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A Multidisciplinary Approach to Implementing PJP Prophylaxis in the Setting of High Dose Steroids on Discharge to Reduce Risk of Incidence of PJP

From the 2018 HVPAA National Conference

Noopur Goyal (University of Utah School of Medicine), Eric Gaskill (University of Utah School of Medicine), Paloma Cariello (University of Utah School of Medicine), Kencee Graves (University of Utah School of Medicine), Stephanie Sanders (University of Utah School of Medicine), Russell Benefield (University of Utah School of Medicine), David Elhalta (University of Utah School of Medicine), Nicholas Link (University of Utah School of Medicine)

Background

Pneumocystis jirovecii pneumonia (PJP) is an opportunistic infection that in non-HIV patients has been associated with immune suppression. Guidelines recommend consideration of prophylaxis in patients receiving high dose steroids (>20mg prednisone daily) for four weeks, as prophylaxis can reduce chance of infection by up to 90%.

Objectives

To create a best practice advisory (BPA) in EPIC to flag providers to consider PJP prophylaxis on discharge for patients on 20mg prednisone, or prednisone equivalents (PEQ), for four weeks duration or longer, to reduce incidence of PJP.

Methods

A retrospective chart review was conducted on all non-HIV PJP cases from October 2016 to September 2017 in the EPIC database at a local institution. Inclusion criteria consisted of PJP diagnosis based on provider documentation, direct fluorescent antibody, or PCR. Primary outcomes included steroid use, dose, and duration prior to diagnosis of PJP. Secondary outcomes included immunosuppressive therapy or condition in the prior 6 months. In conjunction with Informatics Pharmacy, a BPA alert in EPIC was created to fire at discharge with a recommendation to consider PJP prophylaxis based on dose and duration of steroid therapy, with options tailored based on creatinine levels and allergy profile. Currently, the BPA is silent, meaning that it is not firing to provider. However, the informatics team is able to review if the alert would fire under appropriate circumstances.

Results

Of 94 non-HIV PJP positive cases from 2016-2017, 31 cases were found to be PJP positive with concomitant high dose steroid use. Subset analysis included 6 of the 31 cases solely in setting of high dose steroids, while 22 were also on chemotherapy or immune modulating agents, with high dose steroids used as part of treatment. Silent BPA data showed that of 13 out of 16 alerts fired from February 2018 to March 2018, were appropriate recommendations to alert a provider to consider PJP prophylaxis. Of all 13 cases in which PJP prophylaxis would be indicated, zero patients were discharged with prophylaxis.

Conclusion

A multidisciplinary approach to standardize care in patients receiving high dose steroids via a BPA alert, indicates there is currently room for improvement on discharging patients with prophylaxis and thereby reducing incidence and cost associated with diagnosis, workup, and management of PJP in non-HIV patients.

Implications for the Patient

With this quality improvement measure and IT innovation, via creation of a BPA alert, we hope to standardize care for patients receiving high dose steroids at discharge. Goals include improving quality of care, reducing morbidly and mortality associated with PJP, and reducing overall cost to the health care system.