Evaluation of a Geographic Screening Protocol for Chronic Parasitic Infections Before Kidney Transplant: An Institutional Experience in Minnesota.

Pretransplant recommendations advise risk-based screening for strongyloidiasis, schistosomiasis, and Chagas disease. We evaluated the implementation of a chronic parasite screening protocol at a health system in a nonendemic region serving a large foreign-born population. Candidates listed for kidney transplant at Hennepin Healthcare (Minneapolis, MN) between 2010 and 2020 were included. Country of birth and serologic screening for strongyloidiasis, schistosomiasis, and Chagas disease were retrospectively obtained from electronic medical records. Parasite screening frequency and seropositivity was assessed before and after implementation of a geographic risk factor-based screening protocol in 2014. Cost-efficiency of presumptive treatment was modeled. Of 907 kidney transplant candidates, 312 (34%) were born in the United States and 232 (26%) outside the United States, with the remainder missing country of birth information. The 447 (49%) candidates evaluated after implementation of the screening protocol had fewer unidentified countries of birth (53%-27%, P < 0.001) and were more frequently screened for strongyloidiasis, schistosomiasis, and Chagas disease (14%-44%, 8%-22%, and 1-14%, respectively, all Ps < 0.001). The number of identified seropositive candidates increased after protocol implementation from two to 14 for strongyloidiasis and from one to 11 for schistosomiasis, with none seropositive for Chagas disease. The cost-efficiency model favored presumptive ivermectin when strongyloidiasis prevalence reaches 30% of those screened. Implementing a geographic risk screening protocol before kidney transplant increases attention to infectious disease risk associated with country of birth and identification of chronic parasitic infections. In populations with higher strongyloidiasis prevalence or lower ivermectin costs, presumptive treatment may be cost-efficient.

Hospital pharmacy acquisition of nonstocked antimicrobials-current processes and areas for improvement.

BACKGROUND: The delivery of prompt and appropriate antimicrobial therapy for life-threatening infections is an important antimicrobial stewardship measure and a priority for hospitals. OBJECTIVES: To better understand U.S. hospital pharmacy stocking processes and acquisition of nonstocked antimicrobials and to identify strategies for improving this process. METHODS: This mixed-methods study recruited infectious diseases and antimicrobial stewardship pharmacists. Semistructured interviews with pharmacists in Minnesota were conducted via video conferencing software from January 21, 2021, to March 17, 2021. Audio recordings of the interviews guided survey development and were also transcribed, coded, and qualitatively analyzed. Surveys were distributed throughout the United States via an e-mail listserv, and responses were collected between August 5, 2021, and September 15, 2021. RESULTS: Ten interviews and 78 surveys were included in the analysis. Formulary and stocking practices varied based on institution. Stocking decisions were most frequently based on the frequency of use, clinical utility, and cost of antimicrobials. Nonstocked antimicrobials were often ordered from the wholesale distributor but, if needed urgently, acquired from another local institution. Antibacterial agents were the most frequently needed nonstocked antimicrobials, especially those targeting multidrug-resistant gram-negative bacteria. When acquiring nonstocked antimicrobials, barriers include process inefficiencies, cost, availability, and safety concerns. Improved information sharing between local institutions may help improve this process. CONCLUSION: In this exploratory study, antimicrobial stocking practices varied within U.S. hospitals. Acquisition of nonstocked, urgently needed antimicrobials from neighboring hospitals may be common; however, this process lacks guidance and is often inefficient. Establishing better mechanisms for information sharing may improve this process and should be explored.