1
|
Vyas S, Patel D, Bandali A, Giordano P, Roland R, Kessler J. Impact of BioFire® Blood Culture Identification (BCID) panels on antibiotic management of bacteremia due to select organisms. Diagn Microbiol Infect Dis 2024; 110:116384. [PMID: 39002446 DOI: 10.1016/j.diagmicrobio.2024.116384] [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: 03/23/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 07/15/2024]
Abstract
The purpose of this study was to assess changes in time to optimal therapy (TTOT) for bacteremia due to select organisms after implementation of the BioFire® FilmArray® blood culture identification panels at two community teaching hospitals. TTOT (days) was similar in Pre-BCID compared to BCID1 and BCID2 [(2.48 vs. 2.65, p=0.10); (2.48 vs. 2.37, p=0.27)]. There were no significant differences in time to effective antimicrobial therapy between groups. However, there were significantly more therapy changes and appropriate carbapenem use within 24 hours of the Gram stain result for gram-negative organisms in the BCID2 arm compared to the Pre-BCID arm. Additionally, a significant reduction in the duration of vancomycin for gram-positive organisms was noted in the BCID2 arm compared to the Pre-BCID arm. These findings suggest that the incorporation of the BCID2 panel resulted in changes in prescribing practices, leading to more appropriate antimicrobial utilization in a subset of patients.
Collapse
Affiliation(s)
- Shivam Vyas
- Morristown Medical Center, 100 Madison Avenue, Morristown, NJ 07960, United States.
| | - Dimple Patel
- Morristown Medical Center, 100 Madison Avenue, Morristown, NJ 07960, United States
| | - Aiman Bandali
- Overlook Medical Center, 99 Beauvoir Avenue, Summit, NJ 07901, United States
| | - Pamela Giordano
- Morristown Medical Center, 100 Madison Avenue, Morristown, NJ 07960, United States
| | - Robert Roland
- Overlook Medical Center, 99 Beauvoir Avenue, Summit, NJ 07901, United States
| | - Jason Kessler
- Morristown Medical Center, 100 Madison Avenue, Morristown, NJ 07960, United States
| |
Collapse
|
2
|
Peri AM, Chatfield MD, Ling W, Furuya-Kanamori L, Harris PNA, Paterson DL. Rapid Diagnostic Tests and Antimicrobial Stewardship Programs for the Management of Bloodstream Infection: What Is Their Relative Contribution to Improving Clinical Outcomes? A Systematic Review and Network Meta-analysis. Clin Infect Dis 2024; 79:502-515. [PMID: 38676943 PMCID: PMC11327801 DOI: 10.1093/cid/ciae234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Evidence about the clinical impact of rapid diagnostic tests (RDTs) for the diagnosis of bloodstream infections is limited, and whether RDT are superior to conventional blood cultures (BCs) embedded within antimicrobial stewardship programs (ASPs) is unknown. METHODS We performed network meta-analyses using results from studies of patients with bloodstream infection with the aim of comparing the clinical impact of RDT (applied on positive BC broth or whole blood) to conventional BC, both assessed with and without ASP with respect to mortality, length of stay (LOS), and time to optimal therapy. RESULTS Eighty-eight papers were selected, including 25 682 patient encounters. There was an appreciable amount of statistical heterogeneity within each meta-analysis. The network meta-analyses showed a significant reduction in mortality associated with the use of RDT + ASP versus BC alone (odds ratio [OR], 0.72; 95% confidence interval [CI], .59-.87) and with the use of RDT + ASP versus BC + ASP (OR, 0.78; 95% CI, .63-.96). No benefit in survival was found associated with the use of RDT alone nor with BC + ASP compared to BC alone. A reduction in LOS was associated with RDT + ASP versus BC alone (OR, 0.91; 95% CI, .84-.98) whereas no difference in LOS was shown between any other groups. A reduced time to optimal therapy was shown when RDT + ASP was compared to BC alone (-29 hours; 95% CI, -35 to -23), BC + ASP (-18 hours; 95% CI, -27 to -10), and to RDT alone (-12 hours; 95% CI, -20 to -3). CONCLUSIONS The use of RDT + ASP may lead to a survival benefit even when introduced in settings already adopting effective ASP in association with conventional BC.
Collapse
Affiliation(s)
- Anna Maria Peri
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Mark D Chatfield
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Weiping Ling
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Luis Furuya-Kanamori
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Patrick N A Harris
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute, Herston, Brisbane, Queensland, Australia
- Central Microbiology, Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - David L Paterson
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
- ADVANCE-ID, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Infectious Diseases Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| |
Collapse
|
3
|
Performance of the Reveal Rapid Antibiotic Susceptibility Testing System on Gram-Negative Blood Cultures at a Large Urban Hospital. J Clin Microbiol 2022; 60:e0009822. [PMID: 35607972 PMCID: PMC9199398 DOI: 10.1128/jcm.00098-22] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Timely and effective antibiotic treatment is vital for sepsis, with increasing incidence of antimicrobial-resistant bacteremia driving interest in rapid phenotypic susceptibility testing. To enable the widespread adoption needed to make an impact, antibiotic susceptibility testing (AST) systems need to be accurate, enable rapid intervention, have a broad antimicrobial menu and be easy to use and affordable. We evaluated the Specific Reveal (Specific Diagnostics, San Jose, CA) rapid AST system on positive blood cultures with Gram-negative organisms in a relatively resistant population in a large urban hospital to assess its potential for routine clinical use. One hundred four randomly selected positive blood cultures (Virtuo; bioMérieux) were Gram stained, diluted 1:1,000 in Pluronic water, inoculated into 96-well antibiotic plates, sealed with the Reveal sensor panel, and placed in the Reveal instrument for incubation and reading. The MIC and susceptible/intermediate/resistant category was determined and compared to results from Vitek 2 (bioMérieux) for the 17 antimicrobials available and to Sensititre (Thermo Fisher) for 24 antimicrobials. Performance was also assessed with contrived blood cultures with 33 highly resistant strains. Reveal was in 98.0% essential agreement (EA) and 96.3% categorical agreement (CA) with Sensititre, with just 1.3% very major error (VME) and 97.0%/96.2%/1.3% EA/CA/VME versus Vitek 2. Reveal results for contrived highly resistant strains were equivalent, with EA/CA/VME of 97.7%/95.2%/1.0% with CDC/FDA Antibiotic Resistance Isolate Bank references. Average time to result (TTR) for Reveal was 4.6 h. Sample preparation was relatively low skill and averaged 3 min. We conclude that the Reveal system enables accurate and rapid susceptibility testing of Gram-negative blood cultures.
Collapse
|
4
|
Schumann J, Johanns U, Ahmad-Nejad P, Ghebremedhin B, Woebker G. The Impact of the FilmArray-Based Detection of Microbial Pathogens from Positive Blood Culture Vials on the Time to Optimal Antimicrobial Regimen in Intensive Care Units of the Helios University Clinic Wuppertal, Germany. J Clin Med 2021; 10:jcm10245880. [PMID: 34945183 PMCID: PMC8704407 DOI: 10.3390/jcm10245880] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 11/16/2022] Open
Abstract
The role of empirical therapy and time to first effective treatment, including the antimicrobial stewardship program, are decisive in patients presenting with bloodstream infections (BSI). The FilmArray® Blood Culture Identification Panel (FA BCID 1.0) detects 24 bacterial and fungal pathogens as well as 3 resistance genes from positive blood cultures in approximately 70 min. In this paper, we evaluate the impact of the additional FA BCID analysis on the time to an optimal antimicrobial therapy and on the length of stay in the ICU, ICU mortality, and PCT level reduction. This retro-/prospective trial was conducted in BSI patients in the ICU at a German tertiary care hospital. A total of 179 individual patients with 200 episodes of BSI were included in the prospective intervention group, and 150 patients with 170 episodes of BSI in the retrospective control group. In the intervention group, BSI data were analyzed including the MALDI-TOF MS (matrix assisted laser desorption ionization time-of-flight mass spectrometry) and FA BCID results from January 2019 to August 2020; the data from the control group, including the MALDI-TOF results, were collected retrospectively from the year 2018. The effective and appropriate antimicrobial regimen occurred in a median of 17 hours earlier in the intervention versus control group (p = 0.071). Furthermore, changes in the antimicrobial regimens of the intervention group that did not immediately lead to an optimal therapy occurred significantly earlier by a median of 24 hours (p = 0.029). Surrogate markers, indicating an earlier recovery of the patients from the intervention group, such as length of stay at the ICU, duration of mechanical ventilation, or an earlier reduction in PCT level, were not significantly affected. However, mortality did not differ between the patient groups. A postulated reduction of the antimicrobial therapy, in those cases in which coagulase-negative Staphylococcus species were identified, did occur in the control group, but not in the intervention group (p = 0.041). The implementation of FA BCID into the laboratory workflow can improve patient care by optimizing antimicrobial regimen earlier in BSI patients as it provides rapid and accurate results for key pathogens associated with BSI, as well as important antimicrobial resistance markers, e.g., mecA or vanA.
Collapse
Affiliation(s)
- Jannik Schumann
- Center for Clinical and Translational Research (CCTR), Institute for Medical Laboratory Diagnostics, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany; (J.S.); (P.A.-N.); (B.G.)
| | - Ulrike Johanns
- Clinic for Intensive Care Medicine, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany;
| | - Parviz Ahmad-Nejad
- Center for Clinical and Translational Research (CCTR), Institute for Medical Laboratory Diagnostics, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany; (J.S.); (P.A.-N.); (B.G.)
| | - Beniam Ghebremedhin
- Center for Clinical and Translational Research (CCTR), Institute for Medical Laboratory Diagnostics, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany; (J.S.); (P.A.-N.); (B.G.)
| | - Gabriele Woebker
- Clinic for Intensive Care Medicine, Helios University Hospital Wuppertal, Witten/Herdecke University, 42283 Wuppertal, Germany;
- Correspondence: ; Tel.: +49-(0)-202-896-2720; Fax: +49-(0)-202-896-2718
| |
Collapse
|
5
|
New Microbiological Techniques for the Diagnosis of Bacterial Infections and Sepsis in ICU Including Point of Care. Curr Infect Dis Rep 2021; 23:12. [PMID: 34149321 PMCID: PMC8207499 DOI: 10.1007/s11908-021-00755-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 12/22/2022]
Abstract
Purpose of Review The aim of this article is to review current and emerging microbiological techniques that support the rapid diagnosis of bacterial infections in critically ill patients, including their performance, strengths and pitfalls, as well as available data evaluating their clinical impact. Recent Findings Bacterial infections and sepsis are responsible for significant morbidity and mortality in patients admitted to the intensive care unit and their management is further complicated by the increase in the global burden of antimicrobial resistance. In this setting, new diagnostic methods able to overcome the limits of traditional microbiology in terms of turn-around time and accuracy are highly warranted. We discuss the following broad themes: optimisation of existing culture-based methodologies, rapid antigen detection, nucleic acid detection (including multiplex PCR assays and microarrays), sepsis biomarkers, novel methods of pathogen detection (e.g. T2 magnetic resonance) and susceptibility testing (e.g. morphokinetic cellular analysis) and the application of direct metagenomics on clinical samples. The assessment of the host response through new “omics” technologies might also aid in early diagnosis of infections, as well as define non-infectious inflammatory states. Summary Despite being a promising field, there is still scarce evidence about the real-life impact of these assays on patient management. A common finding of available studies is that the performance of rapid diagnostic strategies highly depends on whether they are integrated within active antimicrobial stewardship programs. Assessing the impact of these emerging diagnostic methods through patient-centred clinical outcomes is a complex challenge for which large and well-designed studies are awaited.
Collapse
|
6
|
Savage TJ, Rao S, Joerger J, Ozonoff A, McAdam AJ, Sandora TJ. Predictive Value of Direct Disk Diffusion Testing from Positive Blood Cultures in a Children's Hospital and Its Utility in Antimicrobial Stewardship. J Clin Microbiol 2021; 59:e02445-20. [PMID: 33692138 PMCID: PMC8316030 DOI: 10.1128/jcm.02445-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 03/06/2021] [Indexed: 12/19/2022] Open
Abstract
Accurate and early susceptibility results could reduce overuse of broad-spectrum antibiotics for empirical treatment of bacteremia. Direct disk diffusion testing (dDD) using nonstandardized inocula directly from blood cultures could facilitate earlier narrowing of antibiotics. To determine the predictive value of dDD compared with standardized antimicrobial susceptibility testing (AST), we performed a retrospective cohort study of 582 blood cultures from 495 pediatric patients with bacteremia. Positive and negative predictive value (PPV: number of isolates susceptible by both dDD and AST divided by the total number of isolates susceptible by dDD; NPV: number of isolates not susceptible [either intermediate or resistant] by both dDD and AST divided by the total number of isolates not susceptible by dDD), sensitivity, specificity, and 95% confidence interval were calculated for each bacterium-antibiotic combination. We evaluated the Antibiotic Spectrum Index of prescribed antibiotics to assess change in antibiotic prescribing after availability of Gram stain, dDD, and AST results. dDD results were available a median of 21 h before AST results. dDD had PPVs of ≥96% for most organism-antibiotic pairs, including 100% (CI 96 to 100%) for Staphylococcus aureus with oxacillin and 99% (CI 93 to 100%) for Enterobacterales with ceftriaxone. NPVs of dDD were variable and frequently lower than the PPV. Very major errors and major errors occurred in 31/5,454 (0.6%) and 231/5,454 (4.2%) organism-antibiotic combinations, respectively. Antibiotics were narrowed in 30% of cases after a dDD result and a further 25% of cases after AST result. dDD is highly predictive of susceptibility for many common organism-antibiotic combinations and provides actionable information one day earlier than standard susceptibility approaches. dDD has the potential to facilitate earlier deescalation to narrow-spectrum antibiotic treatment.
Collapse
Affiliation(s)
- Timothy J Savage
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Shun Rao
- Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jill Joerger
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Al Ozonoff
- Precision Vaccines Program, Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Alexander J McAdam
- Department of Laboratory Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas J Sandora
- Division of Infectious Diseases, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
7
|
Hughes J, Barone S. Management of Pediatric Nonpathogenic Blood Cultures After Introduction of PCR Technology. Hosp Pediatr 2021; 11:472-477. [PMID: 33888510 DOI: 10.1542/hpeds.2020-000976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The rapid identification of organisms reported in positive blood cultures via polymerase chain reaction (PCR) can accurately identify a nonpathogenic bacterium and decrease time to definitive identification, as compared with traditional microbiologic methods. How this technology effects clinical and antimicrobial management in children with nonpathogenic bacteria identified in a blood culture without decision support has not been evaluated. METHODS A retrospective study of the management of children with positive blood culture results for nonpathogenic organisms before and after implementation of PCR technology. Each cohort's antibiotic management, frequency of repeat cultures, and return visits to an emergency department (ED) were compared. RESULTS A total 136 patients during this time (49% [n = 67] pre-PCR and 51% [n = 69] post-PCR) had a blood culture positive for nonpathogenic bacterium. Admitted patients had a second specimen sent for testing on fewer occasions (P = .04); however, total antibiotic exposure did not differ significantly (P = .3) after introduction of PCR technology. There was no significant difference in length of stay postintervention (P = .12). Patients discharged directly from the ED had fewer return visits (P = .02) and received fewer repeat blood cultures (P = .04), and antibiotics were administered on fewer occasions after return (P = .04) postintroduction of PCR technology. CONCLUSIONS With the addition of PCR technology, patients with blood cultures positive for nonpathogenic bacteria received less antibiotics, fewer repeat blood cultures, and fewer repeat ED evaluations.
Collapse
Affiliation(s)
- Julianne Hughes
- Cohen Children's Medical Center, New Hyde Park, New York; and
| | - Stephen Barone
- Cohen Children's Medical Center, New Hyde Park, New York; and.,Division of Hospitalist Medicine, Department of Pediatrics, Donald and Barbara Zucker School of Medicine, Hofstra University and Northwell Health, Hempstead, New York
| |
Collapse
|
8
|
Gawrys GW, Tun K, Jackson CB, Astorga B, Fetchick RJ, Septimus E, Lee GC. The impact of rapid diagnostic testing, surveillance software, and clinical pharmacist staffing at a large community hospital in the management of Gram-negative bloodstream infections. Diagn Microbiol Infect Dis 2020; 98:115084. [DOI: 10.1016/j.diagmicrobio.2020.115084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 12/13/2022]
|
9
|
Impact of a Rapid Blood Culture Diagnostic Test in a Children's Hospital Depends on Gram-Positive versus Gram-Negative Organism and Day versus Night Shift. J Clin Microbiol 2020; 58:JCM.01400-19. [PMID: 31852761 DOI: 10.1128/jcm.01400-19] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 12/11/2019] [Indexed: 12/22/2022] Open
Abstract
Rapid diagnostic tests (RDTs) for bloodstream infections (BSIs) decrease the time to organism identification and resistance detection. RDTs are associated with early deescalation of therapy for Gram-positive BSIs. However, it is less clear how RDTs influence antibiotic management for Gram-negative BSIs and whether RDT results are acted on during off-hours. We performed a single-center, retrospective review of children with BSI and Verigene (VG) testing at a children's hospital. Of the 301 positive cultures included in the study (196 Gram-positive, 44 Gram-negative, 32 polymicrobial, and 29 non-VG targets), the VG result had potential to impact antibiotic selection in 171 cases; among these, antibiotic changes occurred in 119 (70%) cases. For Gram-negative cultures, the Verigene result correlated with unnecessary antibiotic escalation and exposure to broader-spectrum antibiotics than needed. In contrast, for Gram-positive cultures, the VG results correlated with appropriate antibiotic selection. VG results permitted early deescalation for methicillin-susceptible Staphylococcus aureus (MSSA) (19/24 [79%]) and avoidance of antibiotics for skin contaminants (30/85 [35%]). Antibiotic changes occurred more quickly during the day than at night (4.6 versus 11.7 h, respectively; P < 0.05), and antibiotic escalations occurred more quickly than did deescalations (4.1 versus 10.1 h, P < 0.01). In a pediatric institution with a low prevalence of Gram-negative resistance, the VG RDT facilitated antibiotic optimization for Gram-positive BSIs but led to unnecessary escalation of antibiotics for Gram-negative BSIs. The time to action was slower for RDT results reported at night than during the day. Laboratories should consider these factors when implementing blood culture RDTs.
Collapse
|