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Berry GJ, Jhaveri TA, Larkin PMK, Mostafa H, Babady NE. ADLM Guidance Document on Laboratory Diagnosis of Respiratory Viruses. J Appl Lab Med 2024; 9:599-628. [PMID: 38695489 DOI: 10.1093/jalm/jfae010] [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] [Received: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 06/06/2024]
Abstract
Respiratory viral infections are among the most frequent infections experienced worldwide. The COVID-19 pandemic has highlighted the need for testing and currently several tests are available for the detection of a wide range of viruses. These tests vary widely in terms of the number of viral pathogens included, viral markers targeted, regulatory status, and turnaround time to results, as well as their analytical and clinical performance. Given these many variables, selection and interpretation of testing requires thoughtful consideration. The current guidance document is the authors' expert opinion based on the preponderance of available evidence to address key questions related to best practices for laboratory diagnosis of respiratory viral infections including who to test, when to test, and what tests to use. An algorithm is proposed to help laboratories decide on the most appropriate tests to use for the diagnosis of respiratory viral infections.
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Affiliation(s)
- Gregory J Berry
- Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian-Columbia University Irving Medical Center, New York, NY, United States
| | - Tulip A Jhaveri
- Department of Internal Medicine, Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, MS, United States
| | - Paige M K Larkin
- University of Chicago Pritzker School of Medicine, NorthShore University Health System, Chicago, IL, United States
| | - Heba Mostafa
- Johns Hopkins School of Medicine, Department of Pathology, Baltimore, MD, United States
| | - N Esther Babady
- Clinical Microbiology and Infectious Disease Services, Department of Pathology and Laboratory Medicine and Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States
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2
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Otto C, Chen D. Point of Care Molecular Testing: Current State and Opportunities for Diagnostic Stewardship. Clin Lab Med 2024; 44:23-32. [PMID: 38280795 DOI: 10.1016/j.cll.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Inappropriate ordering practices, either under or over ordering of diagnostic tests, are recognized problems with possible negative downstream consequences. As the menu of clinical tests, especially molecular tests grows, it is becoming increasingly important to provide guidance to providers on the appropriate utilization. Diagnostic stewardship programs have been established at many institutions to help direct the appropriate utilization of laboratory testing to ultimately guide patient management and treatment decisions. Many molecular tests have now received Clinical Laboratory Improvement Amendments (CLIA)-waived status for use in a point-of-care (POC) setting; however, parallel diagnostic stewardship programs have not been established to help guide providers on how best to use these tests. In this article, we will discuss the available molecular POC tests and opportunities and challenges for establishing diagnostic stewardship programs for molecular testing performed in the POC setting.
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Affiliation(s)
- Caitlin Otto
- Department of Pathology, New York University Langone Health, 560 1st Avenue, New York, NY 10016, USA.
| | - Dan Chen
- Department of Pathology, New York University Langone Health, 560 1st Avenue, New York, NY 10016, USA
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3
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Grech AK, Foo CT, Paul E, Aung AK, Yu C. Epidemiological trends of respiratory tract pathogens detected via mPCR in Australian adult patients before COVID-19. BMC Infect Dis 2024; 24:38. [PMID: 38166699 PMCID: PMC10763466 DOI: 10.1186/s12879-023-08750-7] [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: 03/24/2023] [Accepted: 10/25/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Respiratory tract infections (RTIs) are a major global health burden due to their high morbidity and mortality. This retrospective study described the epidemiology of respiratory pathogens in adults over a 5-year period at an Australian tertiary healthcare network. METHODS All multiplex reverse transcription polymerase chain reaction respiratory samples taken between the 1st of November 2014 and the 31st of October 2019 were included in this study. Overall prevalence and variations according to seasons, age groups and sex were analysed, as well as factors associated with prolonged hospital and intensive care length of stay. RESULTS There were 12,453 pathogens detected amongst the 12,185 positive samples, with coinfection rates of 3.7%. Picornavirus (Rhinovirus), Influenza A and respiratory syncytial virus were the most commonly detected pathogens. Mycoplasma pneumoniae was the most commonly detected atypical bacteria. Significant differences in the prevalence of Chlamydia pneumoniae and Human metapneumovirus infections were found between sexes. Longest median length of intensive care and hospital stay was for Legionella species. Seasonal variations were evident for certain pathogens. CONCLUSIONS The high rates of pathogen detection and hospitalisation in this real-world study highlights the significant burden of RTIs, and the urgent need for an improved understanding of the pathogenicity as well as preventative and treatment options of RTIs.
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Affiliation(s)
- Audrey K Grech
- Department of Respiratory Medicine, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Chuan T Foo
- Department of Respiratory Medicine, Eastern Health, Melbourne, Australia
- Monash Lung and Sleep, Monash Health, Melbourne, Australia
| | - Eldho Paul
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Ar K Aung
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of General Medicine, Alfred Health, Melbourne, Australia
| | - Christiaan Yu
- Department of Respiratory Medicine, Alfred Health, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
- Monash Lung and Sleep, Monash Health, Melbourne, Australia.
- Central Clinical School, Monash University, Melbourne, Australia.
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4
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Dinh J, Hinkle CF, Law AC, Walkey AJ, Bosch NA. Effect of Respiratory Viral Panel Adoption on Antibiotic Use in Ventilated Patients. Ann Am Thorac Soc 2023; 20:1777-1783. [PMID: 37748086 DOI: 10.1513/annalsats.202304-326oc] [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: 04/10/2023] [Accepted: 09/25/2023] [Indexed: 09/27/2023] Open
Abstract
Rationale: Rapid respiratory viral panel (RVP) testing has become widely used to aid in the diagnosis and treatment of acute respiratory failure. However, the impact of RVP on antibiotic stewardship in critically ill patients is unclear. Objectives: To assess if adoption of RVP testing at hospitals was associated with changes in antibiotic duration in intensive care unit patients receiving invasive mechanical ventilation. Methods: With data from the Premier Inc. database from 2016 to 2019, we used interrupted time series with multivariable hierarchical linear regression models to quantify trends in outcomes for 31,644 patients in the 12 months before RVP adoption, the level change in outcomes at the time of RVP adoption (estimand of interest), and changes in outcome trends in the 12 months after RVP adoption. Results: Hospital adoption of RVP testing (n = 62,603) was associated with a decrease in days of antibiotics by 0.5 days (95% confidence interval, -0.8, -0.1) in the first month after adoption. There was also a significant decrease in the risk of Clostridioides difficile infection by 0.9% (95% confidence interval, -1.6, -0.3). There were no significant changes in other outcomes, including hospitalization costs, hospital length of stay, or rates of ventilator-associated pneumonia. Conclusions: Hospital adoption of RVP testing was associated with modest reductions in both antibiotic duration and risk of C. difficile infection among intensive care unit patients with acute respiratory failure and suspected infection.
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Affiliation(s)
| | - Chad F Hinkle
- Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Anica C Law
- Pulmonary, Allergy, Sleep & Critical Care Medicine and
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5
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Gripp EW, Hess BD, Binder AF. Utility of Respiratory Pathogen Panels in the Outpatient Oncology Setting. Am J Med Qual 2023; 38:294-299. [PMID: 37908032 DOI: 10.1097/jmq.0000000000000154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Oncology patients presenting for outpatient evaluation of a respiratory tract infection (RTI) are often tested for a variety of viruses with a respiratory pathogen panel (RPP) in addition to influenza and SARS-CoV-2. This triad of testing is expensive and uncomfortable because it requires 2 nasal swabs. Little evidence supports the use of an RPP in outpatient settings, but it is routinely ordered. This retrospective chart review analyzed 183 RPPs performed at Jefferson between April 2020 and November 2021 in outpatient oncology patients presenting with RTI. Data collected included patient demographics, symptoms, and exam findings at time of RPP, additional testing completed, results of RPP, antibiotic and antiviral use before and after RPP results, and patient outcomes 30 days after RPP. Descriptive statistics were calculated. Of the 183 RPPs analyzed, 16.9% (31) were positive for at least 1 respiratory virus. Fifty-two patients (28.4%) started antibiotics before results of the RPP. Of those, 2 patients (3.8%) had a change in antibiotic plan after RPP results returned. Zero patients were started on antiviral medication before results of the RPP. One patient started antiviral treatment after RPP results returned. In total, only 3 patients (1.6%) had an RPP-driven change in medication management. This study suggests limited utility in use of RPPs for oncology patients presenting to the office with RTI symptoms. Targeted testing with a single nasal swab for influenza, RSV, and SARS-CoV-2 may be more clinically relevant. The authors hope to use these data to implement a quality improvement initiative to reduce RPP utilization in this population.
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Affiliation(s)
- Emily W Gripp
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Bryan D Hess
- Division of Infectious Disease, Department of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Adam F Binder
- Sidney Kimmel Cancer Center, Division of Hematologic Malignancy and Hematopoietic Stem Cell Transplantation, Department of Oncology, Thomas Jefferson University, Philadelphia, PA
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Kitagawa D, Kitano T, Furumori M, Suzuki S, Shintani Y, Nishikawa H, Suzuki R, Yamamoto N, Onaka M, Nishiyama A, Kasamatsu T, Shiraishi N, Suzuki Y, Nakano A, Nakano R, Yano H, Maeda K, Yoshida S, Nakamura F. Impact of the COVID-19 pandemic and multiplex polymerase chain reaction test on outpatient antibiotic prescriptions for pediatric respiratory infection. PLoS One 2023; 18:e0278932. [PMID: 36595501 PMCID: PMC9810151 DOI: 10.1371/journal.pone.0278932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/23/2022] [Indexed: 01/04/2023] Open
Abstract
This study aimed to evaluate the impact of the prolonged COVID-19 pandemic on outpatient antibiotic prescriptions for pediatric respiratory infections at an acute care hospital in Japan in order to direct future pediatric outpatient antibiotic stewardship. The impact of the COVID-19 pandemic and the FilmArray Respiratory Panel (RP) on outpatient antibiotic prescriptions was assessed from January 2019 to December 2021 using an interrupted time series analysis of children <20 years. The overall antimicrobial prescription rate decreased from 38.7% to 22.4% from the pre-pandemic period to the pandemic. The pandemic (relative risk [RR] level, 0.97 [0.58-1.61]; P = 0.90; RR slope, 1.05 [0.95-1.17] per month; P = 0.310) and FilmArray RP (RR level, 0.90 [0.46-1.75]; P = 0.75; RR slope, 0.95 [0.85-1.06] per month; P = 0.330) had no significant effect on the monthly antibiotic prescription rates. The COVID-19 pandemic was not significantly related to the antibiotic prescription rate, suggesting that it did not impact physicians' behavior toward antibiotic prescriptions. Replacing rapid antigen tests with the FilmArray RP introduced on December 1, 2020, did not affect the magnitude of the reduction in antibiotic prescription rate for pediatric respiratory infections.
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Affiliation(s)
- Daisuke Kitagawa
- Department of Laboratory Medicine, Nara Prefecture General Medical Center, Nara, Japan
- Department of Microbiology and Infectious Diseases, Nara Medical University, Kashihara, Nara, Japan
- * E-mail: (DK); (TK)
| | - Taito Kitano
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- * E-mail: (DK); (TK)
| | - Madoka Furumori
- Department of Laboratory Medicine, Nara Prefecture General Medical Center, Nara, Japan
| | - Soma Suzuki
- Department of Laboratory Medicine, Nara Prefecture General Medical Center, Nara, Japan
| | - Yui Shintani
- Department of Laboratory Medicine, Nara Prefecture General Medical Center, Nara, Japan
| | - Hiroki Nishikawa
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Rika Suzuki
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Naohiro Yamamoto
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Masayuki Onaka
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Atsuko Nishiyama
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Takehito Kasamatsu
- Department of Infectious Diseases, Nara Prefecture General Medical Center, Nara, Japan
| | - Naoyuki Shiraishi
- Department of Infectious Diseases, Nara Prefecture General Medical Center, Nara, Japan
| | - Yuki Suzuki
- Department of Microbiology and Infectious Diseases, Nara Medical University, Kashihara, Nara, Japan
| | - Akiyo Nakano
- Department of Microbiology and Infectious Diseases, Nara Medical University, Kashihara, Nara, Japan
| | - Ryuichi Nakano
- Department of Microbiology and Infectious Diseases, Nara Medical University, Kashihara, Nara, Japan
| | - Hisakazu Yano
- Department of Microbiology and Infectious Diseases, Nara Medical University, Kashihara, Nara, Japan
| | - Koichi Maeda
- Department of Infectious Diseases, Nara Prefecture General Medical Center, Nara, Japan
| | - Sayaka Yoshida
- Department of Pediatrics, Nara Prefecture General Medical Center, Nara, Japan
| | - Fumihiko Nakamura
- Department of Laboratory Medicine, Nara Prefecture General Medical Center, Nara, Japan
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Gómez de la Torre Pretell JC, Hueda-Zavaleta M, Cáceres-DelAguila JA, Barletta-Carrillo C, Copaja-Corzo C, Poccorpachi MDPS, Delgado MSV, Sanchez GMML, Benites-Zapata VA. Clinical Characteristics Associated with Detected Respiratory Microorganism Employing Multiplex Nested PCR in Patients with Presumptive COVID-19 but Negative Molecular Results in Lima, Peru. Trop Med Infect Dis 2022; 7:340. [PMID: 36355882 PMCID: PMC9692319 DOI: 10.3390/tropicalmed7110340] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 11/15/2023] Open
Abstract
The COVID-19 pandemic circumstances have varied the pathogens related to acute respiratory infections (ARI), and most specialists have ignored them due to SARS-CoV-2's similar symptomatology. We identify respiratory pathogens with multiplex PCR in samples with presumptive SARS-CoV-2 but negative RT-qPCR results. We performed a retrospective transversal study employing clinical data and nasopharyngeal swab samples from patients with suspected clinical SARS-CoV-2 infection and a negative PCR result in a private laboratory in Lima, Peru. The samples were analyzed using the FilmArray™ respiratory panel. Of 342 samples, we detected at least one pathogen in 50% of the samples. The main ones were rhinovirus (54.38%), influenza A(H3N2) (22.80%), and respiratory syncytial virus (RSV) (14.04%). The clinical characteristics were sore throat (70.18%), cough (58.48%), nasal congestion (56.43%), and fever (40.06%). Only 41.46% and 48.78% of patients with influenza met the definition of influenza-like illness (ILI) by the World Health Organization (WHO) (characterized by cough and fever) and the Centers for Disease Control and Prevention (CDC) (characterized by fever and cough and sore throat), respectively. A higher prevalence of influenza was associated with ILI by WHO (aPR: 2.331) and ILI by CDC (aPR: 1.892), which was not observed with other respiratory viruses. The clinical characteristic associated with the increased prevalence of rhinovirus was nasal congestion (aPR: 1.84). For patients with ARI and negative PCR results, the leading respiratory pathogens detected were rhinovirus, influenza, and RSV. Less than half of patients with influenza presented ILI, although its presence was specific to the disease.
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Affiliation(s)
| | - Miguel Hueda-Zavaleta
- Facultad de Ciencias de la Salud, Universidad Privada de Tacna, Tacna 23003, Peru
- Hospital III Daniel Alcides Carrión-Essalud Tacna, Tacna 23000, Peru
| | | | | | - Cesar Copaja-Corzo
- Facultad de Ciencias de la Salud, Universidad Privada de Tacna, Tacna 23003, Peru
- Red Asistencial Ucayali EsSalud, Pucallpa 25003, Peru
| | | | | | | | - Vicente A. Benites-Zapata
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima 15024, Peru
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8
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Low rates of antibiotic use among ambulatory patients with coronavirus disease 2019 (COVID-19). ANTIMICROBIAL STEWARDSHIP AND HEALTHCARE EPIDEMIOLOGY 2022; 2. [PMID: 35601658 PMCID: PMC9119305 DOI: 10.1017/ash.2022.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We assessed the prevalence of antibiotic prescriptions among ambulatory patients tested for coronavirus disease 2019 (COVID-19) in a large public US healthcare system and found a low overall rate of antibiotic prescriptions (6.7%). Only 3.8% of positive severe acute respiratory coronavirus virus 2 (SARS-CoV-2) tests were associated with an antibiotic prescription within 7 days.
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9
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Burrowes SAB, Barlam TF, Skinner A, Berger R, Ni P, Drainoni ML. Provider views on rapid diagnostic tests and antibiotic prescribing for respiratory tract infections: A mixed methods study. PLoS One 2021; 16:e0260598. [PMID: 34843599 PMCID: PMC8629209 DOI: 10.1371/journal.pone.0260598] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 11/12/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Respiratory tract infections (RTIs) are often inappropriately treated with antibiotics. Rapid diagnostic tests (RDTs) have been developed with the aim of improving antibiotic prescribing but uptake remains low. The aim of this study was to examine provider knowledge, attitudes and behaviors regarding RDT use and their relationship to antibiotic prescribing decisions across multiple clinical departments in an urban safety-net hospital. METHODS We conducted a mixed methods sequential explanatory study. Providers with prescribing authority (attending physicians, nurse practitioners and physician assistants) who had at least 20 RTI encounters from January 1, 2016 to December 31, 2018. Eighty-five providers completed surveys and 16 participated in interviews. We conducted electronic surveys via RedCap from April to July 2019, followed by semi-structured individual interviews from October to December 2019, to ascertain knowledge, attitudes and behaviors related to RDT use and antibiotic prescribing. RESULTS Survey findings indicated that providers felt knowledgeable about antibiotic prescribing guidelines. They reported high familiarity with the rapid streptococcus and rapid influenza tests. Familiarity with comprehensive respiratory panel PCR (RPP-respiratory panel PCR) and procalcitonin differed by clinical department. Qualitative interviews identified four main themes: providers trust their clinical judgment more than rapid test results; patient-provider relationships play an important role in prescribing decisions; there is patient demand for antibiotics and providers employ different strategies to address the demand and providers do not believe RDTs are implemented with sufficient education or evidence for clinical practice. CONCLUSION Prescribers are knowledgeable about prescribing guidelines but often rely on clinical judgement to make final decisions. The utility of RDTs is specific to the type of RDT and the clinical department. Given the low familiarity and clinical utility of RPP and procalcitonin, providers may require additional education and these tests may need to be implemented differently based on clinical department.
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Affiliation(s)
- Shana A. B. Burrowes
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA, United States of America
- * E-mail:
| | - Tamar F. Barlam
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
| | - Alexandra Skinner
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA, United States of America
| | - Rebecca Berger
- Massachusetts Department of Public Health, Boston, MA, United States of America
| | - Pengsheng Ni
- Biostatistics and Epidemiology Data Analytics Center (BEDAC) Boston University School of Public Health, Boston, MA, United States of America
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, United States of America
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA, United States of America
- Evans Center for Implementation and Improvement Sciences (CIIS), Boston University School of Medicine, Boston, MA, United States of America
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10
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The Need for Dedicated Microbiology Leadership in the Clinical Microbiology Laboratory. J Clin Microbiol 2021; 59:e0154919. [PMID: 33597258 DOI: 10.1128/jcm.01549-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Clinical microbiology laboratories play a crucial role in patient care using traditional and innovative diagnostics. Challenges faced by laboratories include emerging pathogens, rapidly evolving technologies, health care-acquired infections, antibiotic-resistant organisms, and diverse patient populations. Despite these challenges, many clinical microbiology laboratories in the United States are not directed by doctoral level microbiology-trained individuals with sufficient time dedicated to laboratory leadership. The manuscript highlights the need for medical microbiology laboratory directors with appropriate training and qualifications.
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11
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Evans SE, Jennerich AL, Azar MM, Cao B, Crothers K, Dickson RP, Herold S, Jain S, Madhavan A, Metersky ML, Myers LC, Oren E, Restrepo MI, Semret M, Sheshadri A, Wunderink RG, Dela Cruz CS. Nucleic Acid-based Testing for Noninfluenza Viral Pathogens in Adults with Suspected Community-acquired Pneumonia. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2021; 203:1070-1087. [PMID: 33929301 PMCID: PMC8314899 DOI: 10.1164/rccm.202102-0498st] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Background: This document provides evidence-based clinical practice guidelines on the diagnostic utility of nucleic acid–based testing of respiratory samples for viral pathogens other than influenza in adults with suspected community-acquired pneumonia (CAP). Methods: A multidisciplinary panel developed a Population–Intervention–Comparison–Outcome question, conducted a pragmatic systematic review, and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations. Results: The panel evaluated the literature to develop recommendations regarding whether routine diagnostics should include nucleic acid–based testing of respiratory samples for viral pathogens other than influenza in suspected CAP. The evidence addressing this topic was generally adjudicated to be of very low quality because of risk of bias and imprecision. Furthermore, there was little direct evidence supporting a role for routine nucleic acid–based testing of respiratory samples in improving critical outcomes such as overall survival or antibiotic use patterns. However, on the basis of direct and indirect evidence, recommendations were made for both outpatient and hospitalized patients with suspected CAP. Testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was not addressed in the literature at the time of the evidence review. Conclusions: The panel formulated and provided their rationale for recommendations on nucleic acid–based diagnostics for viral pathogens other than influenza for patients with suspected CAP.
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12
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Smith ER, Fry AM, Hicks LA, Fleming-Dutra KE, Flannery B, Ferdinands J, Rolfes MA, Martin ET, Monto AS, Zimmerman RK, Nowalk MP, Jackson ML, McLean HQ, Olson SC, Gaglani M, Patel MM. Reducing Antibiotic Use in Ambulatory Care Through Influenza Vaccination. Clin Infect Dis 2021; 71:e726-e734. [PMID: 32322875 DOI: 10.1093/cid/ciaa464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/20/2020] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Improving appropriate antibiotic use is crucial for combating antibiotic resistance and unnecessary adverse drug reactions. Acute respiratory illness (ARI) commonly causes outpatient visits and accounts for ~41% of antibiotics used in the United States. We examined the influence of influenza vaccination on reducing antibiotic prescriptions among outpatients with ARI. METHODS We enrolled outpatients aged ≥6 months with ARI from 50-60 US clinics during 5 winters (2013-2018) and tested for influenza with RT-PCR; results were unavailable for clinical decision making and clinical influenza testing was infrequent. We collected antibiotic prescriptions and diagnosis codes for ARI syndromes. We calculated vaccine effectiveness (VE) by comparing vaccination odds among influenza-positive cases with test-negative controls. We estimated ARI visits and antibiotic prescriptions averted by influenza vaccination using estimates of VE, coverage, and prevalence of antibiotic prescriptions and influenza. RESULTS Among 37 487 ARI outpatients, 9659 (26%) were influenza positive. Overall, 36% of ARI and 26% of influenza-positive patients were prescribed antibiotics. The top 3 prevalent ARI syndromes included: viral upper respiratory tract infection (47%), pharyngitis (18%), and allergy or asthma (11%). Among patients testing positive for influenza, 77% did not receive an ICD-CM diagnostic code for influenza. Overall, VE against influenza-associated ARI was 35% (95% CI, 32-39%). Vaccination prevented 5.6% of all ARI syndromes, ranging from 2.8% (sinusitis) to 11% (clinical influenza). Influenza vaccination averted 1 in 25 (3.8%; 95% CI, 3.6-4.1%) antibiotic prescriptions among ARI outpatients during influenza seasons. CONCLUSIONS Vaccination and accurate influenza diagnosis may curb unnecessary antibiotic use and reduce the global threat of antibiotic resistance.
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Affiliation(s)
- Emily R Smith
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alicia M Fry
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lauri A Hicks
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Brendan Flannery
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jill Ferdinands
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melissa A Rolfes
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | | | | | | | - Michael L Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Huong Q McLean
- Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Scott C Olson
- Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA
| | - Manjusha Gaglani
- Baylor Scott & White Health, Texas A&M University, Temple, Texas, USA
| | - Manish M Patel
- Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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13
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Rader TS, Stevens MP, Bearman G. Syndromic Multiplex Polymerase Chain Reaction (mPCR) Testing and Antimicrobial Stewardship: Current Practice and Future Directions. Curr Infect Dis Rep 2021; 23:5. [PMID: 33679252 PMCID: PMC7909367 DOI: 10.1007/s11908-021-00748-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Syndromic multiplex polymerase chain reaction (mPCR) panels offer the antimicrobial steward a rapid tool for optimizing and de-escalating antimicrobials. In this review, we analyze the role of syndromic mPCR in respiratory, gastrointestinal, and central nervous system infections within the context of antimicrobial stewardship efforts. RECENT FINDINGS For all mPCR syndromic panels, multiple studies analyzed the pre-and-post implementation impact of mPCR on antimicrobial utilization. Prospective studies and trials of respiratory mPCR stewardship interventions, including diagnostic algorithms, educational efforts, co-testing with procalcitonin, and targeted provider feedback currently exist. For gastrointestinal and cerebrospinal fluid mPCR, fewer peer-reviewed reports exist for the use of mPCR in antimicrobial stewardship. These studies demonstrated an inconsistent trend towards decreasing antibiotic use with mPCR. This is further limited by a lack of statistical significance, the absence of controlled, prospective trials, and issues with data generalizability. SUMMARY Antibiotic overuse may improve when mPCR is coupled with electronic medical record algorithm-based approaches and direct provider feedback by an antimicrobial stewardship professional. mPCR may prove a useful tool for antimicrobial stewardship but future studies are needed to define the best practice for its utilization.
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Affiliation(s)
- Theodore S. Rader
- Department of Internal Medicine, Virginia Commonwealth University Health System, 1250 E MARSHALL ST # 980509, Richmond, VA 23298-0019 USA
| | - Michael P. Stevens
- Division of Infectious Diseases, Virginia Commonwealth University Health System, Richmond, VA USA
| | - Gonzalo Bearman
- Division of Infectious Diseases, Virginia Commonwealth University Health System, Richmond, VA USA
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14
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Hardick J, Shaw-Saliba K, McBryde B, Gaydos CA, Hsieh YH, Lovecchio F, Steele M, Talan D, Rothman RE. Identification of pathogens from the upper respiratory tract of adult emergency department patients at high risk for influenza complications in a pre-Sars-CoV-2 environment. Diagn Microbiol Infect Dis 2021; 100:115352. [PMID: 33639376 DOI: 10.1016/j.diagmicrobio.2021.115352] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/09/2021] [Accepted: 02/13/2021] [Indexed: 11/24/2022]
Abstract
The emergence of SARS-CoV-2 and subsequent COVID-19 pandemic highlights the morbidity and potential disease severity caused by respiratory viruses. To elucidate pathogen prevalence, etiology of coinfections and URIs from symptomatic adult Emergency department patients in a pre-SARS-CoV-2 environment, we evaluated specimens from four geographically diverse Emergency departments in the United States from 2013-2014 utilizing ePlex RP RUO cartridges (Genmark Diagnostics). The overall positivity was 30.1% (241/799), with 6.6% (16/241) coinfections. Noninfluenza pathogens from most to least common were rhinovirus/enterovirus, coronavirus, human metapneumovirus and RSV, respectively. Broad differences in disease prevalence and pathogen distributions were observed across geographic regions; the site with the highest detection rate (for both mono and coinfections) demonstrated the greatest pathogen diversity. A variety of respiratory pathogens and geographic variations in disease prevalence and copathogen type were observed. Further research is required to evaluate the clinical relevance of these findings, especially considering the SARS-CoV-2 pandemic and related questions regarding SARS-CoV-2 disease severity and the presence of co-infections.
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Affiliation(s)
- Justin Hardick
- Johns Hopkins University School of Medicine, Department of Infectious Diseases, Baltimore, MD, USA.
| | - Kathryn Shaw-Saliba
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA
| | - Breana McBryde
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA
| | - Charlotte A Gaydos
- Johns Hopkins University School of Medicine, Department of Infectious Diseases, Baltimore, MD, USA; Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA
| | - Yu-Hsiang Hsieh
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA
| | | | | | - David Talan
- Oliver View Medical Center, Los Angeles, CA, USA
| | - Richard E Rothman
- Johns Hopkins University School of Medicine, Department of Infectious Diseases, Baltimore, MD, USA; Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA
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15
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[Virological diagnosis of lower respiratory tract infections]. Rev Mal Respir 2021; 38:58-73. [PMID: 33461842 DOI: 10.1016/j.rmr.2020.11.002] [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: 11/15/2019] [Accepted: 08/06/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The etiological diagnosis of bronchopulmonary infections cannot be assessed with clinical, radiological and epidemiological data alone. Viruses have been demonstrated to cause a large proportion of these infections, both in children and adults. BACKGROUND The diagnosis of viral bronchopulmonary infections is based on the analysis of secretions, collected from the lower respiratory tract when possible, by techniques that detect either influenza and respiratory syncytial viruses, or a large panel of viruses that can be responsible for respiratory disease. The latter, called multiplex PCR assays, allow a syndromic approach to respiratory infection. Their high cost for the laboratory raises the question of their place in the management of patients in terms of antibiotic economy and isolation. In the absence of clear recommendations, the strategy and equipment are very unevenly distributed in France. OUTLOOK Medico-economic analyses need to be performed in France to evaluate the place of these tests in the management of patients. The evaluation of the role of the different viruses often detected in co-infection, especially in children, also deserves the attention of virologists and clinicians. CONCLUSIONS The availability of new diagnostic technologies, the recent emergence of SARS-CoV-2, together with the availability of new antiviral drugs are likely to impact future recommendations for the management of viral bronchopulmonary infections.
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16
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Krantz EM, Zier J, Stohs E, Ogimi C, Sweet A, Marquis S, Klaassen J, Pergam SA, Liu C. Antibiotic Prescribing and Respiratory Viral Testing for Acute Upper Respiratory Infections Among Adult Patients at an Ambulatory Cancer Center. Clin Infect Dis 2021; 70:1421-1428. [PMID: 31095276 PMCID: PMC7108137 DOI: 10.1093/cid/ciz409] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/15/2019] [Indexed: 12/27/2022] Open
Abstract
Background Outpatient antibiotic prescribing for acute upper respiratory infections (URIs) is a high-priority target for antimicrobial stewardship that has not been described for cancer patients. Methods We conducted a retrospective cohort study of adult patients at an ambulatory cancer center with URI diagnoses from 1 October 2015 to 30 September 2016. We obtained antimicrobial prescribing, respiratory viral testing, and other clinical data at first encounter for the URI through day 14. We used generalized estimating equations to test associations of baseline factors with antibiotic prescribing. Results Of 341 charts reviewed, 251 (74%) patients were eligible for analysis. Nearly one-third (32%) of patients were prescribed antibiotics for URIs. Respiratory viruses were detected among 85 (75%) of 113 patients tested. Antibiotic prescribing (P = .001) and viral testing (P < .001) varied by clinical service. Sputum production or chest congestion was associated with higher risk of antibiotic prescribing (relative risk [RR], 2.3; 95% confidence interval [CI], 1.4–3.8; P < .001). Viral testing on day 0 was associated with lower risk of antibiotic prescribing (RR, 0.4; 95% CI 0.2–0.8; P = .01), though collinearity between viral testing and clinical service limited our ability to separate these effects on prescribing. Conclusions Nearly one-third of hematology–oncology outpatients were prescribed antibiotics for URIs, despite viral etiologies identified among 75% of those tested. Antibiotic prescribing was significantly lower among patients who received an initial respiratory viral test. The role of viral testing in antibiotic prescribing for URIs in outpatient oncology settings merits further study.
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Affiliation(s)
- Elizabeth M Krantz
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Jacqlynn Zier
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Erica Stohs
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha
| | - Chikara Ogimi
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Department of Pediatrics, University of Washington.,Pediatric Infectious Diseases Division, Seattle Children's Hospital
| | - Ania Sweet
- Antimicrobial Stewardship Program, Seattle Cancer Care Alliance.,Department of Pharmacy, University of Washington
| | - Sara Marquis
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - John Klaassen
- Antimicrobial Stewardship Program, Seattle Cancer Care Alliance
| | - Steven A Pergam
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Antimicrobial Stewardship Program, Seattle Cancer Care Alliance.,Clinical Research Division, Fred Hutchinson Cancer Research Center.,Division of Allergy and Infectious Diseases, University of Washington
| | - Catherine Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington.,Antimicrobial Stewardship Program, Seattle Cancer Care Alliance.,Clinical Research Division, Fred Hutchinson Cancer Research Center.,Division of Allergy and Infectious Diseases, University of Washington
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17
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Impact of BioFire FilmArray respiratory panel results on antibiotic days of therapy in different clinical settings. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e4. [PMID: 36168499 PMCID: PMC9495546 DOI: 10.1017/ash.2021.164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/11/2021] [Accepted: 05/16/2021] [Indexed: 12/02/2022]
Abstract
Objective: The BioFire FilmArray Respiratory Panel (RFA) has been proposed as a tool that can aid in the timely diagnosis and treatment of respiratory tract infections but its effect on antibiotic prescribing among adult patients has varied. We evaluated the impact of RFA result on antibiotic days of therapy (DOTs) in 2 distinct cohorts: hospitalized patients and patients discharged from the emergency department (ED). Design: Retrospective cohort study. Setting: The study was conducted in 3 community hospitals in Des Moines, Iowa, from March 3 to March 16, 2019. Patients: Adults aged >18 years. Methods: Potential outcome means and average treatment effects for RFA results on antibiotic DOTs were estimated. Inverse probability of treatment weighting with regression adjustment was used. Results: We identified 243 patients each in the hospitalized and ED-discharged cohorts. Among hospitalized patients, RFA results did not affect antibiotic DOTs. Among patients discharged from the ED, we found that if all patients had had influenza detected, the average DOTs would have been 2.3 DOTs (−3.2 to −1.4) less than the average observed if all the patients had had a negative RFA (P < .0001); no differences in DOTs were observed when comparing an RFA with a noninfluenza virus detected compared to an RFA with negative results. Conclusions: The impact of RFA results on antibiotic DOTs varies by clinical setting, and reductions were observed only among patients discharged from the ED who had influenza A or B detected.
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18
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Hanson KE, Azar MM, Banerjee R, Chou A, Colgrove RC, Ginocchio CC, Hayden MK, Holodiny M, Jain S, Koo S, Levy J, Timbrook TT, Caliendo AM. Molecular Testing for Acute Respiratory Tract Infections: Clinical and Diagnostic Recommendations From the IDSA's Diagnostics Committee. Clin Infect Dis 2020; 71:2744-2751. [PMID: 32369578 PMCID: PMC7454374 DOI: 10.1093/cid/ciaa508] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/30/2020] [Indexed: 01/08/2023] Open
Abstract
The clinical signs and symptoms of acute respiratory tract infections (RTIs) are not pathogen specific. Highly sensitive and specific nucleic acid amplification tests have become the diagnostic reference standard for viruses, and translation of bacterial assays from basic research to routine clinical practice represents an exciting advance in respiratory medicine. Most recently, molecular diagnostics have played an essential role in the global health response to the novel coronavirus pandemic. How best to use newer molecular tests for RTI in combination with clinical judgment and traditional methods can be bewildering given the plethora of available assays and rapidly evolving technologies. Here, we summarize the current state of the art with respect to the diagnosis of viral and bacterial RTIs, provide a practical framework for diagnostic decision making using selected patient-centered vignettes, and make recommendations for future studies to advance the field.
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Affiliation(s)
- Kimberly E Hanson
- Division of Infectious Diseases, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Section of Clinical Microbiology, Department of Pathology, University of Utah and ARUP Laboratories, Salt Lake City, Utah, USA
| | - Marwan M Azar
- Department of Medicine, Section of Infectious Diseases, AIDS Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ritu Banerjee
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andrew Chou
- Michael E. DeBakey VA Medical Center, Baylor College of Medicine, Houston, Texas, USA
| | - Robert C Colgrove
- Department of Microbiology and Immunobiology, Harvard Medical School, Boston, Massachusetts, USA
| | - Christine C Ginocchio
- Global Medical Affairs, bioMérieux/BioFire Diagnostics, Salt Lake City, Utah, USA
- Department of Pathology and Laboratory Medicine, Hofstra North Shore–Long Island Jewish School of Medicine, Hempstead, New York, USA
| | - Mary K Hayden
- Division of Infectious Diseases, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
- Division of Laboratory Medicine, Department of Pathology, Rush University Medical Center, Chicago, Illinois, USA
| | - Mark Holodiny
- VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford University, Palo Alto, California, USA
| | - Seema Jain
- Disease Investigations Section, Infectious Diseases Branch, California Department of Public Health, Richmond, California, USA
| | - Sophia Koo
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jaclyn Levy
- Infectious Diseases Society of America, Arlington, Virginia, USA
| | - Tristan T Timbrook
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah USA
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Angela M Caliendo
- Division of Infectious Diseases, Department of Medicine, Brown University Warren Alpert School of Medicine, Providence, Rhode Island, USA
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19
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Abstract
Given the large number of patients seen in the emergency department (ED) and concerns with antibiotic overprescribing, the ED is an important setting to target for antimicrobial stewardship (AS) initiatives. The ED is positioned between ambulatory and inpatient settings, making AS collaboration with clinicians and other health care providers in the hospital, long-term care facilities, and ambulatory settings critical to success. This article details ED-focused AS strategies on empiric antimicrobial selection, prompt administration, preventing ED return and readmissions, suggested collaborations between ED AS leadership and other key partners, and potential future strategies for expansion.
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20
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Durant TJS, Kubilay NZ, Reynolds J, Tarabar AF, Dembry LM, Peaper DR. Antimicrobial Stewardship Optimization in the Emergency Department: The Effect of Multiplex Respiratory Pathogen Testing and Targeted Educational Intervention. J Appl Lab Med 2020; 5:1172-1183. [DOI: 10.1093/jalm/jfaa130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 06/13/2020] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Antibacterial agents are often prescribed for patients with suspected respiratory tract infections even though these are most often caused by viruses. In this study, we sought to evaluate the effect of Respiratory Pathogen Panel (RPP) PCR result availability and antimicrobial stewardship education on antibiotic prescription rates in the adult emergency department (ED).
Methods
We compared rates of antibacterial and oseltamivir prescriptions between 2 nonconsecutive influenza seasons among ED visits, wherein the latter season followed the implementation of a comprehensive educational stewardship campaign. In addition, we sought to elucidate the effect of RPP-PCR on antibiotic prescriptions, with focus on result availability prior to the conclusion of emergency department encounters.
Results
Antibiotic prescription rates globally decreased by 17.9% in the FS-17/18 cohort compared to FS-14/15 (P < 0.001), while oseltamivir prescription rates stayed the same overall (P = 0.42). Multivariate regression across both cohorts revealed that patients were less likely to receive antibiotics if RPP-PCR results were available before the end of the ED visit or if the RPP-PCR result was positive for influenza. Patients in the educational intervention cohort were also less likely to receive an antibiotic prescription.
Conclusion
This study provides evidence that RPP-PCR results are most helpful if available prior to the end of the provider-patient interaction. Further, these data suggest that detection of influenza remains an influential result in the context of antimicrobial treatment decision making. In addition, these data contribute to the body of literature which supports comprehensive ASP interventions including leadership and patient engagement.
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Affiliation(s)
| | | | | | - Asim F Tarabar
- Department of Emergency Medicine, Yale University, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Louise M Dembry
- Department of Internal Medicine, Yale University, New Haven, CT
- Yale School of Public Health, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - David R Peaper
- Department of Laboratory Medicine, Yale University, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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21
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Qavi AJ, McMullen A, Burnham CAD, Anderson NW. Repeat Molecular Testing for Respiratory Pathogens: Diagnostic Gain or Diminishing Returns? J Appl Lab Med 2020; 5:897-907. [PMID: 32674131 PMCID: PMC7454602 DOI: 10.1093/jalm/jfaa029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 01/02/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Upper respiratory tract infections are common, and the ability to accurately and rapidly diagnose the causative pathogen has important implications for patient management. METHODS We evaluated the test-ordering practices for 2 commonly utilized nucleic acid amplification tests (NAATs) for the detection of respiratory pathogens: the Xpert Flu Assay for influenza A/B (Flu assay) and the Biofire FilmArray respiratory panel assay (RP assay), which detects 20 different targets. Our study examined repeat testing; that is, testing within 7 days from an initial test. RESULTS Our study found that repeat testing is common for each of the individual assays: 3.0% of all Flu assays and 10.0% of all RP assays were repeat testing. Of repeat testing, 8/293 (2.7%) of repeat Flu assays and 75/1257 (6.0%) of RP assays resulted diagnostic gains, i.e., new detections. However, for the RP assay, these new detections were not always clinically actionable. The most frequently discrepant organisms were rhinovirus/enterovirus (28/102, 27.5%), followed by respiratory syncytial virus (12/102, 11.8%) and coronavirus OC43 (11/102, 10.8%). Furthermore, there were 3,336 instances in which a patient was tested using both a Flu assay and RP assay, of which only 44 (1.3%) had discrepant influenza results. CONCLUSIONS Our findings suggest opportunities exist to better guide ordering practices for respiratory pathogen testing, including limiting repeat testing, with the goal of optimization of clinical yield, and diagnostic stewardship.
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Affiliation(s)
- Abraham J Qavi
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Allison McMullen
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Carey-Ann D Burnham
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Neil W Anderson
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO
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22
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Peaper DR, Branson B, Parwani V, Ulrich A, Shapiro MJ, Clemons C, Campbell M, Owen M, Martinello RA, Landry ML. Clinical impact of rapid influenza PCR in the adult emergency department on patient management, ED length of stay, and nosocomial infection rate. Influenza Other Respir Viruses 2020; 15:254-261. [PMID: 32851793 PMCID: PMC7902247 DOI: 10.1111/irv.12800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 07/27/2020] [Accepted: 07/28/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Seasonal influenza causes significant morbidity and mortality and incurs large economic costs. Influenza like illness is a common presenting concern to Emergency Departments (ED), and optimizing the diagnosis of influenza in the ED has the potential to positively affect patient management and outcomes. Therapeutic guidelines have been established to identify which patients most likely will benefit from anti-viral therapy. OBJECTIVES We assessed the impact of rapid influenza PCR testing of ED patients on laboratory result generation and patient management across two influenza seasons. METHODS A pre-post study was performed following a multifaceted clinical redesign including the implementation of rapid influenza PCR at three diverse EDs comparing the 2016-2017 and 2017-2018 influenza seasons. Testing parameters including turn-around-time and diagnostic efficiency were measured along with rates of bed transfers, hospital-acquired (HA) influenza, and ED length of stay (LOS). RESULTS More testing of discharged patients was performed in the post-intervention period, but influenza rates were the same. Identification of influenza-positive patients was significantly faster, and there was faster and more appropriate prescription of anti-influenza medication. There were no differences in bed transfer rates or HA influenza, but ED LOS was reduced by 74 minutes following clinical redesign. CONCLUSIONS Multifaceted clinical redesign to optimize ED workflow incorporating rapid influenza PCR testing can be successfully deployed across different ED environments. Adoption of rapid influenza PCR can streamline testing and improve antiviral stewardship and ED workflow including reducing LOS. Further study is needed to determine if other outcomes including bed transfers and rates of HA influenza can be affected by improved testing practices.
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Affiliation(s)
- David R Peaper
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Brittany Branson
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA.,Clinical Redesign, Yale New Haven Health, New Haven, Connecticut, USA
| | - Vivek Parwani
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrew Ulrich
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marc J Shapiro
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Crystal Clemons
- Clinical Redesign, Yale New Haven Health, New Haven, Connecticut, USA
| | - Melissa Campbell
- Department of Pediatrics, Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut, USA
| | - Maureen Owen
- Department of Laboratory Medicine, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Richard A Martinello
- Department of Pediatrics, Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Infection Prevention, Yale New Haven Health, New Haven, Connecticut, USA.,Department of Internal Medicine, Infectious Diseases Section, Yale School of Medicine, New Haven, Connecticut, USA
| | - Marie L Landry
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, Connecticut, USA.,Department of Internal Medicine, Infectious Diseases Section, Yale School of Medicine, New Haven, Connecticut, USA
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23
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Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, Gravenstein S, Hayden FG, Harper SA, Hirshon JM, Ison MG, Johnston BL, Knight SL, McGeer A, Riley LE, Wolfe CR, Alexander PE, Pavia AT. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis 2020; 68:e1-e47. [PMID: 30566567 DOI: 10.1093/cid/ciy866] [Citation(s) in RCA: 332] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/05/2018] [Indexed: 12/19/2022] Open
Abstract
These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.
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Affiliation(s)
- Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Henry H Bernstein
- Division of General Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
| | - John S Bradley
- Division of Infectious Diseases, Rady Children's Hospital.,University of California, San Diego
| | - Janet A Englund
- Department of Pediatrics, University of Washington, Seattle Children's Hospital
| | - Thomas M File
- Division of Infectious Diseases Summa Health, Northeast Ohio Medical University, Rootstown
| | - Alicia M Fry
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stefan Gravenstein
- Providence Veterans Affairs Medical Center and Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville
| | - Scott A Harper
- Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jon Mark Hirshon
- Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B Lynn Johnston
- Department of Medicine, Dalhousie University, Nova Scotia Health Authority, Halifax, Canada
| | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Allison McGeer
- Division of Infection Prevention and Control, Sinai Health System, University of Toronto, Ontario, Canada
| | - Laura E Riley
- Department of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Paul E Alexander
- McMaster University, Hamilton, Ontario, Canada.,Infectious Diseases Society of America, Arlington, Virginia
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
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24
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Escovedo C, Bell D, Cheng E, Garner O, Ziman A, Vangala S, Gounder P, Lerner C. Noninterruptive Clinical Decision Support Decreases Ordering of Respiratory Viral Panels during Influenza Season. Appl Clin Inform 2020; 11:315-322. [PMID: 32349143 DOI: 10.1055/s-0040-1709507] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE A growing body of evidence suggests that testing for influenza virus alone is more appropriate than multiplex respiratory viral panel (RVP) testing for general populations of patients with respiratory tract infections. We aimed to decrease the proportion of RVPs out of total respiratory viral testing ordered during influenza season. METHODS We implemented two consecutive interventions: reflex testing for RVPs only after a negative influenza test, and noninterruptive clinical decision support (CDS) including modifications of the computerized physician order entry search behavior and cost display. We conducted an interrupted time series of RVPs and influenza polymerase chain reaction tests pre- and postintervention, and performed a mixed-effects logistic regression analysis with a primary outcome of proportion of RVPs out of total respiratory viral tests. The primary predictor was the intervention period, and covariates included the provider, clinical setting, associated diagnoses, and influenza incidence. RESULTS From March 2013 to April 2019, there were 24,294 RVPs and 26,012 influenza tests (n = 50,306). Odds of ordering an RVP decreased during the reflex testing period (odds ratio: 0.432, 95% confidence interval: 0.397-0.469), and decreased more dramatically during the noninterruptive CDS period (odds ratio: 0.291, 95% confidence interval: 0.259-0.327). DISCUSSION The odds of ordering an RVP were 71% less with the noninterruptive CDS intervention, which projected 4,773 fewer RVPs compared with baseline. Assuming a cost equal to Medicare reimbursement rates for RVPs and influenza tests, this would generate an estimated averted cost of $1,259,474 per year. CONCLUSION Noninterruptive CDS interventions are effective in reducing unnecessary and expensive testing, and avoid typical pitfalls such as alert fatigue.
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Affiliation(s)
- Cameron Escovedo
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, California, United States
| | - Douglas Bell
- Department of Medicine, University of California, Los Angeles, Los Angeles, California, United States
| | - Eric Cheng
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, United States
| | - Omai Garner
- Department of Pathology & Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, United States
| | - Alyssa Ziman
- Department of Pathology & Laboratory Medicine, University of California, Los Angeles, Los Angeles, California, United States
| | - Sitaram Vangala
- Department of Medicine Statistics Core, University of California, Los Angeles, Los Angeles, California, United States
| | - Prabhu Gounder
- Acute Communicable Disease Control, County of Los Angeles Public Health, Los Angeles, California, United States
| | - Carlos Lerner
- Department of Pediatrics, University of California, Los Angeles, Los Angeles, California, United States
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25
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Multicenter Evaluation of the QIAstat-Dx Respiratory Panel for Detection of Viruses and Bacteria in Nasopharyngeal Swab Specimens. J Clin Microbiol 2020; 58:JCM.00155-20. [PMID: 32132186 PMCID: PMC7180242 DOI: 10.1128/jcm.00155-20] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/25/2020] [Indexed: 11/20/2022] Open
Abstract
The QIAstat-Dx Respiratory Panel (QIAstat-Dx RP) is a multiplex in vitro diagnostic test for the qualitative detection of 20 pathogens directly from nasopharyngeal swab (NPS) specimens. The assay is performed using a simple sample-to-answer platform with results available in approximately 69 min. The pathogens identified are adenovirus, coronavirus 229E, coronavirus HKU1, coronavirus NL63, coronavirus OC43, human metapneumovirus A and B, influenza A, influenza A H1, influenza A H3, influenza A H1N1/2009, influenza B, parainfluenza virus 1, parainfluenza virus 2, parainfluenza virus 3, parainfluenza virus 4, rhinovirus/enterovirus, respiratory syncytial virus A and B, Bordetella pertussis, Chlamydophila pneumoniae, and Mycoplasma pneumoniae This multicenter evaluation provides data obtained from 1,994 prospectively collected and 310 retrospectively collected (archived) NPS specimens with performance compared to that of the BioFire FilmArray Respiratory Panel, version 1.7. The overall percent agreement between QIAstat-Dx RP and the comparator testing was 99.5%. In the prospective cohort, the QIAstat-Dx RP demonstrated a positive percent agreement of 94.0% or greater for the detection of all but four analytes: coronaviruses 229E, NL63, and OC43 and rhinovirus/enterovirus. The test also demonstrated a negative percent agreement of ≥97.9% for all analytes. The QIAstat-Dx RP is a robust and accurate assay for rapid, comprehensive testing for respiratory pathogens.
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Burrowes SAB, Rader A, Ni P, Drainoni ML, Barlam TF. Low Uptake of Rapid Diagnostic Tests for Respiratory Tract Infections in an Urban Safety Net Hospital. Open Forum Infect Dis 2020; 7:ofaa057. [PMID: 32166096 PMCID: PMC7060900 DOI: 10.1093/ofid/ofaa057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 02/13/2020] [Indexed: 01/21/2023] Open
Abstract
Background Rapid diagnostic tests (RDTs) have been developed with the aim of providing accurate results in a timely manner. Despite this, studies report that provider uptake remains low. Methods We conducted a retrospective analysis of ambulatory, urgent care, and emergency department (ED) encounters at an urban safety net hospital with a primary diagnosis of an upper or lower respiratory tract infection (eg, bronchitis, pharyngitis, acute sinusitis) from January 1, 2016, to December 31, 2018. We collected RDT type and results, antibiotics prescribed, demographic and clinical patient information, and provider demographics. Results RDT use was low; a test was performed at 29.5% of the 33 494 visits. The RDT most often ordered was the rapid Group A Streptococcus (GAS) test (n = 7352), predominantly for visits with a discharge diagnosis of pharyngitis (n = 5818). Though antibiotic prescription was more likely if the test was positive (relative risk [RR], 1.68; 95% confidence interval [CI], 1.58–1.8), 92.46% of streptococcal pharyngitis cases with a negative test were prescribed an antibiotic. The Comprehensive Respiratory Panel (CRP) was ordered in 2498 visits; influenza was the most commonly detected pathogen. Physicians in the ED were most likely to order a CRP. Antibiotic prescription was lower if the CRP was not ordered compared with a negative CRP result (RR, 0.77; 95% CI, 0.7–0.84). There was no difference in prescribing by CRP result (negative vs positive). Conclusions RDTs are used infrequently in the outpatient setting, and impact on prescribing was inconsistent. Further work is needed to determine barriers to RDT use and to address potential solutions.
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Affiliation(s)
- Shana A B Burrowes
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Alec Rader
- Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Pengsheng Ni
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, Massachusetts, USA
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Evans Center for Implementation and Improvement Sciences (CIIS), Boston University School of Medicine, Boston, Massachusetts, USA.,Center for Healthcare Organization and Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedford, Massachusetts, USA
| | - Tamar F Barlam
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
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Bouzid D, Zanella MC, Kerneis S, Visseaux B, May L, Schrenzel J, Cattoir V. Rapid diagnostic tests for infectious diseases in the emergency department. Clin Microbiol Infect 2020; 27:182-191. [PMID: 32120036 PMCID: PMC7129254 DOI: 10.1016/j.cmi.2020.02.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/12/2020] [Accepted: 02/17/2020] [Indexed: 12/23/2022]
Abstract
Background Rapid diagnostic tests (RDTs) for infectious diseases, with a turnaround time of less than 2 hours, are promising tools that could improve patient care, antimicrobial stewardship and infection prevention in the emergency department (ED) setting. Numerous RDTs have been developed, although not necessarily for the ED environment. Their successful implementation in the ED relies on their performance and impact on patient management. Objectives The aim of this narrative review was to provide an overview of currently available RDTs for infectious diseases in the ED. Sources PubMed was searched through August 2019 for available studies on RDTs for infectious diseases. Inclusion criteria included: commercial tests approved by the US Food and Drug Administration (FDA) or Conformité Européenne (CE) in vitro diagnostic devices with data on clinical samples, ability to run on fully automated systems and result delivery within 2 hours. Content A nonexhaustive list of representative commercially available FDA- or CE-approved assays was categorized by clinical syndrome: pharyngitis and upper respiratory tract infection, lower respiratory tract infection, gastrointestinal infection, meningitis and encephalitis, fever in returning travellers and sexually transmitted infection, including HIV. The performance of tests was described on the basis of clinical validation studies. Further, their impact on clinical outcomes and anti-infective use was discussed with a focus on ED-based studies. Implications Clinicians should be familiar with the distinctive features of each RDT and individual performance characteristics for each target. Their integration into ED work flow should be preplanned considering local constraints of given settings. Additional clinical studies are needed to further evaluate their clinical effectiveness and cost-effectiveness.
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Affiliation(s)
- D Bouzid
- Emergency Department, AP-HP, Bichat Claude Bernard Hospital, Paris, France; University of Paris, IAME, INSERM, Paris, France
| | - M-C Zanella
- Laboratory of Bacteriology, Division of Laboratory Medicine and Division of Infectious Diseases, University of Geneva Hospitals, Geneva, Switzerland; University of Geneva Medical School, Geneva, Switzerland
| | - S Kerneis
- University of Paris, IAME, INSERM, Paris, France; AP-HP, Antimicrobial Stewardship Team, Hôpitaux Universitaires Paris Centre-Cochin, Paris, France; Pharmacoepidémiology and Infectious Diseases (Phemi), Pasteur Institute, Paris, France
| | - B Visseaux
- University of Paris, IAME, INSERM, Paris, France; AP-HP, Bichat Claude Bernard Hospital, Virology, Paris, France
| | - L May
- Department of Emergency Medicine, University of California-Davis, Sacramento, CA, USA
| | - J Schrenzel
- Laboratory of Bacteriology, Division of Laboratory Medicine and Division of Infectious Diseases, University of Geneva Hospitals, Geneva, Switzerland; University of Geneva Medical School, Geneva, Switzerland; Genomic Research Laboratory, Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - V Cattoir
- Service de Bactériologie-Hygiène Hospitalière, CHU de Rennes, Rennes, France; CNR de `la Résistance aux Antibiotiques (laboratoire associé'Entérocoques), Rennes, France; Unité Inserm U1230, Université de Rennes 1, Rennes, France.
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Bouzid D, Lucet JC, Duval X, Houhou-Fidouh N, Casalino E, Visseaux B. Multiplex PCR implementation as point-of-care testing in a French emergency department. J Hosp Infect 2020; 105:337-338. [PMID: 32032615 PMCID: PMC7134416 DOI: 10.1016/j.jhin.2020.01.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 01/29/2020] [Indexed: 12/02/2022]
Affiliation(s)
- D Bouzid
- AP-HP, Bichat Claude-Bernard Hospital, Emergency Department, Paris, France; Université de Paris, IAME, INSERM, Paris, France.
| | - J-C Lucet
- Université de Paris, IAME, INSERM, Paris, France; AP-HP, Bichat-Claude Bernard Hospital, Infection Control Unit, Paris, France
| | - X Duval
- Université de Paris, IAME, INSERM, Paris, France; AP-HP, Bichat-Claude-Bernard Hospital, Centre d'Investigation Clinique, Paris, France
| | - N Houhou-Fidouh
- AP-HP, Bichat-Claude Bernard Hospital, Virology Department, Paris, France
| | - E Casalino
- AP-HP, Bichat Claude-Bernard Hospital, Emergency Department, Paris, France; Université de Paris, IAME, INSERM, Paris, France
| | - B Visseaux
- Université de Paris, IAME, INSERM, Paris, France; AP-HP, Bichat-Claude Bernard Hospital, Virology Department, Paris, France
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May L, Tatro G, Poltavskiy E, Mooso B, Hon S, Bang H, Polage C. Rapid Multiplex Testing for Upper Respiratory Pathogens in the Emergency Department: A Randomized Controlled Trial. Open Forum Infect Dis 2019; 6:ofz481. [PMID: 32128326 PMCID: PMC7043218 DOI: 10.1093/ofid/ofz481] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 11/04/2019] [Indexed: 01/10/2023] Open
Abstract
Background Acute upper respiratory tract infections are a common cause of emergency department (ED) visits and often result in unnecessary antibiotic treatment. Methods We conducted a randomized clinical trial to evaluate the impact of a rapid, multipathogen respiratory panel (RP) test vs usual care (control). Patients were eligible if they were ≥12 months old, had symptoms of upper respiratory infection or influenza-like illness, and were not on antibiotics. The primary outcome was antibiotic prescription; secondary outcomes included antiviral prescription, disposition, and length of stay (ClinicalTrials.gov# NCT02957136). Results Of 191 patients enrolled, 93 (49%) received RP testing; 98 (51%) received usual care. Fifty-three (57%) RP and 7 (7%) control patients had a virus detected and reported during the ED visit (P = .0001). Twenty (22%) RP patients and 33 (34%) usual care patients received antibiotics during the ED visit (–12%; 95% confidence interval, –25% to 0.4%; P = .06/0.08); 9 RP patients received antibiotics despite having a virus detected. The magnitude of antibiotic reduction was greater in children (–19%) vs adults (–9%, post hoc analysis). There was no difference in antiviral use, length of stay, or disposition. Conclusions Rapid RP testing was associated with a trend toward decreased antibiotic use, suggesting a potential benefit from more rapid viral tests in the ED. Future studies should determine if specific groups are more likely to benefit from testing and evaluate the relative cost and effectiveness of broad testing, focused testing, and a combined diagnostic and antimicrobial stewardship approach.
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Affiliation(s)
- Larissa May
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Grant Tatro
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Eduard Poltavskiy
- Graduate Group in Epidemiology, University of California Davis, Davis, California, USA
| | - Benjamin Mooso
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Simson Hon
- Department of Emergency Medicine, University of California Davis, Sacramento, California, USA
| | - Heejung Bang
- Graduate Group in Epidemiology, University of California Davis, Davis, California, USA.,Department of Public Health Sciences, University of California Davis, Davis, California, USA
| | - Christopher Polage
- Department of Pathology, University of California Davis, Sacramento, California, USA.,Department of Pathology, Duke University, Durham, North Carolina, USA
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Timbrook TT. Antimicrobial Stewardship and Implementation of Rapid Multiplex Respiratory Diagnostics: Is There Method in the Madness? Clin Infect Dis 2019; 71:1690-1692. [DOI: 10.1093/cid/ciz1046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 10/17/2019] [Indexed: 01/19/2023] Open
Affiliation(s)
- Tristan T Timbrook
- IDEAS Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
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Abstract
The timely and accurate diagnosis of respiratory virus infections has the potential to optimize downstream (posttesting) use of limited health care resources, including antibiotics, antivirals, ancillary testing, and inpatient and emergency department beds. Cost-effective algorithms for respiratory virus testing must take into consideration numerous factors, including which patients should be tested, what testing should be performed (for example, antigen testing versus reverse transcription-PCR testing or influenza A/B testing versus testing with a comprehensive respiratory virus panel), and the turnaround time necessary to achieve the desired posttesting outcomes. Despite the clinical impact of respiratory virus infections, the cost-effectiveness of respiratory virus testing is incompletely understood. In this article, we review the literature pertaining to the cost-effectiveness of respiratory virus testing in pediatric and adult patient populations, in emergency department, outpatient, and inpatient clinical settings. Furthermore, we consider the cost-effectiveness of a variety of testing methods, including rapid antigen tests, direct fluorescent antibody assays, and nucleic acid amplification tests.
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Abstract
Advanced microbiology technologies are rapidly changing our ability to diagnose infections, improve patient care, and enhance clinical workflow. These tools are increasing the breadth, depth, and speed of diagnostic data generated per patient, and testing is being moved closer to the patient through rapid diagnostic technologies, including point-of-care (POC) technologies. Advanced microbiology technologies are rapidly changing our ability to diagnose infections, improve patient care, and enhance clinical workflow. These tools are increasing the breadth, depth, and speed of diagnostic data generated per patient, and testing is being moved closer to the patient through rapid diagnostic technologies, including point-of-care (POC) technologies. While select stakeholders have an appreciation of the value/importance of improvements in the microbial diagnostic field, there remains a disconnect between clinicians and some payers and hospital administrators in terms of understanding the potential clinical utility of these novel technologies. Therefore, a key challenge for the clinical microbiology community is to clearly articulate the value proposition of these technologies to encourage payers to cover and hospitals to adopt advanced microbiology tests. Specific guidance on how to define and demonstrate clinical utility would be valuable. Addressing this challenge will require alignment on this topic, not just by microbiologists but also by primary care and emergency room (ER) physicians, infectious disease specialists, pharmacists, hospital administrators, and government entities with an interest in public health. In this article, we discuss how to best conduct clinical studies to demonstrate and communicate clinical utility to payers and to set reasonable expectations for what diagnostic manufacturers should be required to demonstrate to support reimbursement from commercial payers and utilization by hospital systems.
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Tickoo M, Ruthazer R, Bardia A, Doron S, Andujar-Vazquez GM, Gardiner BJ, Snydman DR, Kurz SG. The effect of respiratory viral assay panel on antibiotic prescription patterns at discharge in adults admitted with mild to moderate acute exacerbation of COPD: a retrospective before- after study. BMC Pulm Med 2019; 19:118. [PMID: 31262278 PMCID: PMC6604457 DOI: 10.1186/s12890-019-0872-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 06/10/2019] [Indexed: 11/10/2022] Open
Abstract
Background Despite well-defined criteria for use of antibiotics in patients presenting with mild to moderate Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD), their overuse is widespread. We hypothesized that following implementation of a molecular multiplex respiratory viral panel (RVP), AECOPD patients with viral infections would be more easily identified, limiting antibiotic use in this population. The primary objective of our study was to investigate if availability of the RVP decreased antibiotic prescription at discharge among patients with AECOPD. Methods This is a single center, retrospective, before (pre-RVP) - after (post-RVP) study of patients admitted to a tertiary medical center from January 2013 to March 2016. The primary outcome was antibiotic prescription at discharge. Groups were compared using univariable and multivariable logistic-regression. Results A total of 232 patient-episodes were identified, 133 following RVP introduction. Mean age was 68.1 (pre-RVP) and 68.3 (post-RVP) years respectively (p = 0.88). Patients in pre-RVP group were similar to the post-RVP group with respect to gender (p = 0.54), proportion of patients with BMI < 21(p = 0.23), positive smoking status (p = 0.19) and diagnoses of obstructive sleep apnea (OSA, p = 0.16). We found a significant reduction in antibiotic prescription rate at discharge in patients admitted with AECOPD after introduction of the respiratory viral assay (pre-RVP 77.8% vs. post-RVP 63.2%, p = 0.01). In adjusted analyses, patients in the pre-RVP group [OR 2.11 (CI: 1.13–3.96), p = 0.019] with positive gram stain in sputum [OR 4.02 (CI: 1.61–10.06), p = 0.003] had the highest odds of antibiotic prescription at discharge. Conclusions In patients presenting with mild to moderate Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD), utilization of a comprehensive respiratory viral panel can significantly decrease the rate of antibiotic prescription at discharge.
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Affiliation(s)
- Mayanka Tickoo
- Department of Internal Medicine, Division of Pulmonary, Sleep and Critical Care, Yale School of Medicine, New Haven, CT, USA.
| | - Robin Ruthazer
- Biostatistics, Epidemiology, Research, and Design Center, Tufts Clinical and Translational Science Institute, Tufts University School of Medicine, Boston, MA, USA
| | - Amit Bardia
- Department of Anesthesiology, Yale School of Medicine, New Haven, CT, USA
| | - Shira Doron
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Gabriela M Andujar-Vazquez
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Bradley J Gardiner
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - David R Snydman
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Sebastian G Kurz
- Pulmonary and Critical Care Division, Mount Sinai National Jewish Respiratory Institute, New York, NY, USA
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Drews SJ, Branche AR, Falsey AR, Lee N. What is the role of rapid molecular testing for seniors and other at-risk adults with respiratory syncytial virus infections? J Clin Virol 2019; 117:27-32. [PMID: 31158780 DOI: 10.1016/j.jcv.2019.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 12/16/2022]
Abstract
Lower respiratory tract infections are a leading cause of hospitalization and viruses are important causal pathogens, especially in the elderly, immunocompromised patients and those with respiratory or cardiovascular comorbidities. Respiratory syncytial virus (RSV) is recognized as comprising a substantial burden of morbidity and mortality in older and at-risk adults, and the emergence of rapid point-of-care molecular testing has made it possible to confirm an RSV diagnosis accurately, in a clinically actionable timeframe. RSV patients have significantly higher healthcare resource use (including hospital stays and emergency room/urgent care visits) than non-RSV matched controls, especially if aged ≥65 years, a longer length of hospitalization than those with influenza, and associated costs nearly three times higher. We found no direct clinical outcome data specific to rapid molecular testing for RSV in adults and very little in children. There is very limited evidence that prompt diagnosis may reduce hospital length of stay but this and other outcome parameters need confirmation in larger, prospective clinical trials. Regarding reducing inappropriate antibiotic prescribing, the picture is mixed and testing alone is unlikely to change entrenched habits. There is little incentive for clinicians to order routine RSV tests in adults given the absence of a specific antiviral therapy. However, with numerous vaccine and antiviral candidates in clinical development, we believe it is good practice to plan and start establishing standardized testing protocols - perhaps as part of outcome studies. For especially vulnerable patients, e.g., immunocompromised and transplant patients, prompt accurate RSV diagnosis may prevent disease spread and save lives.
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Affiliation(s)
- Steven J Drews
- 2B1.03 WMC University of Alberta Hospital, 8440 112th St NW, Edmonton, Alberta, T6J 1L9, Canada.
| | - Angela R Branche
- University of Rochester, 601 Elmwood Avenue, Box 689, Rochester, NY 14642, USA.
| | - Ann R Falsey
- 1425 Portland Avenue, Rochester General Hospital, Rochester, NY 14621, USA.
| | - Nelson Lee
- Division of Infectious Diseases, Department of Medicine, University of Alberta, Clinical Sciences Building (CSB), 1-124, 11350-83 Avenue NW, Edmonton, Alberta, T6G 2G3, Canada.
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Maignan M, Viglino D, Hablot M, Termoz Masson N, Lebeugle A, Collomb Muret R, Mabiala Makele P, Guglielmetti V, Morand P, Lupo J, Forget V, Landelle C, Larrat S. Diagnostic accuracy of a rapid RT-PCR assay for point-of-care detection of influenza A/B virus at emergency department admission: A prospective evaluation during the 2017/2018 influenza season. PLoS One 2019; 14:e0216308. [PMID: 31063477 PMCID: PMC6504036 DOI: 10.1371/journal.pone.0216308] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/17/2019] [Indexed: 01/13/2023] Open
Abstract
STUDY OBJECTIVE To investigate the performance of a rapid RT-PCR assay to detect influenza A/B at emergency department admission. METHODS This single-center prospective study recruited adult patients attending the emergency department for influenza-like illness. Triage nurses performed nasopharyngeal swab samples and ran rapid RT-PCR assays using a dedicated device (cobas Liat, Roche Diagnostics, Meylan, France) located at triage. The same swab sample was also analyzed in the department of virology using conventional RT-PCR techniques. Patients were included 24 hours-a-day, 7 days-a-week. The primary outcome was the diagnostic accuracy of the rapid RT-PCR assay performed at triage. RESULTS A total of 187 patients were included over 11 days in January 2018. Median age was 70 years (interquartile range 44 to 84) and 95 (51%) were male. Nine (5%) assays had to be repeated due to failure of the first assay. The sensitivity of the rapid RT-PCR assay performed at triage was 0.98 (95% confidence interval (CI): 0.91-1.00) and the specificity was 0.99 (95% CI: 0.94-1.00). A total of 92 (49%) assays were performed at night-time or during the weekend. The median time from patient entry to rapid RT-PCR assay results was 46 [interquartile range 36-55] minutes. CONCLUSION Rapid RT-PCR assay performed by nurses at triage to detect influenza A/B is feasible and highly accurate.
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Affiliation(s)
- Maxime Maignan
- HP2 INSERM U1042, University Grenoble Alpes, Emergency department, Grenoble Alpes University Hospital, Grenoble, France
- * E-mail:
| | - Damien Viglino
- HP2 INSERM U1042, University Grenoble Alpes, Emergency department, Grenoble Alpes University Hospital, Grenoble, France
| | - Maud Hablot
- HP2 INSERM U1042, University Grenoble Alpes, Emergency department, Grenoble Alpes University Hospital, Grenoble, France
| | - Nicolas Termoz Masson
- HP2 INSERM U1042, University Grenoble Alpes, Emergency department, Grenoble Alpes University Hospital, Grenoble, France
| | - Anne Lebeugle
- HP2 INSERM U1042, University Grenoble Alpes, Emergency department, Grenoble Alpes University Hospital, Grenoble, France
| | - Roselyne Collomb Muret
- HP2 INSERM U1042, University Grenoble Alpes, Emergency department, Grenoble Alpes University Hospital, Grenoble, France
| | - Prudence Mabiala Makele
- HP2 INSERM U1042, University Grenoble Alpes, Emergency department, Grenoble Alpes University Hospital, Grenoble, France
| | - Valérie Guglielmetti
- HP2 INSERM U1042, University Grenoble Alpes, Emergency department, Grenoble Alpes University Hospital, Grenoble, France
| | - Patrice Morand
- Institut de Biologie Structurale (IBS), CEA, CNRS, University Grenoble Alpes, Laboratoire de Virologie, Grenoble Alpes University Hospital, Grenoble, France
| | - Julien Lupo
- Institut de Biologie Structurale (IBS), CEA, CNRS, University Grenoble Alpes, Laboratoire de Virologie, Grenoble Alpes University Hospital, Grenoble, France
| | - Virginie Forget
- TIMC-IMAG, CNRS, Grenoble INP, University Grenoble Alpes, Infection Control Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Caroline Landelle
- TIMC-IMAG, CNRS, Grenoble INP, University Grenoble Alpes, Infection Control Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Sylvie Larrat
- Institut de Biologie Structurale (IBS), CEA, CNRS, University Grenoble Alpes, Laboratoire de Virologie, Grenoble Alpes University Hospital, Grenoble, France
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Uyeki TM, Bernstein HH, Bradley JS, Englund JA, File TM, Fry AM, Gravenstein S, Hayden FG, Harper SA, Hirshon JM, Ison MG, Johnston BL, Knight SL, McGeer A, Riley LE, Wolfe CR, Alexander PE, Pavia AT. Clinical Practice Guidelines by the Infectious Diseases Society of America: 2018 Update on Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management of Seasonal Influenzaa. Clin Infect Dis 2019; 68. [PMID: 30566567 PMCID: PMC6653685 DOI: 10.1093/cid/ciy866 10.1093/cid/ciz044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
These clinical practice guidelines are an update of the guidelines published by the Infectious Diseases Society of America (IDSA) in 2009, prior to the 2009 H1N1 influenza pandemic. This document addresses new information regarding diagnostic testing, treatment and chemoprophylaxis with antiviral medications, and issues related to institutional outbreak management for seasonal influenza. It is intended for use by primary care clinicians, obstetricians, emergency medicine providers, hospitalists, laboratorians, and infectious disease specialists, as well as other clinicians managing patients with suspected or laboratory-confirmed influenza. The guidelines consider the care of children and adults, including special populations such as pregnant and postpartum women and immunocompromised patients.
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Affiliation(s)
- Timothy M Uyeki
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Henry H Bernstein
- Division of General Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
| | - John S Bradley
- Division of Infectious Diseases, Rady Children's Hospital
- University of California, San Diego
| | - Janet A Englund
- Department of Pediatrics, University of Washington, Seattle Children's Hospital
| | - Thomas M File
- Division of Infectious Diseases Summa Health, Northeast Ohio Medical University, Rootstown
| | - Alicia M Fry
- Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Stefan Gravenstein
- Providence Veterans Affairs Medical Center and Center for Gerontology and Healthcare Research, Brown University, Providence, Rhode Island
| | - Frederick G Hayden
- Division of Infectious Diseases and International Health, University of Virginia Health System, Charlottesville
| | - Scott A Harper
- Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jon Mark Hirshon
- Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
| | - Michael G Ison
- Divisions of Infectious Diseases and Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - B Lynn Johnston
- Department of Medicine, Dalhousie University, Nova Scotia Health Authority, Halifax, Canada
| | - Shandra L Knight
- Library and Knowledge Services, National Jewish Health, Denver, Colorado
| | - Allison McGeer
- Division of Infection Prevention and Control, Sinai Health System, University of Toronto, Ontario, Canada
| | - Laura E Riley
- Department of Maternal-Fetal Medicine, Massachusetts General Hospital, Boston
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Paul E Alexander
- McMaster University, Hamilton, Ontario, Canada
- Infectious Diseases Society of America, Arlington, Virginia
| | - Andrew T Pavia
- Division of Pediatric Infectious Diseases, University of Utah, Salt Lake City
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37
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Hayashi D, Akashi Y, Suzuki H, Shiigai M, Kanemoto K, Notake S, Ishiodori T, Ishikawa H, Imai H. Implementation of Point-of-Care Molecular Diagnostics for Mycoplasma pneumoniae Ensures the Correct Antimicrobial Prescription for Pediatric Pneumonia Patients. TOHOKU J EXP MED 2019; 246:225-231. [PMID: 30541996 DOI: 10.1620/tjem.246.225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Mycoplasma pneumoniae is a leading causative pathogen of pneumonia among pediatric patients, and its accurate diagnosis may aid in the selection of appropriate antimicrobial agents. We established a rapid reporting system of a polymerase chain reaction (PCR) examination for M. pneumoniae that enables physicians to obtain test results approximately 90 minutes after ordering the test. In this study, we evaluated the impact of this system on antimicrobial prescriptions for pediatric pneumonia patients after its implementation from May 2016 to April 2017. In total, we identified 375 pediatric pneumonia patients, and the results of the rapid PCR examinations for Mycoplasma pneumoniae were reported immediately in 90.7% of patients (340/375), with physicians able to use these results to decide on patients' management before the prescription of antimicrobial agents. Of the 375 pediatric pneumoniae patients, M. pneumoniae was detected in 223 (59.5%). Among the 223 M. pneumoniae-positive pneumonia cases, antimicrobial agents for atypical pathogens (macrolides, tetracyclines or quinolones) were prescribed in 97.3% (217/223) at the initial evaluation, and their prescription rates increased to 99.1% (221/223) during management. In contrast, antimicrobial agents for atypical pathogens were prescribed only in 10.5% of 152 M. pneumoniae-negative pneumonia cases at the initial evaluations, and only 1 additional case was prescribed clarithromycin for persistent symptoms during management. In conclusion, we show that molecular technology could be applicable in the field of point-of-care testing in infectious disease, and its implementation will ensure the correct antimicrobial prescription for pediatric pneumonia patients.
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Affiliation(s)
| | - Yusaku Akashi
- Division of Infectious Diseases, Department of Medicine, Tsukuba Medical Center Hospital
| | - Hiromichi Suzuki
- Division of Infectious Diseases, Department of Medicine, Tsukuba Medical Center Hospital
| | | | - Koji Kanemoto
- Department of Respiratory Medicine, Tsukuba Medical Center Hospital
| | - Shigeyuki Notake
- Department of Clinical Laboratory, Tsukuba Medical Center Hospital
| | | | | | - Hironori Imai
- Department of Pediatrics, Tsukuba Medical Center Hospital
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38
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Schmitz JE, Tang YW. The GenMark ePlex ®: another weapon in the syndromic arsenal for infection diagnosis. Future Microbiol 2018; 13:1697-1708. [PMID: 30547684 DOI: 10.2217/fmb-2018-0258] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
As one of the most recent additions to the syndromic testing landscape, the ePlex® platform by GenMark Diagnostics is a system that combines the manufacturer's signature electrochemical detection technology with updated microfluidics, providing a new option for multiplex testing that is both rapid and requires minimal hands-on steps. In this review, we detail the ePlex platform and its current/future syndromic panels, with a particular focus on the respiratory pathogen panel - the platform's first assay to undergo clinical trials and receive regulatory approval in the USA. By keeping informed of these ever-expanding laboratory options, clinicians and microbiologists can stay positioned at the forefront of infectious disease diagnosis.
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Affiliation(s)
- Jonathan E Schmitz
- Department of Pathology, Microbiology, & Immunology, Vanderbilt University Medical Center & School of Medicine, Nashville, TN 37232, USA
| | - Yi-Wei Tang
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065 USA.,Department of Pathology & Laboratory Medicine, Weill Cornell Medical College, New York, NY 10065 USA
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39
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Practical Guidance for Clinical Microbiology Laboratories: Viruses Causing Acute Respiratory Tract Infections. Clin Microbiol Rev 2018; 32:32/1/e00042-18. [PMID: 30541871 DOI: 10.1128/cmr.00042-18] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Respiratory viral infections are associated with a wide range of acute syndromes and infectious disease processes in children and adults worldwide. Many viruses are implicated in these infections, and these viruses are spread largely via respiratory means between humans but also occasionally from animals to humans. This article is an American Society for Microbiology (ASM)-sponsored Practical Guidance for Clinical Microbiology (PGCM) document identifying best practices for diagnosis and characterization of viruses that cause acute respiratory infections and replaces the most recent prior version of the ASM-sponsored Cumitech 21 document, Laboratory Diagnosis of Viral Respiratory Disease, published in 1986. The scope of the original document was quite broad, with an emphasis on clinical diagnosis of a wide variety of infectious agents and laboratory focus on antigen detection and viral culture. The new PGCM document is designed to be used by laboratorians in a wide variety of diagnostic and public health microbiology/virology laboratory settings worldwide. The article provides guidance to a rapidly changing field of diagnostics and outlines the epidemiology and clinical impact of acute respiratory viral infections, including preferred methods of specimen collection and current methods for diagnosis and characterization of viral pathogens causing acute respiratory tract infections. Compared to the case in 1986, molecular techniques are now the preferred diagnostic approaches for the detection of acute respiratory viruses, and they allow for automation, high-throughput workflows, and near-patient testing. These changes require quality assurance programs to prevent laboratory contamination as well as strong preanalytical screening approaches to utilize laboratory resources appropriately. Appropriate guidance from laboratorians to stakeholders will allow for appropriate specimen collection, as well as correct test ordering that will quickly identify highly transmissible emerging pathogens.
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40
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Near point-of-care adoption of Cepheid Xpert® Flu/RSV XC testing within an integrated healthcare delivery network. Diagn Microbiol Infect Dis 2018; 94:28-29. [PMID: 30581009 DOI: 10.1016/j.diagmicrobio.2018.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 11/14/2018] [Accepted: 11/16/2018] [Indexed: 11/22/2022]
Abstract
Flu/RSV testing was implemented in out-patient clinic-based physician office laboratories throughout Pennsylvania. On-site testing reduced the collect-to-result time by 70% when compared to testing in a centralized core laboratory; over- or under-treatment for influenza A and B (measured by anti-viral prescription) was reduced by 15% (P < 0.0001). Antimicrobial prescription was not affected by on-site testing.
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41
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Beganovic M, McCreary EK, Mahoney MV, Dionne B, Green DA, Timbrook TT. Interplay between Rapid Diagnostic Tests and Antimicrobial Stewardship Programs among Patients with Bloodstream and Other Severe Infections. J Appl Lab Med 2018; 3:601-616. [PMID: 31639729 DOI: 10.1373/jalm.2018.026450] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 09/04/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Antimicrobial stewardship programs (ASPs) aim to provide optimal antimicrobial therapy to patients quickly to improve the likelihood of overcoming infection while reducing the risk of adverse effects. Rapid diagnostic tests (RDTs) for infectious diseases have become an integral tool for ASPs to achieve these aims. CONTENT This review explored the demonstrated clinical value of longer-standing technologies and implications of newer RDTs from an antimicrobial stewardship perspective. Based on available literature, the focus was on the use of RDTs in bloodstream infections (BSIs), particularly those that perform organism identification and genotypic resistance detection, phenotypic susceptibility testing, and direct specimen testing. Clinical implications of rapid testing among respiratory, central nervous system, and gastrointestinal infections are also reviewed. SUMMARY Coupling RDTs with ASPs facilitates the appropriate and timely use of test results, translating into improved patient outcomes through optimization of antimicrobial use. These benefits are best demonstrated in the use of RDT in BSIs. Rapid phenotypic susceptibility testing offers the potential for early pharmacokinetic/pharmacodynamic optimization, and direct specimen testing on blood may allow ASPs to initiate appropriate therapy and/or tailor empiric therapy even sooner than other RDTs. RDTs for respiratory, central nervous system, and gastrointestinal illnesses have also shown significant promise, although more outcome studies are needed to evaluate their full impact.
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Affiliation(s)
- Maya Beganovic
- Advocate Lutheran General Hospital, Department of Pharmacy, Park Ridge, IL
| | - Erin K McCreary
- University of Pittsburgh Medical Center, Department of Pharmacy, Pittsburgh, PA
| | - Monica V Mahoney
- Beth Israel Deaconess Medical Center, Department of Pharmacy, Boston, MA
| | - Brandon Dionne
- Northeastern University, School of Pharmacy, Bouvé College of Health Sciences, Boston, MA.,Brigham and Women's Hospital, Department of Pharmacy, Boston, MA
| | - Daniel A Green
- Columbia University College of Physicians and Surgeons, New York, NY
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42
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Madigan VM, Sinickas VG, Giltrap D, Kyriakou P, Ryan K, Chan HT, Clifford V. Health service impact of testing for respiratory pathogens using cartridge-based multiplex array versus molecular batch testing. Pathology 2018; 50:758-763. [PMID: 30389216 PMCID: PMC7111697 DOI: 10.1016/j.pathol.2018.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/18/2018] [Accepted: 08/23/2018] [Indexed: 12/26/2022]
Abstract
There is increasing demand for access to rapid microbiological testing, with a view to improving clinical outcomes. The possibility of rapid testing has been facilitated by development of cartridge-based random access molecular technologies that are now widely available. Whether the expense of cartridge-based assays is justified in terms of clinical or laboratory cost savings is controversial. This prospective study evaluated the impact of the Biofire FilmArray Respiratory Panel (‘FilmArray’), a cartridge-based random access molecular test, compared with standard batched molecular testing using an ‘in-house’ respiratory polymerase chain reaction (PCR) on laboratory and health service outcomes for adult patients at a tertiary-level adult hospital in Melbourne, Australia. Laboratory result turnaround time was significantly reduced with the FilmArray (median 4.4 h) compared to a standard validated in-house respiratory PCR assay (median 21.6 h, p < 0.0001) and there was a significant increase in diagnostic yield with the Filmarray (71/124, 57.3%) compared to in-house PCR (79/200; 39.5%; p = 0.002). Despite improved result turnaround time and increased diagnostic yield from testing, there was no corresponding reduction in hospital length of stay or use of isolation beds. Although cartridge-based molecular testing reduced turnaround time to result for respiratory pathogen testing, it did not impact on health service outcomes such as hospital length of stay. Further work is warranted to determine whether cartridge-based tests at the point of care can improve clinical and health service impacts.
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Affiliation(s)
- Victoria M Madigan
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Vic, Australia.
| | - Vincent G Sinickas
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Dawn Giltrap
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Peter Kyriakou
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Katherine Ryan
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Hiu-Tat Chan
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Vanessa Clifford
- Microbiology Department, Royal Melbourne Hospital, Melbourne, Vic, Australia; The University of Melbourne, Melbourne, Vic, Australia; Murdoch Children's Research Institute, Parkville, Vic, Australia
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43
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Abstract
The emergency department (ED) is the hub of the US health care system. Acute infectious diseases are frequently encountered in the ED setting, making this a critical setting for antimicrobial stewardship efforts. Systems level and behavioral stewardship interventions have demonstrated success in the ED setting but successful implementation depends on institutional support and the presence of a physician champion. Antimicrobial stewardship efforts in the ED should target high-impact areas: antibiotic prescribing for nonindicated respiratory tract conditions, such as bronchitis and sinusitis; overtreatment of asymptomatic bacteriuria; and using two antibiotics (double coverage) for uncomplicated cases of cellulitis or abscess.
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Affiliation(s)
- Michael Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
| | - Robert Redwood
- Department of Family Medicine and Community Health, University of Wisconsin Madison School of Medicine and Public Health, 1100 Delaplaine Ct, Madison, WI 53715
| | - Larissa May
- Department of Emergency Medicine, University of California Davis, 4150 V Street, Suite 2100, Sacramento, CA 95817, USA
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44
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Das S, Dunbar S, Tang YW. Laboratory Diagnosis of Respiratory Tract Infections in Children - the State of the Art. Front Microbiol 2018; 9:2478. [PMID: 30405553 PMCID: PMC6200861 DOI: 10.3389/fmicb.2018.02478] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 09/28/2018] [Indexed: 12/13/2022] Open
Abstract
In the pediatric population, respiratory infections are the most common cause of physician visits. Although many respiratory illnesses are self-limiting viral infections that resolve with time and supportive care, it can be critical to identify the causative pathogen at an early stage of the disease in order to implement effective antimicrobial therapy and infection control. Over the last few years, diagnostics for respiratory infections have evolved substantially, with the development of novel assays and the availability of updated tests for newer strains of pathogens. Newer laboratory methods are rapid, highly sensitive and specific, and are gradually replacing the conventional gold standards, although the clinical utility of these assays is still under evaluation. This article reviews the current laboratory methods available for testing for respiratory pathogens and discusses the advantages and disadvantages of each approach.
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Affiliation(s)
- Shubhagata Das
- Global Scientific Affairs, Luminex Corporation, Austin, TX, United States
| | - Sherry Dunbar
- Global Scientific Affairs, Luminex Corporation, Austin, TX, United States
| | - Yi-Wei Tang
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, Weill Medical College of Cornell University, New York, NY, United States.,Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, Weill Medical College of Cornell University, New York, NY, United States
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45
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Babady N. Importance of accuracy of multiplex PCR systems for rapid diagnosis of respiratory virus infection. Clin Microbiol Infect 2018; 24:1033-1034. [DOI: 10.1016/j.cmi.2018.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 05/22/2018] [Accepted: 05/26/2018] [Indexed: 10/14/2022]
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46
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Rapid Antigen Tests for Influenza: Rationale and Significance of the FDA Reclassification. J Clin Microbiol 2018; 56:JCM.00711-18. [PMID: 29899007 DOI: 10.1128/jcm.00711-18] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Rapid antigen tests for influenza, here referred to as rapid influenza diagnostic tests (RIDTs), have been widely used for the diagnosis of influenza since their introduction in the 1990s due to their ease of use, rapid results, and suitability for point of care (POC) testing. However, issues related to the diagnostic sensitivity of these assays have been known for decades, and these issues gained greater attention following reports of their poor performance during the 2009 influenza A(H1N1) pandemic. In turn, significant concerns arose about the consequences of false-negative results, which could pose significant risks to both individual patient care and to public health efforts. In response to these concerns, the FDA convened an advisory panel in June 2013 to discuss options to improve the regulation of the performance of RIDTs. A proposed order was published on 22 May 2014, and the final order published on 12 January 2017, reclassifying RIDTs from class I to class II medical devices, with additional requirements to comply with four new special controls. This reclassification is a landmark achievement in the regulation of diagnostic devices for infectious diseases and has important consequences for the future of diagnostic influenza testing with commercial tests, warranting the prompt attention of clinical laboratories, health care systems, and health care providers.
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47
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Echavarría M, Marcone DN, Querci M, Seoane A, Ypas M, Videla C, O'Farrell C, Vidaurreta S, Ekstrom J, Carballal G. Clinical impact of rapid molecular detection of respiratory pathogens in patients with acute respiratory infection. J Clin Virol 2018; 108:90-95. [PMID: 30267999 PMCID: PMC7172208 DOI: 10.1016/j.jcv.2018.09.009] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 11/24/2022]
Abstract
Diagnosis with FilmArray-RP was associated with changes in medical management. Accurate and rapid diagnosis decreased antibiotic use and complementary studies, and improved oseltamivir use. The multiplex PCR respiratory panel permitted a high viral detection rate not only in children but in adults.
Background Acute respiratory infections (ARI) are a leading cause of morbidity and mortality worldwide. There is a need to demonstrate the clinical impact of using the new, rapid and sensitive molecular assays in prospectively designed studies. Objectives To study the impact on medical management of a rapid molecular assay in patients with respiratory infections. Study design A prospective, randomized, non-blinded study was performed in patients presenting to the Emergency Department during two respiratory seasons (2016–2017). Diagnosis was performed by FilmArray Respiratory Panel (FilmArray-RP) or by immunofluorescence assay (IFA). Results A total of 432 patients (156 children and 276 adults) were analyzed. Diagnosis with FilmArray-RP was associated with significant changes in medical management including withholding antibiotic prescriptions (OR:15.52, 95%CI:1.99–120.83 in adults and OR:12.23, 95%CI:1.56–96.09 in children), and reduction in complementary studies in children (OR:9.64, 95%CI:2.13–43.63) compared to IFA. Decrease in oseltamivir prescriptions was significantly higher in adults in the FilmArray-RP group (p = 0.042; OR:1.19, 95%CI:0.51-2.79) compared to adults managed with IFA. Diagnostic yield was significantly higher by FilmArray-RP (81%) than by IFA (31%)(p < 0.001). The median time from sample collection to reporting was 1 h 52 min by FilmArray-RP and 26 h by IFA (p < 0.001). Conclusions The high respiratory viruses’ detection rate and availability of results within two hours when using FilmArray-RP were associated with decreases in antibiotic prescriptions and complementary studies and more accurate use of oseltamivir.
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Affiliation(s)
- M Echavarría
- Clinical Virology Unit, Centro de Educación Médica e Investigaciones Clínicas "CEMIC" - Consejo Nacional de Investigaciones Científicas y Técnicas "CONICET", Av. Galván 4102 (1431), Buenos Aires City, Argentina; Virology Laboratory, Centro de Educación Médica e Investigaciones Clínicas "CEMIC" - Consejo Nacional de Investigaciones Científicas y Técnicas "CONICET", Av. Galván 4102 (1431), Buenos Aires City, Argentina.
| | - D N Marcone
- Clinical Virology Unit, Centro de Educación Médica e Investigaciones Clínicas "CEMIC" - Consejo Nacional de Investigaciones Científicas y Técnicas "CONICET", Av. Galván 4102 (1431), Buenos Aires City, Argentina
| | - M Querci
- Infectious Diseases Section, Centro de Educación Médica e Investigaciones Clínicas "CEMIC", Av. Galván 4102 (1431), Buenos Aires City, Argentina
| | - A Seoane
- Emergency Department, Centro de Educación Médica e Investigaciones Clínicas "CEMIC", Av. Galván 4102 (1431), Buenos Aires City, Argentina
| | - M Ypas
- Emergency Department, Centro de Educación Médica e Investigaciones Clínicas "CEMIC", Av. Galván 4102 (1431), Buenos Aires City, Argentina
| | - C Videla
- Virology Laboratory, Centro de Educación Médica e Investigaciones Clínicas "CEMIC" - Consejo Nacional de Investigaciones Científicas y Técnicas "CONICET", Av. Galván 4102 (1431), Buenos Aires City, Argentina
| | - C O'Farrell
- Clinical Virology Unit, Centro de Educación Médica e Investigaciones Clínicas "CEMIC" - Consejo Nacional de Investigaciones Científicas y Técnicas "CONICET", Av. Galván 4102 (1431), Buenos Aires City, Argentina; Instituto Universitario CEMIC, Centro de Educación Médica e Investigaciones Clínicas "CEMIC", Av. Galván 4102 (1431), Buenos Aires City, Argentina
| | - S Vidaurreta
- Pediatric Department, Centro de Educación Médica e Investigaciones Clínicas "CEMIC", Av. Galván 4102 (1431), Buenos Aires City, Argentina
| | - J Ekstrom
- Pediatric Department, Centro de Educación Médica e Investigaciones Clínicas "CEMIC", Av. Galván 4102 (1431), Buenos Aires City, Argentina
| | - G Carballal
- Clinical Virology Unit, Centro de Educación Médica e Investigaciones Clínicas "CEMIC" - Consejo Nacional de Investigaciones Científicas y Técnicas "CONICET", Av. Galván 4102 (1431), Buenos Aires City, Argentina
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48
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Quah J, Jiang B, Tan PC, Siau C, Tan TY. Impact of microbial Aetiology on mortality in severe community-acquired pneumonia. BMC Infect Dis 2018; 18:451. [PMID: 30180811 PMCID: PMC6122562 DOI: 10.1186/s12879-018-3366-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 08/29/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The impact of different classes of microbial pathogens on mortality in severe community-acquired pneumonia is not well elucidated. Previous studies have shown significant variation in the incidence of viral, bacterial and mixed infections, with conflicting risk associations for mortality. We aimed to determine the risk association of microbial aetiologies with hospital mortality in severe CAP, utilising a diagnostic strategy incorporating molecular testing. Our primary hypothesis was that respiratory viruses were important causative pathogens in severe CAP and was associated with increased mortality when present with bacterial pathogens in mixed viral-bacterial co-infections. METHODS A retrospective cohort study from January 2014 to July 2015 was conducted in a tertiary hospital medical intensive care unit in eastern Singapore, which has a tropical climate. All patients diagnosed with severe community-acquired pneumonia were included. RESULTS A total of 117 patients were in the study. Microbial pathogens were identified in 84 (71.8%) patients. Mixed viral-bacterial co-infections occurred in 18 (15.4%) of patients. Isolated viral infections were present in 32 patients (27.4%); isolated bacterial infections were detected in 34 patients (29.1%). Hospital mortality occurred in 16 (13.7%) patients. The most common bacteria isolated was Streptococcus pneumoniae and the most common virus isolated was Influenza A. Univariate and multivariate logistic regression showed that serum procalcitonin, APACHE II severity score and mixed viral-bacterial infection were associated with increased risk of hospital mortality. Mixed viral-bacterial co-infections were associated with an adjusted odds ratio of 13.99 (95% CI 1.30-151.05, p = 0.03) for hospital mortality. CONCLUSIONS Respiratory viruses are common organisms isolated in severe community-acquired pneumonia. Mixed viral-bacterial infections may be associated with an increased risk of mortality.
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Affiliation(s)
- Jessica Quah
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, SingHealth, 2 Simei Street 3, Postal Code, Singapore, 529889, Singapore.
| | - Boran Jiang
- Department of Laboratory Medicine, Changi General Hospital, SingHealth, Singapore, Singapore
| | - Poh Choo Tan
- Department of Advanced Nursing Practice, Changi General Hospital, SingHealth, Singapore, Singapore
| | - Chuin Siau
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, SingHealth, 2 Simei Street 3, Postal Code, Singapore, 529889, Singapore
| | - Thean Yen Tan
- Department of Laboratory Medicine, Changi General Hospital, SingHealth, Singapore, Singapore
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49
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Timbrook TT, Spivak ES, Hanson KE. Current and Future Opportunities for Rapid Diagnostics in Antimicrobial Stewardship. Med Clin North Am 2018; 102:899-911. [PMID: 30126579 DOI: 10.1016/j.mcna.2018.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Rapid diagnostic testing has improved clinical care of patients with infectious syndromes when combined with antimicrobial stewardship. The authors review the current data on antimicrobial stewardship and rapid diagnostic testing in bloodstream, respiratory tract, and gastrointestinal tract infections. Evidence for the potential benefit of rapid tests in bloodstream infections seems strong, respiratory tract infections mixed, and gastrointestinal tract infections still evolving. The authors also review future directions in rapid diagnostic testing and suggest areas of focus for antimicrobial stewardship efforts.
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Affiliation(s)
- Tristan T Timbrook
- Department of Pharmacy, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132, USA
| | - Emily S Spivak
- Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - Kimberly E Hanson
- Department of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA; Institute for Clinical and Experimental Pathology, ARUP Laboratories, 500 Chipeta Way, Salt Lake City, UT 84108, USA; Department of Pathology, University of Utah, 15 North Medical Drive East, Salt Lake City, UT 84112, USA.
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50
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Kronman MP, Banerjee R, Duchon J, Gerber JS, Green MD, Hersh AL, Hyun D, Maples H, Nash CB, Parker S, Patel SJ, Saiman L, Tamma PD, Newland JG. Expanding Existing Antimicrobial Stewardship Programs in Pediatrics: What Comes Next. J Pediatric Infect Dis Soc 2018; 7:241-248. [PMID: 29267871 PMCID: PMC7107461 DOI: 10.1093/jpids/pix104] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Accepted: 09/08/2017] [Indexed: 02/06/2023]
Abstract
The prevalence of pediatric antimicrobial stewardship programs (ASPs) is increasing in acute care facilities across the United States. Over the past several years, the evidence base used to inform effective stewardship practices has expanded, and regulatory interest in stewardship programs has increased. Here, we review approaches for established, hospital-based pediatric ASPs to adapt and report standardized metrics, broaden their reach to specialized populations, expand to undertake novel stewardship initiatives, and implement rapid diagnostics to continue their evolution in improving antimicrobial use and patient outcomes.
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Affiliation(s)
- Matthew P Kronman
- Division of Infectious Diseases, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Ritu Banerjee
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Jennifer Duchon
- Division of Infectious Diseases, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael D Green
- Division of Infectious Diseases, Department of Pediatrics, University of Pittsburgh, Pennsylvania
| | - Adam L Hersh
- Division of Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Holly Maples
- Department of Pharmacy, University of Arkansas, Little Rock, Arkansas
| | - Colleen B Nash
- Division of Infectious Diseases, Department of Pediatrics, University of Chicago, Illinois
| | - Sarah Parker
- Division of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Sameer J Patel
- Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lisa Saiman
- Division of Infectious Diseases, Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Pranita D Tamma
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jason G Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University, St. Louis, Missouri
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