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MacVane SH, Dwivedi HP. Evaluating the impact of rapid antimicrobial susceptibility testing for bloodstream infections: a review of actionability, antibiotic use and patient outcome metrics. J Antimicrob Chemother 2024; 79:i13-i25. [PMID: 39298359 PMCID: PMC11412245 DOI: 10.1093/jac/dkae282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2024] Open
Abstract
Antimicrobial susceptibility testing (AST) is a core function of the clinical microbiology laboratory and is critical to the management of patients with bloodstream infections (BSIs) to facilitate optimal antibiotic therapy selection. Recent technological advances have resulted in several rapid methods for determining susceptibility direct from positive blood culture that can provide turnaround times in under 8 h, which is considerably shorter than conventional culture-based methods. As diagnostic results do not directly produce a medical intervention, actionability is a primary determinant of the effect these technologies have on antibiotic use and ultimately patient outcomes. Randomized controlled trials and observational studies consistently show that rapid AST significantly reduces time to results and improves antimicrobial therapy for patients with BSI across various methods, patient populations and organisms. To date, the clinical impact of rapid AST has been demonstrated in some observational studies, but randomized controlled trials have not been sufficiently powered to validate many of these findings. This article reviews various metrics that have been described in the literature to measure the impact of rapid AST on actionability, antibiotic exposure and patient outcomes, as well as highlighting how implementation and workflow processes can affect these metrics.
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Affiliation(s)
- Shawn H MacVane
- Global Medical Affairs-Microbiology, bioMérieux, Inc., Hazelwood, MO, USA
| | - Hari P Dwivedi
- Global Medical Affairs-Microbiology, bioMérieux, Inc., Hazelwood, MO, USA
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Ventres JJ, Ting MH, Parente DM, Rogers R, Norris AM, Benitez G, Shehadeh F, Bobenchik AM, Mylonakis E, Chapin KC, Cunha CB. Combination of a Rapid Diagnostic Assay and Antimicrobial Stewardship Intervention for Gram-Negative Bacteremia. Open Forum Infect Dis 2024; 11:ofae477. [PMID: 39263216 PMCID: PMC11389609 DOI: 10.1093/ofid/ofae477] [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: 06/12/2024] [Accepted: 08/19/2024] [Indexed: 09/13/2024] Open
Abstract
Background Traditional blood cultures for gram-negative bacteremia can take up to 72 hours or more to return results, prolonging the duration of empiric broad-spectrum intravenous antibiotics. The Accelerate Pheno system provides rapid identification and susceptibilities for blood cultures in gram-negative bacteremia. Current data on its clinical utility are mixed overall, so the system requires further research. Methods A multicenter, retrospective quasi-experimental study was conducted comparing the Accelerate Pheno rapid diagnostic system with antimicrobial stewardship intervention and traditional blood cultures alone. Results A total of 264 patients with blood cultures with gram-negative bacteria growth were included in the final analysis (102 pre-intervention, 162 post-intervention). The antimicrobial stewardship team made 364 recommendations in 152/162 (93.8%) patients in the post group. Duration of intravenous therapy was shorter (P < .001) for the post-intervention group (median, 4.0 days) compared with the pre-intervention group (median, 7.5 days). Hospital length of stay was also shorter (P < .001) for the post-intervention group (median, 5.1 days) compared with the pre-intervention group (median, 7.0 days). Readmission rates within 30 days were reduced (P = .042) post-intervention (13.0%) compared with pre-intervention (22.6%). In the post-intervention group, a larger proportion of patients were transitioned to oral therapy at any point (126/162, 77.8%) compared with pre-intervention (62/102, 60.8%; P < .001). Conclusions These results suggest that the Accelerate Pheno system, with active review and intervention by a multidisciplinary antimicrobial stewardship team, is a useful tool in improving both patient-centric and antimicrobial stewardship outcomes.
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Affiliation(s)
- Julian J Ventres
- Department of Pharmacy, The Miriam Hospital, Providence, Rhode Island, USA
| | - Michelle H Ting
- Department of Pharmacy, Banner University Medical Center-Phoenix, Phoenix, Arizona, USA
| | - Diane M Parente
- Department of Pharmacy, The Miriam Hospital, Providence, Rhode Island, USA
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Ralph Rogers
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Ashlyn M Norris
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
- Department of Pharmacy, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Gregorio Benitez
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Fadi Shehadeh
- Department of Medicine, Houston Methodist Hospital, Houston, Texas, USA
| | - April M Bobenchik
- Clinical Pathology Division, Penn State Milton Hershey Medical Center, Hershey, Pennsylvania, USA
- Department of Pathology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | | | - Kimberle C Chapin
- Department of Pathology, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
- Deepull, Barcelona, Spain
| | - Cheston B Cunha
- Division of Infectious Diseases, Brown University, Warren Alpert Medical School, Providence, Rhode Island, USA
- Infectious Disease Division, Rhode Island Hospital and The Miriam Hospital, Providence, Rhode Island, USA
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Kremer AM, Bouchard JL, Orvin AI. Impact of Gram-Negative Rod Bacteremia Rapid Diagnostic Testing and Real-Time Clinical Pharmacist Intervention. J Pharm Pract 2024; 37:940-944. [PMID: 37864345 DOI: 10.1177/08971900231200900] [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: 10/22/2023]
Abstract
Background: The optimal method for implementing rapid diagnostic testing (RDT) into clinical practice has not been determined for gram-negative rod (GNR) bacteremia. At our institution, RDT was implemented in conjunction with real-time notification of results to decentralized clinical pharmacists. Objective: To determine the impact of RDT result notification plus real-time clinical pharmacist review on the management of GNR bacteremia. Methods: This retrospective, matched cohort study included patients with a positive blood culture for a GNR on the BIOFIRE® Blood Culture Identification 2 panel from September 2020 to August 2021 (historical) and October 2021 to September 2022 (interventional). Exclusion criteria were polymicrobial bacteremia, discrepant RDT results from traditional culture, 24-hour mortality, and comfort care or not admitted at the time of RDT result. Patients were matched based on age, pathogen, and resistance. The primary endpoint was time from Gram stain to appropriate antibiotic therapy. Results: This study consisted of 240 patients (n = 120 historical, n = 120 interventional). Escherichia coli was isolated in 71% of patients with extended-spectrum beta-lactamase-producing organisms isolated in 8%. There was no difference in median time to appropriate therapy (0 vs 0 hours, P = 0.28). There was a statistically significant decrease in time to first organism-directed change in therapy (40 vs 11 hours; P < 0.01). Length of stay, days of anti-pseudomonal therapy, and inpatient mortality did not differ between groups. Conclusion: Implementation of RDT plus real-time clinical pharmacist review did not significantly decrease time to appropriate therapy in patients with GNR bacteremia but significantly reduced time to organism-directed antibiotic changes.
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Affiliation(s)
- Abby M Kremer
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Jeannette L Bouchard
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, NC, USA
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Alison I Orvin
- Department of Pharmacy, WakeMed Health and Hospitals, Raleigh, NC, USA
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
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de Lorenzi-Tognon M, Schrenzel J. Simplified Spectrum Score (S 3) app for pathogen-agnostic antimicrobial drug spectrum ranking to assess for antimicrobial de-escalation events. Sci Rep 2024; 14:9776. [PMID: 38684841 PMCID: PMC11059348 DOI: 10.1038/s41598-024-60041-6] [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: 12/14/2023] [Accepted: 04/18/2024] [Indexed: 05/02/2024] Open
Abstract
Antimicrobial/antibiotic de-escalation (ADE) is a key feature of antimicrobial stewardship programs (ASP) that relies mainly on individual panels for determining ADE events based on subjective ranking of antibiotics' spectrum activity. The lack of consensus among ASP experts leads to reproducibility issues in the measure of this clinical outcome, making difficult to assess its real impact on patient care. The S3 score (Simplified Spectrum Score) app was developed to allow an objective ranking of antibiotics. Ranking was achieved by developing a database harboring pairs of bacteria-antibiotics for which each molecule was assigned a score based on published and clinically validated data from a recognized international committee. S3 score shows a strong correlation relationship and substantial agreement to a clinically validated spectrum score, and its framework enables any person to use it for ADE detection without assuming prior knowledge or training. In addition, its design enables regular updates and sustainability.
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Affiliation(s)
- Mikaël de Lorenzi-Tognon
- Bacteriology Laboratory, Division of Laboratory Medicine, Department of Diagnostics, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva 14, Switzerland.
- Genomic Research Laboratory, Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Jacques Schrenzel
- Bacteriology Laboratory, Division of Laboratory Medicine, Department of Diagnostics, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, 1211, Geneva 14, Switzerland
- Genomic Research Laboratory, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Division of Infectious Diseases, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
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Brosh-Nissimov T, Tzur A, Grupel D, Cahan A, Ma'aravi N, Heled-Akiva M, Jawamis H, Leskes H, Barenboim E, Sorek N. Clinical impact of the accelerate PhenoTest® BC system on patients with gram-negative bacteremia and high risk of antimicrobial resistance: a prospective before-after implementation study. Ann Clin Microbiol Antimicrob 2023; 22:62. [PMID: 37516885 PMCID: PMC10387206 DOI: 10.1186/s12941-023-00619-6] [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: 12/31/2022] [Accepted: 07/23/2023] [Indexed: 07/31/2023] Open
Abstract
BACKGROUND The Accelerate PhenoTest® BC system (AXDX) is a novel assay for rapid bacterial identification and antimicrobial susceptibility (AST). We report an evaluation of its impact on treatment of patients with Gram-negative bacteremia (GNB) with a high risk of antimicrobial resistance (AMR). METHODS A prospective single-center evaluation before and after implementation of AXDX in addition to standard-of-care (SOC) microbiology and antimicrobial stewardship program (ASP). Patients with GNB reported during laboratory working hours and prespecified risk factors for AMR were included. The primary outcome was an ASP-oriented beneficial antimicrobial change, defined as either an escalation of an inappropriate empiric treatment or de-escalation of a broad-spectrum treatment of a susceptible organism. Main secondary outcomes were time to an appropriate treatment, antimicrobial treatment duration, length of stay (LOS) and mortality. RESULTS Included were 46 and 57 patients in the pre- and post-intervention periods, respectively. The median time to an AST-oriented beneficial change was 29.2 h vs. 49.6 h, respectively (p < 0.0001). There were no significant differences in the time to appropriate treatment, LOS or mortality. Antimicrobial treatment duration was longer during the intervention period (10 vs. 8 days, p = 0.007). AXDX failed to correctly identify pathogens in all 6 cases of polymicrobial bacteremia. In two cases patient care was potentially compromised due to inappropriate de-escalation. CONCLUSIONS AXDX implementation resulted in a 20.4-hour shorter time to an ASP-oriented beneficial antimicrobial change. This should be weighed against the higher costs, the lack of other proven clinical benefits and the potential harm from mis-identification of polymicrobial bacteremias.
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Affiliation(s)
- Tal Brosh-Nissimov
- Samson Assuta Ashdod University Hospital, Harefua st. 7, Ashdod, 7747629, Israel.
- Faculty of Health Sciences, Ben Gurion University in the Negev, Be'er Sheva, Israel.
| | - Anka Tzur
- Samson Assuta Ashdod University Hospital, Harefua st. 7, Ashdod, 7747629, Israel
| | - Daniel Grupel
- Samson Assuta Ashdod University Hospital, Harefua st. 7, Ashdod, 7747629, Israel
- Faculty of Health Sciences, Ben Gurion University in the Negev, Be'er Sheva, Israel
| | - Amos Cahan
- Samson Assuta Ashdod University Hospital, Harefua st. 7, Ashdod, 7747629, Israel
| | - Nir Ma'aravi
- Samson Assuta Ashdod University Hospital, Harefua st. 7, Ashdod, 7747629, Israel
| | - Maya Heled-Akiva
- Samson Assuta Ashdod University Hospital, Harefua st. 7, Ashdod, 7747629, Israel
| | - Hasan Jawamis
- Samson Assuta Ashdod University Hospital, Harefua st. 7, Ashdod, 7747629, Israel
| | - Hanna Leskes
- Samson Assuta Ashdod University Hospital, Harefua st. 7, Ashdod, 7747629, Israel
| | - Erez Barenboim
- Samson Assuta Ashdod University Hospital, Harefua st. 7, Ashdod, 7747629, Israel
| | - Nadav Sorek
- Samson Assuta Ashdod University Hospital, Harefua st. 7, Ashdod, 7747629, Israel
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Ye D, Yang C, Ji W, Zheng J, Zhang J, Xue R, Gu J, Chen M, Yan K, Liu Y. Impact of the Expert Consensus on Carbapenem Consumption Trends and Patterns in Public Healthcare Institutes: An Interrupted Time Series Analysis, 2017-2020. Front Pharmacol 2022; 12:739960. [PMID: 35095482 PMCID: PMC8793738 DOI: 10.3389/fphar.2021.739960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/27/2021] [Indexed: 01/14/2023] Open
Abstract
Background: Carbapenems are considered the last line of defence against bacterial infections, but their high consumption and the resulting antibacterial resistance are an increasing global concern. In this context, the Chinese health authority issued an expert consensus on the clinical applications of carbapenems. However, the long- and short-term effects of the expert consensus on carbapenem use are not clear. Methods: This study was conducted in Shaanxi, a northwest province of China. We collected all available carbapenem procurement data between January 2017 and December 2020 from the Provincial Drug Centralized Bidding Procurement System. A quasi-experimental interrupted time series analysis was used to evaluate the longitudinal effectiveness of expert consensus by measuring the change in the Defined Daily Dosesper 1,000 inhabitants per day (DID), the percentage of carbapenem expenditures to total antimicrobial expenditure, the total carbapenem expenditure, and the defined daily cost (DDDc). We used Stata SE version 15.0 for data analysis, and p < 0.05 was considered statistically significant. Results: After the distribution of the expert consensus, the level (p = 0.769) and trend (p = 0.184) of DID decreased, but the differences were not statistically significant. The percentage of carbapenem expenditures to total antimicrobial expenditure decreased abruptly (p < 0.001) after the intervention, but the long-term trend was still upward. There was no statistically significant relationship between the release of the expert consensus and carbapenem expenditure in the long term, but there was a decreasing trend (p = 0.032). However, the expert consensus had a positive impact on the economic burden of carbapenem usage in patients, as the level (p < 0.001), and trend (p = 0.003) of DDDc significantly decreased. Conclusion: The long-term effects of the distribution of the expert consensus on the use and expenditure of carbapenems in public health institutions in Shaanxi Province were not optimal. It is time to set up more administrative measures and scientific supervision to establish a specific index to limit the application of carbapenems.
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Affiliation(s)
- Dan Ye
- Department of Pharmacy, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China.,Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Northwest University, Xi'an, China
| | - Caijun Yang
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Wenjing Ji
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmacy, Xi'an Jiaotong University, Xi'an, China
| | - Jie Zheng
- Department of Pharmacy, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China.,Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Northwest University, Xi'an, China
| | - Jingyi Zhang
- Department of Pharmacy, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China.,Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Northwest University, Xi'an, China
| | - Runqing Xue
- Department of Pharmacy, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China.,Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Northwest University, Xi'an, China
| | - Jianli Gu
- Department of Pharmacy, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China.,Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Northwest University, Xi'an, China
| | - Minchun Chen
- Department of Pharmacy, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China.,Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Northwest University, Xi'an, China
| | - Kangkang Yan
- Department of Pharmacy, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China.,Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Northwest University, Xi'an, China
| | - Yongzhong Liu
- Department of Pharmacy, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, China.,Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Northwest University, Xi'an, China
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Systematic Evaluation of the Accelerate Pheno System for Susceptibility Testing of Gram-Negative Bacteria Isolated from Blood Cultures. Microbiol Spectr 2021; 9:e0183621. [PMID: 34937177 PMCID: PMC8694102 DOI: 10.1128/spectrum.01836-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Bacteremia is a major cause of morbidity and mortality. Rapid identification of pathogens for early targeted antimicrobial therapy is crucial for detecting emergence of antibiotic resistance and improving outcomes. However, there are limited data regarding the analytical performance of a rapid identification (ID) and antimicrobial susceptibility testing (AST) method like Accelerate Pheno blood culture detection system compared with the conventional methods routinely used in microbiology laboratories. We undertook a systematic quality improvement (QI) study to compare AST results obtained with Accelerate Pheno system rapid ID/AST system with a standard reference method in a university hospital microbiology laboratory. This was a single center, retrospective (5/10/19 to 8/1/19) and prospective (8/1/19 to 1/31/20) study that evaluated all blood cultures growing Gram-negative rods (GNR). We compared AST results obtained using the reference disk diffusion (DD) susceptibility method with those obtained by the Accelerate Pheno system. We calculated the error rates and categorical agreement between the Accelerate Pheno system and DD for each organism and specific drug tested. We evaluated 355 blood cultures growing GNR, of which 284 met the inclusion criteria. We grouped all Enterobacterales (n = 263) for analysis (156 Escherichiacoli, 60 Klebsiella spp., 20 Proteus mirabilis, 17 Enterobacter spp., and 10 Serratiamarcescens). Twenty-one Pseudomonasaeruginosa isolates were analyzed separately. For Enterobacterales, categorical agreement (CA) was ≥90% for amikacin (AMK), aztreonam (ATM), cefepime (FEP), ceftriaxone (CRO), ertapenem (ETP), gentamicin (GEN), meropenem (MEM), and tobramycin (TOB); and very major error (VME) was <5% for ampicillin/sulbactam (SAM), GEN, MEM, TOB, CRO, and ceftazidime (CAZ). For ciprofloxacin (CIP), CA was 87% and VME was 8%. For P. aeruginosa, CA was ≥90% for AMK and TOB, and VME was ≥5% for AMK, CAZ, GEN, MEM, piperacillin-tazobactam (TZP), and TOB. Accelerate Pheno rapid ID/AST system for GNR isolated from blood culture (BCs) was reliable for some but not all agents in the panel. Based on the findings from this study, our laboratory reports Accelerate Pheno system AST results only for Enterobacterales, and we limit our reports to CRO, CAZ, TZP, CIP, ATM, and GEN. IMPORTANCE This was an 8-month retrospective and prospective study looking at the analytical performance of the Accelerate Pheno system on clinical isolates obtained from patients seen in our tertiary care hospital. Most of the published literature on the analytical performance of Accelerate Pheno System has been from clinical trials with limited data from clinical microbiology laboratories postimplementation of the system. Here we compare the AST results on 355 blood cultures growing Gram-negative bacteria in Accelerate Pheno system with the CLSI reference disk diffusion (DD) method. The findings from this study highlight the “real-world” performance of the Accelerate Pheno system for Gram-negative bacteria from blood cultures. We provide data to show the reliable susceptibility testing results of Enterobacterales for most of the commonly used antimicrobial agents and significant limitation for susceptibility testing results of Pseudomonas aeruginosa on the Accelerate Pheno system.
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Sze DTT, Lau CCY, Chan TM, Ma ESK, Tang BSF. Comparison of novel rapid diagnostic of blood culture identification and antimicrobial susceptibility testing by Accelerate Pheno system and BioFire FilmArray Blood Culture Identification and BioFire FilmArray Blood Culture Identification 2 panels. BMC Microbiol 2021; 21:350. [PMID: 34922463 PMCID: PMC8684256 DOI: 10.1186/s12866-021-02403-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 11/25/2021] [Indexed: 12/25/2022] Open
Abstract
Background
Conventional turnaround time (TAT) for positive blood culture (PBC) identification (ID) and antimicrobial susceptibility testing (AST) is 2–3 days. We evaluated the TAT and ID/AST performance using clinical and seeded samples directly from PBC bottles with different commercial approaches: (1) Accelerate Pheno® system (Pheno) for ID/AST; (2) BioFire® FilmArray® Blood Culture Identification (BCID) Panel and/ or BCID2 for ID; (3) direct AST by VITEK® 2 (direct AST); and (4) overnight culture using VITEK® 2 colony AST. Results
A total of 141 PBC samples were included in this evaluation. Using MALDI-TOF (Bruker MALDI Biotyper) as the reference method for ID, the overall monomicrobial ID sensitivity/specificity are as follows: Pheno 97.9/99.9%; BCID 100/100%; and BCID2 100/100%, respectively. For AST performance, broth microdilution (BMD) was used as the reference method. For gram-negatives, overall categorical and essential agreements (CA/EA) for each method were: Pheno 90.3/93.2%; direct AST 92.6/88.5%; colony AST 94.4/89.5%, respectively. For gram-positives, the overall CA/EAs were as follows: Pheno 97.2/98.89%; direct AST 97.2/100%; colony AST 97.2/100%, respectively. The BCID/BCID2 and direct AST TATs were around 9–20 h (1/9-19 h for ID with resistance markers/AST), with 15 min/sample hands-on time. In comparison, Pheno TATs were around 8–10 h (1.5/7 h for ID/AST) with 2 min/sample hands-on time, maintains a clinically relevant fast report of antibiotic minimal inhibitory concentration (MIC) and allows for less TAT and hands-on time. Conclusion In conclusion, to the best of our knowledge, this is the first study conducted as such in Asia; all studied approaches achieved satisfactory performance, factors such as TAT, panel of antibiotics choices and hands-on time should be considered for the selection of appropriate rapid ID and AST of PBC methods in different laboratory settings. Supplementary Information The online version contains supplementary material available at 10.1186/s12866-021-02403-y.
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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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Bhalodi AA, MacVane SH, Ford B, Ince D, Kinn PM, Percival KM, Bremmer DN, Carr DR, Walsh TL, Bhatti MM, Shelburne SA, Humphries RM, Wolfe K, Rosenbaum ER, Dare RK, Kolev J, Madhusudhan M, Ben-Aderet MA, Morgan MA. Real-World Impact of the Accelerate PhenoTest ® BC Kit on patients with bloodstream infections in IOAS (Improving Outcomes and Antimicrobial Stewardship): A Quasi-Experimental Multicenter Study. Clin Infect Dis 2021; 75:269-277. [PMID: 34718456 PMCID: PMC9410719 DOI: 10.1093/cid/ciab921] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Bloodstream infections (BSI) are a leading cause of morbidity and mortality in hospitalized patients. The IOAS (Improving Outcomes and Antimicrobial Stewardship) study seeks to evaluate the impact of the Accelerate PhenoTest® BC Kit (AXDX) on antimicrobial use and clinical outcomes in BSIs. METHODS This multicenter, quasi-experimental study compared clinical and antimicrobial stewardship metrics, prior to and after implementation of AXDX testing, to evaluate the impact this technology has on patients with BSI. Laboratory and clinical data from hospitalized patients with BSI (excluding contaminants) were compared between two arms, one that underwent testing on AXDX (post-AXDX) and one that underwent alternative organism identification and susceptibility testing (pre-AXDX). The primary outcomes were time to optimal therapy (TTOT) within 96 hours of blood culture positivity and 30-day mortality. RESULTS A total of 854 patients with BSI (435 pre-AXDX, 419 post-AXDX) were included. Median TTOT was 17.2 hours shorter in the post-AXDX arm (23.7 hours) compared to the pre-AXDX arm (40.9 hours; P<0.0001). Compared with pre-AXDX, median time to first antimicrobial modification (24.2 versus 13.9 hours; P<0.0001) and first antimicrobial de-escalation (36.0 versus 27.2 hours; P=0.0004) were shorter in the post-AXDX arm. Mortality (8.7% pre-AXDX versus 6.0% post-AXDX), length of stay (7.0 pre-AXDX versus 6.5 days post-AXDX), and adverse drug events were not significantly different between arms. Length of stay was shorter in the post-AXDX arm (5.4 versus 6.4 days; P=0.03) among patients with Gram-negative bacteremia. CONCLUSIONS For BSIs, use of AXDX was associated with significant decreases in TTOT, first antimicrobial modification, and time to antimicrobial de-escalation.
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Affiliation(s)
| | | | - Bradley Ford
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Dilek Ince
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Patrick M Kinn
- University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Derek N Bremmer
- Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Dustin R Carr
- Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Thomas L Walsh
- Allegheny Health Network, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | | | | | - Kaleb Wolfe
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Eric R Rosenbaum
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ryan K Dare
- University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Johann Kolev
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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MacVane SH, Bhalodi AA, Dare RK, Rosenbaum ER, Wolfe K, Ford B, Ince D, Kinn P, Percival KM, Humphries RM. Improving outcomes and antibiotic stewardship (IOAS) for patients with Gram-positive bloodstream infections through use of rapid testing: a quasi-experimental multicentre study of the Accelerate PhenoTest™ BC Kit. J Antimicrob Chemother 2021; 76:2453-2463. [PMID: 34021752 PMCID: PMC8361360 DOI: 10.1093/jac/dkab165] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 04/26/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Data from the Improving Outcomes and Antibiotic Stewardship for Patients with Bloodstream Infections: Accelerate PhenoTest™ BC Kit (AXDX) Registry Study were analysed to determine the impact of rapid organism identification and antimicrobial susceptibility testing (AST) for Gram-positive bacteraemia. PATIENTS AND METHODS This multicentre, quasi-experimental study evaluated clinical and antimicrobial stewardship metrics following the implementation of AXDX. Data from hospitalized patients with bacteraemia were compared between groups, one that underwent testing on AXDX (post-AXDX) and one that underwent traditional identification and AST (pre-AXDX). An analysis of patients with Gram-positive bacteraemia was performed. The primary outcome was time to optimal therapy (TTOT). Secondary outcomes included time to first antibiotic modification (overall and Gram-positive), duration of unnecessary MRSA coverage, incidence of adverse events, length of stay and mortality. RESULTS A total of 219 (109 pre-AXDX, 110 post-AXDX) patients with Gram-positive bacteraemia were included. Median TTOT was 36.3 h (IQR, 16.9-56.7) in the pre-AXDX group and 20.4 h (IQR, 7.5-36.7) in the post-AXDX group (P = 0.01). Compared with pre-AXDX, median time to first antibiotic modification (29.1 versus 15.9 h; P = 0.002), time to first Gram-positive antibiotic modification (33.2 versus 17.2 h; P = 0.003) and median duration of unnecessary MRSA coverage (58.4 versus 29.7 h; P = 0.04) were reduced post-AXDX. A trend towards decreased acute kidney injury (24% versus 13%; P = 0.06) was observed in the post-AXDX group. Groups did not differ in other secondary outcomes. CONCLUSIONS Implementation of AXDX testing for patients with Gram-positive bacteraemia shortened the TTOT and reduced unnecessary antibiotic exposure due to faster antibiotic modifications.
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Affiliation(s)
| | | | - Ryan K Dare
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Eric R Rosenbaum
- Department of Pathology and Laboratory Services, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kaleb Wolfe
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Bradley Ford
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Dilek Ince
- Division of Infectious Diseases, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Patrick Kinn
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Kelly M Percival
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Romney M Humphries
- Accelerate Diagnostics, Inc, Tucson, AZ, USA.,Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
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Impact of Accelerate Pheno and BacT/Alert Virtuo on Clinical Processes and Outcomes in Patients with Sepsis and Concurrent Gram-Negative Bacteremia. Antimicrob Agents Chemother 2021; 65:AAC.02364-20. [PMID: 33753337 DOI: 10.1128/aac.02364-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 03/14/2021] [Indexed: 12/14/2022] Open
Abstract
The Accelerate Pheno and BacT/Alert Virtuo systems may improve bacteremia management. Here, we evaluated the impact of both devices on outcomes in patients with sepsis and concurrent Gram-negative bacteremia. This quasiexperimental study included a retrospective preimplementation and a prospective postimplementation group. Patients ≥18 years old with Gram-negative bacteremia were included. Patients with neutropenia, pregnant patients, those who were transferred from an outside hospital with active bloodstream infections, and those with polymicrobial bacteremia were excluded. Blood culture incubation in the BacT/Alert 3D device and microdilution antimicrobial susceptibility testing from culture plate growth were used prior to implementation of the BacT/Alert Virtuo and Accelerate Pheno systems. Matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) identification directly from blood culture was used pre- and postimplementation. Time to Gram stain results, identification, susceptibility reporting, initiation of narrow-spectrum Gram-negative therapy at 72 h, 30-day inpatient mortality, sepsis resolution, and length of hospital stay were evaluated. A total of 116 patients were included (63 preimplementation, 53 postimplementation). Median times to Gram stain and susceptibility results were significantly shorter postimplementation (P < 0.001). The postimplementation group had an improved hazard ratio for narrow-spectrum Gram-negative therapy at 72 h (hazard ratio [HR], 2.685 [95% confidence interval {CI}, 1.348 to 5.349]), a reduced hazard ratio for 30-day inpatient mortality (adjusted HR [aHR], 0.150 [95% CI, 0.026 to 0.846]), and improved sepsis resolution (92.5% versus 77.8% [P = 0.030]). The length of hospital stay was unchanged after implementation. We conclude that implementation of the BacT/Alert Virtuo and Accelerate Pheno systems improved microbiology laboratory processes, antibiotic utilization processes, and clinical outcomes. These data support the use of rapid diagnostics in sepsis with concurrent Gram-negative bacteremia.
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