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Kaal AG, Meziyerh S, van Burgel N, Dane M, Kolfschoten NE, Mahajan P, Julián-Jiménez A, Steyerberg EW, van Nieuwkoop C. Procalcitonin for safe reduction of unnecessary blood cultures in the emergency department: Development and validation of a prediction model. J Infect 2024; 89:106251. [PMID: 39182652 DOI: 10.1016/j.jinf.2024.106251] [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: 05/01/2024] [Revised: 08/13/2024] [Accepted: 08/14/2024] [Indexed: 08/27/2024]
Abstract
OBJECTIVES Blood cultures (BCs) are commonly ordered in emergency departments (EDs), while a minority yields a relevant pathogen. Diagnostic stewardship is needed to safely reduce unnecessary BCs. We aimed to develop and validate a bacteremia prediction model for ED patients, with specific focus on the benefit of incorporating procalcitonin. METHODS We included adult patients with suspected bacteremia from a Dutch ED for a one-year period. We defined 23 candidate predictors for a "full model", of which nine were used for an automatable "basic model". Variations of both models with C-reactive protein and procalcitonin were constructed using LASSO regression, with bootstrapping for internal validation. External validation was done in an independent cohort of patients with confirmed infection from 71 Spanish EDs. We assessed discriminative performance using the C-statistic and calibration with calibration curves. Clinical usefulness was evaluated by sensitivity, specificity, saved BCs, and Net Benefit. RESULTS Among 2111 patients in the derivation cohort (mean age 63 years, 46% male), 273 (13%) had bacteremia, versus 896 (20%) in the external cohort (n = 4436). Adding procalcitonin substantially improved performance for all models. The basic model with procalcitonin showed most promise, with a C-statistic of 0.87 (0.86-0.88) upon external validation. At a 5% risk threshold, it showed a sensitivity of 99% and could have saved 29% of BCs while only missing 10 out of 896 (1.1%) bacteremia patients. CONCLUSIONS Procalcitonin-based bacteremia prediction models can safely reduce unnecessary BCs at the ED. Further validation is needed across a broader range of healthcare settings.
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Affiliation(s)
- Anna G Kaal
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.
| | - Soufian Meziyerh
- Department of Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Nathalie van Burgel
- Department of Medical Microbiology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Martijn Dane
- Department of Clinical Chemistry, Haga Teaching Hospital, The Hague, the Netherlands
| | - Nikki E Kolfschoten
- Department of Emergency Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Prashant Mahajan
- Department of Emergency Medicine, University of Michigan Hospital, United States
| | - Agustín Julián-Jiménez
- Department of Emergency Medicine, Complejo Hospitalario Universitario de Toledo, Spain; IDISCAM (Instituto de Investigación Sanitaria de Castilla La Mancha), Universidad de Castilla La Mancha, Toledo, Spain
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Cees van Nieuwkoop
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands; Health Campus The Hague, Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, the Netherlands
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Theophanous R, Ramos J, Calland AR, Krcmar R, Shah P, da Matta LT, Shaheen S, Wrenn RH, Seidelman J. Blood culture algorithm implementation in emergency department patients as a diagnostic stewardship intervention. Am J Infect Control 2024; 52:985-991. [PMID: 38719159 DOI: 10.1016/j.ajic.2024.04.198] [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: 03/06/2024] [Revised: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE Blood cultures (BCx) are important for selecting appropriate antibiotic treatment. Ordering BCx for conditions with a low probability of bacteremia has limited utility, thus improved guidance for ordering BCx is needed. Inpatient studies have implemented BCx algorithms, but no studies examine the intervention in an Emergency Department (ED) setting. METHODS We performed a quasi-experimental pre and postintervention study from January 12, 2020, to October 31, 2023, at a single academic adult ED and implemented a BCx algorithm. The primary outcome was the blood culture event rates (BCE per 100 ED admissions) pre and postintervention. Secondary outcomes included adverse event rates (30-day ED and hospital readmission and antibiotic days of therapy). Seven ED physicians and APP reviewed BCx for appropriateness, with monthly feedback provided to ED leadership and physicians. RESULTS After the BCx algorithm implementation, the BCE rate decreased from 12.17 BCE/100 ED admissions to 10.50 BCE/100 ED admissions. Of the 3,478 reviewed BCE, we adjudicated 2,153 BCE (62%) as appropriate, 653 (19%) as inappropriate, and 672 (19%) as uncertain. Adverse safety events were not statistically different pre and postintervention. CONCLUSIONS Implementation of an ED BCx algorithm demonstrated a reduction in BCE, without increased adverse safety events. Future studies should compare outcomes of BCx algorithm implementation in a community hospital ED without intensive chart review.
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Affiliation(s)
- Rebecca Theophanous
- Department of Emergency Medicine, Duke University School of Medicine, Duke University, Durham, NC
| | - John Ramos
- Department of Emergency Medicine, Duke University School of Medicine, Duke University, Durham, NC
| | - Alyssa R Calland
- Department of Emergency Medicine, Duke University School of Medicine, Duke University, Durham, NC
| | - Rachel Krcmar
- Department of Emergency Medicine, Duke University School of Medicine, Duke University, Durham, NC
| | - Priya Shah
- Department of Emergency Medicine, Duke University School of Medicine, Duke University, Durham, NC
| | - Lucas T da Matta
- Department of Emergency Medicine, Duke University School of Medicine, Duke University, Durham, NC
| | - Stephen Shaheen
- Department of Emergency Medicine, Duke University School of Medicine, Duke University, Durham, NC
| | - Rebekah H Wrenn
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC; Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University Medical Center, Durham, NC
| | - Jessica Seidelman
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University School of Medicine, Duke University, Durham, NC; Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University Medical Center, Durham, NC.
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Giacobbe DR, Marelli C, Guastavino S, Signori A, Mora S, Rosso N, Campi C, Piana M, Murgia Y, Giacomini M, Bassetti M. Artificial intelligence and prescription of antibiotic therapy: present and future. Expert Rev Anti Infect Ther 2024:1-15. [PMID: 39155449 DOI: 10.1080/14787210.2024.2386669] [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: 05/20/2024] [Accepted: 07/28/2024] [Indexed: 08/20/2024]
Abstract
INTRODUCTION In the past few years, the use of artificial intelligence in healthcare has grown exponentially. Prescription of antibiotics is not exempt from its rapid diffusion, and various machine learning (ML) techniques, from logistic regression to deep neural networks and large language models, have been explored in the literature to support decisions regarding antibiotic prescription. AREAS COVERED In this narrative review, we discuss promises and challenges of the application of ML-based clinical decision support systems (ML-CDSSs) for antibiotic prescription. A search was conducted in PubMed up to April 2024. EXPERT OPINION Prescribing antibiotics is a complex process involving various dynamic phases. In each of these phases, the support of ML-CDSSs has shown the potential, and also the actual ability in some studies, to favorably impacting relevant clinical outcomes. Nonetheless, before widely exploiting this massive potential, there are still crucial challenges ahead that are being intensively investigated, pertaining to the transparency of training data, the definition of the sufficient degree of prediction explanations when predictions are obtained through black box models, and the legal and ethical framework for decision responsibility whenever an antibiotic prescription is supported by ML-CDSSs.
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Affiliation(s)
- Daniele Roberto Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- UO Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Cristina Marelli
- UO Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Alessio Signori
- Section of Biostatistics, Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Sara Mora
- UO Information and Communication Technologies, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Nicola Rosso
- UO Information and Communication Technologies, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Cristina Campi
- Department of Mathematics (DIMA), University of Genoa, Genoa, Italy
- Life Science Computational Laboratory (LISCOMP), IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Michele Piana
- Department of Mathematics (DIMA), University of Genoa, Genoa, Italy
- Life Science Computational Laboratory (LISCOMP), IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Ylenia Murgia
- Department of Informatics, Bioengineering, Robotics and System Engineering (DIBRIS), University of Genoa, Genoa, Italy
| | - Mauro Giacomini
- Department of Informatics, Bioengineering, Robotics and System Engineering (DIBRIS), University of Genoa, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
- UO Clinica Malattie Infettive, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Parvataneni S, Sarkis Y, Haugh M, Baker B, Tang Q, Nephew LD, Ghabril MS, Chalasani NP, Vuppalanchi R, Orman ES, Harrison NE, Desai AP. A Comprehensive Evaluation of Emergency Department Utilization by Patients With Cirrhosis. Am J Gastroenterol 2024:00000434-990000000-01201. [PMID: 38912688 DOI: 10.14309/ajg.0000000000002905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 06/06/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION Emergency department (ED)-based care is required for cirrhosis management, yet the burden of cirrhosis-related ED healthcare utilization is understudied. We aimed to describe ED utilization within a statewide health system and compare the outcomes of high ED use (HEDU) vs non-HEDU in individuals with cirrhosis. METHODS We retrospectively reviewed charts of adults with cirrhosis who presented to any of 16 EDs within the Indiana University Health system in 2021. Patient characteristics, features of the initial ED visit, subsequent 90-day healthcare use, and 360-day outcomes were collected. Multivariable logistic regression models were used to identify predictors HEDU status which was defined as ≥2 ED visits within 90 days after the index ED visit. RESULTS There were 2,124 eligible patients (mean age 61.3 years, 53% male, and 91% White). Major etiologies of cirrhosis were alcohol (38%), metabolic dysfunction-associated steatohepatitis (27%), and viral hepatitis (21%). Cirrhosis was newly diagnosed in the ED visit for 18.4%. Most common reasons for ED visits were abdominal pain (21%), shortness of breath (19%), and ascites/volume overload (16%). Of the initial ED visits, 20% (n = 424) were potentially avoidable. The overall 90-day mortality was 16%. Within 90 days, there were 366 HEDU (20%). Notable variables independently associated with HEDU were model for end-stage liver disease-sodium (adjusted odds ratio [aOR] 1.044, 95% confidence interval [CI] 1.005-1.085), prior ED encounter (aOR 1.520, 95% CI 1.136-2.034), and avoidable initial ED visit (aOR 1.938, 95% CI 1.014-3.703). DISCUSSION Abdominal pain, shortness of breath, and ascites/fluid overload are the common presenting reasons for ED visits for patients with cirrhosis. Patients with cirrhosis presenting to the ED experience a 90-day mortality rate of 16%, and among those who initially visited the ED, 20% were HEDU. We identified several variables independently associated with HEDU. Our observations pave the way for developing interventions to optimize the care of patients with cirrhosis presenting to the ED and to lower repeated ED visits.
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Affiliation(s)
- Swetha Parvataneni
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Yara Sarkis
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Michelle Haugh
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Brittany Baker
- Department of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Qing Tang
- Department of Biostatistics, Indiana University, Indianapolis, Indiana, USA
| | - Lauren D Nephew
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Naga P Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Raj Vuppalanchi
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Eric S Orman
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | | | - Archita P Desai
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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van der Zaag AY, Bhagirath SC, Boerman AW, Schinkel M, Paranjape K, Azijli K, Ridderikhof ML, Lie M, Lissenberg-Witte B, Schade R, Wiersinga J, de Jonge R, Nanayakkara PWB. Appropriate use of blood cultures in the emergency department through machine learning (ABC): study protocol for a randomised controlled non-inferiority trial. BMJ Open 2024; 14:e084053. [PMID: 38821574 PMCID: PMC11149153 DOI: 10.1136/bmjopen-2024-084053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 05/10/2024] [Indexed: 06/02/2024] Open
Abstract
INTRODUCTION The liberal use of blood cultures in emergency departments (EDs) leads to low yields and high numbers of false-positive results. False-positive, contaminated cultures are associated with prolonged hospital stays, increased antibiotic usage and even higher hospital mortality rates. This trial aims to investigate whether a recently developed and validated machine learning model for predicting blood culture outcomes can safely and effectively guide clinicians in withholding unnecessary blood culture analysis. METHODS AND ANALYSIS A randomised controlled, non-inferiority trial comparing current practice with a machine learning-guided approach. The primary objective is to determine whether the machine learning based approach is non-inferior to standard practice based on 30-day mortality. Secondary outcomes include hospital length-of stay and hospital admission rates. Other outcomes include model performance and antibiotic usage. Participants will be recruited in the EDs of multiple hospitals in the Netherlands. A total of 7584 participants will be included. ETHICS AND DISSEMINATION Possible participants will receive verbal information and a paper information brochure regarding the trial. They will be given at least 1 hour consideration time before providing informed consent. Research results will be published in peer-reviewed journals. This study has been approved by the Amsterdam University Medical Centers' local medical ethics review committee (No 22.0567). The study will be conducted in concordance with the principles of the Declaration of Helsinki and in accordance with the Medical Research Involving Human Subjects Act, General Data Privacy Regulation and Medical Device Regulation. TRIAL REGISTRATION NUMBER NCT06163781.
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Affiliation(s)
- Anuschka Y van der Zaag
- Department of Internal Medicine, Division of Acute Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Sheena C Bhagirath
- Department of Internal Medicine, Division of Acute Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Anneroos W Boerman
- Department of Internal Medicine, Division of Acute Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Department of Laboratory Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Michiel Schinkel
- Department of Internal Medicine, Division of Acute Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine (C.E.M.M.), Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Ketan Paranjape
- Department of Internal Medicine, Division of Acute Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Kaoutar Azijli
- Department of Emergency Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Milan L Ridderikhof
- Department of Emergency Medicine, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Mei Lie
- Department of EVA Service Center, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Birgit Lissenberg-Witte
- Department of Epidemiology & Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Rogier Schade
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Joost Wiersinga
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
- Center for Experimental and Molecular Medicine (C.E.M.M.), Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Robert de Jonge
- Department of Laboratory Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Prabath W B Nanayakkara
- Department of Internal Medicine, Section General Internal Medicine, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
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Shorten R, Pickering K, Goolden C, Harris C, Clegg A, J H. Diagnostic stewardship in infectious diseases: a scoping review. J Med Microbiol 2024; 73:001831. [PMID: 38722316 PMCID: PMC11165918 DOI: 10.1099/jmm.0.001831] [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: 11/22/2023] [Accepted: 04/11/2024] [Indexed: 06/13/2024] Open
Abstract
Introduction. The term 'diagnostic stewardship' is relatively new, with a recent surge in its use within the literature. Despite its increasing popularity, a precise definition remains elusive. Various attempts have been made to define it, with some viewing it as an integral part of antimicrobial stewardship. The World Health Organization offers a broad definition, emphasizing the importance of timely, accurate diagnostics. However, inconsistencies in the use of this term still persist, necessitating further clarification.Gap Statement. There are currently inconsistencies in the definition of diagnostic stewardship used within the academic literature.Aim. This scoping review aims to categorize the use of diagnostic stewardship approaches and define this approach by identifying common characteristics and factors of its use within the literature.Methodology. This scoping review undertook a multi-database search from date of inception until October 2022. Any observational or experimental study where the authors define the intervention to be diagnostic stewardship from any clinical area was included. Screening of all papers was undertaken by a single reviewer with 10% verification by a second reviewer. Data extraction was undertaken by a single reviewer using a pre-piloted form. Given the wide variation in study design and intervention outcomes, a narrative synthesis approach was applied. Studies were clustered around common diagnostic stewardship interventions where appropriate.Results. After duplicate removal, a total of 1310 citations were identified, of which, after full-paper screening, 105 studies were included in this scoping review. The classification of an intervention as taking a diagnostic stewardship approach is a relatively recent development, with the first publication in this field dating back to 2017. The majority of research in this area has been conducted within the USA, with very few studies undertaken outside this region. Visual inspection of the citation map reveals that the current evidence base is interconnected, with frequent references to each other's work. The interventions commonly adopt a restrictive approach, utilizing hard and soft stops within the pre-analytical phase to restrict access to testing. Upon closer examination of the outcomes, it becomes evident that there is a predominant focus on reducing the number of tests rather than enhancing the current test protocol. This is further reflected in the limited number of studies that report on test performance (including protocol improvements, specificity and sensitivity).Conclusion. Diagnostic stewardship seems to have deviated from its intended course, morphing into a rather rudimentary instrument wielded not to enhance but to constrict the scope of testing. Despite the World Health Organization's advocacy for an ideology that promotes a more comprehensive approach to quality improvement, it may be more appropriate to consider alternative regional narratives when categorizing these types of quality improvement interventions.
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Affiliation(s)
- Robert Shorten
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Foundation Trust, UK
- The University of Manchester, Manchester, UK
| | - Kate Pickering
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Foundation Trust, UK
| | - Callum Goolden
- Department of Microbiology, Lancashire Teaching Hospitals NHS Foundation Trust, Foundation Trust, UK
| | | | - Andrew Clegg
- University of Central Lancashire, Fylde Rd, Preston PR1 2HE, UK
| | - Hill J
- University of Central Lancashire, Fylde Rd, Preston PR1 2HE, UK
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Wu Q, Ye F, Gu Q, Shao F, Long X, Zhan Z, Zhang J, He J, Zhang Y, Xiao Q. A customised down-sampling machine learning approach for sepsis prediction. Int J Med Inform 2024; 184:105365. [PMID: 38350181 DOI: 10.1016/j.ijmedinf.2024.105365] [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: 09/25/2023] [Revised: 12/17/2023] [Accepted: 01/29/2024] [Indexed: 02/15/2024]
Abstract
OBJECTIVE Sepsis is a life-threatening condition in the ICU and requires treatment in time. Despite the accuracy of existing sepsis prediction models, insufficient focus on reducing alarms could worsen alarm fatigue and desensitisation in ICUs, potentially compromising patient safety. In this retrospective study, we aim to develop an accurate, robust, and readily deployable method in ICUs, only based on the vital signs and laboratory tests. METHODS Our method consists of a customised down-sampling process and a specific dynamic sliding window and XGBoost to offer sepsis prediction. The down-sampling process was applied to the retrospective data for training the XGBoost model. During the testing stage, the dynamic sliding window and the trained XGBoost were used to predict sepsis on the retrospective datasets, PhysioNet and FHC. RESULTS With the filtered data from PhysioNet, our method achieved 80.74% accuracy (77.90% sensitivity and 84.42% specificity) and 83.95% (84.82% sensitivity and 82.00% specificity) on the test set of PhysioNet-A and PhysioNet-B, respectively. The AUC score was 0.89 for both datasets. On the FHC dataset, our method achieved 92.38% accuracy (88.37% sensitivity and 95.16% specificity) and 0.98 AUC score on the test set of FHC. CONCLUSION Our results indicate that the down-sampling process and the dynamic sliding window with XGBoost brought robust and accurate performance to give sepsis prediction under various hospital settings. The localisation and robustness of our method can assist in sepsis diagnosis in different ICU settings.
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Affiliation(s)
- Qinhao Wu
- Apriko Research, Eindhoven, the Netherlands; Department of Mathematics and Computer Science, Eindhoven University of Technology, De Zaale, Eindhoven, 5612 AZ, Noord Brabant, the Netherlands
| | - Fei Ye
- Apriko Research, Eindhoven, the Netherlands
| | - Qianqian Gu
- Digital, Data and Informatics, Natural History Museum, London, SW7 5BD, United Kingdom
| | - Feng Shao
- Apriko Research, Eindhoven, the Netherlands
| | - Xi Long
- Department of Electrical Engineering, Eindhoven University of Technology, De Zaale, Eindhoven, 5612 AZ, Noord Brabant, the Netherlands
| | - Zhuozhao Zhan
- Department of Mathematics and Computer Science, Eindhoven University of Technology, De Zaale, Eindhoven, 5612 AZ, Noord Brabant, the Netherlands
| | - Junjie Zhang
- E.N.T. Department, the First Hospital of Changsha, University of South China, Changsha, 410005, China
| | - Jun He
- Department of Critical Care Medicine, the First Hospital of Changsha, University of South China, Changsha, 410005, China
| | - Yangzhou Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Changsha, 410008, China.
| | - Quan Xiao
- E.N.T. Department, the First Hospital of Changsha, University of South China, Changsha, 410005, China.
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Schinkel M, Boerman A, Carroll K, Cosgrove SE, Hsu YJ, Klein E, Nanayakkara P, Schade R, Wiersinga WJ, Fabre V. Impact of Blood Culture Contamination on Antibiotic Use, Resource Utilization, and Clinical Outcomes: A Retrospective Cohort Study in Dutch and US Hospitals. Open Forum Infect Dis 2024; 11:ofad644. [PMID: 38312218 PMCID: PMC10836193 DOI: 10.1093/ofid/ofad644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/20/2023] [Indexed: 02/06/2024] Open
Abstract
Background Blood culture contamination (BCC) has been associated with prolonged antibiotic use (AU) and increased health care utilization; however, this has not been widely reevaluated in the era of increased attention to antibiotic stewardship. We evaluated the impact of BCC on AU, resource utilization, and length of stay in Dutch and US patients. Methods This retrospective observational study examined adults admitted to 2 hospitals in the Netherlands and 5 hospitals in the United States undergoing ≥2 blood culture (BC) sets. Exclusion criteria included neutropenia, no hospital admission, or death within 48 hours of hospitalization. The impact of BCC on clinical outcomes-overall inpatient days of antibiotic therapy, test utilization, length of stay, and mortality-was determined via a multivariable regression model. Results An overall 22 927 patient admissions were evaluated: 650 (4.1%) and 339 (4.8%) with BCC and 11 437 (71.8%) and 4648 (66.3%) with negative BC results from the Netherlands and the United States, respectively. Dutch and US patients with BCC had a mean ± SE 1.74 ± 0.27 (P < .001) and 1.58 ± 0.45 (P < .001) more days of antibiotic therapy than patients with negative BC results. They also had 0.6 ± 0.1 (P < .001) more BCs drawn. Dutch but not US patients with BCC had longer hospital stays (3.36 days; P < .001). There was no difference in mortality between groups in either cohort. AU remained higher in US but not Dutch patients with BCC in a subanalysis limited to BC obtained within the first 24 hours of admission. Conclusions BCC remains associated with higher inpatient AU and health care utilization as compared with patients with negative BC results, although the impact on these outcomes differs by country.
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Affiliation(s)
- Michiel Schinkel
- Center for Experimental and Molecular Medicine, Amsterdam UMC, Location Academic Medical Center, Amsterdam, the Netherlands
- Division of Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Anneroos Boerman
- Division of Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Karen Carroll
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg of School of Public Health, Baltimore, Maryland, USA
| | - Eili Klein
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Prabath Nanayakkara
- Division of Acute Medicine, Department of Internal Medicine, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Rogier Schade
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC, Amsterdam, the Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine, Amsterdam UMC, Location Academic Medical Center, Amsterdam, the Netherlands
- Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, Location Academic Medical Center, Amsterdam, the Netherlands
| | - Valeria Fabre
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Schinkel M, Boerman AW, Paranjape K, Wiersinga WJ, Nanayakkara PWB. Detecting changes in the performance of a clinical machine learning tool over time. EBioMedicine 2023; 97:104823. [PMID: 37793210 PMCID: PMC10550508 DOI: 10.1016/j.ebiom.2023.104823] [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: 05/27/2023] [Revised: 09/21/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Excessive use of blood cultures (BCs) in Emergency Departments (EDs) results in low yields and high contamination rates, associated with increased antibiotic use and unnecessary diagnostics. Our team previously developed and validated a machine learning model to predict BC outcomes and enhance diagnostic stewardship. While the model showed promising initial results, concerns over performance drift due to evolving patient demographics, clinical practices, and outcome rates warrant continual monitoring and evaluation of such models. METHODS A real-time evaluation of the model's performance was conducted between October 2021 and September 2022. The model was integrated into Amsterdam UMC's Electronic Health Record system, predicting BC outcomes for all adult patients with BC draws in real time. The model's performance was assessed monthly using metrics including the Area Under the Curve (AUC), Area Under the Precision-Recall Curve (AUPRC), and Brier scores. Statistical Process Control (SPC) charts were used to monitor variation over time. FINDINGS Across 3.035 unique adult patient visits, the model achieved an average AUC of 0.78, AUPRC of 0.41, and a Brier score of 0.10 for predicting the outcome of BCs drawn in the ED. While specific population characteristics changed over time, no statistical points outside the statistical control range were detected in the AUC, AUPRC, and Brier scores, indicating stable model performance. The average BC positivity rate during the study period was 13.4%. INTERPRETATION Despite significant changes in clinical practice, our BC stewardship tool exhibited stable performance, suggesting its robustness to changing environments. Using SPC charts for various metrics enables simple and effective monitoring of potential performance drift. The assessment of the variation of outcome rates and population changes may guide the specific interventions, such as intercept correction or recalibration, that may be needed to maintain a stable model performance over time. This study suggested no need to recalibrate or correct our BC stewardship tool. FUNDING No funding to disclose.
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Affiliation(s)
- Michiel Schinkel
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Division of Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University, Amsterdam, the Netherlands.
| | - Anneroos W Boerman
- Division of Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University, Amsterdam, the Netherlands; Department of Clinical Chemistry, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - Ketan Paranjape
- Division of Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University, Amsterdam, the Netherlands
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Division of Infectious Diseases, Department of Internal Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Prabath W B Nanayakkara
- Division of Acute Medicine, Department of Internal Medicine, Amsterdam UMC, VU University, Amsterdam, the Netherlands
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Tsai WC, Liu CF, Ma YS, Chen CJ, Lin HJ, Hsu CC, Chow JC, Chien YW, Huang CC. Real-time artificial intelligence system for bacteremia prediction in adult febrile emergency department patients. Int J Med Inform 2023; 178:105176. [PMID: 37562317 DOI: 10.1016/j.ijmedinf.2023.105176] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/29/2023] [Accepted: 08/04/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Artificial intelligence (AI) holds significant potential to be a valuable tool in healthcare. However, its application for predicting bacteremia among adult febrile patients in the emergency department (ED) remains unclear. Therefore, we conducted a study to provide clarity on this issue. METHODS Adult febrile ED patients with blood cultures at Chi Mei Medical Center were divided into derivation (January 2017 to June 2019) and validation groups (July 2019 to December 2020). The derivation group was utilized to develop AI models using twenty-one feature variables and five algorithms to predict bacteremia. The performance of these models was compared with qSOFA score. The AI model with the highest area under the receiver operating characteristics curve (AUC) was chosen to implement the AI prediction system and tested on the validation group. RESULTS The study included 5,647 febrile patients. In the derivation group, there were 3,369 patients with a mean age of 61.4 years, and 50.7% were female, including 508 (13.8%) with bacteremia. The model with the best AUC was built using the random forest algorithm (0.761), followed by logistic regression (0.755). All five models demonstrated better AUC than the qSOFA score (0.560). The random forest model was adopted to build a real-time AI prediction system integrated into the hospital information system, and the AUC achieved 0.709 in the validation group. CONCLUSION The AI model shows promise to predict bacteremia in adult febrile ED patients; however, further external validation in different hospitals and populations is necessary to verify its effectiveness.
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Affiliation(s)
- Wei-Chun Tsai
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
| | - Chung-Feng Liu
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Shan Ma
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Chia-Jung Chen
- Department of Information Systems, Chi Mei Medical Center, Tainan, Taiwan
| | - Hung-Jung Lin
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan; Department of Emergency Medicine, Taipei Medical University, Taipei, Taiwan; School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Chien-Chin Hsu
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan; School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Julie Chi Chow
- Department of Pediatrics, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Wen Chien
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.
| | - Chien-Cheng Huang
- Department of Emergency Medicine, Chi Mei Medical Center, Tainan, Taiwan; School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan; Department of Emergency Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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11
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Karlic KJ, Clouse TL, Hogan CK, Garland A, Seelye S, Sussman JB, Prescott HC. Comparison of Administrative versus Electronic Health Record-based Methods for Identifying Sepsis Hospitalizations. Ann Am Thorac Soc 2023; 20:1309-1315. [PMID: 37163757 DOI: 10.1513/annalsats.202302-105oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/10/2023] [Indexed: 05/12/2023] Open
Abstract
Rationale: Despite the importance of sepsis surveillance, no optimal approach for identifying sepsis hospitalizations exists. The Centers for Disease Control and Prevention Adult Sepsis Event Definition (CDC-ASE) is an electronic medical record-based algorithm that yields more stable estimates over time than diagnostic coding-based approaches but may still result in misclassification. Objectives: We sought to assess three approaches to identifying sepsis hospitalizations, including a modified CDC-ASE. Methods: This cross-sectional study included patients in the Veterans Affairs Ann Arbor Healthcare System admitted via the emergency department (February 2021 to February 2022) with at least one episode of acute organ dysfunction within 48 hours of emergency department presentation. Patients were assessed for community-onset sepsis using three methods: 1) explicit diagnosis codes, 2) the CDC-ASE, and 3) a modified CDC-ASE. The modified CDC-ASE required at least two systemic inflammatory response syndrome criteria instead of blood culture collection and had a more sensitive definition of respiratory dysfunction. Each method was compared with a reference standard of physician adjudication via medical record review. Patients were considered to have sepsis if they had at least one episode of acute organ dysfunction graded as "definitely" or "probably" infection related on physician review. Results: Of 821 eligible hospitalizations, 449 were selected for physician review. Of these, 98 (21.8%) were classified as sepsis by medical record review, 103 (22.9%) by the CDC-ASE, 132 (29.4%) by the modified CDC-ASE, and 37 (8.2%) by diagnostic codes. Accuracy was similar across the three methods of interest (80.6% for the CDC-ASE, 79.6% for the modified CDC-ADE, and 84.2% for diagnostic codes), but sensitivity and specificity varied. The CDC-ASE algorithm had sensitivity of 58.2% (95% confidence interval [CI], 47.2-68.1%) and specificity of 86.9% (95% CI, 82.9-90.2%). The modified CDC-ASE algorithm had greater sensitivity (69.4% [95% CI, 59.3-78.3%]) but lower specificity (81.8% [95% CI, 77.3-85.7%]). Diagnostic codes had lower sensitivity (32.7% [95% CI, 23.5-42.9%]) but greater specificity (98.6% [95% CI, 96.7-99.55%]). Conclusions: There are several approaches to identifying sepsis hospitalizations for surveillance that have acceptable accuracy. These approaches yield varying sensitivity and specificity, so investigators should carefully consider the test characteristics of each method before determining an appropriate method for their intended use.
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Affiliation(s)
- Kevin J Karlic
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Tori L Clouse
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Cainnear K Hogan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Allan Garland
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sarah Seelye
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Jeremy B Sussman
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; and
| | - Hallie C Prescott
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; and
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McFadden BR, Inglis TJJ, Reynolds M. Machine learning pipeline for blood culture outcome prediction using Sysmex XN-2000 blood sample results in Western Australia. BMC Infect Dis 2023; 23:552. [PMID: 37620774 PMCID: PMC10463910 DOI: 10.1186/s12879-023-08535-y] [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: 02/13/2023] [Accepted: 08/11/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Bloodstream infections (BSIs) are a significant burden on the global population and represent a key area of focus in the hospital environment. Blood culture (BC) testing is the standard diagnostic test utilised to confirm the presence of a BSI. However, current BC testing practices result in low positive yields and overuse of the diagnostic test. Diagnostic stewardship research regarding BC testing is increasing, and becoming more important to reduce unnecessary resource expenditure and antimicrobial use, especially as antimicrobial resistance continues to rise. This study aims to establish a machine learning (ML) pipeline for BC outcome prediction using data obtained from routinely analysed blood samples, including complete blood count (CBC), white blood cell differential (DIFF), and cell population data (CPD) produced by Sysmex XN-2000 analysers. METHODS ML models were trained using retrospective data produced between 2018 and 2019, from patients at Sir Charles Gairdner hospital, Nedlands, Western Australia, and processed at Pathwest Laboratory Medicine, Nedlands. Trained ML models were evaluated using stratified 10-fold cross validation. RESULTS Two ML models, an XGBoost model using CBC/DIFF/CPD features with boruta feature selection (BFS) , and a random forest model trained using CBC/DIFF features with BFS were selected for further validation after obtaining AUC scores of [Formula: see text] and [Formula: see text] respectively using stratified 10-fold cross validation. The XGBoost model obtained an AUC score of 0.76 on a internal validation set. The random forest model obtained AUC scores of 0.82 and 0.76 on internal and external validation datasets respectively. CONCLUSIONS We have demonstrated the utility of using an ML pipeline combined with CBC/DIFF, and CBC/DIFF/CPD feature spaces for BC outcome prediction. This builds on the growing body of research in the area of BC outcome prediction, and provides opportunity for further research.
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Affiliation(s)
- Benjamin R McFadden
- School of Physics, Mathematics and Computing, University of Western Australia, Perth, Australia.
| | - Timothy J J Inglis
- Western Australian Country Health Service, Perth, Australia
- School of Medicine, University of Western Australia, Perth, Australia
- Department of Microbiology, Pathwest Laboratory Medicine, Perth, Australia
| | - Mark Reynolds
- School of Physics, Mathematics and Computing, University of Western Australia, Perth, Australia
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13
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Chang YH, Hsiao CT, Chang YC, Lai HY, Lin HH, Chen CC, Hsu LC, Wu SY, Shih HM, Hsueh PR, Cho DY. Machine learning of cell population data, complete blood count, and differential count parameters for early prediction of bacteremia among adult patients with suspected bacterial infections and blood culture sampling in emergency departments. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:782-792. [PMID: 37244761 DOI: 10.1016/j.jmii.2023.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/06/2023] [Accepted: 05/06/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Bacteremia is a life-threatening complication of infectious diseases. Bacteremia can be predicted using machine learning (ML) models, but these models have not utilized cell population data (CPD). METHODS The derivation cohort from emergency department (ED) of China Medical University Hospital (CMUH) was used to develop the model and was prospectively validated in the same hospital. External validation was performed using cohorts from ED of Wei-Gong Memorial Hospital (WMH) and Tainan Municipal An-Nan Hospital (ANH). Adult patients who underwent complete blood count (CBC), differential count (DC), and blood culture tests were enrolled in the present study. The ML model was developed using CBC, DC, and CPD to predict bacteremia from positive blood cultures obtained within 4 h before or after the acquisition of CBC/DC blood samples. RESULTS This study included 20,636 patients from CMUH, 664 from WMH, and 1622 patients from ANH. Another 3143 patients were included in the prospective validation cohort of CMUH. The CatBoost model achieved an area under the receiver operating characteristic curve of 0.844 in the derivation cross-validation, 0.812 in the prospective validation, 0.844 in the WMH external validation, and 0.847 in the ANH external validation. The most valuable predictors of bacteremia in the CatBoost model were the mean conductivity of lymphocytes, nucleated red blood cell count, mean conductivity of monocytes, and neutrophil-to-lymphocyte ratio. CONCLUSIONS ML model that incorporated CBC, DC, and CPD showed excellent performance in predicting bacteremia among adult patients with suspected bacterial infections and blood culture sampling in emergency departments.
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Affiliation(s)
- Yu-Hsin Chang
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chiung-Tzu Hsiao
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Chang Chang
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hsin-Yu Lai
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Hsiu-Hsien Lin
- Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chien-Chih Chen
- Department of Laboratory, Wei-Gong Memorial Hospital, Miaoli City, Taiwan
| | - Lin-Chen Hsu
- Department of Laboratory, An-Nan Hospital, China Medical University, Tainan, Taiwan
| | - Shih-Yun Wu
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hong-Mo Shih
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan; School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Public Health, China Medical University, Taichung, Taiwan.
| | - Po-Ren Hsueh
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan; Department of Laboratory Medicine, China Medical University Hospital, Taichung, Taiwan; Division of Infectious Diseases, Department of Internal Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan.
| | - Der-Yang Cho
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan.
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14
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Schinkel M, Bennis FC, Boerman AW, Wiersinga WJ, Nanayakkara PWB. Embracing cohort heterogeneity in clinical machine learning development: a step toward generalizable models. Sci Rep 2023; 13:8363. [PMID: 37225751 DOI: 10.1038/s41598-023-35557-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 05/20/2023] [Indexed: 05/26/2023] Open
Abstract
This study is a simple illustration of the benefit of averaging over cohorts, rather than developing a prediction model from a single cohort. We show that models trained on data from multiple cohorts can perform significantly better in new settings than models based on the same amount of training data but from just a single cohort. Although this concept seems simple and obvious, no current prediction model development guidelines recommend such an approach.
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Affiliation(s)
- Michiel Schinkel
- Center for Experimental and Molecular Medicine (CEMM), Location Academic Medical Center, Amsterdam UMC Location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Frank C Bennis
- Quantitative Data Analytics Group, Department of Computer Science, Vrije Universiteit Amsterdam, De Boelelaan 1105, Amsterdam, The Netherlands
| | - Anneroos W Boerman
- Department of Internal Medicine, Section General Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
| | - W Joost Wiersinga
- Department of Internal Medicine, Amsterdam UMC University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Prabath W B Nanayakkara
- Department of Internal Medicine, Section General Internal Medicine, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1117, Amsterdam, The Netherlands
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Kullberg RFJ, Schinkel M, Wiersinga WJ. Empiric anti-anaerobic antibiotics are associated with adverse clinical outcomes in emergency department patients. Eur Respir J 2023; 61:61/5/2300413. [PMID: 37169379 DOI: 10.1183/13993003.00413-2023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/22/2023] [Indexed: 05/13/2023]
Affiliation(s)
- Robert F J Kullberg
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- These authors contributed equally
| | - Michiel Schinkel
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- These authors contributed equally
| | - W Joost Wiersinga
- Center for Experimental and Molecular Medicine (CEMM), Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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16
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Rello J, Paiva JA. Antimicrobial stewardship at the emergency department: Dead bugs do not mutate! Eur J Intern Med 2023; 109:30-32. [PMID: 36669904 DOI: 10.1016/j.ejim.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/16/2023] [Indexed: 01/20/2023]
Affiliation(s)
- Jordi Rello
- Clinical Research/Epidemiology in Pneumonia & Sepsis (CRIPS), Vall d'Hebron Research Institute, Barcelona, Spain; Recherche in Pôle Reánimation, Urgences et Douleur, CHU Nîmes, Nîmes, France.
| | - José Artur Paiva
- Intensive Care Department, Centro Hospitalar Universitário Sao Joao, Porto, Portugal; Medicine Departement, Faculty of Medicine, University of Porto, Portugal.
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Cai T, Anceschi U, Prata F, Collini L, Brugnolli A, Migno S, Rizzo M, Liguori G, Gallelli L, Wagenlehner FME, Johansen TEB, Montanari L, Palmieri A, Tascini C. Artificial Intelligence Can Guide Antibiotic Choice in Recurrent UTIs and Become an Important Aid to Improve Antimicrobial Stewardship. Antibiotics (Basel) 2023; 12:antibiotics12020375. [PMID: 36830285 PMCID: PMC9952599 DOI: 10.3390/antibiotics12020375] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/29/2023] [Accepted: 02/06/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND A correct approach to recurrent urinary tract infections (rUTIs) is an important pillar of antimicrobial stewardship. We aim to define an Artificial Neural Network (ANN) for predicting the clinical efficacy of the empiric antimicrobial treatment in women with rUTIs. METHODS We extracted clinical and microbiological data from 1043 women. We trained an ANN on 725 patients and validated it on 318. RESULTS The ANN showed a sensitivity of 87.8% and specificity of 97.3% in predicting the clinical efficacy of empirical therapy. The previous use of fluoroquinolones (HR = 4.23; p = 0.008) and cephalosporins (HR = 2.81; p = 0.003) as well as the presence of Escherichia coli with resistance against cotrimoxazole (HR = 3.54; p = 0.001) have been identified as the most important variables affecting the ANN output decision predicting the fluoroquinolones-based therapy failure. A previous isolation of Escherichia coli with resistance against fosfomycin (HR = 2.67; p = 0.001) and amoxicillin-clavulanic acid (HR = 1.94; p = 0.001) seems to be the most influential variable affecting the output decision predicting the cephalosporins- and cotrimoxazole-based therapy failure. The previously mentioned Escherichia coli with resistance against cotrimoxazole (HR = 2.35; p < 0.001) and amoxicillin-clavulanic acid (HR = 3.41; p = 0.007) seems to be the most influential variable affecting the output decision predicting the fosfomycin-based therapy failure. CONCLUSIONS ANNs seem to be an interesting tool to guide the antimicrobial choice in the management of rUTIs at the point of care.
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Affiliation(s)
- Tommaso Cai
- Department of Urology, Santa Chiara Regional Hospital, 38123 Trento, Italy
- Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway
- Correspondence:
| | - Umberto Anceschi
- IRCCS “Regina Elena” National Cancer Institute, 00144 Rome, Italy
| | - Francesco Prata
- Department of Urology, Campus Bio-Medico University of Rome, 00128 Rome, Italy
| | - Lucia Collini
- Department of Microbiology, Santa Chiara Regional Hospital, 38123 Trento, Italy
| | - Anna Brugnolli
- Centre of Higher Education for Health Sciences, 38122 Trento, Italy
| | - Serena Migno
- Department of Gynecology and Obstetrics, Santa Chiara Regional Hospital, 38123 Trento, Italy
| | - Michele Rizzo
- Department of Urology, University of Trieste, 34127 Trieste, Italy
| | - Giovanni Liguori
- Department of Urology, University of Trieste, 34127 Trieste, Italy
| | - Luca Gallelli
- Department of Health Science, School of Medicine, University of Catanzaro, 88100 Catanzaro, Italy
| | - Florian M. E. Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus Liebig University, 35390 Giessen, Germany
| | - Truls E. Bjerklund Johansen
- Institute of Clinical Medicine, University of Oslo, 0315 Oslo, Norway
- Department of Urology, Oslo University Hospital, 0315 Oslo, Norway
- Institute of Clinical Medicine, University of Aarhus, 8000 Aarhus, Denmark
| | - Luca Montanari
- Department of Medicine (DAME), Infectious Diseases Clinic, University of Udine, 33100 Udine, Italy
| | - Alessandro Palmieri
- Department of Urology, University of Naples Federico II, 80138 Naples, Italy
| | - Carlo Tascini
- Department of Medicine (DAME), Infectious Diseases Clinic, University of Udine, 33100 Udine, Italy
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