Impact of education and clinic site champion on extragenital testing for sexually transmitted infections.

BACKGROUND: Sexually transmitted infections (STIs) are on the rise in the United States. Infections at extragenital (EG) sites (throat or rectum) may serve as an overlooked reservoir for STIs. The aims of this project were to determine the proportion of patients receiving EG testing and to observe the impact of an educational intervention. METHODS: Phase I included four urgent care clinics and baseline data for adults receiving STI testing (Chlamydia trachomatis and Neisseria gonorrhoeae). Clinics received access to an educational presentation regarding the importance of EG testing. Two of these clinics served as pilot sites for the implementation of self-collection kits. Phase II involved further expansion and utilization of clinic site champions. RESULTS: Phase I baseline data indicated that less than 1% of samples from patients receiving STI testing were from EG sites. There was an increase in EG testing after the educational intervention and implementation of self-collection kits. A larger increase in EG testing was seen after utilization of a site champion in Phase II. CONCLUSION: EG infections serve as a potential source for STI transmission which makes multi-site testing necessary. Our interventions to improve EG testing were most effective in Phase II after implementing a clinic site champion.

Factors associated with non-guideline-adherent treatment for gonorrhea and chlamydia among outpatient prescriptions in the Unites States.

Background: Patients at risk for sexually transmitted infections (STI) frequently receive care at non-specialized outpatient clinics staffed by physicians and advanced practice clinicians (APCs).Methods: Retrospective cohort study including adult patients diagnosed with chlamydia and/or gonorrhea at urgent care (UC), family medicine (FM), internal medicine (IM) or obstetrics and gynecology (Ob-Gyn) clinics. The effect of type of clinician on guideline-adherent treatment was estimated using logistic regression adjusted for age, type of clinic, type of infection, and (in female patients) pregnancy status.Results: A total of 1021 patients were identified, 654 (64.1%) females and 367 (35.9%) males. Overall, 12.8% (84/654) of female patients and 19.1% (70/367) of male patients received inadequate antibiotic therapy. Among females, 63.5% (415/654) were treated by APCs and 36.5% (239/654) by physicians. Odds of inadequate therapy did not differ when comparing APCs to physicians (OR 0.83 [95% CI 0.52-1.32; p = .42]). Variables independently associated with inadequate therapy were pregnancy (OR 3.80 [95% CI 1.55-6.10; p < .001]), infection with gonorrhea (OR 2.91 [95% CI 1.65-5.10; p < .0001]) and co-infection (OR 2.63 [95% CI 1.24-5.58; p = .01]) compared to infection with chlamydia alone. Compared to UC clinics, female patients treated at Ob-Gyn clinics had lower odds of inadequate therapy (OR 0.45 [95% CI 0.22-0.90; p = .02]). Among males, odds of inadequate therapy did not differ by clinician type.Conclusions: Inadequate antibiotic therapy for chlamydia and/or gonorrhea was not associated with type of clinician. These results can help guide educational strategies and resources towards the clinical settings with the greatest gaps in adequacy of management of chlamydia and gonorrhea.

Comparison of the performance of a clinical classification tree versus clinical gestalt in predicting sepsis with extended-spectrum beta-lactamase-producing gram-negative rods.

A clinical decision tree was developed using point-of-care characteristics to identify patients with culture-proven sepsis due to extended-spectrum ß-lactamase-producing Enterobacterales (ESBL-PE). We compared its performance with the clinical gestalt of emergency department (ED) clinicians and hospital-based clinicians. The developed tree outperformed ED-based clinicians but was comparable to inpatient-based clinicians.

Cutaneous mucormycosis in a chronic lymphocytic leukemia patient on ibrutinib.

BACKGROUND: Mucorales is a zygomycete fungi known to cause opportunistic infections in immunosuppressed hosts. Spores may be inhaled, causing rhinocerebral or pulmonary infections, or gastrointestinal infections if swallowed. Less often, cutaneous mucormycosis develops after inoculation via broken skin. PRESENTATION: A 72-year old male on ibrutinib and prednisone for chronic lymphocytic leukemia (CLL) presented with localized, right forearm cutaneous mucormycosis at the site of a dog-scratch sustained three weeks prior. The patient failed to respond to cephalexin as an outpatient, prompting biopsy showing ribbon-like pseudo septate hyphae and possible vascular invasion suggestive of Mucorales. Treatment course included liposomal amphotericin B 5 mg/kg IV every 24 h for ten days followed by a 90-day course of posaconazole 300 mg daily after general surgery consultation was sought. CONCLUSION: We outline the second reported case of localized cutaneous mucormycosis arising in the setting of ibrutinib use. Because the combination of immunosuppressed states, ibrutinib and skin trauma may serve as a nidus for mucormycosis, practitioners should be vigilant of thorough skin evaluations in these patients and appropriate anti-fungal treatment. Although amphotericin B has been well studied as first line therapy, oral posaconazole has been shown as an efficacious second-line treatment.

What Women Want: Factors Impacting Contraceptive Satisfaction in Privately Insured Women.

PURPOSE: To identify factors associated with high contraceptive method satisfaction among privately insured, adult women in Pennsylvania. METHODS: We used cross-sectional survey data collected in 2014 from 874 privately insured women participating in the MyNewOptions study who were currently using contraception. Binomial logistic regression assessed the relationship of contraceptive attributes, attitudes, and sociodemographic variables with contraceptive method satisfaction. FINDINGS: More than one-half of the analytic sample (53%) was "very satisfied" with their current contraceptive method. The strongest predictors of high method satisfaction were having a method that was easy to use (adjusted odds ratio [aOR], 2.65; 95% confidence interval [CI], 1.79-3.91), high perceived method effectiveness (aOR, 2.52; 95% CI, 1.68-3.78), cost not being a factor in method selection (aOR, 2.88; 95% CI, 2.08-4.00), and not being troubled by side effects (aOR, 2.27; 95% CI, 1.54-3.34). In contrast with previous studies, long-acting reversible contraception (i.e., intrauterine devices and contraceptive implant) was not independently associated with high method satisfaction, but other hormonal methods were (versus nonprescription methods; aOR, 2.48; 95% CI, 1.65-3.75). CONCLUSIONS: The strongest predictors of high method satisfaction were having a method that was easy to use and effective and for which cost was not a factor in method selection.