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Lapin JS, Smith RD, Hornback KM, Johnson JK, Claeys KC. From bottle to bedside: Implementation considerations and antimicrobial stewardship considerations for bloodstream infection rapid diagnostic testing. Pharmacotherapy 2023; 43:847-863. [PMID: 37158053 DOI: 10.1002/phar.2813] [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: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 05/10/2023]
Abstract
Antimicrobial stewardship (AMS) programs have been quick to adopt novel molecular rapid diagnostic technologies (mRDTs) for bloodstream infections (BSIs) to improve antimicrobial management. As such, most of the literature demonstrating the clinical and economic benefits of mRDTs for BSI is in the presence of active AMS intervention. Leveraging mRDTs to improve antimicrobial therapy for BSI is increasingly integral to AMS program activities. This narrative review discusses available and future mRDTs, the relationship between the clinical microbiology laboratory and AMS programs, and practical considerations for optimizing the use of these tools within a health system. Antimicrobial stewardship programs must work closely with their clinical microbiology laboratories to ensure that mRDTs are used to their fullest benefit while remaining cognizant of their limitations. As more mRDT instruments and panels become available and AMS programs continue to expand, future efforts must consider the expansion beyond traditional settings of large academic medical centers and how combinations of tools can further improve patient care.
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Affiliation(s)
- Jonathan S Lapin
- Department of Pharmacy Practice, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Richard D Smith
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Krutika M Hornback
- Department of Pharmacy Practice, Medical University of South Carolina (MUSC) Health, Charleston, South Carolina, USA
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kimberly C Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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Senok A, Dabal LA, Alfaresi M, Habous M, Celiloglu H, Bashiri S, Almaazmi N, Ahmed H, Mohmed AA, Bahaaldin O, Elimam MAE, Rizvi IH, Olowoyeye V, Powell M, Salama B. Clinical Impact of the BIOFIRE Blood Culture Identification 2 Panel in Adult Patients with Bloodstream Infection: A Multicentre Observational Study in the United Arab Emirates. Diagnostics (Basel) 2023; 13:2433. [PMID: 37510177 PMCID: PMC10378530 DOI: 10.3390/diagnostics13142433] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/10/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Rapid pathogen identification is key to the proper management of patients with bloodstream infections (BSIs), especially in the intensive care setting. This multicentre study compared the time to pathogen identification results in 185 patients admitted to intensive care with a confirmed BSI, using conventional methods (n = 99 patients) and upon implementation of the BIOFIRE® Blood Culture Identification 2 (BCID2) Panel, a rapid molecular test allowing for the simultaneous identification of 43 BSI-related nucleic acids targets (n = 86 patients). The median time to result informing optimal antibiotic therapy was significantly shorter following the implementation of the BCID2 Panel (92 vs. 28 h pre vs. post BCID2 implementation; p < 0.0001). BCID2 usage in addition to conventional methods led to the identification of at least one pathogen in 98.8% patients vs. 87.9% using conventional methods alone (p = 0.003) and was associated with a lower 30-day mortality (17.3% vs. 31.6%, respectively; p = 0.019). This study at three intensive care units in the United Arab Emirates therefore demonstrates that, in addition to conventional microbiological methods and an effective antimicrobial stewardship program, the BCID2 Panel could improve the clinical outcome of patients admitted to the intensive care unit with a confirmed BSI.
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Affiliation(s)
- Abiola Senok
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai P.O. Box 505055, United Arab Emirates
| | - Laila Al Dabal
- Infectious Diseases Unit, Rashid Hospital, Dubai P.O. Box 4545, United Arab Emirates
| | - Mubarak Alfaresi
- Pathology and Laboratory Medicine, Zayed Military Hospital, Abu Dhabi P.O. Box 72763, United Arab Emirates
| | - Maya Habous
- Microbiology and Infection Control Unit, Pathology Department, Rashid Hospital, Dubai P.O. Box 4545, United Arab Emirates
| | - Handan Celiloglu
- Microbiology Department, Mediclinic City Hospital, Dubai Healthcare City, Dubai P.O. Box 505004, United Arab Emirates
| | - Safia Bashiri
- Infectious Diseases Unit, Rashid Hospital, Dubai P.O. Box 4545, United Arab Emirates
| | - Naama Almaazmi
- Infectious Diseases Unit, Rashid Hospital, Dubai P.O. Box 4545, United Arab Emirates
| | - Hassan Ahmed
- Infectious Diseases Unit, Rashid Hospital, Dubai P.O. Box 4545, United Arab Emirates
| | - Ayman A Mohmed
- Intensive Care Unit, Sheikh Khalifa General Hospital, Umm Al Quwain P.O. Box 499, United Arab Emirates
| | - Omar Bahaaldin
- Microbiology and Infection Control Unit, Pathology Department, Rashid Hospital, Dubai P.O. Box 4545, United Arab Emirates
| | - Maimona Ahmed Elsiddig Elimam
- Microbiology and Infection Control Unit, Pathology Department, Rashid Hospital, Dubai P.O. Box 4545, United Arab Emirates
| | - Irfan Hussain Rizvi
- Microbiology Department, Mediclinic City Hospital, Dubai Healthcare City, Dubai P.O. Box 505004, United Arab Emirates
| | - Victory Olowoyeye
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences, Dubai P.O. Box 505055, United Arab Emirates
| | - Michaela Powell
- Data Science Department, bioMérieux Inc., Salt Lake City, UT 84108, USA
| | - Basel Salama
- Medical Affairs, bioMérieux, Dubai P.O. Box 505201, United Arab Emirates
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Kumaraswamy M, Riestra A, Flores A, Uchiyama S, Dahesh S, Bondsäter G, Nilsson V, Chang M, Seo H, Sakoulas G, Nizet V. Unrecognized Potent Activities of Colistin Against Clinically Important mcr+ Enterobacteriaceae Revealed in Synergy with Host Immunity. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.03.21.533661. [PMID: 36993410 PMCID: PMC10055327 DOI: 10.1101/2023.03.21.533661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Colistin (COL) is a cationic cyclic peptide that disrupts negatively-charged bacterial cell membranes and frequently serves as an antibiotic of last resort to combat multidrug-resistant Gram-negative bacterial infections. Emergence of the horizontally transferable plasmid-borne mobilized colistin resistance (mcr) determinant and its spread to Gram-negative strains harboring extended-spectrum β-lactamase and carbapenemase resistance genes threatens futility of our chemotherapeutic arsenal. COL is widely regarded to have zero activity against mcr+ patients based on standard antimicrobial susceptibility testing (AST) performed in enriched bacteriological growth media; consequently, the drug is withheld from patients with mcr+ infections. However, these standard testing media poorly mimic in vivo physiology and omit host immune factors. Here we report previously unrecognized bactericidal activities of COL against mcr-1+ isolates of Escherichia coli (EC), Klebsiella pneumoniae (KP), and Salmonella enterica (SE) in standard tissue culture media containing the physiological buffer bicarbonate. Moreover, COL promoted serum complement deposition on the mcr-1+ Gram-negative bacterial surface and synergized potently with active human serum in pathogen killing. At COL concentrations readily achievable with standard dosing, the peptide antibiotic killed mcr-1+ EC, KP, and SE in freshly isolated human blood proved effective as monotherapy in a murine model of mcr-1+ EC bacteremia. Our results suggest that COL, currently ignored as a treatment option based on traditional AST, may in fact benefit patients with mcr-1+ Gram negative infections based on evaluations performed in a more physiologic context. These concepts warrant careful consideration in the clinical microbiology laboratory and for future clinical investigation of their merits in high risk patients with limited therapeutic options.
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Affiliation(s)
- Monika Kumaraswamy
- Division of Infectious Diseases and Global Public Health, Department of Medicine, UC San Diego, La Jolla, CA, USA
- Infectious Diseases Section, VA San Diego Healthcare System, San Diego, CA, USA
| | - Angelica Riestra
- Department of Biology, San Diego State University, San Diego, CA, USA
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, UC San Diego, La Jolla, CA, USA
| | - Anabel Flores
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, UC San Diego, La Jolla, CA, USA
- Department of Biological Sciences, California Baptist University, Riverside, CA, USA
| | - Satoshi Uchiyama
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, UC San Diego, La Jolla, CA, USA
| | - Samira Dahesh
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, UC San Diego, La Jolla, CA, USA
| | - Gunnar Bondsäter
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, UC San Diego, La Jolla, CA, USA
- Faculty of Medicine, Lund University, Lund, Sweden
| | - Victoria Nilsson
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, UC San Diego, La Jolla, CA, USA
- Faculty of Medicine, Lund University, Lund, Sweden
| | - Melanie Chang
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, UC San Diego, La Jolla, CA, USA
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Hideya Seo
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, UC San Diego, La Jolla, CA, USA
- Department of Anesthesia, Kyoto University, Kyoto, Japan
| | - George Sakoulas
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, UC San Diego, La Jolla, CA, USA
- Sharp Rees Stealy Medical Group, San Diego, CA, USA
| | - Victor Nizet
- Division of Host-Microbe Systems and Therapeutics, Department of Pediatrics, UC San Diego, La Jolla, CA, USA
- Skaggs School of Pharmacy and Pharmaceutical Sciences, UC San Diego, La Jolla, CA, USA
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Caméléna F, Péan de Ponfilly G, Pailhoriès H, Bonzon L, Alanio A, Poncin T, Lafaurie M, Dépret F, Cambau E, Godreuil S, Chenouard R, Le Monnier A, Jacquier H, Berçot B. Multicenter Evaluation of the FilmArray Blood Culture Identification 2 Panel for Pathogen Detection in Bloodstream Infections. Microbiol Spectr 2023; 11:e0254722. [PMID: 36519852 PMCID: PMC9927563 DOI: 10.1128/spectrum.02547-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 11/18/2022] [Indexed: 12/23/2022] Open
Abstract
The FilmArray Blood Culture Identification 2 panel (BCID2; bioMérieux) is a fully automated PCR-based assay for identifying bacteria, fungi, and bacterial resistance markers in positive blood cultures (BC) in about 1 h. In this multicenter study, we evaluated the performance of the BCID2 panel for pathogen detection in positive BC. Conventional culture and BCID2 were performed in parallel at four tertiary-care hospitals. We included 152 positive BC-130 monomicrobial and 22 polymicrobial cultures-in this analysis. The BCID2 assay correctly identified 90% (88/98) of Gram-negative and 89% (70/79) of Gram-positive bacteria. Five bacterial isolates targeted by the BCID2 panel and recovered from five positive BC, including three polymicrobial cultures, were missed by the BCID2 assay. Fifteen isolates were off-panel organisms, accounting for 8% (15/182) of the isolates obtained from BC. The mean positive percent agreement between the BCID2 assay and standard culture was 97% (95% confidence interval, 95 to 99%), with agreement ranging from 67% for Candida albicans to 100% for 17 targets included in the BCID2 panel. BCID2 also identified the blaCTX-M gene in seven BC, including one for which no extended-spectrum β-lactamase (ESBL)-producing isolate was obtained in culture. However, it failed to detect ESBL-encoding genes in three BC. Two of the 18 mecA/C genes detected by the BCID2 were not confirmed. No carbapenemase, mecA/C, or MREJ targets were detected. The median turnaround time was significantly shorter for BCID2 than for culture. The BCID2 panel may facilitate faster pathogen identification in bloodstream infections. IMPORTANCE Rapid molecular diagnosis combining the identification of pathogens and the detection of antibiotic resistance genes from positive blood cultures (BC) can improve the outcome for patients with bloodstream infections. The FilmArray BCID2 panel, an updated version of the original BCID, can detect 11 Gram-positive bacteria, 15 Gram-negative bacteria, 7 fungal pathogens, and 10 antimicrobial resistance genes directly from a positive BC. Here, we evaluated the real-life microbiological performance of the BCID2 assay in comparison to the results of standard methods used in routine practice at four tertiary care hospitals.
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Affiliation(s)
- François Caméléna
- Département de Bactériologie, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, IAME, Paris, France
| | - Gauthier Péan de Ponfilly
- Service de Microbiologie clinique, Groupe hospitalier Paris Saint Joseph, Paris, France
- Institut Micalis UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Châtenay Malabry, France
| | - Hélène Pailhoriès
- Laboratoire de Bactériologie, Institut de Biologie en Santé, Centre Hospitalier Universitaire d’Angers, Laboratoire HIFIH, UPRES EA3859, SFR ICAT 4208, Université d’Angers, Angers, France
| | - Lucas Bonzon
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire de Montpellier et MIVEGEC, UMR IRD-CNRS-Université de Montpellier, Montpellier, France
| | - Alexandre Alanio
- Laboratoire de Parasitologie-Mycologie, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, Assistance Publique-Hôpitaux de Paris, Paris, France
- Institut Pasteur, Université Paris Cité, CNRS, Unité de Mycologie Moléculaire, UMR2000, Paris, France
| | - Thibaut Poncin
- Département de Bactériologie, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, IAME, Paris, France
| | - Matthieu Lafaurie
- Département des Maladies Infectieuses et Tropicales, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - François Dépret
- Département d’Anesthésie et Réanimation chirurgicale et brûlés, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emmanuel Cambau
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, IAME, Paris, France
- Laboratoire de mycobactériologie spécialisée et de référence, Laboratoire associé du Centre National de Référence des mycobactéries et résistance des mycobactéries aux antituberculeux, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sylvain Godreuil
- Laboratoire de Bactériologie, Centre Hospitalier Universitaire de Montpellier et MIVEGEC, UMR IRD-CNRS-Université de Montpellier, Montpellier, France
| | - Rachel Chenouard
- Laboratoire de Bactériologie, Institut de Biologie en Santé, Centre Hospitalier Universitaire d’Angers, Laboratoire HIFIH, UPRES EA3859, SFR ICAT 4208, Université d’Angers, Angers, France
| | - Alban Le Monnier
- Service de Microbiologie clinique, Groupe hospitalier Paris Saint Joseph, Paris, France
- Institut Micalis UMR 1319, Université Paris-Saclay, INRAe, AgroParisTech, Châtenay Malabry, France
| | - Hervé Jacquier
- Département de Bactériologie, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, IAME, Paris, France
| | - Béatrice Berçot
- Département de Bactériologie, Groupe Hospitalier Saint-Louis-Lariboisière-Fernand Widal, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, INSERM, IAME, Paris, France
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Peri AM, Bauer MJ, Bergh H, Butkiewicz D, Paterson DL, Harris PN. Performance of the BioFire Blood Culture Identification 2 panel for the diagnosis of bloodstream infections. Heliyon 2022; 8:e09983. [PMID: 35874050 PMCID: PMC9304729 DOI: 10.1016/j.heliyon.2022.e09983] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 03/01/2022] [Accepted: 07/13/2022] [Indexed: 01/09/2023] Open
Abstract
Background Conventional blood cultures methods are associated with long turnaround times, preventing early treatment optimization in bloodstream infections. The BioFire Blood Culture Identification 2 (BCID2) Panel is a new multiplex PCR applied on positive blood cultures, reducing time to pathogen identification and resistant markers detection. Methods We conducted a prospective observational study including positive blood cultures from Intensive Care Units and Emergency Departments and performed BCID2 in addition to conventional testing. Concordance between the two methods was assessed and BCID2 performance characteristics were evaluated. Resistance markers detected by BCID2 were confirmed by in-house PCR. Whole genome sequencing was performed in discordant cases. Results Among 60 monomicrobial blood cultures, BCID2 correctly identified 55/56 (91.7%) on-panel pathogens, showing an overall concordance of 98%. In 4/60 cases BCID2 did not detect any target and these all grew BCID2 off-panel bacteria. Only one discordant case was found. Sensitivity and specificity for Gram-positive bacteria on monomicrobial samples were 100% (95% CI 85.8-100%) and 100% (95% CI 90.3-100%) respectively, while for Gram-negatives 100% (95% CI 87.7-100) and 96.9% (95% CI 83.8-99.9%), respectively. Among two polymicrobial blood cultures, full concordance was observed in one case only. BCID2 identified antimicrobial resistance genes in 6/62 samples, all confirmed by in-house PCR (3 mecA/C S. epidermidis, 3 bla CTX-M E. coli). Estimated time to results gained using BCID2 as compared to conventional testing was 9.69 h (95% CI: 7.85-11.53). Conclusions BCID2 showed good agreement with conventional methods. Studies to assess its clinical impact are warranted.
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Affiliation(s)
- Anna Maria Peri
- University of Queensland Centre for Clinical Research, Herston, Brisbane City, QLD, 4029, Australia
| | - Michelle J Bauer
- University of Queensland Centre for Clinical Research, Herston, Brisbane City, QLD, 4029, Australia
| | - Haakon Bergh
- Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Herston, Brisbane City, QLD, 4029, Australia
| | - Dominika Butkiewicz
- University of Queensland Centre for Clinical Research, Herston, Brisbane City, QLD, 4029, Australia
| | - David L Paterson
- University of Queensland Centre for Clinical Research, Herston, Brisbane City, QLD, 4029, Australia.,Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Herston, Brisbane City, QLD, 4029, Australia
| | - Patrick Na Harris
- University of Queensland Centre for Clinical Research, Herston, Brisbane City, QLD, 4029, Australia.,Central Microbiology, Pathology Queensland, Royal Brisbane and Women's Hospital, Herston, Brisbane City, QLD, 4029, Australia
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Abstract
PURPOSE OF REVIEW Gram-negative bloodstream infections (GNBSI) are common and carry considerable mortality. Treatment is complicated by increasing antimicrobial resistance, posing a challenge for timely appropriate antibiotics and limiting the choices of effective definitive therapy. The present review aims to summarize recent studies addressing the management of GNBSI. RECENT FINDINGS New rapid diagnostic tests (RDT) for pathogen identification and antibiotic susceptibility are associated with improved antimicrobial stewardship and reduced length of stay. No mortality benefit or patient-related outcomes are reported. Data regarding the use of new beta-lactam beta-lactamase inhibitors (BLBLIs) for treating multidrug resistance Gram-negative bacteria is supportive, though questions regarding combinations, optimal dosing, mode of administration, and resistance emergence remain to be clarified. Current data regarding cefiderocol necessitates further studies in order to support its use in GNBSI. Shortened (≤7 days) duration of therapy and early oral step down for GNBSI are supported by the literature. The role of repeated blood cultures should be further defined. SUMMARY RDTs should be implemented to improve antibiotic stewardship. Clinical implications on patient-related outcomes should be evaluated. New BLBLIs show promise in the treatment of GNBSI. Additional data are needed regarding the use of cefiderocol. Antibiotic therapy should be shortened and early oral step down should be considered.
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Perez F, Colindres RV, Wilson BM, Saade E, Jump RLP, Banerjee R, Patel R, Evans SR, Bonomo RA. Desirability of Outcome Ranking for the Management of Antimicrobial Therapy (DOOR MAT) Reveals Improvements in the Treatment of Bloodstream Infections Caused by Escherichia coli and Klebsiella pneumoniae in Patients from the Veterans Health Administration. Clin Infect Dis 2021; 73:1231-1238. [PMID: 33978146 PMCID: PMC8492112 DOI: 10.1093/cid/ciab384] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Reductions in the use of broad-spectrum antibiotics is a cornerstone of antimicrobial stewardship. We aim to demonstrate use of the Desirability of Outcome Ranking Approach for the Management of Antimicrobial Therapy (DOOR MAT) to evaluate the treatment of Escherichia coli and Klebsiella pneumoniae bloodstream infections in patients from the Veterans Health Administration (VHA) across a decade. METHODS Using electronic records, we determined empiric and definitive antibiotic treatments, clinical characteristics, and 30-day mortality of patients with monomicrobial E. coli and K. pneumoniae bloodstream infections hospitalized in VHA medical centers from 2009 to 2018. Focusing on patients treated with parenteral β-lactams and with available antibiotic susceptibility testing results, we applied a range of DOOR MAT scores that reflect the desirability of antibiotic choices according to spectrum and activity against individual isolates. We report trends in resistance and desirability of empiric and definitive antibiotic treatments. RESULTS During the 10-year period analyzed, resistance to expanded-spectrum cephalosporins and fluoroquinolones increased in E. coli but not in K. pneumoniae, while resistance to carbapenems and piperacillin-tazobactam remained unchanged. In 6451 cases analyzed, we observed improvements in DOOR MAT scores consistent with deescalation. Improvement in desirability of definitive treatment compared with empiric treatment occurred in 26% of cases, increasing from 16% in 2009 to 34% in 2018. Reductions in overtreatment were sustained and without negative impact on survival. CONCLUSIONS DOOR MAT provides a framework to assess antibiotic treatment of E. coli and K. pneumoniae bloodstream infections and can be a useful metric in antimicrobial stewardship.
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Affiliation(s)
- Federico Perez
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Roberto Viau Colindres
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, Massachusetts, USA
| | - Brigid M Wilson
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Elie Saade
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Population & Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ritu Banerjee
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Robin Patel
- Division of Infectious Diseases and Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott R Evans
- George Washington Biostatistics Center, George Washington University, Washington, DC, USA
| | - Robert A Bonomo
- Geriatric Research Education and Clinical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Departments of Pharmacology, Molecular Biology and Microbiology, Biochemistry, Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Case Western Reserve University–Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio, USA
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8
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Comparing the Clinical Utility of Rapid Diagnostics for Treatment of Bloodstream Infections Using Desirability of Outcome Ranking Approach for the Management of Antibiotic Therapy (DOOR-MAT). Antimicrob Agents Chemother 2021; 65:e0044121. [PMID: 34228533 PMCID: PMC8370220 DOI: 10.1128/aac.00441-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Decisions regarding which rapid diagnostic test (RDT) for bloodstream infections to implement remain challenging given the diversity of organisms detected by different platforms. We used the desirability of outcome ranking management of antimicrobial therapy (DOOR-MAT) as a framework to compare two RDT platforms on potential desirability of antimicrobial therapy decisions. An observational study was performed at University of Maryland Medical System comparing Verigene blood culture (BC) to GenMark Dx ePlex blood culture ID (BCID) (research use only) panels on blood cultures from adult patients. Positive percent agreement (PPA) between each RDT platform and Vitek MS was calculated for comparison of on-panel targets. Theoretical antimicrobial decisions were made based on RDT results, taking into consideration patient parameters, antimicrobial stewardship practices, and local infectious diseases epidemiology. DOOR-MAT with a partial credit scoring system was applied to these decisions, and mean scores were compared across platforms using a paired t test. The study consisted of 160 unique patients. The Verigene BC PPA was 98.6% (95% confidence interval [CI], 95.1 to 99.8), and ePlex BCID PPA was 98% (95% CI, 94.3 to 99.6). Among the 31 organisms not on the Verigene BC panels, 61% were identified by the ePlex BCID panels. The mean (standard deviation [SD]) DOOR-MAT score for Verigene BC was 86.8 (28.5), while that for ePlex BCID was 91.9 (23.1) (P = 0.01). Both RDT platforms had high PPA for on-panel targets. The ePlex BCID was able to identify more organisms than Verigene, resulting in higher mean DOOR-MAT scores.
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Abstract
Rapid pathogen characterization from positive blood cultures (BC) can improve management of patients with bloodstream infections (BSI). The FilmArray blood culture identification (BCID) assay is a molecular test approved for direct identification of BSI causing pathogens from positive BC. A recently updated version of the panel (BCID2) comprises improved species identification characteristics and allows for the detection of one expanded-spectrum β-lactamase (ESBL)- and several carbapenemase-encoding genes. Here, the clinical performance of the BCID2 assay for species identification in 180 positive BCs was evaluated. BCID2 results were concordant with the standard of care (SOC) in 159/180 (88.3%) BCs; 68/74 (91.9%) and 71/74 (96.0%) of all samples growing monobacterial, Gram-positive or Gram-negative pathogens, respectively, were identified, in agreement with SOC results. Nonconcordance was related to the detection of additional pathogens by the BCID2 assay (n = 4), discrepant species identification (n = 4), or failure of BCID2 to detect on-panel pathogens (n = 1). A number (12/31; 38.7%) of discordant results became evident in polymicrobial BC specimens. BCID2 identified the presence of blaCTX-M-carrying species in 12 BC specimens but failed to predict third-generation cephalosporin resistance in four isolates exhibiting independent cephalosporin resistance mechanisms. Carbapenem resistance related to the presence of blaVIM-2 or blaOxa-48-like was correctly predicted in two isolates. In conclusion, the BCID2 assay is a reliable tool for rapid BC processing and species identification. Despite inclusion of common ESBL- or carbapenemase-encoding markers, the multifactorial nature of β-lactam resistance in Gram-negative organisms warrants combination of BCID2 with (rapid) phenotypic susceptibility assays.
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