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Otto C, Chen D. Point of Care Molecular Testing: Current State and Opportunities for Diagnostic Stewardship. Clin Lab Med 2024; 44:23-32. [PMID: 38280795 DOI: 10.1016/j.cll.2023.10.010] [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
Inappropriate ordering practices, either under or over ordering of diagnostic tests, are recognized problems with possible negative downstream consequences. As the menu of clinical tests, especially molecular tests grows, it is becoming increasingly important to provide guidance to providers on the appropriate utilization. Diagnostic stewardship programs have been established at many institutions to help direct the appropriate utilization of laboratory testing to ultimately guide patient management and treatment decisions. Many molecular tests have now received Clinical Laboratory Improvement Amendments (CLIA)-waived status for use in a point-of-care (POC) setting; however, parallel diagnostic stewardship programs have not been established to help guide providers on how best to use these tests. In this article, we will discuss the available molecular POC tests and opportunities and challenges for establishing diagnostic stewardship programs for molecular testing performed in the POC setting.
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Affiliation(s)
- Caitlin Otto
- Department of Pathology, New York University Langone Health, 560 1st Avenue, New York, NY 10016, USA.
| | - Dan Chen
- Department of Pathology, New York University Langone Health, 560 1st Avenue, New York, NY 10016, USA
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Ku TSN, Al Mohajer M, Newton JA, Wilson MH, Monsees E, Hayden MK, Messacar K, Kisgen JJ, Diekema DJ, Morgan DJ, Sifri CD, Vaughn VM. Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship. Infect Control Hosp Epidemiol 2023; 44:1901-1908. [PMID: 37665212 DOI: 10.1017/ice.2023.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.
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Affiliation(s)
- Tsun Sheng N Ku
- Billings Clinic, Billings, Montana
- Rocky Vista University Montana College of Osteopathic Medicine, Billings, Montana
| | - Mayar Al Mohajer
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Infectious Diseases Section, Baylor St. Luke's Medical Center, Houston, Texas
- Infection Prevention, Diagnostic Stewardship and Antibiotic Stewardship, CommonSpirit Health Texas Division, Houston, Texas
| | - James A Newton
- Department of Antibiotic Stewardship, Washington Regional Medical Center, Fayetteville, Arkansas
| | - Marie H Wilson
- Infection Prevention & Control, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Elizabeth Monsees
- Performance Excellence, Children's Mercy Hospital, Kansas City, Missouri
- University of Missouri School of Medicine, Kansas City, Missouri
| | - Mary K Hayden
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Kevin Messacar
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado/Children's Hospital Colorado, Aurora, Colorado
| | | | - Daniel J Diekema
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Maine Medical Center, Portland, Maine
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
- VA Maryland Healthcare System, Baltimore, Maryland
| | - Costi D Sifri
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Velly L, Cancella de Abreu M, Boutolleau D, Cherubini I, Houas E, Aurousseau A, Hausfater P. Point-of-care multiplex molecular diagnosis coupled with procalcitonin-guided algorithm for antibiotic stewardship in lower respiratory tract infection: a randomized controlled trial. Clin Microbiol Infect 2023; 29:1409-1416. [PMID: 37549731 DOI: 10.1016/j.cmi.2023.07.031] [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: 04/25/2023] [Revised: 07/25/2023] [Accepted: 07/29/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE We aimed to show that coupling molecular syndromic respiratory panel (RP) testing with procalcitonin (PCT) measurement in the emergency department improves antibiotic (ATB) stewardship in lower respiratory tract infection. METHODS Open-label, prospective, randomized interventional trial, conducted from 2019 to 2022 in an adult emergency department. Patients with a suspicion of lower respiratory tract infection were randomized into an intervention arm (PCT measurement and point-of-care BIOFIRE RP2.1 plus testing, accompanied by a recommended ATB algorithm) or a standard of care (SOC) arm (PCT allowed as current practice). The primary endpoint was the duration of antibiotic exposure. RESULTS Four hundred fifty-one patients were randomized, median age 65 years (Q1-Q3: 49-77), the hospitalization rate was 59.9% (270/451), the median length of stay 5 days (Q1-Q3: 3 - 12), and the 28-day mortality rate 5.3% (23/451). The median duration of ATB exposure was 6 days (Q1-Q3: 0-9) and 5 days (Q1-Q3: 0-9) in the SOC and interventional arm respectively (p = 0.71). ATB was started in 29.6 % (67/226) and 33.8% (76/225) respectively (p = 0.54). The BIOFIRE RP2.1 plus identified at least one viral species in 112/225 patients (49.8%) of intervention arm. Two hundred twelve out of two hundred twenty-six (93.8%) SOC patients had PCT measurement. The adherence rate to algorithm in the intervention arm was 93.3 % (210/225). CONCLUSION Displaying PCT and real-time RP results to emergency physicians failed to significantly reduce ATB exposure in lower respiratory tract infection suspicions. However, the median ATB duration and rate of initiation were already low in the SOC arm using PCT measurement routinely.
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Affiliation(s)
- Laetitia Velly
- Emergency Department, APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France; GRC-14 BIOSFAST, CIMI, UMR 1135, Sorbonne Université, Paris, France
| | - Marta Cancella de Abreu
- Emergency Department, APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France; GRC-14 BIOSFAST, CIMI, UMR 1135, Sorbonne Université, Paris, France
| | - David Boutolleau
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (iPLESP), GH AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Virologie, Paris, France
| | - Ilaria Cherubini
- Emergency Department, APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Enfel Houas
- Emergency Department, APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Pierre Hausfater
- Emergency Department, APHP-Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France; GRC-14 BIOSFAST, CIMI, UMR 1135, Sorbonne Université, Paris, France.
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