Improving Emergency Access to Human Immunodeficiency Virus Prophylaxis for Patients Evaluated After Sexual Assault.

INTRODUCTION: Patients evaluated after sexual assault may benefit from nonoccupational postexposure prophylaxis (nPEP) to prevent infection with HIV, yet multiple barriers may prohibit nPEP delivery. The IN-STEP (Integrating nPEP after Sexual Trauma in Emergency Practice) project was designed to improve access to HIV screening and prevention for patients evaluated in the emergency department (ED) of our academic hospital after a sexual assault. METHODS: The IN-STEP team identified and addressed four key areas for improvement: (1) training of ED providers to perform nPEP assessments; (2) access to HIV testing in the ED; (3) provision of nPEP medications, using a patient-centered approach; and (4) continuity of care between the ED and follow-up sites in the community. Improvements were implemented using parallel plan-do-study-act cycles corresponding to these four key areas. RESULTS: IN-STEP resulted in significant systems improvements in HIV screening, prevention, and continuity of care. This program not only improved the care of patients affected by sexual assault but also those evaluated for HIV due to other indications. CONCLUSIONS: Involvement of a multidisciplinary leadership team, clear delineation of a patient-centered project focus, and coordination across four parallel areas for improvement were useful for completing this complex effort.

A Single-Center Evaluation of Extended Infusion Piperacillin/Tazobactam for Empiric Treatment in the Intensive Care Unit.

Background: Piperacillin/tazobactam (PTZ) extended infusion (EI) is often used empirically in the intensive care unit (ICU). Gram-negative (GN) organisms with PTZ minimum inhibitory concentrations (MICs) >16/4 µg/mL are considered intermediate or resistant. Objective: The objective of this study was to evaluate MICs of GN isolates from the ICU to determine whether the hospital protocol for PTZ 3.375 g EI over 4 hours administered every 8 hours is an appropriate empiric regimen for ICU patients and to evaluate patient-specific risk factors associated with elevated MICs. Methods: All ICU patients admitted during 2017 with a confirmed GN organism from a non-urinary source were included for retrospective chart review. Patients with cystic fibrosis or cultures obtained >48 hours prior to ICU admission were excluded. Demographics, GN organism, culture source, risk factors for resistance, susceptibility profile, comorbidities, and creatinine clearance were collected. Appropriateness was defined as PTZ MIC ≤16/4 µg/mL in >80% of isolates. Results: Two hundred and thirty-one patients were included. The average patient was 56 years old. The majority of patients were white (64.1%) and male (69.7%). Pseudomonas aeruginosa (41%) was the most common organism isolated. Overall, 28% of GN isolates had MICs >16/4 µg/mL. Dialysis (P = .01), intravenous antibiotics within 90 days (P < .001), and presence of wounds/trauma (P = .01) were associated with elevated MICs. Conclusion: Current PTZ EI 3.375 g dosing regimens may not provide adequate empiric coverage for some GN organisms in ICU patients, especially for those who have previously received intravenous antibiotics, are on dialysis, or have wounds/trauma.