed dengue and severe dengue in clinical studies on 4–16-year old's living in endemic areas. For individuals 16–60 years old only serological data exists and there is no data for individuals > 60 years. Its use as a travel vaccine is still unclear. We present the studies behind the approval and the recommendations for travelers as issued by the Swedish Society for Infectious Diseases Physicians.

Validation of antibiotic stewardship metrics for genitourinary infection management in Veterans Affairs outpatient settings

Background: Diagnosis and management of suspected urinary tract infection (UTI) in outpatient settings has been shown to be suboptimal. We previously developed a set of stewardship metrics for UTIs based on electronic health record (EHR) data (Antimicrobial Stewardship &amp; Healthcare Epidemiology 2022;2 suppl 1:S5–S6. doi:10.1017/ash.2022). A tier-based approach was used to more fully capture antibiotic use associated with genitourinary (GU) symptoms and diagnoses. Herein we report a preliminary analysis of validity and reliability of these metrics based on chart abstraction. Methods: The study cohort consisted of patients who visited Veterans Affairs emergency departments or primary care clinics between 2015 and 2022 and who had a GU diagnosis based on International Classification of Disease, Tenth Revision (ICD-10) codes, divided into 3 categories: tier 1 (antibiotics always indicated), tier 2 (antibiotics sometimes indicated), and tier 3 (antibiotics not indicated). Visits related to urological procedures, nontarget settings, or concomitant non-GU infections were excluded. Cases were randomly sampled for manual review from within 8 strata based on tier, use of antibiotics, and visit type. An infectious disease physician and pharmacist abstracted charts using a standardized data-collection instrument. Clinical judgments regarding diagnosis and treatment were recorded on a Likert scale without knowledge of how the patient was managed. The intraclass correlation coefficient (ICC) was used to estimate interrater reliability. Results: To date, 148 cases have been reviewed (50 by both reviewers). Mean (SD) age was 67.5 (15.3) years and 12.2% were female. In a majority of tier 1 and 2 visits in which antibiotics were given, the reviewers found evidence for GU infection (69.7%) and favored prescribing of antibiotics (60.6%) (Table). In contrast, most patients in the tier 3 category who received antibiotics were judged to have noninfectious conditions (eg, benign prostatic hypertrophy) and to not require antibiotics. In the subset of records examined by both reviewers, the interrater reliability of judgments of whether antibiotics were warranted was good (ICC = .704). Conclusions: This preliminary validation provides support for a tier-based approach for stewardship metrics for GU conditions that relies upon electronic data to identify patients for whom antibiotics are generally not indicated.Disclosures: None

Examining the effects of organizational influencers on the implementation of clinical innovations: A qualitative analysis

Background: The FIRST Trial is a 5-year study funded by the Agency for Healthcare Research and Quality. Our investigation is situated within a more extensive study to restrict fluoroquinolone antibiotics by requiring providers to obtain authorization from an infectious disease physician before prescribing fluoroquinolones. Our research team is performing a systematic evaluation to identify organizational characteristics and influencers of the fluoroquinolone preprescription authorization implementation process to understand variables that may facilitate or hinder implementation success. Methods: To address this critical gap, we present a qualitative analysis from our ongoing, multisite research project aimed at systematically assessing the adoption of an antimicrobial stewardship intervention in the form of an EHR-integrated best-practice alert (BPA) at each site to identify work system factors that impact uptake and variability in the implementation of the BPA at each location. The evaluation provides a detailed explanation of activities through the implementation process (eg, before implementation, during implementation, and after implementation) to assess how an organization effectively negotiates the phases and transitions, ultimately influencing the impact of the intervention. We have used a contextual determinant framework (CFIR) that has enabled us to perform a systematic and comprehensive exploration and identification of potential explanatory themes or variables to shed light on the complex social phenomenon of implementation. Results: Participants who will be a part of our poster presentation will learn about implementing a BPA, the potential barriers to implementation, and strategies for overcoming these barriers. Stakeholders within our study include site coordinators, medical doctors, nurses, pharmacists, and clinical informaticists. Our analysis synthesizes their experiences implementing and sustaining this evidence-based antimicrobial stewardship intervention. It includes (1) a detailed description of the process of change, (2) work-system factors (eg, inner setting and outer setting) that they believe influenced the success of the intervention, (3) barriers and facilitators (eg, CFIR constructs) within the implementation process; and (4) description of how these could have influenced the outcomes of interest (eg, implementation and intervention effectiveness). Conclusions: Our research is expected to advance patient safety research and initiatives by providing a more robust approach to performing systematic intervention evaluations. By outlining stakeholders’ experiences within our study, implementation leaders within healthcare systems will utilize our findings to aid them in their design and implementation process when designing and implementing similar types of healthcare interventions.Disclosures: None

Electrifying the case review process for better speed, reach, and impact

Background: Prevention of healthcare-associated infections (HAIs) requires timely feedback to and input from all staff involved in patient care to best identify practice gaps and improvement targets. However, multidisciplinary review of HAI events can be challenging to promptly complete given staffing shortages and the excess administrative burden of emailed and printed forms and disjointed analyses, reporting, and visualization tools. Plagued by a lack of feedback from attending and ordering physicians, difficulty transcribing and analyzing nonstandardized data, and challenges in summarizing and distributing actionable findings, we sought to reduce turnaround time (TAT), improve data collection, and broaden communication of HAI contributing factors and proposed solutions. Methods: A secure web application for electronic data capture and reporting, Research Electronic Data Capture (REDCap), was used; the software application is free to nonprofit organizations. The review process is now initiated by an infection preventionist entering HAI information into an initial survey, which automatically cascades information into 4 subsequent surveys, distributed through automated email links, providing an opportunity for individual responses from the nursing unit, the attending provider, an infectious disease physician, and the ordering provider for the positive test that detected the HAI. Survey questions focus on evaluation of adherence to CDC and SHEA HAI prevention strategies. Reminders are automatically generated and continue to be sent to involved staff until their portion is completed. Survey responses are automatically summarized upon completion of all reviews and are shared with several stakeholders, including hospital leadership, the care team, infection prevention staff, and quality-control partners (Fig.). Discrete qualitative and quantitative data are exported in a standard application-programming interface (API) format for immediate analysis and interpretation. Results: After the review process was launched using new electronic technology, the average TAT and completion rate improved from 23 days and 40% to 7 days and 95%, respectively. Input from ordering and attending physicians, once extremely rare, became frequent. Nuanced insight into causative and preventive factors, previously unachievable, occurred during review of all 38 HAIs reported in December 2022. Reviewers believed that 48% of HAIs reviewed could have been prevented. Conclusions: Applying electronic technology to HAI case review improved completion and timeliness of reviews by both providers and nurses. By sharing data and insights with all stakeholders in real time, the new procedure permitted multidirectional communication between the care teams and increased awareness of patient harm as well as ownership of patient safety. Our process is freely and readily generalizable to any nonprofit healthcare facility.Disclosures: None

The effectiveness of the appropriate prophylactic antibiotic use program for surgery

Background: Evaluation of the adequacy of prophylactic antibiotics in surgery has been implemented as a national policy in Korea since August 2007, and the appropriate use of prophylactic antibiotics has improved. However, antibiotic prescriptions that are not recommended or discontinuation of prophylactic antibiotic administration within 24 hours after surgery are still not well done. This study introduced a program to improve the adequacy of prophylactic antibiotics for surgery and analyzed its effects. Methods: We retrospectively analyzed the effectiveness of the appropriate prophylactic antibiotic use program for surgery conducted at a university hospital in Seoul. The participants were patients aged ≥18 years who underwent any of 18 types of surgery. The program started was implemented in June 2020. First, a computer system was used to confirm the antibiotic prescription recommended for each surgery. It also assessed whether the number of days of administration was exceeded, whether antibiotics were prescribed in combination, and whether antibiotics prescribed for discharge medicine were checked in 4 steps. A pop-up window appeared in each patient record to enter the reason for the prescription. If the reason was appropriate, the prescription was allowed, but if not, the prescription was restricted. In addition, infectious diseases physicians and an insurance review team visited each department to conduct an education session. To analyze the effect 3 months before activity (January–March 2020) and 3 months after activity (October–December 2020), we compared the first antibiotic administration rate within 1 hour prior to skin incision, the recommended prophylactic antibiotic administration rate, and surgery type. The rate of discontinuation of prophylactic antibiotics within 24 hours after administration and the rate of prescription of prophylactic antibiotics at discharge were compared. Results: In total, 1,339 surgeries during the study period were included in the analysis. There were 695 cases before the introduction of the program and 644 cases after the introduction. The rate of first antibiotic use within 1 hour prior to skin incision was 93.1%–99.5% (P &lt; .001), the rate of recommended prophylactic antibiotic administration was 85.0%–99.2% (P &lt; .001), and the rate of discontinuation of antibiotic administration within 24 hours after surgery improved from 51.8% to 98.3% (P &lt; .001), respectively. The prescription rate of antibiotics at discharge improved from 20.7% to 0.8% (P &lt;.001) (Table 1). Conclusions: A computerized program to improve the adequacy of prophylactic antibiotic use in surgery combined with education of medical staff was very effective.Disclosure: None

The Current Policy Debate around the Regulation of LDTs: What It Means for Infectious Disease Testing and Where It May Be Headed

The debate over federal regulation of diagnostic tests is not new, but scientific advances, societal developments, and global events over the past decade have accelerated efforts by the Food and Drug Administration (FDA) and members of Congress to revise the regulatory oversight of these devices, including laboratory-developed tests (LDTs). Despite years of congressional hearings and public meetings, legislation in the House and Senate, draft guidance from the FDA, and debate in the stakeholder community, LDT regulation remains unchanged, and the path forward remains unclear. LDTs play an essential role in infectious disease (ID) management and treatment, and changes in their regulation will have far-reaching implications for diagnostic laboratories. LDTs are widely used by clinical microbiology laboratories for the diagnosis and monitoring of a myriad infectious diseases, and until three years ago, such testing was conducted largely out of the spotlight. The COVID-19 pandemic changed this by bringing ID tests into the forefront. As the 118th Congress gets under way, the regulation and oversight of diagnostic tests, including LDTs, remains at the forefront of health care policy discussions on Capitol Hill and with the FDA. Change is coming, and it is important that clinical microbiologists, ID physicians, and other laboratorians have a seat at the table when such changes are being discussed.

Learning what matters in allogeneic transplant: Insights into older patient preferences in an age-friendly multidisciplinary clinic.

e24029 Background: HCT is increasingly being considered for older adults (60+) with blood cancers, with emerging data suggesting HCT imparts a survival benefit for eligible patients (pts). HCT-related morbidity and mortality remains significant in older adults, with no consensus on how to best prospectively evaluate HCT versus other approaches. Shared decision making (SDM) may help reconcile such treatment options for older adults. Understanding pts preferences (PP) and values is a cornerstone of SDM, yet no data exist in how to elicit and apply PP for older adults facing this treatment choice. Methods: We analyzed documented PP among the first 40 older adults from an ongoing IRB-approved prospective protocol enrolling HCT candidates ≥60 years to participate in a multi-disciplinary optimization clinic, the Aging &amp; Blood Cancers (ABC) clinic. The ABC clinic is comprised of pre-HCT consultations with a geriatrician, HCT physician, physical therapist, dietician and social worker and an ID physician. We reviewed the primary treating team documentation relative to the ABC clinic documentation, notes reviewed from HLA typing orders or documented plan for HCT. Categorization of PP consisted of any of the following: (1) care goals after HCT (e.g. cure, disease control, functional recovery, spending time with family/friends, attending life events), (2) toxicity concerns, and (3) pt rationale for proceeding to HCT. We included PP when summarized in the advanced care planning (ACP) documents if signed by a team member or referenced in their note. Findings were extracted by one physician and then reviewed by a second physician to adjudicate assignment as a PP. P-values were derived from incidence rates and chi-squared testing. Results: Among 40 pts with a median age of 74 yrs (range 60-), 856 notes and 38 ACP documents were reviewed. We found PP in 26 notes (2.9%) in 19 pts (47.5%). Of pts with PP documented, the primary team accounted for 4, compared to 14 pts in the ABC clinic (p &lt; 0.02). Notably, the primary team documented a risk:benefit discussion about HCT in 31 patients (p &lt; 0.0001). Among total PP (n = 19) the most common included functional recovery (73.6%), spending time with family or specific people (73.6%) and minimizing toxicity (42.1%). Less common PP were disease control/cure (31.6%) or avoiding the need for future disease treatments (15.8%). Conclusions: To our knowledge, this is the first study to document older adult PPs before HCT, finding them to be rarely documented. The older adult specific HCT clinic enhanced preference documentation, yet still in less than half of pts. Future studies to develop tools to better elicit and incorporate pt preferences should be prioritized to facilitate shared decision making for HCT among older adults.

Variations in implementation of antimicrobial stewardship via telehealth at select Veterans Affairs medical centers

Background: Antimicrobial stewardship programs (ASPs) seek to reduce the prevalence of antimicrobial-resistant and healthcare-associated infections. There are limited infectious disease (ID) physicians and pharmacists to support these ASPs, particularly in rural areas. The Veterans Health Administration has a robust telehealth program in place. Our previous work has demonstrated the feasibility of using telehealth modalities to support ASPs at rural Veterans Affairs medical centers (VAMCs) by pairing them with an ID expert from a larger, geographically distant, VAMC. This program, dubbed the Videoconference Antimicrobial Stewardship Team (VAST), emphasizes discussion of patients undergoing treatment for an active infection and additional relevant clinical topics with a multidisciplinary team at the rural VA. VAST implementation is ongoing at VAMCs. To understand and compare the qualitative differences in implementation, we used process maps to describe the VAST at 3 VAMC dyads. Methods: Team members from each dyad participated in interviews at 3, 6, and 9 months after beginning their VAST sessions. Questions addressed several aspects of VAST implementation and included identifying cases and topics to discuss; advance preparation for meetings; the frequency and general structure of VAST meetings; and documentation including workload capture. The research team used the responses to develop process maps to permit visual display and comparison of VAST implementation. Results: The first dyad began in January 2022 and the third in March 2022. The sessions had 3 phases: preparation, team meeting, and documentation of experts’ recommendations. Tasks were shared between VAST champions at the rural VAMC and the ID experts (Fig. 1). The preparation phase showed the most variation among the 3 dyads. In general, champions at the rural VA identified cases and topics for discussion that were sent to the ID expert for review. The approaches used to find cases and the type of preparatory work by the ID expert differed. Team meetings differed in both frequency and participation by professionals from the rural site. Documentation of expert recommendations processes appeared similar among the dyads. Discussion: Each of the 3 dyads implemented VAST differently. These results suggest that the overall structure of the VAST is readily adaptable and that each site tailored VAST to suit the clinical needs, workflow, and culture of their partner facility. Future work will seek to determine which aspects in the preparation, team meeting, or documentation phases are associated with successful ASPs, including assessment of quantitative and qualitative outcomes.Disclosures: None