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Yoke LH, Miller W, Beieler AM. Advanced practice providers in infectious disease: Enhancing the infectious disease team of the future. Transpl Infect Dis 2024; 26:e14261. [PMID: 38430484 DOI: 10.1111/tid.14261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 03/03/2024]
Abstract
As the infectious disease (ID) workforce encounters increasing demand for services with fewer physicians entering the field, advanced practice providers (APPs) in infectious disease offer a unique ability to enhance high-quality patient care. However, little is known about their incorporation into ID, their utilization in immunocompromised settings, or their future use. This article reviews currently known data on APPs in ID including how some groups have used APPs and provides a framework for thoughtful, deliberate steps to incorporate APPs into the ID medical team, including transplant infectious disease. Highlighted specifically are education and mentorship opportunities with ideas for curriculum development and onboarding approaches. Strategic steps must be taken for APP inclusion as the medical landscape continues to change, patient complexity increases, and the ID team of the future takes shape.
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Affiliation(s)
- Leah H Yoke
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
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2
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Nimgaonkar I, Yoke LH, Roychoudhury P, Flaherty PW, Oshima MU, Weixler A, Gauthier J, Greninger AL, Mielcarek M, Boeckh M, Liu C, Hill JA. Outcomes in Hematopoietic Cell Transplant and Chimeric Antigen Receptor T Cell Therapy Recipients with Pre-Cellular Therapy SARS-CoV-2 Infection. Clin Infect Dis 2024:ciae116. [PMID: 38427848 DOI: 10.1093/cid/ciae116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/12/2024] [Accepted: 02/27/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Hematopoietic cell transplant (HCT) or chimeric antigen receptor T cell (CAR-T) therapy recipients have high morbidity from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. There are limited data on outcomes from SARS-CoV-2 infection shortly before cellular therapy and uncertainty whether to delay therapy. METHODS We conducted a retrospective cohort study of patients with SARS-CoV-2 infection within 90 days prior to HCT or CAR-T therapy between January 2020 and November 2022. We characterized the kinetics of SARS-CoV-2 detection, clinical outcomes following cellular therapy, and impact on delays in cellular therapy. RESULTS We identified 37 patients (n=15 allogeneic HCT, n=11 autologous HCT, n=11 CAR-T therapy) with SARS-CoV-2 infections within 90 days of cellular therapy. Most infections (73%) occurred between March and November 2022, when Omicron strains were prevalent. Most patients had asymptomatic (27%) or mild (68%) coronavirus disease 2019 (COVID-19). SARS-CoV-2 positivity lasted a median of 20.0 days [IQR, 12.5-26.25]. The median time from first positive SARS-CoV-2 test to cellular therapy was 45 days [IQR, 37.75-70]; one patient tested positive on the day of infusion. After cellular therapy, no patients had recrudescent SARS-CoV-2 infection or COVID-19-related complications. Cellular therapy delays related to SARS-CoV-2 infection occurred in 70% of patients for a median of 37 days. Delays were more common after allogeneic (73%) and autologous (91%) HCT compared to CAR-T cell therapy (45%). CONCLUSIONS Patients with asymptomatic or mild COVID-19 may not require prolonged delays in cellular therapy in the context of contemporary circulating variants and availability of antiviral therapies.
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Affiliation(s)
- Ila Nimgaonkar
- Department of Medicine, University of Washington, Seattle, WA, United States
| | - Leah H Yoke
- Department of Medicine, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Pavitra Roychoudhury
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
| | - Patrick W Flaherty
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Masumi Ueda Oshima
- Department of Medicine, University of Washington, Seattle, WA, United States
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Amelia Weixler
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
| | - Jordan Gauthier
- Department of Medicine, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Alexander L Greninger
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
| | - Marco Mielcarek
- Department of Medicine, University of Washington, Seattle, WA, United States
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Michael Boeckh
- Department of Medicine, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Catherine Liu
- Department of Medicine, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
| | - Joshua A Hill
- Department of Medicine, University of Washington, Seattle, WA, United States
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, United States
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3
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Liu C, Yoke LH, Bhattacharyya P, Cassaday RD, Cheng GS, Escobar ZK, Ghiuzeli C, McCulloch DJ, Pergam SA, Roychoudhury P, Tverdek F, Schiffer JT, Ford ES. Successful Treatment of Persistent Symptomatic Coronavirus Disease 19 Infection With Extended-Duration Nirmatrelvir-Ritonavir Among Outpatients With Hematologic Cancer. Open Forum Infect Dis 2023; 10:ofad306. [PMID: 37383248 PMCID: PMC10296060 DOI: 10.1093/ofid/ofad306] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/02/2023] [Indexed: 06/30/2023] Open
Abstract
Persistent symptomatic coronavirus disease 2019 (COVID-19) is a distinct clinical entity among patients with hematologic cancer and/or profound immunosuppression. The optimal medical management is unknown. We describe 2 patients who had symptomatic COVID-19 for almost 6 months and were successfully treated in the ambulatory setting with extended courses of nirmatrelvir-ritonavir.
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Affiliation(s)
- Catherine Liu
- Correspondence: Catherine Liu, MD, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA, 98109 ()
| | - Leah H Yoke
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Pooja Bhattacharyya
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Ryan D Cassaday
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Hematology, University of Washington, Seattle, Washington, USA
| | - Guang-Shing Cheng
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Zahra Kassamali Escobar
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Cristina Ghiuzeli
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Hematology, University of Washington, Seattle, Washington, USA
| | - Denise J McCulloch
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Steven A Pergam
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Pavitra Roychoudhury
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Department of Laboratory Medicine, University of Washington, Seattle, Washington, USA
| | - Frank Tverdek
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Joshua T Schiffer
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
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4
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Childs-Kean LM, Beieler AM, Coroniti AM, Cortés-Penfield N, Keller SC, Mahoney MV, Rajapakse NS, Rivera CG, Yoke LH, Ryan KL. A Bundle of the Top 10 OPAT Publications in 2022. Open Forum Infect Dis 2023; 10:ofad283. [PMID: 37323428 PMCID: PMC10264063 DOI: 10.1093/ofid/ofad283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/19/2023] [Indexed: 06/17/2023] Open
Abstract
Outpatient parenteral antimicrobial therapy (OPAT) has become more common in clinical settings. Correspondingly, OPAT-related publications have also increased; the objective of this article was to summarize clinically meaningful OPAT-related publications in 2022. Seventy-five articles were initially identified, with 54 being scored. The top 20 OPAT articles published in 2022 were reviewed by a group of multidisciplinary OPAT clinicians. This article provides a summary of the "top 10" OPAT publications of 2022.
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Affiliation(s)
- Lindsey M Childs-Kean
- Correspondence: Lindsey M. Childs-Kean, PharmD, MPH, University of Florida, 1225 Center Drive, Gainesville, FL 32610 ()
| | - Alison M Beieler
- Infectious Diseases Clinic, Harborview Medical Center, Seattle, Washington, USA
| | - Ann-Marie Coroniti
- Department of Pharmacy, Infectious Diseases and Immunology Center, The Miriam Hospital, Providence, Rhode Island, USA
| | - Nicolás Cortés-Penfield
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Sara C Keller
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Monica V Mahoney
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nipunie S Rajapakse
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children’s Center, Rochester, Minnesota, USA
| | | | - Leah H Yoke
- Vaccine and Infectious Disease Division, Fred Hutch Cancer Research Center, Allergy and Infectious Disease Division, University of Washington, Seattle, Washington, USA
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5
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Ford ES, Simmons W, Karmarkar EN, Yoke LH, Braimah AB, Orozco JJ, Ghiuzeli CM, Barnhill S, Sack CL, Benditt JO, Roychoudhury P, Greninger AL, Shapiro AE, Hammond JL, Rusnak JM, Dolsten M, Boeckh M, Liu C, Cheng GS, Corey L. Successful Treatment of Prolonged, Severe Coronavirus Disease 2019 Lower Respiratory Tract Disease in a B cell Acute Lymphoblastic Leukemia Patient With an Extended Course of Remdesivir and Nirmatrelvir/Ritonavir. Clin Infect Dis 2023; 76:926-929. [PMID: 36326680 PMCID: PMC10226728 DOI: 10.1093/cid/ciac868] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022] Open
Abstract
A patient with B-cell acute lymphoblastic leukemia (ALL) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had persistent, progressive pneumonia with viremia after 5 months of infection despite monoclonal antibodies, intravenous (IV) remdesivir and prolonged oral steroids. Twenty days of nirmatrelvir/ritonavir and 10 days of IV remdesivir led to full recovery.
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Affiliation(s)
- Emily S Ford
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
| | - William Simmons
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Ellora N Karmarkar
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Leah H Yoke
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
| | - Ayodale B Braimah
- Division of General Internal Medicine, Department of Medicine, University of Washington,Seattle, Washington, USA
| | - Johnnie J Orozco
- Clinical Research Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Division of Medical Oncology, Department of Medicine, University of Washington,Seattle, Washington, USA
| | - Cristina M Ghiuzeli
- Clinical Research Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Division of Hematology, Department of Medicine, University of Washington,Seattle, Washington, USA
| | - Serena Barnhill
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington,Seattle, Washington, USA
| | - Coralynn L Sack
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington,Seattle, Washington, USA
| | - Joshua O Benditt
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington,Seattle, Washington, USA
| | - Pavitra Roychoudhury
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Department of Laboratory Medicine, University of Washington,Seattle, Washington, USA
| | - Alexander L Greninger
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Department of Laboratory Medicine, University of Washington,Seattle, Washington, USA
| | - Adrienne E Shapiro
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Department of Global Health, University of Washington,Seattle, Washington, USA
| | | | | | | | - Michael Boeckh
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
| | - Catherine Liu
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
| | - Guang-Shing Cheng
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington,Seattle, Washington, USA
| | - Lawrence Corey
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
- Vaccine and Infectious Diseases Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Clinical Research Division, Fred Hutchinson Cancer Center,Seattle, Washington, USA
- Department of Laboratory Medicine, University of Washington,Seattle, Washington, USA
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Abdul-Mutakabbir JC, Hirsch EB, Ko C, Brown BR, Bandali A, Mordino J, Yoke LH, Bell T, Swartz TH, Syed U, Hlatshwayo M, Saunders IM. A call to action: A need for initiatives that increase equitable access to COVID-19 therapeutics. The Lancet Regional Health - Americas 2022; 11:100263. [PMID: 35600636 PMCID: PMC9114692 DOI: 10.1016/j.lana.2022.100263] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rivera CG, Beieler AM, Childs-Kean LM, Cortés-Penfield N, Idusuyi AM, Keller SC, Rajapakse NS, Ryan KL, Yoke LH, Mahoney MV. A Bundle of the Top 10 OPAT Publications in 2021. Open Forum Infect Dis 2022; 9:ofac242. [PMID: 35855003 PMCID: PMC9277647 DOI: 10.1093/ofid/ofac242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 05/07/2022] [Indexed: 11/16/2022] Open
Abstract
As outpatient parenteral antimicrobial therapy (OPAT) becomes more common, it may be difficult to stay current with recent related publications. A group of multidisciplinary OPAT clinicians reviewed and ranked all OPAT publications published in 2021. This article provides a high-level summary of the OPAT manuscripts that were voted the “top 10” publications of 2021.
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Affiliation(s)
- Christina G. Rivera
- Department of Pharmacy, Mayo Clinic, Rochester, MN, United States. Twitter: @MsSmallsO
| | - Alison M. Beieler
- Harborview Medical Center, Seattle, WA, United States. Twitter: @ABeieler
| | - Lindsey M. Childs-Kean
- College of Pharmacy, University of Florida, Gainesville, FL, United States. Twitter: @corevalues5
| | | | - Ann-Marie Idusuyi
- Department of Pharmacy, Infectious Diseases and Immunology Center, The Miriam Hospital, Providence RI, United States. Twitter: @AnnMarieI3
| | - Sara C. Keller
- Associate Professor, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, United States. Twitter: @SaraKellerMD1
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, United States
| | - Nipunie S. Rajapakse
- Division of Pediatric Infectious Diseases, Department of Pediatric and Adolescent Medicine, Mayo Clinic Children’s Center, Rochester, MN, United States. Twitter: @nrajapakseMD
| | - Keenan L. Ryan
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, New Mexico, United States. Twitter: @keenanconazole
| | - Leah H. Yoke
- Vaccine and Infectious Disease Division, Fred Hutch Cancer Research Center; Allergy and Infectious Disease Division, University of Washington, United States. Twitter: @LeahYoke
| | - Monica V. Mahoney
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, United States. Twitter: @mmPharmD
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Yoke LH, Boeckh M, Banda H, Kimble EL, Martino C, Cassaday R, Zamora D. 924. Cytomegalovirus (CMV) Retinitis during Maintenance Chemotherapy for Acute Lymphoblastic Leukemia. Open Forum Infect Dis 2021. [DOI: 10.1093/ofid/ofab466.1119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Acute leukemia patients are at risk for cytomegalovirus (CMV) retinitis following hematopoietic stem cell transplantation, though the disease can also occur in non-transplant adult leukemia patients. Emerging data suggest a shift to pediatric-inspired chemotherapy regimens in adults with acute lymphoblastic leukemia (ALL) can lead to increasing cytopenias and impaired functional immunity, placing these patients at risk for this opportunistic infection. Here we describe a case of CMV retinitis in an ALL patient following a lower-intensity regimen during maintenance chemotherapy.
Methods
Chart review.
Results
A 55-year-old male with ALL presented to his optometrist with complaints of visual changes including “fogginess” and “floaters”. The patient had completed 8 cycles of dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab (EPOCH-R) and achieved complete remission. He had been on maintenance chemotherapy with 6-mercaptopurine, vincristine, methotrexate, and prednisone (POMP) for 2 months at the time of symptom onset. He was referred to his local ophthalmologist who had concerns for bilateral, zone 1 CMV retinitis based on fundoscopic exam (Figure 1). Vitreous aspiration was performed and CMV DNA PCR returned positive at 1.6 million IUs/ml. Peripheral blood CMV DNA PCR was also positive at 1133 IU/ml. He was started on combination therapy with intravitreal ganciclovir injections and oral valganciclovir 900 mg twice daily (Figure 2). The patient received 14 intravitreal injections with resultant stability of his eye exam, though he remained on induction valganciclovir for 5 months due to persistent blood CMV DNAemia. Letermovir was added to help suppress his peripheral CMV DNAemia and he attained partial vision recovery.
Figure 1. Fundoscopic images
Conclusion
CMV retinitis is an uncommon and highly morbid infection that can occur during maintenance chemotherapy in adult non-transplant ALL patients. Early identification of the disease is imperative as delay can result in blindness or further systemic CMV disease. Treatment is challenging, involving systemic and intravitreal antiviral therapy, serial ophthalmologic exams, serum CMV monitoring, and close coordination with the treating hematologist.
Disclosures
Michael Boeckh, MD PhD, AlloVir (Consultant)Ansun Biopharma (Grant/Research Support)Astellas (Grant/Research Support)EvrysBio (Consultant, Other Financial or Material Support, Options to acquire equity, but have not exercised them)Gilead Sciences (Consultant, Grant/Research Support)GlaxoSmithKline (Consultant)Helocyte (Consultant, Other Financial or Material Support, Options to acquire equity, but have not exercised them)Janssen (Grant/Research Support)Kyorin (Consultant)Merck (Consultant, Grant/Research Support)Moderna (Consultant)Symbio (Consultant)Takeda (formerly known as Shire) (Consultant, Grant/Research Support)VirBio (Consultant, Grant/Research Support) Ryan Cassaday, MD, Amgen (Grant/Research Support, Advisor or Review Panel member)Kite/Gilead (Grant/Research Support, Advisor or Review Panel member)Merck (Grant/Research Support)Pfizer (Grant/Research Support, Advisor or Review Panel member)Seagen (Other Financial or Material Support, Spouse is employee and hold stock)Vanda Pharmaceuticals (Grant/Research Support)
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Affiliation(s)
- Leah H Yoke
- University of Washington; Fred Hutch Cancer Research Center, Seattle, Washington
| | - Michael Boeckh
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Erik L Kimble
- University of Washington and Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Ryan Cassaday
- University of Washington/Fred Hutch, seattle, Washington
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Yoke LH, Beieler AM, Liu C, Pergam SA, Pergam SA, Dhanireddy S. 965. Advanced Practice Providers in Infectious Disease: Educational Needs and Opportunities. Open Forum Infect Dis 2021. [PMCID: PMC8645047 DOI: 10.1093/ofid/ofab466.1160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Advanced Practice Providers (APPs) practice throughout Infectious Disease (ID) in a variety of settings through interprofessional collaboration with physicians, pharmacists, and other team members. However, there is a paucity of specific and directed educational opportunities available for APPs within ID. In order to better understand this, we examined specific APP educational needs and how educational programs could provide high quality opportunities for APPs in ID. Methods Voluntary anonymous surveys were created in the REDCap data tool and distributed by email lists, social media, and Infectious Diseases Society of America community forums to APPs working in ID. Results Ninety-nine APPs responded to the survey (figure 1). 97% (96) of respondents were interested in APP specific ID educational opportunities. Of respondents, 76% (74) felt ID specific podcasts would be most helpful, while 86% (84) noted that access to ID clinical case conferences or self-directed, online modules would be instructive (figure 2). 91% (90) did not attend IDWeek annually due to various barriers, including lack of clinical coverage and cost associated with the conference (figure 3) despite 89% (88) receiving Continuing Education (CE) reimbursement. 64% (62) respondents were interested in future APP mentorship opportunities, from either more senior APPs or physicians. ![]()
Figure 1. Geographic Distribution of Respondents, n=99 ![]()
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Conclusion APPs provide collaborative and specialized ID care in a variety of settings. However, continued educational needs specifically for APPs have been identified. From survey respondents, the majority of APPs did not attend IDWeek, a sentinel ID education event, citing clinical coverage and cost being significant barriers. This represents an opportunity for clinically focused educational opportunities, both at IDWeek and also through other platforms, particularly since many APPs receive CE funding from their employers. Podcasts, online lecture series, and self-study certificate programs were identified as avenues for ID teaching and also present accessible, alternative methods for training. Ultimately, as the growing APP workforce continues to provide patient care in a variety of ID settings, educational opportunities with mentorship are necessary to support them in their practice. Disclosures Steven A. Pergam, MD, MPH, Chimerix Inc. (Other Financial or Material Support, Clinical Trial)Global Life Technologies, Inc. (Grant/Research Support)Merck and Co. (Other Financial or Material Support, Clinical Trial) Steven A. Pergam, MD, MPH, Chimerix (Individual(s) Involved: Self): Clinical Trial; Global Life Technologies, Inc (Individual(s) Involved: Self): Research Grant or Support; Merck & Co. (Individual(s) Involved: Self): Scientific Research Study Investigator; Sanofi Aventis (Individual(s) Involved: Self): Other Financial or Material Support, Provided vaccines for clinical trial sponsored by the NIH
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Affiliation(s)
- Leah H Yoke
- University of Washington; Fred Hutch Cancer Research Center, Seattle, Washington
| | | | - Catherine Liu
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
| | - Steven A Pergam
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
| | - Steven A Pergam
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
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10
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Yoke LH, Lee JM, Krantz EM, Morris J, Marquis S, Bhattacharyya P, So L, Riedo FX, Simmons J, Khaki AR, Cheng GS, Greninger AL, Pergam SA, Waghmare A, Ogimi C, Liu C. Clinical and Virologic Characteristics and Outcomes of Coronavirus Disease 2019 at a Cancer Center. Open Forum Infect Dis 2021; 8:ofab193. [PMID: 34183982 PMCID: PMC8083314 DOI: 10.1093/ofid/ofab193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 04/13/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND High morbidity and mortality have been observed in patients with cancer and coronavirus disease 2019 (COVID-19); however, there are limited data on antimicrobial use, coinfections, and viral shedding. METHODS We conducted a retrospective cohort study of adult patients at the Seattle Cancer Care Alliance diagnosed with COVID-19 between February 28, 2020 and June 15, 2020 to characterize antimicrobial use, coinfections, viral shedding, and outcomes within 30 days after diagnosis. Cycle threshold values were used as a proxy for viral load. We determined viral clearance, defined as 2 consecutive negative results using severe acute respiratory syndrome coronavirus 2 reverse-transcription polymerase chain reaction results through July 30, 2020. RESULTS Seventy-one patients were included with a median age of 61 years; 59% had a solid tumor. Only 3 patients had documented respiratory bacterial coinfection. Empiric antibiotics for pneumonia were prescribed more frequently early in the study period (February 29-March 28, 2020; 12/34) compared to the later period (March 29-June 15, 2020; 2/36) (P = .002). The median number of days from symptom onset to viral clearance was 37 days with viral load rapidly declining in the first 7-10 days after symptom onset. Within 30 days of diagnosis, 29 (41%) patients were hospitalized and 12 (17%) died. Each additional comorbidity was associated with 45% lower odds of days alive and out of hospital in the month following diagnosis in adjusted models. CONCLUSIONS Patients at a cancer center, particularly those with multiple comorbidities, are at increased risk of poor outcomes from COVID-19. Prolonged viral shedding is frequently observed among cancer patients, and its implications on transmission and treatment strategies warrant further study.
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Affiliation(s)
- Leah H Yoke
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Juhye M Lee
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Elizabeth M Krantz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Jessica Morris
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Sara Marquis
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Pooja Bhattacharyya
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Lisa So
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | | | - Jason Simmons
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Ali Raza Khaki
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Oncology, University of Washington, Seattle, Washington, USA
- Division of Oncology, Department of Medicine, Stanford University, Palo Alto, California, USA
| | - Guang-Shing Cheng
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Pulmonary and Critical Care, University of Washington, Seattle, Washington, USA
| | - Alexander L Greninger
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Steven A Pergam
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
| | - Alpana Waghmare
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Pediatric Infectious Diseases Division, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Chikara Ogimi
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Pediatric Infectious Diseases Division, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Catherine Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
- Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington, USA
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11
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Yoke LH, Yoke LH, Beieler AM, Beieler AM, Liu C, Pergam SA, Wald A, Wald A, Dhanireddy S, Dhanireddy S. 628. The Role of the Advanced Practice Provider in Infectious Disease: Opportunities for Growth. Open Forum Infect Dis 2020. [PMCID: PMC7777091 DOI: 10.1093/ofid/ofaa439.822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Advanced Practice Providers (APPs), including nurse practitioners and physician assistants, provide high quality medical care in multiple specialties by extending the physician workforce. However, within the Infectious Disease (ID) specialty, their demographics, areas of practice, and experience are not well described. To better understand this key group, we examined APP years of experience in ID, primary practice settings, and perceived practice barriers from the APP perspective. Methods We created a survey using REDCap which was distributed between 12/1/2019-1/31/2020 to APPs practicing in ID by social media, direct emails to key stakeholders, and online Infectious Disease Society of America (IDSA) community forums. Results Ninety-three APPs responded to the posted survey from across the US (figure 1). Most respondents (45 [49%]) had between 2-9 years of overall experience as an APP, while 14 (15%) between 10-15 years, and 24 (26%) had >16 years of experience. Experience specifically as an ID APP varied, with the majority (56%) having 2-9 years of experience and 25% reporting >16 years of experience as an APP. Although over half of the respondents worked in an outpatient adult ID clinic, they also practiced in diverse settings and within multiple ID sub-specialties (figure 2). The other most common areas of practice included inpatient adult ID, HIV care, and outpatient parental antimicrobial therapy programs. Limited formalized ID education and misconceptions about APP scope of practice were perceived barriers to practicing in ID (figure 3). Lack of recognition as a peer amongst physician colleagues was also identified as a practice barrier. Advanced Practice Provider Survey Response by Region ![]()
Advanced Practice Provider ID Practice Areas ![]()
Perceived Advanced Practice Provider Barriers ![]()
Conclusion Our survey results demonstrate that the APP ID workforce is an experienced provider group, both in terms of total years as an APP and years exclusively in ID, working in a large variety of ID settings in a number of geographic locations. Creation of specific and directed ID educational opportunities, along with collaborating physician support and inclusion, are identified as significant areas of improvement. The establishment of APP-specific training programs and educational courses will create more opportunities for APPs and further expand the ID workforce. Disclosures Steven A. Pergam, MD, MPH, Chimerix, Inc (Scientific Research Study Investigator)Global Life Technologies, Inc. (Research Grant or Support)Merck & Co. (Scientific Research Study Investigator)Sanofi-Aventis (Other Financial or Material Support, Participate in clinical trial sponsored by NIAID (U01-AI132004); vaccines for this trial are provided by Sanofi-Aventis)
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Affiliation(s)
- Leah H Yoke
- University of Washington; Fred Hutch Cancer Research Center, Seattle, Washington
| | - Leah H Yoke
- University of Washington; Fred Hutch Cancer Research Center, Seattle, Washington
| | | | | | - Catherine Liu
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
| | - Steven A Pergam
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
| | - Anna Wald
- University of Washington, Seattle, Washington
| | - Anna Wald
- University of Washington, Seattle, Washington
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12
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Yoke LH, Yoke LH, Lee J, Krantz EM, Morris J, Marquis S, Bhattacharyya P, So L, Riedo FX, Simmons J, Khaki AR, Pergam SA, Waghmare A, Ogimi C, Liu C. 370. Clinical Features and Outcomes of COVID-19 Infection Among Cancer Patients in Seattle, Washington. Open Forum Infect Dis 2020. [PMCID: PMC7777094 DOI: 10.1093/ofid/ofaa439.565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background High morbidity and mortality has been observed with COVID-19 infection; however, there are limited data on clinical characteristics including exposures, coinfections, and antimicrobial use among cancer patients. We aimed to better characterize clinical features and outcomes in this population. Methods We conducted a retrospective chart review of consecutive patients at the Seattle Cancer Care Alliance diagnosed with SARS-CoV-2 infection by RT-PCR between February 28, 2020 and May 3, 2020. We obtained demographic and clinical data including coinfections, antimicrobial use and outcomes at 30 days after diagnosis. Results Of 60 patients reviewed, the median age was 62 years (range 22–98) and 43% were male. 34 (57%) patients had solid tumors and 16 (27%) hematologic malignancies. Breast (12%), colorectal (8%) and non-Hodgkin lymphoma (8%) were the most prevalent cancers. 34 (57%) had ≥ 2 comorbidities. The majority of identified exposures were from long-term care facilities (LTCF) (27%) or household contacts (25%) (Fig 1). The most common symptoms at diagnosis were cough (72%), fevers/chills (57%), shortness of breath (38%), nasal congestion/rhinorrhea (35%), and diarrhea (30%). 18 (31%) patients were prescribed at least one course of antibiotics within 30 days of diagnosis; antibiotics were prescribed to 54% of hospitalized patients (Fig 2). 6 (10%) had a documented bacterial infection; of these, 3 were respiratory coinfections. No viral or fungal copathogens were reported. 26 (43%) patients were hospitalized, 9 (15%) admitted to intensive care, and one (2%) required mechanical ventilation. 12 (20%) died within 30 days of diagnosis (Fig 3); of these, 10 (83%) had ≥ 2 comorbidities and 8 (67%) had LTCF exposure. ![]()
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Conclusion COVID-19 is associated with significant morbidity and mortality in cancer patients, particularly among older age groups with multiple comorbidities and those with LTCF exposure. More than half of cases appeared to acquire SARS-CoV-2 from LTCF or household exposures, indicating need for infection prevention and family/caregiver education. Despite few documented bacterial coinfections, antibiotic use within 30 days of diagnosis was common and likely empiric due to limited diagnostics in the era of COVID-19. Disclosures Steven A. Pergam, MD, MPH, Chimerix, Inc (Scientific Research Study Investigator)Global Life Technologies, Inc. (Research Grant or Support)Merck & Co. (Scientific Research Study Investigator)Sanofi-Aventis (Other Financial or Material Support, Participate in clinical trial sponsored by NIAID (U01-AI132004); vaccines for this trial are provided by Sanofi-Aventis) Alpana Waghmare, MD, Amazon (Grant/Research Support)Amazon (Employee, Shareholder)Ansun Biopharma (Scientific Research Study Investigator)Kyorin Pharmaceuticals (Advisor or Review Panel member)
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Affiliation(s)
- Leah H Yoke
- University of Washington; Fred Hutch Cancer Research Center, Seattle, Washington
| | - Leah H Yoke
- University of Washington; Fred Hutch Cancer Research Center, Seattle, Washington
| | - Juhye Lee
- Fred Hutch/University of Washington, Seattle, Washington
| | | | | | | | | | - Lisa So
- Fred Hutch/University of Washington, Seattle, Washington
| | | | | | - Ali R Khaki
- University of Washington, Seattle, Washington
| | - Steven A Pergam
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, WA
| | | | | | - Catherine Liu
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, WA
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Beieler AM, Beieler AM, Yoke LH, Yoke LH, Liu C, Pergam SA, Wald A, Wald A, Dhanireddy S, Dhanireddy S. 617. Physician Perspective: Utilization of Advanced Practice Providers (APPs) in the ID Workforce. Open Forum Infect Dis 2020. [PMCID: PMC7776608 DOI: 10.1093/ofid/ofaa439.811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Applicants entering Infectious Disease (ID) fellowships are declining and shortages of ID physicians is a challenge recognized by the clinical workforce and Infectious Diseases Society of America (IDSA). There is increased awareness of more Advanced Practice Providers (APPs) being used within ID to expand and extend existing practices. However, little is known about APP utilization, APP clinical scope of practice, specific roles, and opportunities for education. Methods To evaluate physician perspectives on APP utilization in ID, we created an anonymous and voluntary survey using the REDCap data tool that was distributed by social media, key stakeholder emails, and IDSA online community forum between 12/1/2019-1/31/2020. In addition to collecting geographic information and the type of ID practice, participants were also surveyed about the use of APPs and any perceived barriers that may limit their use. Results 218 practicing ID physicians responded to the survey (Figure 1). 155 (71%) physicians work with APPs in their current practice (Figure 2); specifically, 56 (27%) with 1 APP, 62 (30%) with 2-4 APPs, 28 (13%) with 5-9 APPs, and 11 (5%) with > 10 APPs. Of respondents, 104 (48%) practiced at University/Medical schools, 80 (37%) in hospitals/clinics, and 28 (13%) in private practice (Table 1); most work in adult inpatient/outpatient ID. The main reasons selected by respondents for not using APPs in their practice included concerns around a lack of formal ID training 22 (15%), lack of time/lack of ability to assist with APP training 29 (20%), practice is already sufficiently staffed 19 (13%), and concern for physician revenue loss 16 (11%) (Table 1). Figure 1. Physician Responses by Region, n = 218 ![]()
Figure 2. Physicians Utilizing APPs in Practice, n = 210 (*no response, 8) ![]()
Table 1. Physician ID Practice Type, Setting, and Concerns ![]()
Conclusion Results suggest that while collaboration between ID physicians and APPs exists to meet current needs, a lack of ID training is a limiting factor. Our findings demonstrate there is an opportunity for formal ID education and resource development both to enhance APPs clinical skills and address perceived knowledge gaps. Inclusion of APPs in the ID workforce may allow physicians to expand ID care into more resource limited areas to continue to provide high quality patient care. Disclosures Steven A. Pergam, MD, MPH, Chimerix, Inc (Scientific Research Study Investigator)Global Life Technologies, Inc. (Research Grant or Support)Merck & Co. (Scientific Research Study Investigator)Sanofi-Aventis (Other Financial or Material Support, Participate in clinical trial sponsored by NIAID (U01-AI132004); vaccines for this trial are provided by Sanofi-Aventis)
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Affiliation(s)
| | | | - Leah H Yoke
- University of Washington; Fred Hutch Cancer Research Center, Seattle, Washington
| | - Leah H Yoke
- University of Washington; Fred Hutch Cancer Research Center, Seattle, Washington
| | - Catherine Liu
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
| | - Steven A Pergam
- Fred Hutchinson Cancer Research Center; University of Washington, Seattle, Washington
| | - Anna Wald
- University of Washington, Seattle, Washington
| | - Anna Wald
- University of Washington, Seattle, Washington
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