Alex Perry

Interests

Research

1. Clostribioides difficile infection2. Antimicrobial stewardship3. Infection prevention4. Quality improvement in medicine

Courses

No activities entered.

Scholarly Contributions

Chapters

• Perry, D. A. (2020). Healthcare-Associated Infections Related to the Use of Intravascular Devices. In Mayhall’s Hospital Epidemiology and Infection Prevention. Wolters Kluwer.

Journals/Publications

• Berinstein, J. A., Steiner, C. A., Rifkin, S., Alexander Perry, D., Micic, D., Shirley, D., Higgins, P. D., Young, V. B., Lee, A., & Rao, K. (2023). A Predictive Model to Identify ComplicatedClostridiodes difficileInfection. Open Forum Infectious Diseases, 10(2). doi:10.1093/ofid/ofad049
• Dueker, J. M., Luty, J., Perry, D. A., Izumi, S., Fromme, E. K., & DiVeronica, M. (2019). A Resident-Led Initiative to Increase Documentation of Surrogate Decision Makers for Hospitalized Patients. Journal of Graduate Medical Education, 11(3), 295-300.
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  Identification of surrogate decision makers (SDMs) is an important part of advance care planning for hospitalized patients. Despite its importance, the best methods for engaging residents to sustainably improve SDM documentation have not been identified.
• Jaramillo, M., Musmar, A. S., Shi, A., Al, M. S., Alexander Perry, D., & Zangeneh, T. (2023). 688. Risk of Clostridioides difficile Infection and Antibiotic Associated Diarrhea in Patients Receiving Outpatient Parenteral Antimicrobial Therapy. Open Forum Infectious Diseases, 10(Supplement_2), ofad500.750.
• El-Dalati, S., Cronin, D., Riddell, J., Shea, M., Weinberg, R. L., Washer, L., Stoneman, E., Perry, D. A., Bradley, S., Burke, J., Murali, S., Fagan, C., Chanderraj, R., Christine, P., Patel, T., Ressler, K., Fukuhara, S., Romano, M., Yang, B., & Deeb, G. M. (2022). The Clinical Impact of Implementation of a Multidisciplinary Endocarditis Team. The Annals of thoracic surgery, 113(1), 118-124.
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  Infectious endocarditis is associated with substantial in-hospital mortality of 15%-20%. Effective management requires coordination between multiple medical and surgical subspecialties, which can often lead to disjointed care. Previous European studies have identified multidisciplinary endocarditis teams as a tool for reducing endocarditis mortality.
• Menon, A., Perry, D. A., Motyka, J., Weiner, S., Standke, A., Penkevich, A., Keidan, M., Young, V. B., & Rao, K. (2021). Changes in the Association Between Diagnostic Testing Method, Polymerase Chain Reaction Ribotype, and Clinical Outcomes From Clostridioides difficile Infection: One Institution's Experience. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 73(9), e2883-e2889.
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  In Clostridioides difficile infection (CDI), the relationship between clinical, microbial, and temporal/epidemiological trends, disease severity and adverse outcomes is incompletely understood. In a follow-up to our study from 2010-2013, we evaluate stool toxin levels and C. difficile polymerase chain reaction (PCR) ribotypes. We hypothesized that elevated stool toxins and infection with ribotype 027 associate with adverse outcomes.
• Perry, D. A., Shirley, D., Micic, D., Patel, C. P., Putler, R., Menon, A., Young, V. B., & Rao, K. (2021). External Validation and Comparison of Clostridioides difficile Severity Scoring Systems. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.
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  Many models have been developed to predict severe outcomes from Clostridioides difficile infection. These models are usually developed at a single institution and largely are not externally validated. This aim of this study was to validate previously published risk scores in a multicenter cohort of patients with CDI.
• Dieterle, M. G., Putler, R., Perry, D. A., Menon, A., Abernathy-Close, L., Perlman, N. S., Penkevich, A., Standke, A., Keidan, M., Vendrov, K. C., Bergin, I. L., Young, V. B., & Rao, K. (2020). Systemic Inflammatory Mediators Are Effective Biomarkers for Predicting Adverse Outcomes in Clostridioides difficile Infection. mBio, 11(3).
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  infection (CDI) can result in severe disease and death, with no accurate models that allow for early prediction of adverse outcomes. To address this need, we sought to develop serum-based biomarker models to predict CDI outcomes. We prospectively collected sera ≤48 h after diagnosis of CDI in two cohorts. Biomarkers were measured with a custom multiplex bead array assay. Patients were classified using IDSA severity criteria and the development of disease-related complications (DRCs), which were defined as ICU admission, colectomy, and/or death attributed to CDI. Unadjusted and adjusted models were built using logistic and elastic net modeling. The best model for severity included procalcitonin (PCT) and hepatocyte growth factor (HGF) with an area (AUC) under the receiver operating characteristic (ROC) curve of 0.74 (95% confidence interval, 0.67 to 0.81). The best model for 30-day mortality included interleukin-8 (IL-8), PCT, CXCL-5, IP-10, and IL-2Rα with an AUC of 0.89 (0.84 to 0.95). The best model for DRCs included IL-8, procalcitonin, HGF, and IL-2Rα with an AUC of 0.84 (0.73 to 0.94). To validate our models, we employed experimental infection of mice with Antibiotic-treated mice were challenged with and a similar panel of serum biomarkers was measured. Applying each model to the mouse cohort of severe and nonsevere CDI revealed AUCs of 0.59 (0.44 to 0.74), 0.96 (0.90 to 1.0), and 0.89 (0.81 to 0.97). In both human and murine CDI, models based on serum biomarkers predicted adverse CDI outcomes. Our results support the use of serum-based biomarker panels to inform infection treatment. Each year in the United States, causes nearly 500,000 gastrointestinal infections that range from mild diarrhea to severe colitis and death. The ability to identify patients at increased risk for severe disease or mortality at the time of diagnosis of infection (CDI) would allow clinicians to effectively allocate disease modifying therapies. In this study, we developed models consisting of only a small number of serum biomarkers that are capable of predicting both 30-day all-cause mortality and adverse outcomes of patients at time of CDI diagnosis. We were able to validate these models through experimental mouse infection. This provides evidence that the biomarkers reflect the underlying pathophysiology and that our mouse model of CDI reflects the pathogenesis of human infection. Predictive models can not only assist clinicians in identifying patients at risk for severe CDI but also be utilized for targeted enrollment in clinical trials aimed at reduction of adverse outcomes from severe CDI.
• El-Dalati, S., Khurana, I., Soper, N., Cronin, D., Shea, M., Weinberg, R. L., Riddell, J., Washer, L., Shuman, E., Burke, J., Murali, S., Perry, D. A., Fagan, C., Patel, T., Ressler, K., & Deeb, G. M. (2020). Physician perceptions of a multidisciplinary endocarditis team. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology, 39(4), 735-739.
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  Infectious endocarditis is a highly morbid infection that requires coordination of care across medical and surgical specialties, often through the use of a multidisciplinary team model. Multiple studies have demonstrated that such conferences can improve clinical outcomes. However, little is known about physicians' impressions of these groups. We surveyed 126 (response rate of 30%) internal medicine, infectious diseases, cardiology, and cardiac surgery providers 1 year after the implementation of an endocarditis team at the University of Michigan. Ninety-eight percent of physicians felt that the endocarditis team improved communication between specialties. Additionally, over 85% of respondents agreed that the group influenced diagnostic evaluation, reduced management errors, increased access to surgery, and decreased in-hospital mortality for endocarditis patients. These results suggest that multidisciplinary endocarditis teams are valued by physicians as a tool to improve patient care and serve an important role in increasing communication between providers.
• El-Dalati, S., Shea, M., Fukuhara, S., Weinberg, R. L., Ressler, K., Perry, D. A., Wolverton, J., Geltz, A., & Deeb, G. M. (2020). The Role of Coronary Catheterization with Angiography in Surgically Managed Infectious Endocarditis. The American journal of medicine, 133(9), 1101-1104.
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  Coronary catheterization with angiography is often performed prior to surgical valve replacement in infectious endocarditis. There are no existing data as to whether this intervention is clinically necessary or leads to a change in surgical management. In order to determine the frequency with which coronary angiography impacts surgical management in infectious endocarditis, we conducted a retrospective review of surgically managed endocarditis cases at a tertiary care medical center.
• Perry, D. A., Rao, K., Young, V. B., Bergin, I. L., Vendrov, K. C., Keidan, M., Standke, A., Penkevich, A., Perlman, N. S., Abernathy-Close, L., Menon, A., Putler, R. K., & Dieterle, M. G. (2019). 76. Validation of Systemic Inflammatory Mediators as Biomarkers for Severity and Adverse Outcomes in Clostridium difficile Infection. Open Forum Infectious Diseases. doi:10.1093/ofid/ofz359.000
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  Abstract Background Clostridium difficile infection (CDI) can result in severe disease and death. We are currently unable to identify patients at risk for developing adverse outcomes. We previously showed multiple inflammatory mediators were associated with severity and adverse outcomes. Here, we set out to validate these findings in patients and a murine model of CDI. Methods CDI was diagnosed by the clinical microbiology laboratory. Sera were collected ≤48 hours after diagnosis from pilot (October 2010–November 2012) and validation (January–September 2016) cohorts. Inflammatory mediators were measured with a custom multiplex assay. IDSA severity was defined as serum creatinine >1.5-fold above baseline or white blood cell count >15,000 cells/mL. The 30-day outcomes were all-cause mortality and disease-related complications (DRCs): ICU admission, colectomy, or death attributed to CDI. We sought to validate our patient findings in a murine model of CDI: 67 antibiotic-treated mice were infected with 630 g (37 mice), a low virulence strain, or VPI 10463 (30 mice), a highly virulent strain. Host responses were assessed with a murine version of the multiplex panel. Unadjusted and adjusted models were built using logistic and L1 regression, respectively. Results The pilot cohort had 156 CDI cases; 63 (40%) with IDSA severity. The inflammatory response in IDSA severe cases was distinct based on redundancy analysis of all measured analytes (P = 0.01). In unadjusted analysis, IL-2R, IL-6, and procalcitonin associated with severity (P < 0.001, P = 0.003, and P = 0.003, respectively). The same findings were seen in the validation cohort of 272 cases (Figure 1). Unadjusted analyses revealed several predictors of severity and outcomes (Table 1). Adjusted models performed well (Figure 2) with AUCs of 0.74 [0.67–0.81] (IDSA severity), 0.89 [0.83–0.95] (death), and 0.84 [0.74–0.95] (DRCs). Application of each model to the mouse cohort for high vs. low virulence infections revealed AUCs of 0.59 [0.44–0.74], 0.96 [0.90–1.0], and 0.89 [0.81–0.97] (Figure 3). Conclusion In both humans and a murine CDI model, a panel of biomarkers from sera associated with severe CDI and predicted adverse outcomes. Our results support the possibility of a serum-based biomarker panel to inform medical decision-making for patients with CDI. Disclosures All Authors: No reported Disclosures.
• Perry, D. A., Rao, K., Young, V. B., Higgins, P. D., Menon, A., Patel, P., Putler, R. K., Micic, D., & Shirley, D. (2019). 2409. External Validation and Comparison of Clostridioides difficile Severity Scoring Systems. Open Forum Infectious Diseases. doi:10.1093/ofid/ofz360.2087
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  Abstract Background Annually in the US alone, Clostridioides difficile infection (CDI) afflicts nearly 500,000 patients causing 29,000 deaths. Since early and aggressive interventions could save lives but are not optimally deployed in all patients, numerous studies have published predictive models for adverse outcomes. These models are usually developed at a single institution, and largely are not externally validated. This aim of this study was to validate the predictability for severe CDI with previously published risk scores in a multicenter cohort of patients with CDI. Methods We conducted a retrospective study on four separate inpatient cohorts with CDI from three distinct sites: the Universities of Michigan (2010–2012 and 2016), Chicago (2012), and Wisconsin (2012). The primary composite outcome was admission to an intensive care unit, colectomy, and/or death attributed to CDI within 30 days of positive test. Structured query and manual chart review abstracted data from the medical record at each site. Published CDI severity scores were assessed and compared with each other and the IDSA guideline definition of severe CDI. Sensitivity, specificity, area under the receiver operator characteristic curve (AuROC), precision-recall curves, and net reclassification index (NRI) were calculated to compare models. Results We included 3,775 patients from the four cohorts (Table 1) and evaluated eight severity scores (Table 2). The IDSA (baseline comparator) model showed poor performance across cohorts(Table 3). Of the binary classification models, including those that were most predictive of the primary composite outcome, Jardin, performed poorly with minimal to no NRI improvement compared with IDSA. The continuous score models, Toro and ATLAS, performed better, but the AuROC varied by site by up to 17% (Table 3). The Gujja model varied the most: from most predictive in the University of Michigan 2010–2012 cohort to having no predictive value in the 2016 cohort (Table 3). Conclusion No published CDI severity score showed stable, acceptable predictive ability across multiple cohorts/institutions. To maximize performance and clinical utility, future efforts should focus on a multicenter-derived and validated scoring system, and/or incorporate novel biomarkers. Disclosures All authors: No reported disclosures.
• Perry, D. A., & Hakki, M. (2016). Assessment of a Cytomegalovirus serology dual-testing strategy in hematopoietic stem cell transplant recipients. Transplant infectious disease : an official journal of the Transplantation Society, 18(5), 809-814.
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  Accurate determination of recipient cytomegalovirus (CMV) serostatus before allogeneic hematopoietic stem cell transplantation (HSCT) is critical, as it is the most important predictor of post-transplant CMV infection and remains associated with non-relapse mortality. The purpose of this study was to assess a recipient dual-testing strategy before HSCT.
• Perry, D. A., Morrison, H. G., & Adam, R. D. (2011). Optical map of the genotype A1 WB C6 Giardia lamblia genome isolate. Molecular and Biochemical Parasitology, 180(2), 112-4.
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  The Giardia lamblia genome consists of 12 Mb divided among 5 chromosomes ranging in size from approximately 1 to 4 Mb. The assembled contigs of the genotype A1 isolate, WB, were previously mapped along the 5 chromosomes on the basis of hybridization of plasmid clones representing the contigs to chromosomes separated by PFGE. In the current report, we have generated an MluI optical map of the WB genome to improve the accuracy of the physical map. This has allowed us to correct several assembly errors and to better define the extent of the subtelomeric regions that are not included in the genome assembly.

Presentations

• Perry, D. (2024, Aug). Phage Therapy. Banner-University of Arizona Infectious Disease Ground Rounds.
• Perry, D. (2024, Dec). Nontuberculous Mycobacterial Pulmonary Disease. Banner-University of Arizona Pulmonary & Critical Care Ground Rounds.
• Perry, D. (2015, December). Pertussis Pneumonia. Noon Report; Portland, OR, USA.
• Perry, D. (2015, December). Sinonasal Undifferentiated Carcinoma. Noon Report. Portland, OR.
• Perry, D. (2016, June). It is Great Art to Laugh at Your Own Mis-Fortuitum. Noon Report. Portland, OR.
• Perry, D. (2016, March). Syphilis. Noon Reposrt. Portland, OR.
• Perry, D. (2017, February). A Culture of Safety. OHSU Performance Excellence Week 2017-Grand Rounds. Portland, OR.
• Perry, D. (2017, June). TB or Not TB. Noon Report. Portland, OR.
• Perry, D. (2017, March). Chronic Cough. Noon Report. Portland, OR.
• Perry, D. (2018, November). Vaccine Preventable Diseases in Adults. University of Michigan Infectious Disease Grand rounds. Ann Arbor, MI.
• Perry, D. (2018, September). Baloxivir. University of Michigan Infectious disease Journal Club Grand Rounds. Ann Arbor, MI.
• Perry, D. (2019, April). What is the Role for Metronidazole in the Treatment of Clostridium difficile Infection. University of Michigan Infectious Disease Grand Rounds. Ann Arbor, MI.
• Perry, D. (2019, March). Risk Modeling with Severe Clostridium difficile. University of Michigan Infectious Disease Grand Rounds. Ann Arbor, MI.
• Perry, D. (2019, May). Clostridioides difficile Scoring System External Validation and Other Adventures in Fellowship. University of Michigan Infectious Disease Grand Rounds. Ann Arbor, MI.
• Perry, D. (2019, September). New Antibiotics on the Block. University of Michigan Infectious Disease Grand Rounds. Ann Arbor, MI.
• Perry, D. (2020, November). Viral Dermatology. Banner University of Arizona Dermatology Residency Didactics. Tucson, AZ.
• Perry, D. (2021, April). Esophagitis, Enteritis. Colitis.. Banner University of Arizona Gastroenterology Grand Rounds. Tucson, AZ.

Poster Presentations

• Perry, D. (2016, February). The Use of CTPA in ED and Inpatient Settings for Evaluation of PE: Are We Choosing Wisely?. OHSU Performance Excellence Week. Portland, OR.
• Perry, D. (2017, March). Survey of Multidrug-Resistant Organism Admission Screening and Preoperative S. aureus Decolonization. Society for Healthcare Epidemiology of America Spring 2017 Conference. St. Louis, OR.
• Perry, D. (2019, October). External Validation and Comparison of Clostridioides difficile Severity Scoring Systems. ID Week 2019 Conference. Washington, DC.
• Perry, D. (2016, November). Finding a Voice for the Voiceless: A Housestaff-Led Initiative to Facilitate Advance Care Planning Through Documentation of Surrogate Decision Maker in the Electronic Medical Record. American College of Physicians. Salem, OR, USA: ACP Oregon Chapter Scientific Meeting.
• Perry, D. (2014, November). Gemcitabine Induced Hemolytic Uremic Syndrome Treated with Eculizumab. American College of Physicians. Salem, OR, USA: ACP Oregon Chapter Meeting.