1
|
Lowin J, Sotak M, Haas L, Wastlund D. Cost-consequence analysis of a combined COVID-19/influenza rapid diagnostic test in the Brazilian private healthcare setting. Braz J Infect Dis 2024; 28:103840. [PMID: 38991654 DOI: 10.1016/j.bjid.2024.103840] [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: 01/05/2024] [Revised: 05/20/2024] [Accepted: 06/22/2024] [Indexed: 07/13/2024] Open
Abstract
Combination COVID-19/influenza rapid tests provide a way to quickly and accurately differentiate between the two infections. The goal of this economic evaluation was to assess the cost and health benefits of a combination COVID-19/influenza Rapid Diagnostic Test (RDT) vs. current standard-of-care in the Brazilian private healthcare setting. A dual decision tree model was developed to estimate the impact of rapid differentiation of COVID-19 and influenza in a hypothetical cohort of 1,000 adults with influenza-like illness in an ambulatory healthcare setting. The model compared the use of a combination COVID-19/influenza RDT to Brazil standard diagnostic practice of a COVID-19 RDT and presumptive influenza diagnosis. Different levels of influenza prevalence were modeled with co-infection estimated as a function of the COVID-19 prevalence. Outcomes included accuracy of diagnosis, antiviral prescriptions and healthcare resource use (hospital bed days and ICU occupancy). Depending on influenza prevalence, considering 1,000 patients with influenza-like illness, a combination RDT compared to standard practice was estimated to result in between 88 and 149 fewer missed diagnoses of influenza (including co-infection), 161 to 185 fewer cases of over-diagnosis of influenza; a 24 to 34% reduction in hospital bed days and a 16 to 26% reduction in ICU days. In the base case scenario (20% influenza, 5% COVID-19), the combination RDT was estimated to result in cohort cost savings of $99. Based upon a de novo economic model, this analysis indicates that use of a combination RDT could positively impact influenza antiviral prescriptions and lower healthcare resource use.
Collapse
Affiliation(s)
| | | | - Laura Haas
- Abbott, Rapid Diagnostics Division, São Paulo, SP, Brazil
| | | |
Collapse
|
2
|
Ehrhard S, Herren L, Ricklin ME, Suter-Riniker F, Exadaktylos AK, Hautz W, Müller M, Jent P. Do all Emergency Room Patients With Influenza-like Symptoms Need Blood Cultures? A Retrospective Cohort Study of 2 Annual Influenza Seasons. Open Forum Infect Dis 2024; 11:ofae242. [PMID: 38770207 PMCID: PMC11103619 DOI: 10.1093/ofid/ofae242] [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: 11/08/2023] [Accepted: 04/28/2024] [Indexed: 05/22/2024] Open
Abstract
In this retrospective cohort study, we evaluated risk factors for bacteremia in emergency department patients presenting with influenza-like symptoms during influenza epidemic seasons. In patients without fever, chronic heart or chronic liver disease, blood culture collection might be omitted.
Collapse
Affiliation(s)
- Simone Ehrhard
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas Herren
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Meret E Ricklin
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Wolf Hautz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Philipp Jent
- Department of Infectious Diseases, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| |
Collapse
|
3
|
Cavallazzi R, Ramirez JA. Influenza and Viral Pneumonia. Infect Dis Clin North Am 2024; 38:183-212. [PMID: 38280763 DOI: 10.1016/j.idc.2023.12.010] [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: 01/29/2024]
Abstract
Influenza and other respiratory viruses are commonly identified in patients with community-acquired pneumonia, hospital-acquired pneumonia, and in immunocompromised patients with pneumonia. Clinically, it is difficult to differentiate viral from bacterial pneumonia. Similarly, the radiological findings of viral infection are in general nonspecific. The advent of polymerase chain reaction testing has enormously facilitated the identification of respiratory viruses, which has important implications for infection control measures and treatment. Currently, treatment options for patients with viral infection are limited but there is ongoing research on the development and clinical testing of new treatment regimens and strategies.
Collapse
Affiliation(s)
- Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Disorders, University of Louisville, Louisville, KY, USA.
| | - Julio A Ramirez
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| |
Collapse
|
4
|
Hung SK, Wu CC, Singh A, Li JH, Lee C, Chou EH, Pekosz A, Rothman R, Chen KF. Developing and validating clinical features-based machine learning algorithms to predict influenza infection in influenza-like illness patients. Biomed J 2023; 46:100561. [PMID: 36150651 PMCID: PMC10498408 DOI: 10.1016/j.bj.2022.09.002] [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] [Received: 06/22/2022] [Revised: 09/05/2022] [Accepted: 09/16/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Seasonal influenza poses a significant risk, and patients can benefit from early diagnosis and treatment. However, underdiagnosis and undertreatment remain widespread. We developed and compared clinical feature-based machine learning (ML) algorithms that can accurately predict influenza infection in emergency departments (EDs) among patients with influenza-like illness (ILI). MATERIAL AND METHODS We conducted a prospective cohort study in five EDs in the US and Taiwan from 2015 to 2020. Adult patients visiting the EDs with symptoms of ILI were recruited and tested by real-time RT-PCR for influenza. We evaluated seven ML algorithms and compared their results with previously developed clinical prediction models. RESULTS Out of the 2189 enrolled patients, 1104 tested positive for influenza. The eXtreme Gradient Boosting achieved superior performance with an area under the receiver operating characteristic curve of 0.82 (95% confidence interval [CI] = 0.79-0.85), with a sensitivity of 0.92 (95% CI = 0.88-0.95), specificity of 0.89 (95% CI = 0.86-0.92), and accuracy of 0.72 (95% CI = 0.69-0.76) in the testing set over cut-offs of 0.4, 0.6 and 0.5, respectively. These results were superior to those of previously proposed clinical prediction models. The model interpretation revealed that body temperature, cough, rhinorrhea, and exposure history were positively associated with and the days of illness and influenza vaccine were negatively associated with influenza infection. We also found the week of the influenza season, pulse rate, and oxygen saturation to be associated with influenza infection. CONCLUSIONS The clinical feature-based ML model outperformed conventional models for predicting influenza infection.
Collapse
Affiliation(s)
- Shang-Kai Hung
- Department of Emergency Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Chin-Chieh Wu
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Avichandra Singh
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Jin-Hua Li
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Christian Lee
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX, USA
| | - Eric H Chou
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX, USA
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Richard Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kuan-Fu Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan; Department of Emergency Medicine, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan.
| |
Collapse
|
5
|
Nairz M, Todorovic T, Gehrer CM, Grubwieser P, Burkert F, Zimmermann M, Trattnig K, Klotz W, Theurl I, Bellmann-Weiler R, Weiss G. Single-Center Experience in Detecting Influenza Virus, RSV and SARS-CoV-2 at the Emergency Department. Viruses 2023; 15:v15020470. [PMID: 36851685 PMCID: PMC9958692 DOI: 10.3390/v15020470] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 02/10/2023] Open
Abstract
Reverse transcription polymerase chain reaction (RT-PCR) on respiratory tract swabs has become the gold standard for sensitive and specific detection of influenza virus, respiratory syncytial virus (RSV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In this retrospective analysis, we report on the successive implementation and routine use of multiplex RT-PCR testing for patients admitted to the Internal Medicine Emergency Department (ED) at a tertiary care center in Western Austria, one of the hotspots in the early coronavirus disease 2019 (COVID-19) pandemic in Europe. Our description focuses on the use of the Cepheid® Xpert® Xpress closed RT-PCR system in point-of-care testing (POCT). Our indications for RT-PCR testing changed during the observation period: From the cold season 2016/2017 until the cold season 2019/2020, we used RT-PCR to diagnose influenza or RSV infection in patients with fever and/or respiratory symptoms. Starting in March 2020, we used the RT-PCR for SARS-CoV-2 and a multiplex version for the combined detection of all these three respiratory viruses to also screen subjects who did not present with symptoms of infection but needed in-hospital medical treatment for other reasons. Expectedly, the switch to a more liberal RT-PCR test strategy resulted in a substantial increase in the number of tests. Nevertheless, we observed an immediate decline in influenza virus and RSV detections in early 2020 that coincided with public SARS-CoV-2 containment measures. In contrast, the extensive use of the combined RT-PCR test enabled us to monitor the re-emergence of influenza and RSV detections, including asymptomatic cases, at the end of 2022 when COVID-19 containment measures were no longer in place. Our analysis of PCR results for respiratory viruses from a real-life setting at an ED provides valuable information on the epidemiology of those infections over several years, their contribution to morbidity and need for hospital admission, the risk for nosocomial introduction of such infection into hospitals from asymptomatic carriers, and guidance as to how general precautions and prophylactic strategies affect the dynamics of those infections.
Collapse
|
6
|
Brachmann M, Serwa P, Sauerland D. Cost-of-illness comparison between clinical judgment and molecular point-of-care testing for influenza-like illness patients in Germany. NPJ Prim Care Respir Med 2023; 33:3. [PMID: 36650143 PMCID: PMC9844933 DOI: 10.1038/s41533-022-00325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 12/20/2022] [Indexed: 01/18/2023] Open
Abstract
A high economic burden stems from seasonal influenza as a well-known but serious public health problem. Rapid diagnostic tests have not yet been integrated into routine use in German primary care, even though they are likely to reduce overall costs in cases of suspected infection. This study aims to demonstrate that the use of point-of-care testing (POCT) produces lower costs of illness compared to the costs incurred by relying on clinical judgment alone. With the help of a decision tree model, two different diagnostic approaches for influenza-like illness (ILI) in primary care were compared: (1) clinical judgment with no technical support and (2) POCT. The costs of illness, as well as their differences, vary widely among the three age groups considered (elderly people, adults, and children). For the pathway of using clinical judgment alone, the costs of illness sum up to 155.99 € for elderly people compared to 76.31 € for adults and 74.15 € for children. With POCT, the costs of illness for the elderly amount to 115,09 €, which is 26% lower than the costs without diagnostic support. The costs for adults and children are 74.42 € and 75.66 €, respectively, which means 2.5% lower costs of illness for adults and 2% higher costs for children. The results demonstrate that the use of POCT to support detecting influenza in ILI patients may reduce the overall cost of illness. The provided data can help governments make informed decisions about potential cost savings by integrating POCT into the reimbursement scheme.
Collapse
Affiliation(s)
- M. Brachmann
- grid.412581.b0000 0000 9024 6397Witten/Herdecke University, Witten, Germany ,bcmed GmbH, Ulm, Germany
| | | | - D. Sauerland
- grid.412581.b0000 0000 9024 6397Witten/Herdecke University, Witten, Germany
| |
Collapse
|
7
|
Maita H, Kobayashi T, Akimoto T, Matsuoka F, Funakoshi S, Osawa H, Kato H. Clinical diagnosis of seasonal influenza by physicians: a retrospective observational study. BMJ Open 2022; 12:e055910. [PMID: 35868823 PMCID: PMC9315920 DOI: 10.1136/bmjopen-2021-055910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To elucidate the diagnostic accuracy of pretest probability of influenza (%) by physicians and the factors affecting the clinical diagnosis. DESIGN Retrospective, single-centre observational study. SETTING A community primary care clinic in Japan. PARTICIPANTS The participants were recruited from a database of studies conducted during the influenza season from December 2017 to April 2019. PRIMARY OUTCOME MEASURE Sensitivity and specificity of the physician's clinical diagnosis of influenza recorded in the medical record as pretest probability. RESULTS A total of 335 patients (median age, 31 years; male, 66.6%) were analysed in this study. The area under the curve (AUC) of the physician's pretest probability was 0.77. At a cut-off value of 30%, the sensitivity and negative likelihood ratio were 92.0% (95% CI 86.7 to 95.7) and 0.19 (95% CI 0.11 to 0.33), respectively. At a cut-off value of 80%, the specificity and positive likelihood ratio were 90.8% (95% CI 85.4 to 94.6) and 4.01 (95% CI 2.41 to 6.66), respectively. The AUCs of patients who had and had not taken any medications before visiting the clinic were 0.77 (95% CI 0.69 to 0.85) and 0.78 (95% CI 0.71 to 0.84), respectively. The AUCs of patients with type A and B influenza were 0.78 (95% CI 0.72 to 0.84) and 0.76 (95% CI 0.70 to 0.82), respectively. The AUCs of vaccinated and unvaccinated patients were 0.80 (95% CI 0.72 to 0.88) and 0.76 (95% CI 0.63 to 0.89), respectively. The AUC for patients less than 12 hours after onset was 0.69 (95% CI 0.51 to 0.88), and that for patients aged younger than 6 years was 0.69 (95% CI 0.49 to 0.88). CONCLUSIONS The physician's pretest probability of influenza (%) may be useful for both definitive and exclusionary diagnoses within the limits of our study.
Collapse
Affiliation(s)
- Hiroki Maita
- Development of Community Healthcare, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Tadashi Kobayashi
- Department of General Medicine, Hirosaki University School of Medicine and Hospital, Hirosaki, Aomori, Japan
| | - Takashi Akimoto
- Department of General Medicine, Hirosaki University School of Medicine and Hospital, Hirosaki, Aomori, Japan
| | - Fumihiko Matsuoka
- Rokkasho Center for Community and Family Medicine, Rokkasho, Aomori, Japan
| | - Shigeki Funakoshi
- Rokkasho Center for Community and Family Medicine, Rokkasho, Aomori, Japan
| | - Hiroshi Osawa
- Department of General Medicine, Hirosaki University School of Medicine and Hospital, Hirosaki, Aomori, Japan
| | - Hiroyuki Kato
- Development of Community Healthcare, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
- Department of General Medicine, Hirosaki University School of Medicine and Hospital, Hirosaki, Aomori, Japan
- General Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| |
Collapse
|
8
|
Jung BK, Ham SK, Kim JK. Comparison of Blood Test Results and Symptoms of Patients with COVID-19 Monoinfection and with COVID-19 and Influenza Virus Co-Infection. KOREAN JOURNAL OF CLINICAL LABORATORY SCIENCE 2022. [DOI: 10.15324/kjcls.2022.54.2.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Bo Kyeung Jung
- Department of Laboratory Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Seung Keun Ham
- Department of Biomedical Laboratory Science, Dankook University College of Health Sciences, Cheonan, Korea
| | - Jae Kyung Kim
- Department of Biomedical Laboratory Science, Dankook University College of Health Sciences, Cheonan, Korea
| |
Collapse
|
9
|
Whitlock F, Murcia PR, Newton JR. A Review on Equine Influenza from a Human Influenza Perspective. Viruses 2022; 14:v14061312. [PMID: 35746783 PMCID: PMC9229935 DOI: 10.3390/v14061312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/31/2022] [Accepted: 06/07/2022] [Indexed: 12/12/2022] Open
Abstract
Influenza A viruses (IAVs) have a main natural reservoir in wild birds. IAVs are highly contagious, continually evolve, and have a wide host range that includes various mammalian species including horses, pigs, and humans. Furthering our understanding of host-pathogen interactions and cross-species transmissions is therefore essential. This review focuses on what is known regarding equine influenza virus (EIV) virology, pathogenesis, immune responses, clinical aspects, epidemiology (including factors contributing to local, national, and international transmission), surveillance, and preventive measures such as vaccines. We compare EIV and human influenza viruses and discuss parallels that can be drawn between them. We highlight differences in evolutionary rates between EIV and human IAVs, their impact on antigenic drift, and vaccine strain updates. We also describe the approaches used for the control of equine influenza (EI), which originated from those used in the human field, including surveillance networks and virological analysis methods. Finally, as vaccination in both species remains the cornerstone of disease mitigation, vaccine technologies and vaccination strategies against influenza in horses and humans are compared and discussed.
Collapse
Affiliation(s)
- Fleur Whitlock
- Medical Research Council, University of Glasgow Centre for Virus Research, Garscube Estate, Glasgow G61 1QH, UK; (F.W.); (P.R.M.)
- Equine Infectious Disease Surveillance (EIDS), Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES, UK
| | - Pablo R. Murcia
- Medical Research Council, University of Glasgow Centre for Virus Research, Garscube Estate, Glasgow G61 1QH, UK; (F.W.); (P.R.M.)
| | - J. Richard Newton
- Equine Infectious Disease Surveillance (EIDS), Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES, UK
- Correspondence:
| |
Collapse
|
10
|
Ouchi D, García-Sangenís A, Moragas A, van der Velden AW, Verheij TJ, Butler CC, Bongard E, Coenen S, Cook J, Francis NA, Godycki-Cwirko M, Lundgren PT, Lionis C, Radzeviciene Jurgute R, Chlabicz S, De Sutter A, Bucher HC, Seifert B, Kovács B, de Paor M, Sundvall PD, Aabenhus R, Harbin NJ, Ieven G, Goossens H, Lindbæk M, Bjerrum L, Llor C. Clinical prediction of laboratory-confirmed influenza in adults with influenza-like illness in primary care. A randomized controlled trial secondary analysis in 15 European countries. Fam Pract 2022; 39:398-405. [PMID: 34611715 DOI: 10.1093/fampra/cmab122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical findings do not accurately predict laboratory diagnosis of influenza. Early identification of influenza is considered useful for proper management decisions in primary care. OBJECTIVE We evaluated the diagnostic value of the presence and the severity of symptoms for the diagnosis of laboratory-confirmed influenza infection among adults presenting with influenza-like illness (ILI) in primary care. METHODS Secondary analysis of patients with ILI who participated in a clinical trial from 2015 to 2018 in 15 European countries. Patients rated signs and symptoms as absent, minor, moderate, or major problem. A nasopharyngeal swab was taken for microbiological identification of influenza and other microorganisms. Models were generated considering (i) the presence of individual symptoms and (ii) the severity rating of symptoms. RESULTS A total of 2,639 patients aged 18 or older were included in the analysis. The mean age was 41.8 ± 14.7 years, and 1,099 were men (42.1%). Influenza was microbiologically confirmed in 1,337 patients (51.1%). The area under the curve (AUC) of the model for the presence of any of seven symptoms for detecting influenza was 0.66 (95% confidence interval [CI]: 0.65-0.68), whereas the AUC of the symptom severity model, which included eight variables-cough, fever, muscle aches, sweating and/or chills, moderate to severe overall disease, age, abdominal pain, and sore throat-was 0.70 (95% CI: 0.69-0.72). CONCLUSION Clinical prediction of microbiologically confirmed influenza in adults with ILI is slightly more accurate when based on patient reported symptom severity than when based on the presence or absence of symptoms.
Collapse
Affiliation(s)
- Dan Ouchi
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Ana García-Sangenís
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain
| | - Ana Moragas
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Christopher C Butler
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Emily Bongard
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine & Population Health, University of Antwerp, Antwerp, Belgium
| | - Johanna Cook
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Nick A Francis
- Primary Care Research Centre, University of Southampton, Southampton,United Kingdom
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Pia Touboul Lundgren
- Département de Santé Publique, Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Christos Lionis
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Crete, Greece
| | | | - Sławomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
| | - An De Sutter
- Centre for Family Medicine UGent, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Bohumil Seifert
- Department of General Practice, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Muireann de Paor
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Health Research Board Primary Care Clinical Trial Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Pär-Daniel Sundvall
- Research, Education, Development & Innovation Primary Health Care, Region Västra Götaland and Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Rune Aabenhus
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicolay Jonassen Harbin
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Greet Ieven
- Laboratory of Clinical Microbiology, Antwerp, University Hospital, Edegem, Belgium
| | - Herman Goossens
- Laboratory of Clinical Microbiology, Antwerp, University Hospital, Edegem, Belgium
| | - Morten Lindbæk
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain.,Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
11
|
Greshake Tzovaras B, Senabre Hidalgo E, Alexiou K, Baldy L, Morane B, Bussod I, Fribourg M, Wac K, Wolf G, Ball M. Using an Individual-Centered Approach to Gain Insights From Wearable Data in the Quantified Flu Platform: Netnography Study. J Med Internet Res 2021; 23:e28116. [PMID: 34505836 PMCID: PMC8463949 DOI: 10.2196/28116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/16/2021] [Accepted: 07/05/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Wearables have been used widely for monitoring health in general, and recent research results show that they can be used to predict infections based on physiological symptoms. To date, evidence has been generated in large, population-based settings. In contrast, the Quantified Self and Personal Science communities are composed of people who are interested in learning about themselves individually by using their own data, which are often gathered via wearable devices. OBJECTIVE This study aims to explore how a cocreation process involving a heterogeneous community of personal science practitioners can develop a collective self-tracking system for monitoring symptoms of infection alongside wearable sensor data. METHODS We engaged in a cocreation and design process with an existing community of personal science practitioners to jointly develop a working prototype of a web-based tool for symptom tracking. In addition to the iterative creation of the prototype (started on March 16, 2020), we performed a netnographic analysis to investigate the process of how this prototype was created in a decentralized and iterative fashion. RESULTS The Quantified Flu prototype allowed users to perform daily symptom reporting and was capable of presenting symptom reports on a timeline together with resting heart rates, body temperature data, and respiratory rates measured by wearable devices. We observed a high level of engagement; over half of the users (52/92, 56%) who engaged in symptom tracking became regular users and reported over 3 months of data each. Furthermore, our netnographic analysis highlighted how the current Quantified Flu prototype was a result of an iterative and continuous cocreation process in which new prototype releases sparked further discussions of features and vice versa. CONCLUSIONS As shown by the high level of user engagement and iterative development process, an open cocreation process can be successfully used to develop a tool that is tailored to individual needs, thereby decreasing dropout rates.
Collapse
Affiliation(s)
- Bastian Greshake Tzovaras
- Center for Research & Interdisciplinarity, INSERM U1284, Université de Paris, Paris, France
- Open Humans Foundation, Sanford, NC, United States
| | - Enric Senabre Hidalgo
- Center for Research & Interdisciplinarity, INSERM U1284, Université de Paris, Paris, France
| | | | | | | | - Ilona Bussod
- Center for Research & Interdisciplinarity, Paris, France
| | | | - Katarzyna Wac
- Quality of Life Technologies, GSEM/CUI, University of Geneva, Geneva, Switzerland
| | - Gary Wolf
- Article 27 Foundation, Berkeley, CA, United States
| | - Mad Ball
- Open Humans Foundation, Sanford, NC, United States
- Center for Research & Interdisciplinarity, Paris, France
| |
Collapse
|
12
|
Choi H, Choi WS, Han E. Suggestion of a simpler and faster influenza-like illness surveillance system using 2014-2018 claims data in Korea. Sci Rep 2021; 11:11243. [PMID: 34045533 PMCID: PMC8159991 DOI: 10.1038/s41598-021-90511-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 05/06/2021] [Indexed: 11/10/2022] Open
Abstract
Influenza is an important public health concern. We propose a new real-time influenza-like illness (ILI) surveillance system that utilizes a nationwide prospective drug utilization monitoring in Korea. We defined ILI-related claims as outpatient claims that contain both antipyretic and antitussive agents and calculated the weekly rate of ILI-related claims, which was compared to weekly ILI rates from clinical sentinel surveillance data during 2014-2018. We performed a cross-correlation analysis using Pearson's correlation, time-series analysis to explore actual correlations after removing any dubious correlations due to underlying non-stationarity in both data sets. We used the moving epidemic method (MEM) to estimate an absolute threshold to designate potential influenza epidemics for the weeks with incidence rates above the threshold. We observed a strong correlation between the two surveillance systems each season. The absolute thresholds for the 4-years were 84.64 and 86.19 cases per 1000claims for claims data and 12.27 and 16.82 per 1000 patients for sentinel data. The epidemic patterns were more similar in the 2016-2017 and 2017-2018 seasons than the 2014-2015 and 2015-2016 seasons. ILI claims data can be loaded to a drug utilization review system in Korea to make an influenza surveillance system.
Collapse
Affiliation(s)
- HeeKyoung Choi
- College of Pharmacy, Yonsei Institute of Pharmaceutical Research, Yonsei University, 162-1 Songdo-dong, Yeonsu-gu, Incheon, Seoul, Republic of Korea
- Division of Infectious Diseases, Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Ilsan, Republic of Korea
| | - Won Suk Choi
- Division of Infectious Diseases, Department of Internal Medicine, Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea
| | - Euna Han
- College of Pharmacy, Yonsei Institute of Pharmaceutical Research, Yonsei University, 162-1 Songdo-dong, Yeonsu-gu, Incheon, Seoul, Republic of Korea.
| |
Collapse
|
13
|
Wiriyachaiporn N, Sirikaew S, Chitchai N, Janchompoo P, Maneeprakorn W, Bamrungsap S, Pasomsub E, Japrung D. Pre-clinically evaluated visual lateral flow platform using influenza A and B nucleoprotein as a model and its potential applications. RSC Adv 2021; 11:18597-18604. [PMID: 35480952 PMCID: PMC9033468 DOI: 10.1039/d1ra01361k] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/08/2021] [Indexed: 12/26/2022] Open
Abstract
A visual colorimetric rapid screening system based on a lateral flow device for simultaneous detection and differentiation between influenza A and B nucleoprotein as a model was developed. Monoclonal antibodies, specific for either influenza A or B nucleoproteins, were evaluated for their reactivities and were used as targeting ligands. With the best antibody pairs selected, the system exhibited good specificity to both viruses without cross reactivity to other closely related respiratory viruses. Further semi-quantitative analysis using a strip reader revealed that the system is capable of detecting influenza A and B protein content as low as 0.04 and 1 ng per test, respectively, using a sample volume as low as 100 μL, within 10 minutes (R2 = 0.9652 and 0.9718). With a performance comparison to the commercial tests, the system demonstrated a four-to-eight-fold higher sensitivity. Pre-clinical evaluation with 101 nasopharyngeal swabs reveals correlated results with a standard molecular approach, with 89% and 83% sensitivity towards influenza A and B viruses, and 100% specificity for both viruses. Visual colorimetric rapid screening system based on lateral flow device for influenza A and B virus detection as a model and its pre-clinical evaluation.![]()
Collapse
Affiliation(s)
- Natpapas Wiriyachaiporn
- National Nanotechnology Center (NANOTEC), National Science and Technology Development Agency (NSTDA) PathumThani 12120 Thailand
| | - Siriwan Sirikaew
- National Nanotechnology Center (NANOTEC), National Science and Technology Development Agency (NSTDA) PathumThani 12120 Thailand
| | - Nawakarn Chitchai
- National Nanotechnology Center (NANOTEC), National Science and Technology Development Agency (NSTDA) PathumThani 12120 Thailand .,Faculty of Pharmacy, Thammasat University Thailand
| | - Pareena Janchompoo
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University Bangkok Thailand
| | - Weerakanya Maneeprakorn
- National Nanotechnology Center (NANOTEC), National Science and Technology Development Agency (NSTDA) PathumThani 12120 Thailand
| | - Suwussa Bamrungsap
- National Nanotechnology Center (NANOTEC), National Science and Technology Development Agency (NSTDA) PathumThani 12120 Thailand
| | - Ekawat Pasomsub
- Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University Bangkok Thailand
| | - Deanpen Japrung
- National Nanotechnology Center (NANOTEC), National Science and Technology Development Agency (NSTDA) PathumThani 12120 Thailand
| |
Collapse
|
14
|
Heimonen J, McCulloch DJ, O'Hanlon J, Kim AE, Emanuels A, Wilcox N, Brandstetter E, Stewart M, McCune D, Fry S, Parsons S, Hughes JP, Jackson ML, Uyeki TM, Boeckh M, Starita LM, Bedford T, Englund JA, Chu HY. A remote household-based approach to influenza self-testing and antiviral treatment. Influenza Other Respir Viruses 2021; 15:469-477. [PMID: 33939275 PMCID: PMC8189204 DOI: 10.1111/irv.12859] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/19/2021] [Accepted: 03/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background Households represent important settings for transmission of influenza and other respiratory viruses. Current influenza diagnosis and treatment relies upon patient visits to healthcare facilities, which may lead to under‐diagnosis and treatment delays. This study aimed to assess the feasibility of an at‐home approach to influenza diagnosis and treatment via home testing, telehealth care, and rapid antiviral home delivery. Methods We conducted a pilot interventional study of remote influenza diagnosis and treatment in Seattle‐area households with children during the 2019‐2020 influenza season using pre‐positioned nasal swabs and home influenza tests. Home monitoring for respiratory symptoms occurred weekly; if symptoms were reported within 48 hours of onset, participants collected mid‐nasal swabs and used a rapid home‐based influenza immunoassay. An additional home‐collected swab was returned to a laboratory for confirmatory influenza RT‐PCR testing. Baloxavir antiviral treatment was prescribed and delivered to symptomatic and age‐eligible participants, following a telehealth encounter. Results 124 households comprising 481 individuals self‐monitored for respiratory symptoms, with 58 home tests administered. 12 home tests were positive for influenza, of which eight were true positives confirmed by RT‐PCR. The sensitivity and specificity of the home influenza test were 72.7% and 96.2%, respectively. There were eight home deliveries of baloxavir, with 7 (87.5%) occurring within 3 hours of prescription and all within 48 hours of symptom onset. Conclusions We demonstrate the feasibility of self‐testing combined with rapid home delivery of influenza antiviral treatment. This approach may be an important control strategy for influenza epidemics and pandemics.
Collapse
Affiliation(s)
- Jessica Heimonen
- Department of Medicine, University of Washington, Seattle, WA, USA
| | | | - Jessica O'Hanlon
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ashley E Kim
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Anne Emanuels
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Naomi Wilcox
- Department of Medicine, University of Washington, Seattle, WA, USA
| | | | | | | | - Scott Fry
- Ellume, East Brisbane, Qld, Australia
| | | | - James P Hughes
- Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Timothy M Uyeki
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Michael Boeckh
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lea M Starita
- Brotman Baty Institute, Seattle, WA, USA.,Department of Genome Sciences, University of Washington, Seattle, WA, USA
| | - Trevor Bedford
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Janet A Englund
- Seattle Children's Research Institute and Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Helen Y Chu
- Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
15
|
Sutton SS, Magagnoli J, Cummings T, Hardin J. Association Between the Use of Antibiotics, Antivirals, and Hospitalizations Among Patients With Laboratory-confirmed Influenza. Clin Infect Dis 2021; 72:566-573. [PMID: 31974543 DOI: 10.1093/cid/ciaa074] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 01/22/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Clinicians may prescribe antibiotics to influenza patients at high risk for bacterial complications. We explored the association between antibiotics, antivirals, and hospitalization among people with influenza. METHODS A retrospective cohort study of patients with confirmed influenza with encounters during January 2011-January 2019 was conducted using data from the Veterans Affairs Informatics and Computing Infrastructure (VINCI). We compared inpatient hospitalizations (all-cause and respiratory) within 30 days of influenza diagnosis between 4 patient cohorts: (1) no treatment (n = 4228); (2) antibiotic only (n = 671); (3) antiviral only (n = 6492); and (4) antibiotic plus antiviral (n = 1415). We estimated relative risk for hospitalization using Poisson generalized linear model and robust standard errors. RESULTS Among 12 806 influenza cases, most were white men (mean age, 57-60 years). Those with antivirals only, antibiotic plus antiviral, and antibiotics only all had a statistically significant lower risk of all-cause and respiratory hospitalization compared to those without treatment. Comparing the antibiotic plus antiviral cohort to those who were prescribed an antiviral alone, there was a 47% lower risk for respiratory hospitalization (relative risk, 0.53 [95% confidence interval, .31-.94]), and no other statistical differences were detected. CONCLUSIONS Those prescribed an antiviral, antibiotic, or both had a lower risk of hospitalization within 30 days compared to those without therapy. Furthermore, intervention with both an antibiotic and antiviral had a lower risk of respiratory hospitalization within 30 days compared to those with an antiviral alone. Importantly, the absolute magnitude of decreased risk with antibiotic plus antiviral therapy is small and must be interpreted within the context of the overall risk of antibiotic usage.
Collapse
Affiliation(s)
- S Scott Sutton
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, College of Pharmacy, Columbia, South Carolina, USA
| | - Joseph Magagnoli
- Department of Clinical Pharmacy and Outcomes Sciences, University of South Carolina, College of Pharmacy, Columbia, South Carolina, USA
| | - Tammy Cummings
- Wm Jennings Bryan Dorn Veterans Affairs Medical Center, Columbia, South Carolina, USA
| | - James Hardin
- Department of Epidemiology and Biostatistics, University of South Carolina, Columbia, South Carolina, USA
| |
Collapse
|
16
|
Spagnolello O, Pierangeli A, Cedrone MC, Di Biagio V, Gentile M, Leonardi A, Valeriano C, Innocenti GP, Santinelli L, Borrazzo C, Russo A, Oliveto G, Viscido A, Ciccozzi M, Bertazzoni G, d'Ettorre G, Ceccarelli G. Viral community acquired pneumonia at the emergency department: Report from the pre COVID-19 age. J Med Virol 2021; 93:4399-4404. [PMID: 33783850 PMCID: PMC8250557 DOI: 10.1002/jmv.26980] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/12/2021] [Accepted: 03/23/2021] [Indexed: 12/19/2022]
Abstract
The role of viruses in community acquired pneumonia (CAP) has been largely underestimated in the pre‐coronavirus disease 2019 age. However, during flu seasonal early identification of viral infection in CAP is crucial to guide treatment and in‐hospital management. Though recommended, the routine use of nasopharyngeal swab (NPS) to detect viral infection has been poorly scaled‐up, especially in the emergency department (ED). This study sought to assess the prevalence and associated clinical outcomes of viral infections in patients with CAP during peak flu season. In this retrospective, observational study adults presenting at the ED of our hospital (Rome, Italy) with CAP from January 15th to February 22th, 2019 were enrolled. Each patient was tested on admission with Influenza rapid test and real time multiplex assay. Seventy five consecutive patients were enrolled. 30.7% (n = 23) tested positive for viral infection. Of these, 52.1% (n = 12) were H1N1/FluA. 10 patients had multiple virus co‐infections. CAP with viral infection did not differ for any demographic, clinic and laboratory features by the exception of CCI and CURB‐65. All intra‐ED deaths and mechanical ventilations were recorded among CAP with viral infection. Testing only patients with CURB‐65 score ≥2, 10 out of 12 cases of H1N1/FluA would have been detected saving up to 40% tests. Viral infection occurred in one‐third of CAP during flu seasonal peak 2019. Since not otherwise distinguishable, NPS is so far the only reliable mean to identify CAP with viral infection. Testing only patients with moderate/severe CAP significantly minimize the number of tests. This study stresses the incidence of viral pneumonia during the flu season and underlies the role of viral infection screening at the ED regardless of the current COVID‐19 pandemic.
Collapse
Affiliation(s)
- Ornella Spagnolello
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, Rome, Italy.,Emergency Department, University of Rome Sapienza, Rome, Italy
| | - Alessandra Pierangeli
- Laboratory of Virology, Department of Molecular Medicine, University of Rome Sapienza, Rome, Italy
| | | | | | - Massimo Gentile
- Laboratory of Virology, Department of Molecular Medicine, University of Rome Sapienza, Rome, Italy
| | | | | | | | - Letizia Santinelli
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, Rome, Italy
| | - Cristian Borrazzo
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, Rome, Italy
| | - Alessandro Russo
- Department of Public Health and Infectious Diseases, University of Pisa, Pisa, Italy
| | - Giuseppe Oliveto
- Laboratory of Virology, Department of Molecular Medicine, University of Rome Sapienza, Rome, Italy
| | - Agnese Viscido
- Laboratory of Virology, Department of Molecular Medicine, University of Rome Sapienza, Rome, Italy
| | - Massimo Ciccozzi
- Unit of Medical Statistics and Molecular Epidemiology, University Campus Bio-Medico of Rome, Rome, Italy
| | | | - Gabriella d'Ettorre
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, Rome, Italy
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, University of Rome Sapienza, Rome, Italy
| |
Collapse
|
17
|
Clark TW, Beard KR, Brendish NJ, Malachira AK, Mills S, Chan C, Poole S, Ewings S, Cortes N, Nyimbili E, Presland L. Clinical impact of a routine, molecular, point-of-care, test-and-treat strategy for influenza in adults admitted to hospital (FluPOC): a multicentre, open-label, randomised controlled trial. THE LANCET. RESPIRATORY MEDICINE 2021; 9:419-429. [PMID: 33285143 PMCID: PMC9764870 DOI: 10.1016/s2213-2600(20)30469-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/10/2020] [Accepted: 10/06/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Diagnosis of influenza in patients admitted to hospital is delayed due to long turnaround times with laboratory testing, leading to inappropriate and late antiviral treatment and isolation facility use. Molecular point-of-care tests (mPOCTs) are highly accurate, easy to use, and generate results in less than 1 h, but high-quality evidence for their effect on management and clinical outcomes is needed. The aim of this study was to assess the clinical impact of an mPOCT on influenza detection, antiviral use, infection control measures, and clinical outcomes in adults admitted to hospital with acute respiratory illness. METHODS In this multicentre, pragmatic, open-label, randomised controlled trial (FluPOC), we recruited adults admitted to hospital with acute respiratory illness during influenza seasons from two hospitals in Hampshire, UK. Eligible patients were aged 18 years and older, with acute respiratory illness of 10 days or fewer duration before admission to hospital, who were recruited within 16 h of admission to hospital. Participants were randomly assigned (1:1), using random permuted blocks of varying sizes (4, 6 and 8), to receive mPOCT for influenza or routine clinical care (control group). The primary outcome was the proportion of patients infected with influenza who were treated appropriately with antivirals (neuraminidase inhibitors) within 5 days of admission. Safety was assessed in all patients. Secondary outcomes included time to antivirals, isolation facility use, and clinical outcomes. This study is registered with the ISRCTN registry, ISRCTN17197293, and is now complete. FINDINGS Between Dec 12, 2017, and May 3, 2019, over two influenza seasons, 613 patients were enrolled, of whom 307 were assigned to the mPOCT group and 306 to the control group, and all were analysed. Median age was 62 years (IQR 45-75) and 332 (54%) of 612 participants with data were female. 100 (33%) of 307 patients in the mPOCT group and 102 (33%) of 306 in the control group had influenza. 100 (100%) of 100 patients with influenza were diagnosed in the mPOCT group and 60 (59%) of 102 were diagnosed though routine clinical care in the control group (relative risk 1·7, 95% CI 1·7-1·7; p<0·0001). 99 (99%) of 100 patients with influenza in the mPOCT group were given antiviral treatment within 5 days of admission versus 63 (62%) 102 in the control group (relative risk 1·6, 95% CI 1·4-1·9; p<0·0001). Median time to antivirals was 1·0 h (IQR 0·0 to 2·0) in the mPOCT group versus 6·0 h (0·0 to 12·0) in the control group (difference of 5·0 h [95% CI 0·0-6·0; p=0·0039]). 70 (70%) of 100 patients with influenza in the mPOCT group were isolated to single-room accommodation versus 39 (38%) of 102 in the control group (relative risk 1·8 [95% CI 1·4-2·4; p<0·0001]). 19 adverse events occurred among patients with influenza in the mPOCT group compared with 34 events in the control group. No patients with influenza died in the mPOCT group and two (2%) died in the control group (p=0·16). INTERPRETATION Routine mPOCT for influenza was associated with improved influenza detection and improvements in appropriate and timely antiviral and isolation facility use. Routine mPOCT should replace laboratory-based diagnostics for acute admissions to hospital during the influenza season. FUNDING National Institute for Health Research.
Collapse
Affiliation(s)
- Tristan W Clark
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| | - Kate R Beard
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nathan J Brendish
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ahalya K Malachira
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Samuel Mills
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Cathleen Chan
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Stephen Poole
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sean Ewings
- School of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nick Cortes
- Department of Microbiology, Hampshire Hospitals Foundation NHS Trust, Winchester, UK
| | - Esther Nyimbili
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Laura Presland
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|
18
|
Aung AH, Lye DC, Cui L, Ooi CK, Chow ALP. The "timeless" use of influenza-like illness criteria for influenza detection in the tropics. Int J Infect Dis 2021; 106:160-168. [PMID: 33741485 DOI: 10.1016/j.ijid.2021.03.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVE We assessed the performance of influenza-like illness (ILI) case definitions by the Centers for Disease Control and Prevention (CDC), European Centers for Disease Control and Prevention and World Health Organization (WHO) in the tropics where seasonal patterns of respiratory viruses in acute upper respiratory tract infections (AURTIs) are ill-defined. METHODS Clinical data and samples for respiratory multiplex polymerase chain reaction test were collected from 717 consecutive patients attending an emergency department in Singapore for uncomplicated AURTI in 2016-2018. RESULTS Influenza (20.6%), rhinoviruses (14.4%), and coronaviruses (3.6%) were the most common viral pathogens identified. Biannual peaks with year-round activity were identified for influenza. Although higher rhinovirus activity was observed in inter-influenza seasonal periods, rhinoviruses and coronaviruses circulated year-round without distinct seasonal patterns. During high influenza activity months, the CDC and WHO ILI case definitions had moderate-to-high positive likelihood ratio (LR+) of 3.8-6.8 and 4.5-10.7, respectively, for ruling in influenza. They had moderately-high LR + of 3.3-3.8 and 3.9-4.6 for diagnosing influenza during other months. The ILI case definitions had high specificity (77.2%-85.4%) for rhinoviruses and coronaviruses. CONCLUSION The CDC and WHO ILI case definitions can be applied to clinically diagnose influenza in the tropics, regardless of the time of the year.
Collapse
Affiliation(s)
- Aung H Aung
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore
| | - David C Lye
- Department of Infectious Disease, Tan Tock Seng Hospital, Singapore
| | - Lin Cui
- National Public Health Laboratory, Ministry of Health, Singapore
| | - Chee K Ooi
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore
| | - Angela L P Chow
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore.
| |
Collapse
|
19
|
Dugas AF, Hsieh YH, LoVecchio F, Moran GJ, Steele MT, Talan DA, Rothman RE. Derivation and Validation of a Clinical Decision Guideline for Influenza Testing in 4 US Emergency Departments. Clin Infect Dis 2021; 70:49-58. [PMID: 30843056 DOI: 10.1093/cid/ciz171] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/27/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND An accurate diagnosis of influenza is essential for appropriate antiviral treatment, in accordance with Centers for Disease Control and Prevention (CDC) guidelines. However, no clear guidance exists on which patients should be tested. We sought to develop a clinical decision guideline (CDG) to inform influenza testing decisions for those adult emergency department (ED) patients deemed appropriate for antiviral treatment by CDC guidelines. METHODS A prospective cohort study was performed at 4 US EDs. From November 2013 to April 2014, we enrolled adult ED patients with fever or respiratory symptoms who met criteria for antiviral treatment, per 2013 CDC guidelines. All patients were tested for influenza using polymerase chain reaction. Data were randomly split into derivation (80%) and validation (20%) data sets. A discrete set of independent variables was selected by logistic regression, using the derivation set to create a scoring system, with a target sensitivity of at least 90%. The derived CDG was then validated. RESULTS Of 1941 enrolled participants, 183 (9.4%) had influenza. The derived CDG included new or increased cough (2 points), headache (1 point), subjective fever (1 point), and triage temperature >100.4°C (1 point), with a score of ≥3 indicating influenza testing was warranted. The CDG had a sensitivity and specificity of 94.1% and 36.6%, respectively, in the derivation set and of 91.5% and 34.6%, respectively, in the validation set. CONCLUSIONS A CDG with high sensitivity was derived and validated. Incorporation into practice could standardize testing for high-risk patients in adult EDs during influenza seasons, potentially improving diagnoses and treatment. CLINICAL TRIAL REGISTRATION NCT01947049.
Collapse
Affiliation(s)
- Andrea F Dugas
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Yu-Hsiang Hsieh
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frank LoVecchio
- Department of Emergency Medicine, University of Arizona College of Medicine, Phoenix
| | - Gregory J Moran
- Department of Emergency Medicine, Department of Medicine, Division of Infectious Diseases, The David Geffen School of Medicine at University of California Los Angeles (UCLA), Olive View-UCLA Medical Center
| | - Mark T Steele
- Department of Emergency Medicine, University of Missouri-Kansas City School of Medicine/Truman Medical Center
| | - David A Talan
- Department of Emergency Medicine, Department of Medicine, Division of Infectious Diseases, The David Geffen School of Medicine at University of California Los Angeles (UCLA), Olive View-UCLA Medical Center
| | - Richard E Rothman
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | |
Collapse
|
20
|
Zhou M, Yang D, Chen Y, Xu Y, Xu JF, Jie Z, Yao W, Jin X, Pan Z, Tan J, Wang L, Xia Y, Zou L, Xu X, Wei J, Guan M, Yan F, Feng J, Zhang H, Qu J. Deep learning for differentiating novel coronavirus pneumonia and influenza pneumonia. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:111. [PMID: 33569413 PMCID: PMC7867927 DOI: 10.21037/atm-20-5328] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Chest computed tomography (CT) has been found to have high sensitivity in diagnosing novel coronavirus pneumonia (NCP) at the early stage, giving it an advantage over nucleic acid detection during the current pandemic. In this study, we aimed to develop and validate an integrated deep learning framework on chest CT images for the automatic detection of NCP, focusing particularly on differentiating NCP from influenza pneumonia (IP). Methods A total of 148 confirmed NCP patients [80 male; median age, 51.5 years; interquartile range (IQR), 42.5–63.0 years] treated in 4 NCP designated hospitals between January 11, 2020 and February 23, 2020 were retrospectively enrolled as a training cohort, along with 194 confirmed IP patients (112 males; median age, 65.0 years; IQR, 55.0–78.0 years) treated in 5 hospitals from May 2015 to February 2020. An external validation set comprising 57 NCP patients and 50 IP patients from 8 hospitals was also enrolled. Two deep learning schemes (the Trinary scheme and the Plain scheme) were developed and compared using receiver operating characteristic (ROC) curves. Results Of the NCP lesions, 96.6% were >1 cm and 76.8% were of a density <−500 Hu, indicating them to have less consolidation than IP lesions, which had nodules ranging from 5–10 mm. The Trinary scheme accurately distinguished NCP from IP lesions, with an area under the curve (AUC) of 0.93. For patient-level classification in the external validation set, the Trinary scheme outperformed the Plain scheme (AUC: 0.87 vs. 0.71) and achieved human specialist-level performance. Conclusions Our study has potentially provided an accurate tool on chest CT for early diagnosis of NCP with high transferability and showed high efficiency in differentiating between NCP and IP; these findings could help to reduce misdiagnosis and contain the pandemic transmission.
Collapse
Affiliation(s)
- Min Zhou
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dexiang Yang
- Department of Respiratory Medicine, Tongling People's Hospital, Tongling, China
| | - Yong Chen
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanping Xu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhijun Jie
- Department of Respiratory and Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Weiwu Yao
- Department of Radiology, Shanghai Tongren Hospital Affiliated to Jiao Tong University School of medicine, Shanghai, China
| | - Xiaoyan Jin
- Department of Pulmonary and Critical Care Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zilai Pan
- Department of Radiology, Ruijin North Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingwen Tan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yihan Xia
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Xin Xu
- Haohua Technology Co., Ltd., Shanghai, China
| | - Jingqi Wei
- Haohua Technology Co., Ltd., Shanghai, China
| | | | - Fuhua Yan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Huan Zhang
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jieming Qu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
21
|
Zhou M, Yang D, Chen Y, Xu Y, Xu JF, Jie Z, Yao W, Jin X, Pan Z, Tan J, Wang L, Xia Y, Zou L, Xu X, Wei J, Guan M, Yan F, Feng J, Zhang H, Qu J. Deep learning for differentiating novel coronavirus pneumonia and influenza pneumonia. ANNALS OF TRANSLATIONAL MEDICINE 2021. [PMID: 33569413 DOI: 10.1101/2020.03.24.20043117] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND Chest computed tomography (CT) has been found to have high sensitivity in diagnosing novel coronavirus pneumonia (NCP) at the early stage, giving it an advantage over nucleic acid detection during the current pandemic. In this study, we aimed to develop and validate an integrated deep learning framework on chest CT images for the automatic detection of NCP, focusing particularly on differentiating NCP from influenza pneumonia (IP). METHODS A total of 148 confirmed NCP patients [80 male; median age, 51.5 years; interquartile range (IQR), 42.5-63.0 years] treated in 4 NCP designated hospitals between January 11, 2020 and February 23, 2020 were retrospectively enrolled as a training cohort, along with 194 confirmed IP patients (112 males; median age, 65.0 years; IQR, 55.0-78.0 years) treated in 5 hospitals from May 2015 to February 2020. An external validation set comprising 57 NCP patients and 50 IP patients from 8 hospitals was also enrolled. Two deep learning schemes (the Trinary scheme and the Plain scheme) were developed and compared using receiver operating characteristic (ROC) curves. RESULTS Of the NCP lesions, 96.6% were >1 cm and 76.8% were of a density <-500 Hu, indicating them to have less consolidation than IP lesions, which had nodules ranging from 5-10 mm. The Trinary scheme accurately distinguished NCP from IP lesions, with an area under the curve (AUC) of 0.93. For patient-level classification in the external validation set, the Trinary scheme outperformed the Plain scheme (AUC: 0.87 vs. 0.71) and achieved human specialist-level performance. CONCLUSIONS Our study has potentially provided an accurate tool on chest CT for early diagnosis of NCP with high transferability and showed high efficiency in differentiating between NCP and IP; these findings could help to reduce misdiagnosis and contain the pandemic transmission.
Collapse
Affiliation(s)
- Min Zhou
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dexiang Yang
- Department of Respiratory Medicine, Tongling People's Hospital, Tongling, China
| | - Yong Chen
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanping Xu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jin-Fu Xu
- Department of Respiratory and Critical Care Medicine, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhijun Jie
- Department of Respiratory and Critical Care Medicine, Shanghai Fifth People's Hospital, Fudan University, Shanghai, China
| | - Weiwu Yao
- Department of Radiology, Shanghai Tongren Hospital Affiliated to Jiao Tong University School of medicine, Shanghai, China
| | - Xiaoyan Jin
- Department of Pulmonary and Critical Care Medicine, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zilai Pan
- Department of Radiology, Ruijin North Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jingwen Tan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lan Wang
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yihan Xia
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Xin Xu
- Haohua Technology Co., Ltd., Shanghai, China
| | - Jingqi Wei
- Haohua Technology Co., Ltd., Shanghai, China
| | | | - Fuhua Yan
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | | | - Huan Zhang
- Department of Radiology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jieming Qu
- Department of Respiratory and Critical Care Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Institute of Respiratory Diseases, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
22
|
El Feghaly RE, Nolen JD, Lee BR, Abraham G, Nedved A, Hassan F, Selvarangan R. Impact of Rapid Influenza Molecular Testing on Management in Pediatric Acute Care Settings. J Pediatr 2021; 228:271-277.e1. [PMID: 32828881 DOI: 10.1016/j.jpeds.2020.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/01/2020] [Accepted: 08/04/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To measure the impact of rapid influenza real-time qualitative reverse transcriptase polymerase chain reaction (RT-PCR) on patient management in busy pediatric emergency department (ED) and urgent care clinic settings. STUDY DESIGN We developed a brief, elective survey that clinicians completed when an influenza RT-PCR order was placed in the ED or urgent care clinic between February 18, 2019, and March 13, 2019. We captured the clinical suspicion for influenza, intended management plans, and actual management plans once influenza RT-PCR results were available. RESULTS We evaluated 339 encounters, of which 164 (48.4%) had a positive influenza RT-PCR. Clinical suspicion for influenza was a nonsignificant predictor for influenza PT-PCR positivity (P = .126). After rapid influenza RT-PCR results were available, clinicians changed their original plans in 44.5% of influenza RT-PCR positive vs 92.6% of influenza RT-PCR negative cases (P < .0001). Change in plans for antiviral use was observed in 26% of influenza positive vs 77% of influenza negative cases (P < .0001). A total of 135 antiviral prescriptions were avoided in patients with negative influenza RT-PCR. CONCLUSIONS Implementation of a rapid and accurate influenza RT-PCR in the acute care setting is important to systematically diagnose influenza in children and improve outpatient management decisions, because clinical suspicion for influenza is inaccurate. A negative influenza RT-PCR decreases unnecessary antiviral use and has the potential for significant cost savings.
Collapse
Affiliation(s)
- Rana E El Feghaly
- Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO
| | - John David Nolen
- University of Missouri Kansas City, Kansas City, MO; Division of Pathology and Laboratory Medicine, Children's Mercy Kansas City, Kansas City, MO
| | - Brian R Lee
- University of Missouri Kansas City, Kansas City, MO; Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO
| | - George Abraham
- University of Missouri Kansas City, Kansas City, MO; Division of Emergency Medicine, Children's Mercy Kansas City, Kansas City, MO
| | - Amanda Nedved
- University of Missouri Kansas City, Kansas City, MO; Division of Urgent Care, Children's Mercy Kansas City, Kansas City, MO
| | - Ferdaus Hassan
- University of Missouri Kansas City, Kansas City, MO; Division of Pathology and Laboratory Medicine, Children's Mercy Kansas City, Kansas City, MO
| | - Rangaraj Selvarangan
- Division of Infectious Diseases, Children's Mercy Kansas City, Kansas City, MO; University of Missouri Kansas City, Kansas City, MO; Division of Pathology and Laboratory Medicine, Children's Mercy Kansas City, Kansas City, MO.
| |
Collapse
|
23
|
Mac S, O’Reilly R, Adhikari NKJ, Fowler R, Sander B. Point-of-care diagnostic tests for influenza in the emergency department: A cost-effectiveness analysis in a high-risk population from a Canadian perspective. PLoS One 2020; 15:e0242255. [PMID: 33196653 PMCID: PMC7668582 DOI: 10.1371/journal.pone.0242255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/30/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Our objective was to assess the cost-effectiveness of novel rapid diagnostic tests: rapid influenza diagnostic tests (RIDT), digital immunoassays (DIA), rapid nucleic acid amplification tests (NAAT), and other treatment algorithms for influenza in high-risk patients presenting to hospital with influenza-like illness (ILI). METHODS We developed a decision-analytic model to assess the cost-effectiveness of diagnostic test strategies (RIDT, DIA, NAAT, clinical judgement, batch polymerase chain reaction) preceding treatment; no diagnostic testing and treating everyone; and not treating anyone. We modeled high-risk 65-year old patients from a health payer perspective and accrued outcomes over a patient's lifetime. We reported health outcomes, quality-adjusted life years (QALYs), healthcare costs, and net health benefit (NHB) to measure cost-effectiveness per cohort of 100,000 patients. RESULTS Treating everyone with no prior testing was the most cost-effective strategy, at a cost-effectiveness threshold of $50,000/QALY, in over 85% of simulations. This strategy yielded the highest NHB of 15.0344 QALYs, but inappropriately treats all patients without influenza. Of the novel rapid diagnostics, NAAT resulted in the highest NHB (15.0277 QALYs), and the least number of deaths (1,571 per 100,000). Sensitivity analyses determined that results were most impacted by the pretest probability of ILI being influenza, diagnostic test sensitivity, and treatment effectiveness. CONCLUSIONS Based on our model, treating high-risk patients presenting to hospital with influenza-like illness, without performing a novel rapid diagnostic test, resulted in the highest NHB and was most cost-effective. However, consideration of whether treatment is appropriate in the absence of diagnostic confirmation should be taken into account for decision-making by clinicians and policymakers.
Collapse
Affiliation(s)
- Stephen Mac
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Canada
| | - Ryan O’Reilly
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Neill K. J. Adhikari
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Robert Fowler
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Canada
- ICES, Toronto, Canada
- Public Health Ontario, Toronto, Canada
| |
Collapse
|
24
|
Fjelltveit EB, Cox RJ, Østensjø J, Blomberg B, Ebbesen MH, Langeland N, Mohn KGI. Point-of-care influenza testing impacts clinical decision, patient flow and length of stay in hospitalized adults. J Infect Dis 2020; 226:97-108. [PMID: 33151320 PMCID: PMC9373161 DOI: 10.1093/infdis/jiaa690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/28/2020] [Indexed: 01/03/2023] Open
Abstract
Background Influenza is difficult to distinguish clinically from other acute respiratory infections. Rapid laboratory diagnosis can help initiate early effective antiviral treatment and isolation. Implementing a novel point-of-care test (POCT) for influenza in the emergency department (ED) could improve treatment and isolation strategies and reduce the length of stay (LOS). Methods In a prospective, controlled observational cohort study, we enrolled patients admitted due to acute respiratory illness to 2 public hospitals in Bergen, Norway, one using a rapid POCT for influenza (n = 400), the other (n = 167) using conventional rapid laboratory-based assay. Results Prevalence of influenza was similar in the 2 hospitals (154/400, 38% vs 38%, 63/167; P = .863). Most patients in both hospitals received antiviral (83% vs 81%; P = .703) and antibiotic treatment (72% vs 62%; P = .149). Isolation was more often initiated in ED in the hospital using POCT (91% vs 80%; P = .025). Diagnosis by POCT was associated with shorter hospital stay; old age, diabetes, cancer, and use of antibiotics, particularly broad-spectrum antibiotics, were associated with prolonged stay. Conclusions POCT implementation in ED resulted in improved targeted isolation and shorter LOS. Regardless of POCT use, most influenza patients received antivirals (>80%) and antibiotics (>69%).
Collapse
Affiliation(s)
- E B Fjelltveit
- The Influenza Centre, University of Bergen, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway.,Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - R J Cox
- The Influenza Centre, University of Bergen, Bergen, Norway.,Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - J Østensjø
- Haraldsplass Deaconess Hospital, Bergen, Norway
| | - B Blomberg
- Department of Clinical Science, University of Bergen, Bergen, Norway.,National Advisory Unit on Tropical Infectious Diseases, Haukeland University Hospital, Bergen, Norway
| | - M H Ebbesen
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - N Langeland
- Department of Clinical Science, University of Bergen, Bergen, Norway.,National Advisory Unit on Tropical Infectious Diseases, Haukeland University Hospital, Bergen, Norway.,Department of Research and Development, Haukeland University Hospital, Bergen, Norway.,Haraldsplass Deaconess Hospital, Bergen, Norway
| | - K G-I Mohn
- The Influenza Centre, University of Bergen, Bergen, Norway.,Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| |
Collapse
|
25
|
Predictors and Outcomes of Hospitalization for Influenza: Real-World Evidence from the United States Medicare Population. Infect Dis Ther 2020; 10:213-228. [PMID: 33108613 PMCID: PMC7954998 DOI: 10.1007/s40121-020-00354-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/06/2020] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION The purpose of this study was to identify predictors of initial hospitalization and describe the outcomes of high-risk patients hospitalized with influenza. METHODS Data were taken from the 5% national US Medicare database from 2012 to 2015. Patients (aged at least 13 years) were required to have at least one diagnosis for influenza and have continuous health plan enrollment for 6 months before (baseline) and 3 months (follow-up) after the date of influenza diagnosis. Patients who died during follow-up were included. Patients were categorized as initially hospitalized if hospitalized within 0-1 day of diagnosis. High-risk initially hospitalized patients were defined as patients aged at least 65 years or those that had a diagnostic code for chronic lung disease, cardiovascular or cerebrovascular disease, or weakened immune system during baseline period. Logistic regression models were developed to determine predictors of initial hospitalization. RESULTS The study population included 8127 high-risk patients who were initially hospitalized and 16,784 who were not hospitalized. Among high-risk patients, 89.3% were diagnosed in the emergency room, whereas 7.5% and 3.2% were diagnosed in a physician's office or other Medicare settings, respectively. Chronic obstructive pulmonary disorder, congestive heart failure, chronic kidney disease, older age, being male, other comorbidities, number of comorbidities, and baseline healthcare resource use were the predictors of hospitalization. Median length of stay for the hospitalization was 5.0 days, and the 30-day readmission rate was 14%. All-cause mortality rate was 5.1% during the inpatient stay and 9.2% within 30 days of diagnosis. Hospitalized patients with influenza incurred an increase of $16,568 per patient in total all-cause healthcare costs from pre-influenza to post-influenza diagnosis. CONCLUSION The study characterized the burden of hospitalization for influenza and found that hospitalized high-risk patients experience greater comorbidity burden, higher likelihood of multiple inpatient admissions, and costly medical interventions compared to patients who were not hospitalized.
Collapse
|
26
|
Smith BJ, Price DJ, Johnson D, Garbutt B, Thompson M, Irving LB, Putland M, Tong SYC. Influenza With and Without Fever: Clinical Predictors and Impact on Outcomes in Patients Requiring Hospitalization. Open Forum Infect Dis 2020; 7:ofaa268. [PMID: 33123614 PMCID: PMC7580166 DOI: 10.1093/ofid/ofaa268] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 06/27/2020] [Indexed: 12/15/2022] Open
Abstract
Background The Infectious Diseases Society of America influenza guidelines no longer require fever as part of their influenza case definition in patients requiring hospitalization. However, the impact of fever or lack of fever on clinical decision-making and patient outcomes has not been studied. Methods We conducted a retrospective review of adult patients admitted to our tertiary health service between April 2016 and June 2019 with laboratory-confirmed influenza, with and without fever (≥37.8ºC). Patient demographics, presenting features, and outcomes were analyzed using Pearson's chi-square test, the Wilcoxon rank-sum test, and logistic regression. Results Of 578 influenza inpatients, 219 (37.9%) had no fever at presentation. Fever was less likely in individuals with a nonrespiratory syndrome (adjusted odds ratio [aOR], 0.44; 95% CI, 0.26-0.77), symptoms for ≥3 days (aOR, 0.53; 95% CI, 0.36-0.78), influenza B infection (aOR, 0.45; 95% CI, 0.29-0.70), chronic lung disease (aOR, 0.55; 95% CI, 0.37-0.81), age ≥65 (aOR, 0.36; 95% CI, 0.23-0.54), and female sex (aOR, 0.69; 95% CI, 0.48-0.99). Patients without fever had lower rates of testing for influenza in the emergency department (64.8% vs 77.2%; P = .002) and longer inpatient stays (median, 2.4 vs 1.9 days; P = .015). These patients were less likely to receive antiviral treatment (55.7% vs 65.6%; P = .024) and more likely die in the hospital (3.2% vs 0.6%; P = .031), and these differences persisted after adjustment for potential confounders. Conclusions Absence of fever in influenza is associated with delayed diagnosis, longer length of stay, and higher mortality.
Collapse
Affiliation(s)
- Benjamin J Smith
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - David J Price
- Doherty Department, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.,University of Melbourne, Melbourne, Australia
| | - Douglas Johnson
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Department of General Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Bruce Garbutt
- Emergency Department, Royal Melbourne Hospital, Melbourne, Australia
| | - Michelle Thompson
- Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Louis B Irving
- University of Melbourne, Melbourne, Australia.,Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Australia
| | - Mark Putland
- Emergency Department, Royal Melbourne Hospital, Melbourne, Australia
| | - Steven Y C Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia.,Doherty Department, University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| |
Collapse
|
27
|
Lee N, Walsh EE, Sander I, Stolper R, Zakar J, Wyffels V, Myers D, Fleischhackl R. Delayed Diagnosis of Respiratory Syncytial Virus Infections in Hospitalized Adults: Individual Patient Data, Record Review Analysis and Physician Survey in the United States. J Infect Dis 2020; 220:969-979. [PMID: 31070757 PMCID: PMC6688061 DOI: 10.1093/infdis/jiz236] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/08/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Despite the prevalence of respiratory syncytial virus (RSV) in adults hospitalized with acute respiratory infections, guidelines for the diagnosis and management of RSV have not been established. This analysis evaluated the role and timeliness of RSV diagnostic testing and its potential impact on clinical outcomes. METHODS We analyzed individual patient data from hospitalized adults with confirmed RSV infections during 2 North American RSV seasons. Participating physicians reported clinical, virologic diagnosis, and outcome variables using a standardized online case form. RESULTS Across 32 US states, 132 physicians reported 379 RSV cases. Polymerase chain reaction-based diagnostics were the most common type of test ordered (94.2%) with <5% ordered specifically to diagnose RSV. Most tests (67.6%) were ordered in hospital wards or intensive care units. Overall, 47.4%, 30.9%, and 21.7% of patients had RSV diagnosed <12, 12‒24, and >24 hours after hospital admission, respectively. Later diagnosis was associated with longer hospital stays (n = 145; R = +0.191; P < .05) and greater antibiotic use. CONCLUSION Diagnosis of RSV infection in hospitalized adults is often delayed, which may affect clinical management and outcomes. Our findings indicate the need to improve the diagnostic strategies in this patient population.
Collapse
Affiliation(s)
- Nelson Lee
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Edward E Walsh
- Infectious Disease Division, Department of Medicine, University of Rochester School of Medicine and Dentistry, New York
| | - Ian Sander
- IQVIA Consulting Services, Cambridge, Massachusetts
| | | | | | | | | | | |
Collapse
|
28
|
Abstract
BACKGROUND AND OBJECTIVES Influenza causes significant annual burden among children. Current guidelines recommend empiric treatment for a broadly defined group of children at high risk for influenza complications, resulting in overtreatment or costly viral testing. This study creates an algorithm for clinicians to risk stratify children with influenza-like illness (ILI) according to likelihood of influenza infection. METHODS A retrospective analysis was performed on 818 children seen in the emergency department from November 2012 to April 2013 for ILI. We reviewed medical records for symptoms, influenza risk factors, and viral assay results. Classification and regression tree analyses were performed separately for children older and younger than 2 years. RESULTS In children younger than 2 years, populations likely to test positive were those with an influenza-positive contact, unimmunized children, and those presenting in high-incidence influenza periods. In this subgroup, immunized patients in low-incidence seasons and those with absence of cough are low risk for influenza infection. For children 2 years and older, high-risk populations were unimmunized children, those presenting in high-incidence influenza periods and those with myalgia or absence of diarrhea. CONCLUSIONS These risk-stratification analyses were summarized into Suspected Pediatric Influenza Risk-Stratification Algorithm (SPIRA). For those in whom influenza infection is likely, clinicians may consider empiric treatment. Conversely, patients whom SPIRA identifies as unlikely to be infected with influenza are candidates for viral testing and targeted treatment. In assessing children with ILI, SPIRA aids clinicians in determining who to test versus treat empirically, saving children from costly viral testing or unnecessary antiviral exposure.
Collapse
|
29
|
Beard K, Brendish N, Malachira A, Mills S, Chan C, Poole S, Clark T. Pragmatic multicentre randomised controlled trial evaluating the impact of a routine molecular point-of-care 'test-and-treat' strategy for influenza in adults hospitalised with acute respiratory illness (FluPOC): trial protocol. BMJ Open 2019; 9:e031674. [PMID: 31852699 PMCID: PMC6937093 DOI: 10.1136/bmjopen-2019-031674] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Influenza infections often remain undiagnosed in patients admitted to hospital due to lack of routine testing. When tested for, the diagnosis and treatment of influenza are often delayed due to the slow turnaround times of centralised laboratory PCR testing. Newer molecular systems, have comparable accuracy to laboratory PCR testing, and can generate a result in under 1 hour, making them potentially deployable as point-of-care tests (POCTs). High-quality evidence for the impact of routine POCT for influenza on clinical outcomes is, however, currently lacking. This large pragmatic multicentre randomised controlled trial aims to address this evidence gap. METHODS AND ANALYSIS The FluPOC trial is a pragmatic, multicentre, randomised controlled trial evaluating adults admitted to a large teaching hospital and a district general hospital with an acute respiratory illness, during influenza season and defined by Public Health England. Up to 840 patients will be recruited over up to three influenza seasons, and randomised (1:1) to receive either POCT using the FilmArray respiratory panel, or routine clinical care. Clinical and infection control teams will be informed of the results in real time and where influenza is detected clinical teams will be encouraged to offer neuraminidase inhibitor (NAI) treatment in accordance with national guidelines. Those allocated to standard clinical care will have a swab taken for later analysis to allow assessment of missed diagnoses. The outcomes assessment will be by retrospective case note analysis. The outcome measures include the proportion of influenza-positive patients detected and appropriately treated with NAIs, isolation facility use, antibiotic use, length of hospital stay, complications and mortality. ETHICS AND DISSEMINATION Prior to commencing the study, approval was obtained from the South Central Hampshire A Ethics Committee (reference 17/SC/0368, granted 7 September 2017). Results generated from this protocol will be published in peer-reviewed scientific journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER ISRCTN17197293.
Collapse
Affiliation(s)
- Kate Beard
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nathan Brendish
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ahalya Malachira
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Samuel Mills
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Cathleen Chan
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Stephen Poole
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Tristan Clark
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| |
Collapse
|
30
|
Combining Procalcitonin and Rapid Multiplex Respiratory Virus Testing for Antibiotic Stewardship in Older Adult Patients With Severe Acute Respiratory Infection. J Am Med Dir Assoc 2019; 21:62-67. [PMID: 31791902 PMCID: PMC7106143 DOI: 10.1016/j.jamda.2019.09.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/14/2019] [Accepted: 09/27/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Virus infection is underevaluated in older adults with severe acute respiratory infections (SARIs). We aimed to evaluate the clinical impact of combining point-of-care molecular viral test and serum procalcitonin (PCT) level for antibiotic stewardship in the emergency department (ED). DESIGN A prospective twin-center cohort study was conducted between January 2017 and March 2018. SETTING AND PARTICIPANTS Older adult patients who presented to the ED with SARIs received a rapid molecular test for 17 respiratory viruses and a PCT test. MEASURES To evaluate the clinical impact, we compared the outcomes of SARI patients between the experimental cohort and a propensity score-matched historical cohort. The primary outcome was the proportion of antibiotics discontinuation or de-escalation in the ED. The secondary outcomes included duration of intravenous antibiotics, length of hospital stay, and mortality. RESULTS A total of 676 patients were included, of which 169 patients were in the experimental group and 507 patients were in the control group. More than one-fourth (27.9%) of the patients in the experimental group tested positive for virus. Compared with controls, the experimental group had a significantly higher proportion of antibiotics discontinuation or de-escalation in the ED (26.0% vs 16.1%, P = .007), neuraminidase inhibitor uses (8.9% vs 0.6%, P < .001), and shorter duration of intravenous antibiotics (10.0 vs 14.5 days, P < .001). CONCLUSIONS AND IMPLICATIONS Combining rapid viral surveillance and PCT test is a useful strategy for early detection of potential viral epidemics and antibiotic stewardship. Clustered viral respiratory infections in a nursing home is common. Patients transferred from nursing homes to ED may benefit from this approach.
Collapse
|
31
|
May L, Tatro G, Poltavskiy E, Mooso B, Hon S, Bang H, Polage C. Rapid Multiplex Testing for Upper Respiratory Pathogens in the Emergency Department: A Randomized Controlled Trial. Open Forum Infect Dis 2019; 6:ofz481. [PMID: 32128326 PMCID: PMC7043218 DOI: 10.1093/ofid/ofz481] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/04/2019] [Indexed: 01/10/2023] Open
Abstract
Background Acute upper respiratory tract infections are a common cause of emergency department (ED) visits and often result in unnecessary antibiotic treatment. Methods We conducted a randomized clinical trial to evaluate the impact of a rapid, multipathogen respiratory panel (RP) test vs usual care (control). Patients were eligible if they were ≥12 months old, had symptoms of upper respiratory infection or influenza-like illness, and were not on antibiotics. The primary outcome was antibiotic prescription; secondary outcomes included antiviral prescription, disposition, and length of stay (ClinicalTrials.gov# NCT02957136). Results Of 191 patients enrolled, 93 (49%) received RP testing; 98 (51%) received usual care. Fifty-three (57%) RP and 7 (7%) control patients had a virus detected and reported during the ED visit (P = .0001). Twenty (22%) RP patients and 33 (34%) usual care patients received antibiotics during the ED visit (–12%; 95% confidence interval, –25% to 0.4%; P = .06/0.08); 9 RP patients received antibiotics despite having a virus detected. The magnitude of antibiotic reduction was greater in children (–19%) vs adults (–9%, post hoc analysis). There was no difference in antiviral use, length of stay, or disposition. Conclusions Rapid RP testing was associated with a trend toward decreased antibiotic use, suggesting a potential benefit from more rapid viral tests in the ED. Future studies should determine if specific groups are more likely to benefit from testing and evaluate the relative cost and effectiveness of broad testing, focused testing, and a combined diagnostic and antimicrobial stewardship approach.
Collapse
Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Grant Tatro
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Eduard Poltavskiy
- Graduate Group in Epidemiology, University of California Davis, Davis, California, USA
| | - Benjamin Mooso
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Simson Hon
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Heejung Bang
- Graduate Group in Epidemiology, University of California Davis, Davis, California, USA.,Department of Public Health Sciences, University of California Davis, Davis, California, USA
| | - Christopher Polage
- Department of Pathology, University of California Davis, Sacramento, California, USA.,Department of Pathology, Duke University, Durham, North Carolina, USA
| |
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW Seasonal and pandemic influenza are major causes of morbidity and mortality globally. Neuraminidase inhibitors (NAIs) are the only class of antiviral agent recommended for the treatment of currently circulating strains of influenza. There has previously been controversy over the level of evidence for patient benefit with NAIs. We review here the current evidence base for the clinical impact of treatment of influenza with NAIs. RECENT FINDINGS Meta-analysis of pharma-sponsored studies (including previously unpublished data) shows that NAIs reduce the duration of illness in influenza-infected patients, and suggest a possible reduction in the rate of complications and hospitalization. Meta-analysis of observational studies examining oseltamivir use during the H1N1 2009 pandemic, suggest a reduction in hospitalization rate in community-dwelling patients and a reduction in mortality in hospitalized adults treated with NAIs. Current NAI use in the community and hospitals varies widely but in general they are underutilized. SUMMARY Although there has been controversy over the level of evidence for patient benefit, a growing body of evidence suggests that treatment of influenza with NAIs is associated with improved outcomes for both patients in the community and more severely unwell patients in hospital. Clinical outcomes are optimal with earlier use and strategies to improve early widespread NAI utilization are needed.
Collapse
|
33
|
Kalil AC, Thomas PG. Influenza virus-related critical illness: pathophysiology and epidemiology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:258. [PMID: 31324202 PMCID: PMC6642581 DOI: 10.1186/s13054-019-2539-x] [Citation(s) in RCA: 245] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 07/10/2019] [Indexed: 12/22/2022]
Abstract
Influenza virus affects the respiratory tract by direct viral infection or by damage from the immune system response. In humans, the respiratory epithelium is the only site where the hemagglutinin (HA) molecule is effectively cleaved, generating infectious virus particles. Virus transmission occurs through a susceptible individual's contact with aerosols or respiratory fomites from an infected individual. The inability of the lung to perform its primary function of gas exchange can result from multiple mechanisms, including obstruction of the airways, loss of alveolar structure, loss of lung epithelial integrity from direct epithelial cell killing, and degradation of the critical extracellular matrix.Approximately 30-40% of hospitalized patients with laboratory-confirmed influenza are diagnosed with acute pneumonia. These patients who develop pneumonia are more likely to be < 5 years old, > 65 years old, Caucasian, and nursing home residents; have chronic lung or heart disease and history of smoking, and are immunocompromised.Influenza can primarily cause severe pneumonia, but it can also present in conjunction with or be followed by a secondary bacterial infection, most commonly by Staphylococcus aureus and Streptococcus pneumoniae. Influenza is associated with a high predisposition to bacterial sepsis and ARDS. Viral infections presenting concurrently with bacterial pneumonia are now known to occur with a frequency of 30-50% in both adult and pediatric populations. The H3N2 subtype has been associated with unprecedented high levels of intensive care unit (ICU) admission.Influenza A is the predominant viral etiology of acute respiratory distress syndrome (ARDS) in adults. Risk factors independently associated with ARDS are age between 36 and 55 years old, pregnancy, and obesity, while protective factors are female sex, influenza vaccination, and infections with Influenza A (H3N2) or Influenza B viruses.In the ICU, particularly during the winter season, influenza should be suspected not only in patients with typical symptoms and epidemiology, but also in patients with severe pneumonia, ARDS, sepsis with or without bacterial co-infection, as well as in patients with encephalitis, myocarditis, and rhabdomyolysis.
Collapse
Affiliation(s)
- Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, 68198, USA.
| | - Paul G Thomas
- Immunology Department, St. Jude Children's Research Hospital, Memphis, TN, USA
| |
Collapse
|
34
|
Impact of Rapid On-demand Molecular Diagnosis of Pediatric Seasonal Influenza on Laboratory Workflow and Testing Costs: A Retrospective Study. Pediatr Infect Dis J 2019; 38:559-563. [PMID: 31117115 DOI: 10.1097/inf.0000000000002224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Seasonal influenza imposes a considerable burden worldwide. We aimed to evaluate impact of rapid pediatric seasonal influenza diagnosis on laboratory workflow and cost using a rapid antigen detection-based test combined with either a reverse transcriptase polymerase chain reaction (RT-PCR) or the Alere i Influenza A and B (Alere i) assay for confirmation of negative results as well as single Alere i testing on nasopharyngeal aspirates. A secondary objective was assessing performance of Alere i against RT-PCR. METHODS Effects of implementing the 3 diagnostic algorithms were assessed in the Emergency Department of Hospital Sant Joan de Déu (Barcelona, Spain) across the 2014-2015, 2015-2016 and 2016-2017 influenza seasons. Alere i performance against RT-PCR was determined during the 2015-2016 epidemic period. RESULTS Median time to result decreased when using Alere i as a confirmatory test of previous antigen detection and RT-PCR results or alone (9.7vs. 3.5/2.0 and 0.7 hours, P < 0.001) along with mean testing costs (&OV0556;87.3 vs. &OV0556;38.2 and &OV0556;25.0, P < 0.001). Results available before patient discharge from the emergency department increased from 42.7% for sequential testing by antigen detection and RT-PCR to 80.0% when Alere i was utilized as a stand-alone test. Alere i sensitivity and specificity values were 96.6% (95% confidence interval: 82.8%-99.4%) and 94.4% (95% confidence interval: 86.6%-97.8%), respectively. CONCLUSIONS Rapid Alere i testing facilitated efficient laboratory workflow near the patient during influenza epidemics while contributing cost savings when compared with serial testing by antigen and RT-PCR assays.
Collapse
|
35
|
|
36
|
Brendish NJ, Clark TW. Molecular Point-of-care Testing for Influenza to Improve Early Neuraminidase Inhibitor Treatment and Outcomes in Hospitalized Adults. Clin Infect Dis 2019; 68:2154-2155. [PMID: 30541020 DOI: 10.1093/cid/ciy1042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Nathan J Brendish
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton.,Department of Infection, University Hospital Southampton National Health Service (NHS) Foundation Trust
| | - Tristan W Clark
- Academic Unit of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton.,Department of Infection, University Hospital Southampton National Health Service (NHS) Foundation Trust.,National Institute of Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust.,NIHR Post-Doctoral Fellowship Programme, UK
| |
Collapse
|
37
|
Pedersen CJ, Quinn JV, Rogan DT, Yang S. Factors Associated With Influenza in an Emergency Department Setting. J Emerg Med 2019; 56:478-483. [PMID: 30803847 DOI: 10.1016/j.jemermed.2018.12.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/03/2018] [Accepted: 12/08/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Emergency departments (EDs) become more overcrowded during peak respiratory virus season. Distinguishing influenza from other viruses is crucial to implement social distancing practices, early treatment, and prompt disposition. OBJECTIVES We sought to determine factors associated with influenza among a prospective cohort of consecutive ED patients with acute respiratory illness (ARI). METHODS Between December 2016 and March 2017, trained research assistants screened consecutive ED patients with ARI symptoms. ARI criteria included measured fever at home or in the ED >38°C and a cough, sore throat, or rhinorrhea with a duration of symptoms >12 hours and <1 week. After consent, research assistants collected demographics and clinical history using a standardized data form, and patients had a polymerase chain reaction-based assay that is nearly 100% sensitive for influenza. Univariate analysis was conducted on all predictor variables. Significant variables were entered into a multivariate logistic regression model to find factors that were independently associated with influenza. RESULTS One hundred nineteen patients consented to enrollment and 31% were found to be positive for influenza. Myalgia, the absence of gastrointestinal symptoms (no diarrhea or vomiting), sore throat, chills, headache, and oxygen saturation ≥97% were significant on univariate analysis and were entered into the multivariate model. Myalgia (adjusted odds ratio [AOR] 3.9), the absence of gastrointestinal symptoms (AOR 4.7), and oxygen saturation ≥97% (AOR 2.8) were significant independent factors of influenza. CONCLUSION The presence of myalgia, the absence of gastrointestinal symptoms, and oxygen saturation ≥97% are factors that can help distinguish influenza from other acute respiratory illnesses in the ambulatory ED population.
Collapse
Affiliation(s)
| | - James V Quinn
- Department of Emergency Medicine, Stanford University, Palo Alto, California
| | - Daniel T Rogan
- Department of Emergency Medicine, Stanford University, Palo Alto, California
| | - Samuel Yang
- Department of Emergency Medicine, Stanford University, Palo Alto, California
| |
Collapse
|
38
|
Brachmann M, Kikull K, Kill C, Betz S. Economic and operational impact of an improved pathway using rapid molecular diagnostic testing for patients with influenza-like illness in a German emergency department. J Clin Monit Comput 2019; 33:1129-1138. [PMID: 30610515 PMCID: PMC6823314 DOI: 10.1007/s10877-018-00243-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/22/2018] [Indexed: 11/27/2022]
Abstract
To evaluate the economic and operational effects of implementing a shorted diagnostic pathway during influenza epidemics. This retrospective study used emergency department (ED) data from the 2014/2015 influenza season. Alere i influenza A & B rapid molecular diagnostic test (RDT) was compared with the polymerase chain reaction (PCR) pathway. Differences in room occupancy time in the ED and inpatient ward and cost differences were calculated for the 14-week influenza season. The process flow was more streamlined with the RDT pathway, and the necessary isolation time in the ED was 9 h lower than for PCR. The difference in the ED examination room occupancy time was 2.9 h per patient on a weekday and 4 h per patient on a weekend day, and the difference in the inpatient room occupancy time was 2 h per patient on a weekday and 3 h per patient on a weekend day. Extrapolated time differences across the influenza season were projected to be 2733 h in the ED examination room occupancy and 1440 h in inpatient room occupancy. In patients with a negative diagnosis, the RDT was also estimated to reduce the total diagnostic costs by 41.52 € per patient compared with PCR. The total cost difference was projected to be 31,892 € across a 14-week influenza season. The improved process and earlier diagnosis with the RDT pathway compared with conventional PCR resulted in considerable savings in ED, inpatient room occupancy time and cost across the influenza season.
Collapse
Affiliation(s)
- Matthias Brachmann
- bcmed GmbH, Neue Strasse 76, 89073, Ulm, Germany
- Witten/Herdecke University, 58448, Witten, Germany
| | - Katja Kikull
- Ategris hospitals, CEO's Office, 45468, Muelheim, Germany
| | - Clemens Kill
- Center for Emergency Medicine, Essen University Hospital, 45147, Essen, Germany.
| | - Susanne Betz
- Department of Emergency Medicine, University Hospital Marburg, 35033, Marburg, Germany
| |
Collapse
|
39
|
|
40
|
Abstract
Influenza and other respiratory viruses are commonly identified in patients with community-acquired pneumonia, hospital-acquired pneumonia, and in immunocompromised patients with pneumonia. Clinically, it is difficult to differentiate viral from bacterial pneumonia. Similarly, the radiological findings of viral infection are nonspecific. The advent of polymerase chain reaction testing has enormously facilitated the identification of respiratory viruses, which has important implications for infection control measures and treatment. Currently, treatment options for patients with viral infection are limited, but there is ongoing research on the development and clinical testing of new treatment regimens and strategies.
Collapse
Affiliation(s)
- Rodrigo Cavallazzi
- Division of Pulmonary, Critical Care, and Sleep Disorders, University of Louisville, 550 South Jackson Street, ACB, A3R27, Louisville, KY 40202, USA.
| | - Julio A Ramirez
- Division of Infectious Diseases, University of Louisville, Med Center One, 501 E. Broadway Suite 100, Louisville, KY 40202, USA
| |
Collapse
|
41
|
Pedersen CJ, Rogan DT, Yang S, Quinn JV. Using a novel rapid viral test to improve triage of emergency department patients with acute respiratory illness during flu season. J Clin Virol 2018; 108:72-76. [PMID: 30261422 PMCID: PMC7106347 DOI: 10.1016/j.jcv.2018.09.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/01/2018] [Accepted: 09/08/2018] [Indexed: 01/13/2023]
Abstract
Seasonal viral respiratory illnesses overburden emergency department resources. Current viral testing practices are ineffective for patient management in the ED. Triage viral testing can reduce transmission risk & optimize antimicrobial therapy.
Background Acute respiratory illnesses (ARI) are mostly viral in etiology and cause significant morbidity and mortality. Point of care PCR (POC-PCR) is a promising new technology for rapid virus identification but utility in the Emergency Department (ED) is not yet defined. Objectives Primarily, to investigate the value of POC-PCR in rapidly identifying RSV and influenza in the setting of ED triage. Additionally, to assess whether rapid knowledge of accurate test results would improve patient management by preventing nosocomial transmission and optimizing the prescription of antimicrobials for ARIs. Study Design A prospective cohort study of consecutive ED patients with ARI symptoms during peak flu season was conducted. Patient nasopharyngeal swabs were collected and tested using a POC-PCR device; physicians and patients were blinded to results. Virus positive and negative groups were compared by ED patient room placement and antimicrobial therapy ordered. Specificity and sensitivity were calculated using laboratory-PCR as the gold standard. Results Of 119 participants, 52.9% were POC-PCR positive - Influenza A (42.9%), RSV (41.3%), influenza B (15.9%). Nearly 70% of virus positive patients were placed rooms shared with non-ARI patients. Antibiotics were prescribed for 27.3% of virus positive patients, and 77.8% of oseltamivir-eligible patients did not receive therapy. POC-PCR was 100% sensitive (95% CI, 80.5–100.0%) and 95.2% specific (95% CI, 76.2–99.9%). Conclusions Rapid POC-PCR for influenza and RSV in ED triage has excellent sensitivity and specificity and the potential to improve social distancing practices through better triage and increase appropriate prescription of antimicrobials.
Collapse
Affiliation(s)
- Courtney J Pedersen
- Stanford School of Medicine, Stanford University, 291 Campus Dr, Stanford, CA, 94305, USA.
| | - Daniel T Rogan
- Department of Emergency Medicine, Stanford University, Alway Building, M023, 300 Pasteur Drive - MC: 5768, Stanford, CA, 94305, USA.
| | - Samuel Yang
- Department of Emergency Medicine, Stanford University, Alway Building, M023, 300 Pasteur Drive - MC: 5768, Stanford, CA, 94305, USA.
| | - James V Quinn
- Department of Emergency Medicine, Stanford University, Alway Building, M023, 300 Pasteur Drive - MC: 5768, Stanford, CA, 94305, USA.
| |
Collapse
|
42
|
Li X, May L, Grock A, Mason J. Out With the Old, In With the Flu. Ann Emerg Med 2018; 71:518-520. [DOI: 10.1016/j.annemergmed.2018.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
43
|
Frazee BW, Rodríguez-Hoces de la Guardia A, Alter H, Chen CG, Fuentes EL, Holzer AK, Lolas M, Mitra D, Vohra J, Dekker CL. Accuracy and Discomfort of Different Types of Intranasal Specimen Collection Methods for Molecular Influenza Testing in Emergency Department Patients. Ann Emerg Med 2018; 71:509-517.e1. [DOI: 10.1016/j.annemergmed.2017.09.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 09/01/2017] [Accepted: 09/06/2017] [Indexed: 10/18/2022]
|
44
|
Hansen GT, Moore J, Herding E, Gooch T, Hirigoyen D, Hanson K, Deike M. Clinical decision making in the emergency department setting using rapid PCR: Results of the CLADE study group. J Clin Virol 2018; 102:42-49. [PMID: 29494950 PMCID: PMC7106512 DOI: 10.1016/j.jcv.2018.02.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/15/2018] [Accepted: 02/19/2018] [Indexed: 11/06/2022]
Abstract
The influence of an influenza diagnosis on patient managed during ED visits is examined. An influenza diagnosis in the ED is actionable, impacting empiric management in 61% of cases. The clinical diagnosis of influenza, based on presenting symptoms, lacks sensitivity at 36%. A 30 min result from collection to report could be achieved in the ED for 91.7%, of cases tested. ED testing resulted in savings of $200.40/ED visit but is dependent on avoiding planned admissions.
Background Emergency Departments (ED) are challenged during influenza season by patients who present acutely during sporadic ED visits. ED management is largely empiric, often occurring without reliable diagnostics needed for targeted therapies, safe outpatient discharge, or hospital admissions. Objective To evaluate the impact of the influenza diagnosis on physician decision making during ED visits using the Cobas Liat® influenza A + B assay. Study design Prospective study assessing the impact of rapid (<30 min), reverse-transcriptase polymerase chain reaction (RT-PCR) influenza testing on physician decision making in the ED. Physician responses established pre-and post-diagnosis management courses which required confirmation via secondary documentation in the medical record. Changes in physician decision making were analyzed across four clinical touchpoints: (i) admission/discharge status, (ii) medical procedures, (iii) antiviral and antibiotic prescribing, and (iv) laboratory studies. Results An influenza diagnosis changed patient management courses, relative to empiric, pre-diagnosis plans, in in 61% of the cases resulting in cost savings of $49,420-to-$42,270 over 143 patients and 104 days during influenza season resulting in a cost savings of $200.40/ED visit. Evaluation over 2000 ED patient visits projects cost savings > $578,000 due to deferred admissions, and reduction in antiviral prescribing. Sensitivity of ED-based influenza testing using the Cobas Liat® assay was equivalent to centralized lab testing at 98.8% sensitivity and 98.5% specificity respectively. Conclusion Providing rapid, RT-PCR influenza testing to ED settings is actionable and used to guide patient care decisions. Understanding the cascade of events linked to the influenza diagnosis in the ED provides overall cost savings which offset the cost of providing ED-based testing.
Collapse
Affiliation(s)
- Glen T Hansen
- Department of Pathology & Laboratory Medicine, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415, United States; Department of Pathology & Laboratory Medicine, University of Minnesota, United States; University of Minnesota, Department of Infectious Disease, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415, United States.
| | - Johanna Moore
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415, United States.
| | - Emily Herding
- Minneapolis Medical Research Foundation, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415, United States.
| | - Tami Gooch
- Department of Pathology & Laboratory Medicine, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415, United States.
| | - Diane Hirigoyen
- Department of Pathology & Laboratory Medicine, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415, United States.
| | - Kevan Hanson
- Department of Pathology & Laboratory Medicine, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415, United States.
| | - Marcia Deike
- Department of Pathology & Laboratory Medicine, Hennepin County Medical Center, 701 Park Ave, Minneapolis, MN 55415, United States.
| |
Collapse
|
45
|
Allen AJ, O’Leary RA, Davis S, Graziadio S, Jones WS, Simpson AJ, Price DA, Vale L, Power M. Cost implications for the NHS of using the Alere™ i Influenza A & B near patient test with nasal swabs. Diagn Progn Res 2018; 2:15. [PMID: 31093564 PMCID: PMC6460782 DOI: 10.1186/s41512-018-0031-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/18/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Influenza is an acute viral infection of the respiratory tract. A rapid confirmatory diagnosis of influenza is important, since it is highly transmissible and outbreaks of influenza within the hospital setting increase morbidity and mortality. The objective of this study was to evaluate the cost implications, from the perspective of the UK NHS, of using on-label nasal swabs with the Alere™ i Influenza A & B test in a near patient setting. METHODS A cost consequence model was developed. The time horizon of the model was from hospital admission on suspicion of influenza until the end of treatment (following a diagnosis of influenza or discharge from hospital). Data on the prevalence of influenza and the sensitivity and specificity of the Alere™ i Influenza A & B test came from two prospective observational diagnostic accuracy studies. Costs were obtained from published resources. Uncertainties in the model data were investigated using deterministic, one-way sensitivity analyses. RESULTS Using the Alere™ i Influenza A & B point of care test with nasal swabs (on label) in NHS medical assessment units and emergency departments could save approximately £242,730 per 1000 adults presenting with influenza-like symptoms. The main cause for this was reduced times to availability of the result compared with the laboratory RT-PCR test. Other key drivers of savings were the cost of isolation, the prevalence of influenza, the specificity of the test, and the availability of isolation resources. CONCLUSIONS The Alere™ i Influenza A & B point of care test would have greatest impact in hospitals that have extensive delays in the time to receive a result. Sensitivity analyses identified the model parameters which would have greatest effect on the result and confirmed that assumptions were conservative, i.e. did not change key results.
Collapse
Affiliation(s)
- A. J. Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne, UK
- 0000 0001 0462 7212grid.1006.7Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - R. A. O’Leary
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne, UK
- 0000 0004 0444 2244grid.420004.2Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - S. Davis
- 0000 0000 9422 8284grid.31410.37Department of Virology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S. Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne, UK
- 0000 0004 0444 2244grid.420004.2Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - W. S. Jones
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne, UK
- 0000 0001 0462 7212grid.1006.7Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - A. J. Simpson
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne, UK
- 0000 0001 0462 7212grid.1006.7Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - D. A. Price
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne, UK
- 0000 0004 0641 3236grid.419334.8Department of Infectious Diseases, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - L. Vale
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne, UK
- 0000 0001 0462 7212grid.1006.7Health Economics Group, Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, UK
| | - M. Power
- NIHR Newcastle In Vitro Diagnostics Co-operative, Newcastle upon Tyne, UK
- 0000 0004 0444 2244grid.420004.2Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| |
Collapse
|
46
|
Trabattoni E, Le V, Pilmis B, Pean de Ponfilly G, Caisso C, Couzigou C, Vidal B, Mizrahi A, Ganansia O, Le Monnier A, Lina B, Nguyen Van JC. Implementation of Alere i Influenza A & B point of care test for the diagnosis of influenza in an ED. Am J Emerg Med 2017; 36:916-921. [PMID: 29137903 DOI: 10.1016/j.ajem.2017.10.046] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 09/28/2017] [Accepted: 10/18/2017] [Indexed: 01/26/2023] Open
Abstract
STUDY OBJECTIVE This study aimed to evaluate the impact of implementing rapid point-of-care testing (POCT) with the Alere i Influenza A & B in an emergency department (ED) during an influenza epidemic. METHODS Direct nasal swabs were prospectively collected following the physical examination of patients aged >18years who presented to the ED of a tertiary hospital in France with influenza-like illness (ILI) symptoms (N=301) between February 1st and March 31st, 2016, which coincided with an influenza epidemic. Laboratory-based testing (standard of care) was used to obtain a diagnosis in February 2016 (pre-POCT cohort) and positive results were confirmed using polymerase chain reaction. The primary endpoint was patient time in the ED. RESULTS A total of 169 and 132 patients participated in the pre-POCT phase and POCT phase respectively. A significantly higher proportion of patients received a positive diagnosis in the POCT cohort compared with the pre-POCT cohort (31% versus 5.3%, P<0.01). Mean time spent in the ED and hospitalization rate were significantly lower in the POCT cohort (6.06h versus 4.15h, P=0.03, and 44.4% versus 9.7%, P=0.02, respectively). Despite similar rates in the prescription of antibiotics and antiviral therapies, the proportion of patients who were referred for additional tests was significantly lower in the POCT cohort (78.1% versus 62.1%, P=0.003, and 80.5% versus 63.6%, P=0.01, respectively). CONCLUSIONS The Alere i Influenza A & B POCT reduced the length of stay in ED, the hospitalization rates, and the number of additional diagnostic tests compared with standard of care testing.
Collapse
Affiliation(s)
- E Trabattoni
- Service des Urgences, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - V Le
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - B Pilmis
- Equipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - G Pean de Ponfilly
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - C Caisso
- Service des Urgences, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - C Couzigou
- Equipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France; Equipe Opérationnelle d'Hygiène, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - B Vidal
- Equipe Mobile de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France; Equipe Opérationnelle d'Hygiène, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - A Mizrahi
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - O Ganansia
- Service des Urgences, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - A Le Monnier
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - B Lina
- Laboratoire de Virologie Centre National de Référence des Virus Influenzae, Hôpital de la Croix Rousse, Lyon, France
| | - J C Nguyen Van
- Service de Microbiologie Clinique, Groupe Hospitalier Paris Saint-Joseph, Paris, France.
| |
Collapse
|
47
|
Davis S, Allen AJ, O'Leary R, Power M, Price DA, Simpson AJ, Tunbridge A, Vale L, Whiteside M, Evans C, Raza M. Diagnostic accuracy and cost analysis of the Alere™ i Influenza A&B near-patient test using throat swabs. J Hosp Infect 2017; 97:301-309. [PMID: 28558954 DOI: 10.1016/j.jhin.2017.05.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 05/23/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Clinical diagnostic sensitivity alone is inadequate in the diagnosis of influenza. Polymerase chain reaction (PCR) testing is sensitive but the inherent delays in result availability potentially prolong time to isolation and treatment. Until recently no near-patient test (NPT) has demonstrated adequate sensitivity for routine clinical use. AIM To evaluate diagnostic accuracy, time to result availability, clinical impact, and cost consequences of Alere™ i Influenza A&B NPT (Alere Inc., Waltham, MA, USA) using off-label throat swabs. METHODS Prospective, multi-centre [four UK National Health Service (NHS) hospitals], diagnostic accuracy cohort study with cost modelling. Throat swab samples from suspected influenza patients were tested for influenza using the reference standard of PCR; a second throat swab was tested using NPT. FINDINGS A total of 827 participants were recruited; 589 were suitable for analysis: sensitivity was 75.8% [95% confidence interval (CI): 67.0-84.6]; specificity was 96.8% (95% CI: 95.2-98.3). Sensitivity varied between Sheffield (Northern General Hospital: 82.1%; Royal Hallamshire Hospital: 83.3%) and other sites (Doncaster Royal Infirmary: 71.4%; Newcastle's Royal Victoria Infirmary: 50.0%) whereas specificity was high (92-100%). Positive predictive value (PPV) was 81.2% (95% CI: 72.9-89.5) with negative predictive value 95.6% (95% CI: 93.9-97.4) with observed prevalence of 15.4%. Median time to result for PCR was 1.1 days (on-site laboratories) and 5.2 days (remote laboratories). Isolation findings: 75% influenza positive not isolated; 69% of isolated participants did not have influenza. For a cohort of 1000 participants, annual estimated non-diagnostic cost savings with NPT are £215,040. CONCLUSION This first prospective study of the Alere i NPT using throat swabs demonstrates high specificity, high PPV during seasonal epidemics, and rapid result availability which could lead to substantial cost savings.
Collapse
Affiliation(s)
- S Davis
- Department of Virology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
| | - A J Allen
- National Institute for Health Research (NIHR) Diagnostic Evidence Co-operative Newcastle, Newcastle upon Tyne, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - R O'Leary
- National Institute for Health Research (NIHR) Diagnostic Evidence Co-operative Newcastle, Newcastle upon Tyne, UK
| | - M Power
- National Institute for Health Research (NIHR) Diagnostic Evidence Co-operative Newcastle, Newcastle upon Tyne, UK
| | - D A Price
- Department of Infectious Diseases, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A J Simpson
- National Institute for Health Research (NIHR) Diagnostic Evidence Co-operative Newcastle, Newcastle upon Tyne, UK; Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - A Tunbridge
- Department of Infectious Diseases, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - L Vale
- Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, UK
| | - M Whiteside
- Department of Acute Medicine, Doncaster Royal Infirmary, Doncaster, UK
| | - C Evans
- Department of Virology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - M Raza
- Department of Virology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
48
|
Klepser ME, Klepser DG, Dering-Anderson AM, Morse JA, Smith JK, Klepser SA. Effectiveness of a pharmacist-physician collaborative program to manage influenza-like illness. J Am Pharm Assoc (2003) 2017; 56:14-21. [PMID: 26802915 DOI: 10.1016/j.japh.2015.11.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 07/21/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To examine the effectiveness of collaborative physician-community pharmacist programs to treat influenza-like illness (ILI) with respect to clinical outcomes and health care utilization. DESIGN Prospective multicenter cohort study. SETTING Fifty-five pharmacies in Michigan, Minnesota, and Nebraska. PATIENTS Adult patients presenting to the pharmacy with ILI during the 2013-14 influenza season (October 1, 2013 to May 30, 2014). INTERVENTION Pharmacists screened adult patients presenting with ILI, completed a brief physical assessment, performed a point-of-care rapid influenza diagnostic test (RIDT), and provided appropriate referral or treatment per an established collaborative practice agreement (CPA) with a licensed prescriber. Pharmacists followed-up with patients 24 to 48 hours after the encounter to assess patient status and possible need for further intervention. MAIN OUTCOME MEASURES Number of patients screened, tested, and treated for influenza. RESULTS Of the 121 patients screened, 45 (37%) were excluded and referred to their primary care provider or an urgent care facility for management. Of the 75 patients (62%) eligible for participation, 8 (11%) had a positive RIDT and were managed according to the CPA. Of the patients tested, 34.6% had no primary care physician and 38.7% visited the pharmacy outside of normal office hours. Only 3% of patients reported feeling worse at follow-up. CONCLUSION This study describes a physician-pharmacist collaborative model for treating ILI. Using an evidence-based CPA, pharmacists were able to provide timely treatment to patients with and without influenza.
Collapse
|
49
|
Brendish NJ, Malachira AK, Armstrong L, Houghton R, Aitken S, Nyimbili E, Ewings S, Lillie PJ, Clark TW. Routine molecular point-of-care testing for respiratory viruses in adults presenting to hospital with acute respiratory illness (ResPOC): a pragmatic, open-label, randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2017; 5:401-411. [PMID: 28392237 PMCID: PMC7164815 DOI: 10.1016/s2213-2600(17)30120-0] [Citation(s) in RCA: 211] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 03/02/2017] [Accepted: 03/02/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Respiratory virus infection is a common cause of hospitalisation in adults. Rapid point-of-care testing (POCT) for respiratory viruses might improve clinical care by reducing unnecessary antibiotic use, shortening length of hospital stay, improving influenza detection and treatment, and rationalising isolation facility use; however, insufficient evidence exists to support its use over standard clinical care. We aimed to assess the effect of routine POCT on a broad range of clinical outcomes including antibiotic use. METHODS In this pragmatic, parallel-group, open-label, randomised controlled trial, we enrolled adults (aged ≥18 years) within 24 h of presenting to the emergency department or acute medical unit of a large UK hospital with acute respiratory illness or fever higher than 37·5°C (≤7 days duration), or both, over two winter seasons. Patients were randomly assigned (1:1), via an internet-based allocation sequence with random permuted blocks, to have a molecular POC test for respiratory viruses or routine clinical care. The primary outcome was the proportion of patients who received antibiotics while hospitalised (up to 30 days). Secondary outcomes included duration of antibiotics, proportion of patients receiving single doses or brief courses of antibiotics, length of stay, antiviral use, isolation facility use, and safety. Analysis was by modified intention to treat, excluding patients who declined intervention or were withdrawn for protocol violations. This study is registered with ISRCTN, number 90211642, and has been completed. FINDINGS Between Jan 15, 2015, and April 30, 2015, and between Oct 1, 2015, and April 30, 2016, we enrolled 720 patients (362 assigned to POCT and 358 to routine care). Six patients withdrew or had protocol violations. 301 (84%) of 360 patients in the POCT group received antibiotics compared with 294 (83%) of 354 controls (difference 0·6%, 95% CI -4·9 to 6·0; p=0·84). Mean duration of antibiotics did not differ between groups (7·2 days [SD 5·1] in the POCT group vs 7·7 days [4·9] in the control group; difference -0·4, 95% CI -1·2 to 0·4; p=0·32). 50 (17%) of 301 patients treated with antibiotics in the POCT group received single doses or brief courses of antibiotics (<48 h) compared with 26 (9%) of 294 patients in the control group (difference 7·8%, 95% CI 2·5 to 13·1; p=0·0047; number needed to test=13). Mean length of stay was shorter in the POCT group (5·7 days [SD 6·3]) than in the control group (6·8 days [7·7]; difference -1·1, 95% CI -2·2 to -0·3; p=0·0443). Appropriate antiviral treatment of influenza-positive patients was more common in the POCT group (52 [91%] of 57 patients) than in the control group (24 [65%] of 37 patients; difference 26·4%, 95% CI 9·6 to 43·2; p=0·0026; number needed to test=4). We found no differences in adverse outcomes between the groups (77 [21%] of 360 patients in the POCT group vs 88 [25%] of 354 patients in the control group; -3·5%, -9·7 to 2·7; p=0·29). INTERPRETATION Routine use of molecular POCT for respiratory viruses did not reduce the proportion of patients treated with antibiotics. However, the primary outcome measure failed to capture differences in antibiotic use because many patients were started on antibiotics before the results of POCT could be made available. Although POCT was not associated with a reduction in the duration of antibiotics overall, more patients in the POCT group received single doses or brief courses of antibiotics than did patients in the control group. POCT was also associated with a reduced length of stay and improved influenza detection and antiviral use, and appeared to be safe. FUNDING University of Southampton.
Collapse
Affiliation(s)
- Nathan J Brendish
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Ahalya K Malachira
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Lawrence Armstrong
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Rebecca Houghton
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sandra Aitken
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Esther Nyimbili
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sean Ewings
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Patrick J Lillie
- Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Tristan W Clark
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Department of Infection, University Hospital Southampton NHS Foundation Trust, Southampton, UK; NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
| |
Collapse
|
50
|
Rogan DT, Kochar MS, Yang S, Quinn JV. Impact of Rapid Molecular Respiratory Virus Testing on Real-Time Decision Making in a Pediatric Emergency Department. J Mol Diagn 2017; 19:460-467. [PMID: 28341587 DOI: 10.1016/j.jmoldx.2017.01.009] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 01/25/2017] [Indexed: 11/24/2022] Open
Abstract
Acute respiratory illnesses (ARIs) are usually viral [influenza, respiratory syncytial virus (RSV)] and account for 25% of emergency department (ED) peak-season visits. Laboratory PCR testing is accurate albeit slow, whereas rapid antigen testing is inaccurate. We determined the impact of bedside PCR (molecular point-of-care test; mPOCT) on pediatric ARI management. This was a prospective cohort study of consecutive pediatric patients with ED-ordered respiratory PCR test, enrolled over 9 weeks during peak flu season. On ordering, ED physicians were interviewed to ascertain real-time plans if given immediate influenza/RSV PCR results for the current patient. Two groups were compared: actual management and management adjusted for mPOCT results. We compared ED length of stay (LOS), tests ordered, and antibiotic/antiviral ordering. One-hundred thirty-six respiratory PCR panels were ordered, 71 by admitting team, 61 for ED management. Of 61 ED-initiated tests, physicians indicated in 39 cases (64%) they would change patient management were bedside viral results available. Physicians would have decreased ED LOS by 33 minutes, ordered fewer tests (18%; P < 0.001) with average patient charge savings of $669, fewer antibiotics among discharged patients (17%; P = 0.043), and increased appropriate antiviral use (13%; P = 0.023). Rapid bedside ARI mPOCT PCR has the potential to decrease ED LOS, reduce diagnostic tests and patient charges, and increase appropriate use of antibiotics and antiviral agents.
Collapse
Affiliation(s)
- Daniel T Rogan
- Department of Health Research and Policy, Stanford University, Stanford, California
| | - Mohit S Kochar
- Department of Emergency Medicine, Stanford University, Stanford, California
| | - Samuel Yang
- Department of Emergency Medicine, Stanford University, Stanford, California.
| | - James V Quinn
- Department of Emergency Medicine, Stanford University, Stanford, California.
| |
Collapse
|