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Sapozhnikov J, Albarillo FS, Pulia MS. Optimizing Antimicrobial Stewardship in the Emergency Department. Emerg Med Clin North Am 2024; 42:443-459. [PMID: 38641398 DOI: 10.1016/j.emc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Antibiotic stewardship is a core component of emergency department (ED) practice and impacts patient safety, clinical outcomes, and public health. The unique characteristics of ED practice, including crowding, time pressure, and diagnostic uncertainty, need to be considered when implementing antibiotic stewardship interventions in this setting. Rapid advances in pathogen detection and host response biomarkers promise to revolutionize the diagnosis of infectious diseases in the ED, but such tests are not yet considered standard of care. Presently, clinical decision support embedded in the electronic health record and pharmacist-led interventions are the most effective ways to improve antibiotic prescribing in the ED.
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Affiliation(s)
- Julia Sapozhnikov
- Medical Science Liaison, Karius Inc, 975 Island Drive, Redwood City, CA 94065, USA
| | - Fritzie S Albarillo
- Department of Medicine, Infectious Diseases Division, Loyola University Medical Center, Loyola University Medical Center is 2160 South First Avenue, Maywood, IL 60153, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
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Kitagawa D, Kitano T, Uchihara Y, Ando T, Nishikawa H, Suzuki R, Onaka M, Kasamatsu T, Shiraishi N, Takemoto K, Sekine M, Suzuki S, Suzuki Y, Nakano A, Nakano R, Yano H, Yoshida S, Kawahara M, Maeda K, Nakamura F. Impact of Multiplex Polymerase Chain Reaction Test in Patients With Meningitis or Encephalitis. Open Forum Infect Dis 2023; 10:ofad634. [PMID: 38156045 PMCID: PMC10753909 DOI: 10.1093/ofid/ofad634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 12/15/2023] [Indexed: 12/30/2023] Open
Abstract
Background The objective of this study was to evaluate the impact of the FilmArray meningitis/encephalitis panel (FAME) on length of stay (LOS) and duration of antimicrobial treatment in children and adults in a Japanese community hospital. Methods This retrospective cohort study was conducted in Japan between January 2016 and December 2022. We included hospitalized patients with cerebrospinal fluid (CSF) samples and those aged <2 months or who had 5 or more white blood cells/μL in the CSF. To compare the days of therapy (DOT) and LOS between the pre-FAME and FAME periods, multivariate Poisson regression analyses were conducted without an offset term. Results The number of cases undergoing pathogen-specific polymerase chain reaction increased from 3.7% in the pre-FAME period to 57.5% in the FAME period (P < .001). The pathogen identification rate also increased during the FAME period, from 0.4% to 18.7% (P < .001). While the antibacterial DOT was not statistically different between the 2 periods (adjusted rate ratio [aRR], 1.06 [95% confidence interval {CI}, 1.00-1.13]; P = .063]), the antiviral DOT was significantly shorter in the FAME period (aRR, 0.80 [95% CI, .71-.89]; P < .001). Conclusions This study revealed a significant reduction in antiviral use during the FAME period, whereas LOS and antibacterial use did not decrease. Given the possibility of factors (eg, the COVID-19 pandemic) affecting the epidemiology of meningitis and encephalitis, the indications and impact of the FAME test should be evaluated with continuous monitoring of the epidemiology of meningitis and encephalitis and its clinical impact.
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Affiliation(s)
- Daisuke Kitagawa
- Department of Laboratory Medicine, Nara Prefecture General Medical Center, Nara, Japan
- Department of Microbiology and Infectious Diseases, Nara Medical University, Kashihara, Japan
| | - Taito Kitano
- Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Yuto Uchihara
- Department of Neurology, Nara Prefecture General Medical Center, Nara, Japan
| | - Takafusa Ando
- Department of Neurology, Nara Prefecture General Medical Center, Nara, Japan
| | - Hiroki Nishikawa
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Rika Suzuki
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Masayuki Onaka
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Takehito Kasamatsu
- Department of Infectious Diseases, Nara Prefecture General Medical Center, Nara, Japan
| | - Naoyuki Shiraishi
- Department of Infectious Diseases, Nara Prefecture General Medical Center, Nara, Japan
| | - Kiyoshi Takemoto
- Department of Critical Care Medicine, Nara Prefecture General Medical Center, Nara, Japan
| | - Madoka Sekine
- Department of Laboratory Medicine, Nara Prefecture General Medical Center, Nara, Japan
| | - Soma Suzuki
- Department of Laboratory Medicine, Nara Prefecture General Medical Center, Nara, Japan
| | - Yuki Suzuki
- Department of Microbiology and Infectious Diseases, Nara Medical University, Kashihara, Japan
| | - Akiyo Nakano
- Department of Microbiology and Infectious Diseases, Nara Medical University, Kashihara, Japan
| | - Ryuichi Nakano
- Department of Microbiology and Infectious Diseases, Nara Medical University, Kashihara, Japan
| | - Hisakazu Yano
- Department of Microbiology and Infectious Diseases, Nara Medical University, Kashihara, Japan
| | - Sayaka Yoshida
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Makoto Kawahara
- Department of Neurology, Nara Prefecture General Medical Center, Nara, Japan
| | - Koichi Maeda
- Department of Infectious Diseases, Nara Prefecture General Medical Center, Nara, Japan
| | - Fumihiko Nakamura
- Department of Laboratory Medicine, Nara Prefecture General Medical Center, Nara, Japan
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Ota K, Fujiwara S, Ishii J, Yoshimura H, Kohara N, Kawamoto M. [Efficacy of FilmArray ® ME panel for the rapid diagnosis of meningitis and encephalitis]. Rinsho Shinkeigaku 2023; 63:528-531. [PMID: 37518019 DOI: 10.5692/clinicalneurol.cn-001840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
Microbial tests are essential for appropriate management for acute meningitis and encephalitis, but it often takes several days to identify the results of culture tests or PCR. BioFire FilmArray® meningitis/encephalitis panel (ME panel) is a rapid multiplex PCR assay that targets 14 bacteria, viruses, and yeast in 1 hour. In this single-center retrospective study, we reviewed adult patients who underwent ME panel test in parallel with conventional microbial tests from January to August 2021. Eighteen of 70 patients (26%) tested positive by ME panel, of which 8 patients (11%) were helpful in altering treatment strategy. Fifty-two patients (74%) could stop empirical treatment such as acyclovir or antibiotics due to negative results on ME panel. All results of ME panel were same as traditional assays. Use of ME panel can contribute to early diagnosis and treatment.
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Affiliation(s)
- Kazuma Ota
- Department of Neurology, Kobe City Medical Center General Hospital
| | - Satoru Fujiwara
- Department of Neurology, Kobe City Medical Center General Hospital
| | - Junko Ishii
- Department of Neurology, Kobe City Medical Center General Hospital
| | - Hajime Yoshimura
- Department of Neurology, Kobe City Medical Center General Hospital
| | - Nobuo Kohara
- Department of Neurology, Kobe City Medical Center General Hospital
| | - Michi Kawamoto
- Department of Neurology, Kobe City Medical Center General Hospital
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Hara M, Ishihara M, Nakajima H. Use of the FilmArray® Meningitis/Encephalitis panel to detect pathogenic microorganisms in cerebrospinal fluid specimens: a single-center retrospective study. J Int Med Res 2022; 50:3000605221129561. [PMID: 36214109 PMCID: PMC9551344 DOI: 10.1177/03000605221129561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Meningitis and encephalitis are neurological emergencies requiring rapid diagnosis and treatment. The performance of the FilmArray® Meningitis/Encephalitis (ME) panel, a multiplex polymerase chain reaction test, and conventional methods for diagnosing meningitis and encephalitis was compared. METHODS This retrospective study assessed 20 patients diagnosed with meningitis or encephalitis according to clinical symptoms and laboratory examination findings between January 2018 and December 2019. The results of the FilmArray® ME panel were compared with those of conventional methods. RESULTS Pathogens were identified in 11 (55%) patients using the FilmArray® ME panel and in nine (45%) patients using conventional methods. The test identified herpes simplex virus type 1 in two patients, herpes simplex virus type 2 in one, varicella-zoster virus in four, Streptococcus pneumoniae in three, and Cryptococcus neoformans in one. Furthermore, additional pathogens were detected (n = 1, S. pneumoniae and n = 1, varicella-zoster virus). The median times to pathogen identification were 2 hours using the FilmArray® ME panel and 96 hours with conventional methods. CONCLUSIONS The sensitivity of the FilmArray® ME panel for rapidly detecting the most common pathogens was similar to that of conventional methods. Hence, this method could decrease the time to definitive diagnosis and treatment initiation.
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Affiliation(s)
| | | | - Hideto Nakajima
- Hideto Nakajima, Division of Neurology,
Department of Medicine, Nihon University School of Medicine, 30-1
Oyaguchikamicho, Itabashi, Tokyo 173-8610, Japan.
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Trujillo-Gómez J, Tsokani S, Arango-Ferreira C, Atehortúa-Muñoz S, Jimenez-Villegas MJ, Serrano-Tabares C, Veroniki AA, Florez ID. Biofire FilmArray Meningitis/Encephalitis panel for the aetiological diagnosis of central nervous system infections: A systematic review and diagnostic test accuracy meta-analysis. EClinicalMedicine 2022; 44:101275. [PMID: 35198914 PMCID: PMC8851290 DOI: 10.1016/j.eclinm.2022.101275] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 12/30/2021] [Accepted: 01/07/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The FilmArray Meningitis/Encephalitis(FA/ME) panel brings benefits in clinical practice, but its diagnostic test accuracy (DTA) remains unclear. We aimed to determine the DTA of FA/ME for the aetiological diagnostic in patients with suspected central nervous system(CNS) infection. METHODS We performed a systematic review with DTA meta-analysis (PROSPERO: CRD42020139285). We searched Embase, Medline (Ovid), and Web of Science from inception until September 1st, 2021. We assessed the study-level risk of bias with the QUADAS-2 tool and applied the GRADE approach to assess the certainty of the synthesised evidence. We included studies that simultaneously measured the reference test (CSF/blood culture for bacteria, and specific polymerase chain reaction for viruses) and the FA/ME in patients with suspected CNS infection. We performed random-effects bivariate meta-analysis models of combined sensitivity and specificity using CSF/blood cultures(reference test 1) and a final diagnosis adjudication based on clinical/laboratory criteria (reference test 2). FINDINGS We included 19 studies (11,351 participants). For all bacteria with reference test 1 (16 studies/6183 patients) sensitivity was estimated at 89·5% (95%CI 81·1-94·4), and specificity at 97·4% (95%CI 94-98·9). With reference test 2 (15 studies/5,524 patients), sensitivity was estimated at 92·1%(95%CI 86·8-95·3) and specificity at 99.2(95%CI 98·3-99·6) For herpes simplex virus-2(HSV-2), enteroviruses, and Varicella-Zoster virus (VZV), we obtained sensitivities between 75·5 and 93·8%, and specificities above 99% (reference test 1). Certainty of the evidence was low. INTERPRETATION FA/ME may have acceptable-to-high sensitivities and high specificities for identifying bacteria, especially for S.pneumoniae, and viruses, especially for HSV-2, and enteroviruses. Sensitivities for L.monocytogenes, H.influenzae, E.coli, and HSV-1 were suboptimal. FUNDING None.
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Affiliation(s)
- Juliana Trujillo-Gómez
- Department of Paediatrics, Universidad de Antioquia, Calle 67 No. 53-108, Medellín, Antioquia 050001, Colombia
- Hospital San Vicente Fundacion, Calle 64 # 51D - 154, Medellín 050010, Colombia
- Hospital General de Medellín, Carrera 48 # 32-102, Medellín 0500515, Colombia
| | - Sofia Tsokani
- Department of Primary Education, School of Education, University of Ioannina, PO Box: 1186, Ioannina 45110, Greece
| | - Catalina Arango-Ferreira
- Department of Paediatrics, Universidad de Antioquia, Calle 67 No. 53-108, Medellín, Antioquia 050001, Colombia
- Hospital San Vicente Fundacion, Calle 64 # 51D - 154, Medellín 050010, Colombia
| | | | - Maria José Jimenez-Villegas
- Department of Paediatrics, Universidad de Antioquia, Calle 67 No. 53-108, Medellín, Antioquia 050001, Colombia
- Hospital San Vicente Fundacion, Calle 64 # 51D - 154, Medellín 050010, Colombia
| | - Carolina Serrano-Tabares
- Department of Paediatrics, Universidad de Antioquia, Calle 67 No. 53-108, Medellín, Antioquia 050001, Colombia
- Clínica Universitaria Bolivariana, Carrera 72A # 78b -50, Medellín 050015, Colombia
| | - Areti-Angeliki Veroniki
- St. Michael's Hospital, Li Ka Shing Knowledge Institute, 8 Shuter St, Toronto, ON M5B 1A6, Canada
| | - Ivan D. Florez
- Department of Paediatrics, Universidad de Antioquia, Calle 67 No. 53-108, Medellín, Antioquia 050001, Colombia
- School of Rehabilitation Science, McMaster University, 1400 Main St. W. Hamilton, Hamilton, ON L8S 1C7, Canada
- Paediatric Intensive Care Unit, Clínica Las Americas AUNA, Dg. 75B ##2A-80/140, Medellin, Colombia
- Corresponding author at: Department of Paediatrics, Universidad de Antioquia, Calle 67 No. 53-108, Medellín, Antioquia 050001, Colombia.
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