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Freedman SB, van de Kar NCAJ, Tarr PI. Shiga Toxin-Producing Escherichia coli and the Hemolytic-Uremic Syndrome. N Engl J Med 2023; 389:1402-1414. [PMID: 37819955 DOI: 10.1056/nejmra2108739] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Affiliation(s)
- Stephen B Freedman
- From the Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (S.B.F.); the Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands (N.C.A.J.K.); and the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and the Department of Molecular Microbiology, Washington University School of Medicine, St. Louis (P.I.T.)
| | - Nicole C A J van de Kar
- From the Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (S.B.F.); the Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands (N.C.A.J.K.); and the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and the Department of Molecular Microbiology, Washington University School of Medicine, St. Louis (P.I.T.)
| | - Phillip I Tarr
- From the Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada (S.B.F.); the Department of Pediatric Nephrology, Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands (N.C.A.J.K.); and the Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, and the Department of Molecular Microbiology, Washington University School of Medicine, St. Louis (P.I.T.)
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Xie J, Kim K, Berenger BM, Chui L, Vanderkooi OG, Grisaru S, Freedman SB. Comparison of a Rapid Multiplex Gastrointestinal Panel with Standard Laboratory Testing in the Management of Children with Hematochezia in a Pediatric Emergency Department: Randomized Controlled Trial. Microbiol Spectr 2023; 11:e0026823. [PMID: 37039648 PMCID: PMC10269456 DOI: 10.1128/spectrum.00268-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/10/2023] [Indexed: 04/12/2023] Open
Abstract
Advances in diagnostic microbiology allow for the rapid identification of a broad range of enteropathogens; such knowledge can inform care and reduce testing. We conducted a randomized, unblinded trial in a tertiary-care pediatric emergency department. Participants had stool (and rectal swabs if stool was not immediately available) tested using routine microbiologic approaches or by use of a device (BioFire FilmArray gastrointestinal panel), which identifies 22 pathogens with a 1-h instrument turnaround time. Participants were 6 months to <18.0 years and had acute bloody diarrhea. Primary outcome was performance of blood tests within 72 h. From 15 June 2018 through 7 May 2022, 60 children were randomized. Patients in the BioFire FilmArray arm had a reduced time to test result (median 3.0 h with interquartile range [IQR] of 3.0 to 4.0 h, versus 42.0 h (IQR 23.5 to 47.3 h); difference of -38.0 h, 95% confidence interval [CI] of -41.0 to -22.0 h). Sixty-five percent (20/31) of participants in the BioFire FilmArray group had a pathogen detected-most frequently enteropathogenic Escherichia coli (19%), Campylobacter (16%), and Salmonella (13%). Blood tests were performed in 52% of children in the BioFire FilmArray group and 62% in the standard-of-care group (difference of -10.5%, 95% CI of -35.4% to 14.5%). There were no between-group differences in the proportions of children administered intravenous fluids, antibiotics, hospitalized, or who had diagnostic imaging performed. Testing with the BioFire FilmArray reduced the time to result availability by 38 h. Although statistical significance was limited by study power, BioFire FilmArray use was not associated with clinically meaningful reductions in health care utilization or improved outcomes. IMPORTANCE Advances in diagnostic microbiology now allow for the faster and more accurate detection of an increasing number of pathogens. We determined, however, that in children with acute bloody diarrhea, these advances did not necessarily translate into improved clinical outcomes. While a greater number of pathogens was identified using a rapid turnaround multiplex stool diagnostic panel, with a reduction in the time to stool test result of over 1.5 days, this did not alter the practice of pediatric emergency medicine physicians, who continued to perform blood tests on a large proportion of children. While our conclusions may be limited by the relatively small sample size, targeted approaches that educate clinicians on the implementation of such technology into clinical care will be needed to optimize usage and maximize benefits.
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Affiliation(s)
- Jianling Xie
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly Kim
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Byron M. Berenger
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
| | - Linda Chui
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Alberta Precision Laboratories, Alberta Health Services, Edmonton, Alberta, Canada
| | - Otto G. Vanderkooi
- Section of Infectious Diseases, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Silviu Grisaru
- Section of Pediatric Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B. Freedman
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Section of Pediatric Gastroenterology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Sova C, Lewis SS, Smith BA, Reynolds S. Multi-faceted strategies improve collection compliance and sample acceptance rate for carbapenem-resistant Enterobacteriaceae (CRE) active surveillance testing. Am J Infect Control 2021; 49:1043-1047. [PMID: 33556392 DOI: 10.1016/j.ajic.2021.01.021] [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: 01/19/2021] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Active surveillance testing (AST) is one element of a comprehensive Carbapenem-resistant Enterobacteriaceae (CRE) prevention strategy. However, the utility of AST may be impacted by compliance with sample collection and the quality of specimens. Here, we describe strategies used to optimize a CRE AST program at a large academic medical center. METHODS Tests ordered, collected, rejected, and processed were tracked weekly for each participating unit. Sample collection compliance and acceptance rates were calculated and tracked weekly. Strategies were implemented to improve collection compliance and sample acceptance rates, including computerized provider order entry, printed educational materials, and audit and feedback. Weekly dedicated Infection Preventionist (IP) time was estimated. RESULTS Over 35 months, mean collection compliance increased from 82.7% to 91.2%, and then decreased to 86.2%. Over 27 months, sample acceptance rate increased from 57.7% to 83.6%, and then remained stable at 83.4%. Over 39 months, dedicated weekly IP time decreased 92%. DISCUSSION Use of evidence-based quality improvement strategies optimized our CRE AST program. Optimizing the AST process aids in early CRE detection, leading to timely isolation and preventing the spread of CRE to other patients. Other hospitals may benefit from these lessons and enhance local AST programs.
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Bhavanam S, Freedman SB, Lee BE, Zhuo R, Qiu Y, Chui L, Xie J, Ali S, Vanderkooi OG, Pang XL. Differences in Illness Severity among Circulating Norovirus Genotypes in a Large Pediatric Cohort with Acute Gastroenteritis. Microorganisms 2020; 8:E1873. [PMID: 33256234 PMCID: PMC7760397 DOI: 10.3390/microorganisms8121873] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022] Open
Abstract
Norovirus is a major pathogen identified in children with acute gastroenteritis (AGE), little is known about the strain's diversity and their clinical severity. Stool and/or rectal swabs were collected from children ≤18 years of age recruited at emergency departments (ED), and a provincial nursing advice phone line due to AGE symptoms in the province of Alberta, Canada between December 2014 and August 2018. Specimens were tested using a reverse transcription real time PCR and genotyped by Sanger sequencing. The Modified Vesikari Scale score (MVS) was used to evaluate the disease severity. The objectives are to identify the Genogroup and Genotype distribution and to compare illness severity between the GI and GII genogroups and to complete further analyses comparing the GII genotypes identified. GII.4 was the genotype most commonly identified. Children with GII.4 had higher MVS scores (12.0 (10.0, 14.0; p = 0.002)) and more prolonged diarrheal (5 days (3.0, 7.8)) and vomiting (3.2 days (1.7, 5.3; p < 0.001)) durations compared to other non GII.4 strains. The predominant strain varied by year with GII.4 Sydney[P31] predominant in 2014/15, GII.4 Sydney[P16] in 2015/16 and 2017/18, and GII.3[P12] in 2016/17. Genogroup II norovirus strains predominated in children with AGE with variance between years; clinical severity associated with different strains varied with episodes being most severe among GII.4 infected children.
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Affiliation(s)
- Sudha Bhavanam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (S.B.); (R.Z.); (Y.Q.); (L.C.)
| | - Stephen B. Freedman
- Divisions of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T3B 6A8, Canada;
| | - Bonita E. Lee
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children’s Health Research Institute, Stollery Children’s Hospital, University of Alberta, Edmonton, AB T6G 2R3, Canada; (B.E.L.); (S.A.)
| | - Ran Zhuo
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (S.B.); (R.Z.); (Y.Q.); (L.C.)
| | - Yuanyuan Qiu
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (S.B.); (R.Z.); (Y.Q.); (L.C.)
| | - Linda Chui
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (S.B.); (R.Z.); (Y.Q.); (L.C.)
- Public Health Laboratories (ProvLab), Alberta Precision Laboratories (APL), Edmonton, AB T6G 2J2, Canada
| | - Jianling Xie
- Departments of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T3B 6A8, Canada;
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children’s Health Research Institute, Stollery Children’s Hospital, University of Alberta, Edmonton, AB T6G 2R3, Canada; (B.E.L.); (S.A.)
| | - Otto G. Vanderkooi
- Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology & Laboratory Medicine and Community Health Sciences, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T3B 6A8, Canada;
| | - Xiaoli L. Pang
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (S.B.); (R.Z.); (Y.Q.); (L.C.)
- Public Health Laboratories (ProvLab), Alberta Precision Laboratories (APL), Edmonton, AB T6G 2J2, Canada
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Maasch JRMA, Arzika AM, Cook C, Lebas E, Pilotte N, Grant JR, Williams SA, Keenan JD, Lietman TM, Aiemjoy K. Rectal Swabs as an Alternative Sample Collection Method to Bulk Stool for the Real-Time PCR Detection of Giardia duodenalis. Am J Trop Med Hyg 2020; 103:1276-1282. [PMID: 32524959 PMCID: PMC7470573 DOI: 10.4269/ajtmh.19-0909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 05/02/2020] [Indexed: 12/19/2022] Open
Abstract
Though bulk stool remains the gold standard specimen type for enteropathogen diagnosis, rectal swabs may offer comparable sensitivity with greater ease of collection for select pathogens. This study sought to evaluate the validity and reproducibility of rectal swabs as a sample collection method for the molecular diagnosis of Giardia duodenalis. Paired rectal swab and bulk stool samples were collected from 86 children ages 0-4 years living in southwest Niger, with duplicate samples collected among a subset of 50 children. Infection was detected using a previously validated real-time PCR diagnostic targeting the small subunit ribosomal RNA gene. Giardia duodenalis was detected in 65.5% (55/84) of bulk stool samples and 44.0% (37/84) of swab samples. The kappa evaluating test agreement was 0.81 (95% CI: 0.54-1.00) among duplicate stool samples (N = 49) and 0.75 (95% CI: 0.47-1.00) among duplicate rectal swabs (N = 48). Diagnostic sensitivity was 93% (95% CI: 84-98) by bulk stool and 63% (95% CI: 49-75) by rectal swabs. When restricting to the lowest three quartiles of bulk stool quantitation cycle values (an indication of relatively high parasite load), sensitivity by rectal swabs increased to 78.0% (95% CI: 64-89, P < 0.0001). These findings suggest that rectal swabs provide less sensitive and reproducible results than bulk stool for the real-time PCR diagnosis of G. duodenalis. However, their fair sensitivity for higher parasite loads suggests that swabs may be a useful tool for detecting higher burden infections when stool collection is excessively expensive or logistically challenging.
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Affiliation(s)
| | | | - Catherine Cook
- Proctor Foundation, University of California San Francisco, San Francisco, California
| | - Elodie Lebas
- Proctor Foundation, University of California San Francisco, San Francisco, California
| | - Nils Pilotte
- Department of Biological Sciences, Smith College, Northampton, Massachusetts
- Molecular and Cellular Biology Program, University of Massachusetts, Amherst, Massachusetts
| | - Jessica R. Grant
- Department of Biological Sciences, Smith College, Northampton, Massachusetts
| | - Steven A. Williams
- Department of Biological Sciences, Smith College, Northampton, Massachusetts
- Molecular and Cellular Biology Program, University of Massachusetts, Amherst, Massachusetts
| | - Jeremy D. Keenan
- Proctor Foundation, University of California San Francisco, San Francisco, California
| | - Thomas M. Lietman
- Proctor Foundation, University of California San Francisco, San Francisco, California
| | - Kristen Aiemjoy
- Proctor Foundation, University of California San Francisco, San Francisco, California
- Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
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Evaluation of the FecalSwab for Stool Specimen Storage and Molecular Detection of Enteropathogens on the BD Max System. J Clin Microbiol 2020; 58:JCM.00178-20. [PMID: 32461284 PMCID: PMC7448620 DOI: 10.1128/jcm.00178-20] [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] [Received: 02/09/2020] [Accepted: 05/21/2020] [Indexed: 12/30/2022] Open
Abstract
The FecalSwab system (Copan Italia, Brescia, Italy) is a convenient alternative to bulk stool for the diagnosis of enteric pathogens. Although the U.S. Food and Drug Administration (FDA) approved for transport and culture of enteric bacterial pathogens, the FecalSwab has not been well assessed for its suitability with molecular platforms. In this study, we evaluated the FecalSwab as a specimen type for the BD Max system using the viral and bacterial enteric panels (BD Diagnostics, Baltimore, MD, USA). A total of 186 unpreserved stool specimens were collected and used to prepare matched bulk stool and FecalSwab samples. Performance was equivalent (P > 0.48) to bulk stool for all targets when 50 μl of FecalSwab specimen was loaded onto the BD Max assays. As stool specimens are often collected off-site from the clinical microbiology laboratory and require transport, we assessed the stability of stool specimens stored for up to 14 days at 4°C, 22°C, or 35°C to account for varying transportation conditions. Molecular detection for the majority of viral targets (excluding astrovirus) was unaffected (change in cycle threshold [ΔCT ] ≤ 1) by sample storage temperature over the 2-week period; however, detection of enteric bacteria was variable if specimens were not refrigerated (22°C or 35°C). By demonstrating equivalent performance to matched bulk stool and maintaining molecular detection sensitivity when stored at 4°C, we suggest that the FecalSwab is a suitable specimen type for enteropathogen diagnostics on the BD Max system.
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A prospective comparative study of children with gastroenteritis: emergency department compared with symptomatic care at home. Eur J Clin Microbiol Infect Dis 2019; 38:2371-2379. [PMID: 31502119 DOI: 10.1007/s10096-019-03688-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 08/26/2019] [Indexed: 12/20/2022]
Abstract
Little is known about the epidemiology and severity of gastroenteritis among children treated at home. We sought to compare illness severity and etiology between children brought for emergency department (ED) care to those managed at home (i.e., community). Prospective cohort study of children enrolled between December 2014 and December 2016 in two pediatric EDs in Alberta, Canada along with children treated at home after telephone triage (i.e., community). Primary outcomes were maximal frequency of vomiting and diarrhea in the 24-h pre-enrollment period; secondary outcomes included etiologic pathogens, dehydration severity, future healthcare visits, and treatments provided. A total of 1613 patients (1317 ED, 296 community) were enrolled. Median maximal frequency of vomiting was higher in the ED cohort (5 (3, 10) vs. 5 (2, 8); P < 0.001). Proportion of children with diarrhea and its 24-h median frequency were lower in the ED cohort (61.3 vs. 82.8% and 2 (0, 6) vs. 4 (1, 7); P < 0.001, respectively). In regression analysis, the ED cohort had a higher maximum number of vomiting episodes pre-enrollment (incident rate ratio (IRR) 1.25; 95% CI 1.12, 1.40) while the community cohort had higher maximal 24-h period diarrheal episodes (IRR 1.20; 95% CI 1.01, 1.43). Norovirus was identified more frequently in the community cohort (36.8% vs. 23.6%; P < 0.001). Children treated in the ED have a greater number of vomiting episodes; those treated at home have more diarrheal episodes. Norovirus is more common among children treated symptomatically at home and thus may represent a greater burden of disease than previously thought.
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