Cawcutt, Kelly

Background To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management. Methods Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines. Results After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient’s unique characteristics. Conclusions The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

Abstract Background Specialty societies, including the Infectious Diseases Society of America, strive to address gender and racial inequities in professional advancement. Microaggressions remain a persistent and pervasive barrier to these goals. Nonprofessional speaker introductions are a manifestation of race- and gender-based microaggressions, which have not been previously assessed at IDWeek. We assessed disparities in speaker introductions at IDWeek over a 7-year period that included formal gender equity initiatives introduced in 2016. Methods We conducted a retrospective observational study of video-recorded IDWeek speaker introductions from 2013 to 2019. Trained coders reviewed presentation video archives to assess a primary outcome of nonprofessional introductions: when a speaker's professional title was not used as the first introduction. We used descriptive statistics, Fisher exact tests, Cochrane-Armitage trend tests, and multivariable logistic regression to characterize relationships between speaker introductions and presentation year, speaker demographics, and speaker-moderator demographic concordance. Results Of 1940 videos reviewed, 48.9% of IDWeek speakers received nonprofessional introductions during and before 2016 vs 41.5% of speakers after 2016 (P = .0013). There was an increasing linear trend in the frequency of professional introductions by speaker age group from 47.1% for age <40 years to 65.3% for age >60 years (P < .0001). White moderators more frequently used nonprofessional introductions than moderators from backgrounds underrepresented in medicine (47.7% vs 29.1%, P = .0014). Women-men speaker-moderator pairs had more nonprofessional introductions (54.6%, P < .001). Conclusions In the largest assessment of microaggressions in speaker introductions at a national medical specialty conference, we highlighted some progress over time and ample opportunity to further standardize equitable speaker introductions, especially for women and junior speakers

IMPORTANCE: Initial Society of Critical Care Medicine Discovery Viral Infection and Respiratory illness Universal Study (VIRUS) Registry analysis suggested that improvements in critical care processes offered the greatest modifiable opportunity to improve critically ill COVID-19 patient outcomes. OBJECTIVES: The Structured Team-based Optimal Patient-Centered Care for Virus COVID-19 ICU Collaborative was created to identify and speed implementation of best evidence based COVID-19 practices. DESIGN, SETTING, AND PARTICIPANTS: This 6-month project included volunteer interprofessional teams from VIRUS Registry sites, who received online training on the Checklist for Early Recognition and Treatment of Acute Illness and iNjury approach, a structured and systematic method for delivering evidence based critical care. Collaborators participated in weekly 1-hour videoconference sessions on high impact topics, monthly quality improvement (QI) coaching sessions, and received extensive additional resources for asynchronous learning. MAIN OUTCOMES AND MEASURES: Outcomes included learner engagement, satisfaction, and number of QI projects initiated by participating teams. RESULTS: Eleven of 13 initial sites participated in the Collaborative from March 2, 2021, to September 29, 2021. A total of 67 learners participated in the Collaborative, including 23 nurses, 22 physicians, 10 pharmacists, nine respiratory therapists, and three nonclinicians. Site attendance among the 11 sites in the 25 videoconference sessions ranged between 82% and 100%, with three sites providing at least one team member for 100% of sessions. The majority reported that topics matched their scope of practice (69%) and would highly recommend the program to colleagues (77%). A total of nine QI projects were initiated across three clinical domains and focused on improving adherence to established critical care practice bundles, reducing nosocomial complications, and strengthening patient- and family-centered care in the ICU. Major factors impacting successful Collaborative engagement included an engaged interprofessional team; an established culture of engagement; opportunities to benchmark performance and accelerate institutional innovation, networking, and acclaim; and ready access to data that could be leveraged for QI purposes. CONCLUSIONS AND RELEVANCE: Use of a virtual platform to establish a learning collaborative to accelerate the identification, dissemination, and implementation of critical care best practices for COVID-19 is feasible. Our experience offers important lessons for future collaborative efforts focused on improving ICU processes of care.

AbstractBackgroundIn 2016, the IDWeek program committee was charged with ensuring gender equity in speaker sessions. Whether this charge also resulted in more opportunities for historically underrepresented speakers is unknown.MethodsWe conducted a retrospective analysis of trends in the demographic composition of IDWeek speakers and program committee members between 2013 and 2021. We used descriptive statistics to summarize data, χ2 tests to compare speaker demographics between 2013–2016 (before 2016) and 2017–2021 (after 2016), and Cochran–Armitage tests for trend. Each speaker slot was considered an independent event.ResultsA total of 5482 speaker slots were filled by 3389 individuals from 2013 to 2021. There was a linear increase in female speakers from 38.6% in 2013 to 58.4% in 2021 (P < .001). The proportion of white speakers decreased overall from 84.9% in 2013 to 63.5% in 2021. Compared with white speakers, more slots were filled by Asian speakers after 2016 versus before 2016 (20.1% vs 14.8%, respectively; P < .001). Program committee members from 2013–2021 were >80% non-Hispanic white; <5% of committee members identified as black, American Indian, Alaska Native, Native Hawaiian, Pacific Islander, or Hispanic. More program committee slots were filled by women after 2016 than before 2016 (52.7% vs 33.9%; P = .004).ConclusionsIntentional consideration of gender equity by the program committee was associated with equitable gender representation of invited speakers at IDWeek after 2016. Gradually, the proportions of IDWeek speakers from historically excluded racial/ethnic approached their respective proportions in the IDSA membership. White speakers remained overrepresented relative to membership proportions until 2021, and gaps in program committee racial/ethnic demographic representation highlights opportunities for continued inclusion, diversity, access, and equity at IDWeek.

Abstract Background Over the last decade, there have been sustained efforts to diversify the healthcare workforce. In 2016, the IDWeek Program Committee was charged to ensure gender equity in speaker sessions. Whether this intervention also resulted in more opportunities for underrepresented speakers has not been determined. Methods This project was supported by IDSA, who provided demographic information on IDWeek speakers (excluding poster sessions) from 2013-2019. Data were summarized using descriptive statistics, and chi-square analysis evaluated changes over time. Each speaker slot was considered an independent event. Data was combined for 2013-2016 (≤2016) and 2017-2019 (>2016). IDSA membership demographics were available from 2014 for gender, race/ethnicity, from 2016 for age, and from 2018 for professional degree. Results A total of 3640 speaker slots were filled by 2504 individuals from 2013-2019. A larger proportion of speaker slots were filled by women >2016 (51%) vs ≤ 2016 (43%), with a linear increase from 38.6% in 2013 to 52.1% in 2019 (p< 0.001). Averaged across 2013-2019, IDSA membership was 67.5% White, 20.6% Asian, 7.7% Latinx, 3.9% Black, and 0.4% Other. IDWeek Speakers during that timeframe were 77.7% White, 13.9% Asian, 4.7% Latinx, 2.7% Black, and 1.0% Other; a larger proportion of slots were filled by Asian speakers >2016 (16.3%) vs ≤ 2016 (12.8%) (p=0.005). The proportion of pharmacist speakers increased over time; 5.1% of speakers in 2019 reflected IDSA pharmacist membership (5.4%). The proportion of individuals invited to speak more than once differed by age (19% in < 40yo, 28% 40-49yo, 32% 50-59yo, and 22% >60yo; p< 0.001), and professional degree (28% physicians, 18% pharmacists, 9% other doctorates, and 7% non-doctorate speakers; p< 0.001). Figure 1: Trends in Gender Distribution of IDWeek Speakers and IDSA Members, 2013-2019 Figure 2: Trends in Race/Ethnicity Distribution of IDWeek Speakers and IDSA Members, 2013-2019 Conclusion Intentional consideration of gender equity by the Program Committee significantly improved equitable gender representation of invited speakers at IDWeek. This effort has not resulted in increased diversity of invited speakers from groups underrepresented in IDSA membership. To ensure that invited speakers represent the membership of IDSA/IDWeek partner organizations and more importantly, the communities we serve, we call for continued application of the principles of Inclusion, Diversity, Access, and Equity at IDWeek. Disclosures All Authors: No reported disclosures

Abstract Respiratory tract infections (RTIs) drive many outpatient encounters and, despite being predominantly viral, are associated with high rates of antibiotic prescriptions. With rising antibacterial resistance, optimization of prescribing of antibiotics in outpatients with RTIs is a critical need. Fortunately, this challenge arises at a time of increasing availability of novel RTI diagnostics to help discern which patients have bacterial infections warranting treatment. Effective implementation of antibiotic stewardship is needed, but optimal approaches for ambulatory settings are unknown. Future research needs are reviewed in this summary of a research summit convened by the Infectious Diseases Society of America in the fall of 2019.

Abstract Background Whipple disease (WD), a rare systemic infection caused by Tropheryma whipplei, can be a diagnostic challenge due to its variable presentation. The role of T. whipplei polymerase chain reaction (PCR) is unclear as small bowel biopsy with Periodic acid-Schiff (PAS) staining remains the diagnostic gold standard. Individualized diagnostic approaches based on variable clinical manifestations are underutilized. We investigated the methodologies employed at our institution to diagnose WD. Methods We retrospectively collected all cases of WD diagnosed from 1994 to 2016. Microbiology laboratory and anatomic pathology databases were queried. Case characteristics and disease clinical phenotypes (classical, localized WD arthritis, and localized central nervous system [CNS] disease) were described. The diagnostic approach and testing yield were analyzed and reported. Results Thirty-three cases of WD were diagnosed (18 classic WD [CWD], 9 localized WD arthritis [LWD], 6 CNS WD). Misdiagnosis and delay in diagnosis were frequent. Diagnostic approach and test yield differed by classical vs localized WD involvement. Small bowel tissue biopsy PAS stain/PCR was overwhelmingly positive (86%/92%) in CWD, yet seldom positive (12%/42%) in LWD (P < .001). Affected joint synovial fluid PCR was frequently positive in both CWD (100%, 3/3) and LWD (85%, 6/7). Conclusions These results support the role of small bowel biopsy PAS stain/PCR in the diagnosis of CW, though this approach may be of limited utility in LWD or CNS WD without gastrointestinal symptoms. Affected joint synovial fluid or cerebrospinal fluid PCR was frequently positive in both CWD and LWD, supporting its diagnostic usefulness.

Abstract Background Clostridium difficile is a major cause of diarrhea in thoracic organ transplant recipients. We investigated the epidemiology, risk factors, and outcome of Clostridium difficile infection ( CDI ) in heart and heart‐lung transplant ( HT ) recipients. Methods This is a retrospective study from 2004 to 2013. CDI was defined by diarrhea and a positive toxigenic C. difficile in stool measured by toxin enzyme immunoassay (2004‐2006) or polymerase chain reaction (2007‐2013). Cox proportional hazards regression was used to model the association of risk factors with time to CDI and survival with CDI following transplantation. Results There were 254 HT recipients, with a median age of 53 years ( IQR , 45‐60); 34% were female. During the median follow‐up of 3.1 years ( IQR , 1.3‐6.1), 22 (8.7%) patients developed CDI . In multivariable analysis, risk factors for CDI were combined heart‐lung transplant ( HR 4.70; 95% CI , 1.30‐17.01 [ P =.02]) and retransplantation ( HR 7.19; 95% CI , 1.61‐32.12 [ P =.01]). Acute cellular rejection was associated with a lower risk of CDI ( HR 0.34; 95% CI , 0.11‐0.94 [ P =.04]). CDI was found to be an independent risk factor for mortality ( HR 7.66; 95% CI , 3.41‐17.21 [ P <.0001]). Conclusions Clostridium difficile infection after HT is more common among patients with combined heart‐lung and those undergoing retransplantation. CDI was associated with a higher risk of mortality in HT recipients.