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Pavia AT, Cohen DM, Leber AL, Daly JA, Jackson JT, Selvarangan R, Kanwar N, Bender JM, Dien Bard J, Festekjian A, Duffy S, Larsen C, Holmberg KM, Bardsley T, Haaland B, Bourzac KM, Stockmann C, Chapin KC, Leung DT. Clinical Impact of Multiplex Molecular Diagnostic Testing in Children With Acute Gastroenteritis Presenting to an Emergency Department: A Multicenter Prospective Study. Clin Infect Dis 2024; 78:573-581. [PMID: 38097379 PMCID: PMC10954335 DOI: 10.1093/cid/ciad710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Indexed: 12/26/2023] Open
Abstract
BACKGROUND Multiplex molecular diagnostic panels have greatly enhanced detection of gastrointestinal pathogens. However, data on the impact of these tests on clinical and patient-centered outcomes are limited. METHODS We conducted a prospective, multicenter, stepped-wedge trial to determine the impact of multiplex molecular testing at 5 academic children's hospitals on children presenting to the emergency department with acute gastroenteritis. Caregivers were interviewed on enrollment and 7-10 days after enrollment to determine symptoms, risk factors, subsequent medical visits, and impact on family members. During the pre-intervention period, diagnostic testing was performed at the clinician's discretion . During the intervention period, multiplex molecular testing was performed on all children, with results available to clinicians. The primary outcome was return visits to a healthcare provider within 10 days of enrollment. RESULTS Potential pathogens were identified by clinician-ordered tests in 19 of 571 (3.3%) in the pre-intervention period compared with 434 of 586 (74%) in the intervention period; clinically relevant pathogens were detected in 2.1% and 15%, respectively. In the multivariate model, the intervention was associated with a 21% reduction in the odds of any return visit (odds ratio, 0.79; 95% confidence interval, .70-.90) after adjusting for potential confounders. Appropriate treatment was prescribed in 11.3% compared with 19.6% during the intervention period (P = .22). CONCLUSIONS Routine molecular multiplex testing for all children who presented to the ED with acute gastroenteritis detected more clinically relevant pathogens and led to a 21% decrease in return visits. Additional research is needed to define patients most likely to benefit from testing. Clinical Trials Registration. NCT02248285.
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Affiliation(s)
- Andrew T Pavia
- Departments of Pediatrics and Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Daniel M Cohen
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Amy L Leber
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Judy A Daly
- Department of Pathology, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | | | - Neena Kanwar
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Jeffrey M Bender
- Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jennifer Dien Bard
- Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Ara Festekjian
- Children's Hospital of Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Susan Duffy
- Department of Emergency Medicine, Hasbro Children's Hospital, Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Chari Larsen
- Departments of Pediatrics and Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Tyler Bardsley
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin Haaland
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Christopher Stockmann
- Departments of Pediatrics and Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Kimberle C Chapin
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Daniel T Leung
- Departments of Pediatrics and Internal Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Pathology, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
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Saif NT, Dooley C, Baghdadi JD, Morgan DJ, Coffey KC. Clinical decision support for gastrointestinal panel testing. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e22. [PMID: 38415090 PMCID: PMC10897720 DOI: 10.1017/ash.2024.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 02/29/2024]
Abstract
Objective This study aimed to assess the impact of clinical decision support (CDS) to improve ordering of multiplex gastrointestinal polymerase chain reaction (PCR) testing panel ("GI panel"). Design Single-center, retrospective, before-after study. Setting Tertiary care Veteran's Affairs (VA) Medical Center provides inpatient, outpatient, and residential care. Patients All patients tested with a GI panel between June 22, 2022 and April 20, 2023. Intervention We designed a CDS questionnaire in the electronic medical record (EMR) to guide appropriate ordering of the GI panel. A "soft stop" reminder at the point of ordering prompted providers to confirm five appropriateness criteria: 1) documented diarrhea, 2) no recent receipt of laxatives, 3) C. difficile is not the leading suspected cause of diarrhea, 4) time period since a prior test is >14 days or prior positive test is >4 weeks and 5) duration of hospitalization <72 hours. The CDS was implemented in November 2022. Results Compared to the pre-implementation period (n = 136), fewer tests were performed post-implementation (n = 92) with an IRR of 0.61 (p = 0.003). Inappropriate ordering based on laxative use or undocumented diarrhea decreased (IRR 0.37, p = 0.012 and IRR 0.25, p = 0.08, respectively). However, overall inappropriate ordering and outcome measures did not significantly differ before and after the intervention. Conclusions Implementation of CDS in the EMR decreased testing and inappropriate ordering based on use of laxatives or undocumented diarrhea. However, inappropriate ordering of tests overall remained high post-intervention, signaling the need for continued diagnostic stewardship efforts.
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Affiliation(s)
- Nadia T. Saif
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cara Dooley
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan D. Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J. Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Medicine, Veteran’s Affairs (VA) Maryland Healthcare System, Baltimore, MD, USA
| | - KC Coffey
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Medicine, Veteran’s Affairs (VA) Maryland Healthcare System, Baltimore, MD, USA
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Ambrosius-Eichner J, Hogardt M, Berger A, Dultz G, Idris R, Kempf VAJ, Wichelhaus TA. Comparative evaluation of the detection rate, workflow and associated costs of a multiplex PCR panel versus conventional methods in diagnosis of infectious gastroenteritis. J Med Microbiol 2024; 73. [PMID: 38362908 DOI: 10.1099/jmm.0.001795] [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: 02/17/2024] Open
Abstract
Introduction. Infectious gastroenteritis is a common reason for consulting a physician. Although most cases of gastrointestinal illness are self-limiting, the identification of the etiologic pathogen by stool specimen analysis is important in cases of more severe illness and for epidemiological reasons.Due to the broad range of causative pathogens, the conventional examination of a stool specimen is labour-intensive and usually requires different diagnostic methods. Multiplex PCR tests [e.g. BioFire Gastrointestinal (GI) Panel] allow the rapid detecting of up to 22 pathogens in one test.Hypothesis. Using a multiplex PCR panel to test stool specimens for infectious gastroenteritis pathogens can improve the detection rate, reduce the time-to-result and hands-on time and lower the costs of a microbiology laboratory.Aim. This study was aimed at evaluating the detection rate, the workflow and associated costs of stool specimen management using the BioFire GI Panel versus conventional methods.Methodology. Stool specimens were evaluated prospectively during the routine operation. Pathogen detection rate, hands-on time, time-to-result and material and personnel costs were determined for the BioFire GI Panel and conventional methods-the latter based on physician request and excluding viral testing.Results. Analysing 333 specimens collected between 2019 and 2020, the detection rate of enteropathogens was significantly higher with a positivity rate of 39.9 % using the multiplex PCR panel compared with 15.0 % using the conventional methods. The BioFire GI Panel presented results in a median time of 2.2 h compared with 77.5 h for culture and 22.1 h for antigen testing, noting that no tests were performed at weekends except for toxinogenic Clostridioides difficile. Based on list prices, the BioFire GI Panel was nine times more expensive compared with conventional methods, whereas hands-on-time was significantly lower using the BioFire GI Panel.Conclusion. Multiplex PCR panels are valuable tools for laboratory identification of infectious agents causing diarrhoea. The higher costs of such a multiplex PCR panel might be outweighed by the higher detection rate, ease of handling, rapid results and most likely improved patient management. However, these panels do not provide information on antimicrobial susceptibility testing. Therefore, if this is necessary for targeted therapy or if outbreak monitoring and control is required, specimens must still be cultured.
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Affiliation(s)
- J Ambrosius-Eichner
- Institute of Medical Microbiology and Infection Control, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- University Center for Infectious Diseases, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - M Hogardt
- Institute of Medical Microbiology and Infection Control, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- University Center for Infectious Diseases, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - A Berger
- University Center for Infectious Diseases, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Institute of Medical Virology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - G Dultz
- University Center for Infectious Diseases, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Department of Medicine I, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - R Idris
- University Center for Infectious Diseases, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- Department of Medicine II-Infectious Diseases, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - V A J Kempf
- Institute of Medical Microbiology and Infection Control, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- University Center for Infectious Diseases, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
| | - T A Wichelhaus
- Institute of Medical Microbiology and Infection Control, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
- University Center for Infectious Diseases, Goethe University Frankfurt, University Hospital, Frankfurt, Germany
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Kang HM, Yoo IH, Jeong DC. The role of rapid syndromic diagnostic testing of gastrointestinal pathogens as a clinical decision support tool in a pediatric emergency department. Ann Clin Microbiol Antimicrob 2024; 23:3. [PMID: 38183046 PMCID: PMC10770992 DOI: 10.1186/s12941-023-00662-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 12/16/2023] [Indexed: 01/07/2024] Open
Abstract
PURPOSE This study aimed to investigate the role of rapid syndromic diagnostic testing of gastrointestinal pathogens as a clinical decision support tool in a pediatric emergency department (ED) by comparing clinical decision and patient outcome parameters pre- and post-implementation. METHODS This was a big data analytical study of children < 18 years old without any underlying diseases, that visited the ED with acute moderate to severe diarrhea during a 34-month period from 2018 to 2022 using Seoul St. Mary's hospital's healthcare corporate data warehouse to retrieve demographic, clinical, and laboratory parameters. Outcome measures pre- and post-implementation of a rapid syndromic multiplex gastrointestinal panel (GI panel) were compared. RESULTS A total of 4,184 patients' data were included in the analyses. Broad spectrum antibiotics were prescribed at a significantly lower rate to patients presenting with acute infectious diarrhea at discharge from the ED (9.9% vs 15.8%, P < 0.001) as well as upon admission (52.2% vs 66.0%, P < 0.001) during the post-implementation period compared to the pre-implementation period. Although the duration of ED stay was found to be significantly longer (6.5 vs 5.5 h, P < 0.0001), the rate of ED revisit due to persistent or aggravated symptoms was significantly lower (Δ in intercept, β = -0.027; SE = 0.013; P = 0.041), and the admission rate at follow up after being discharged from the ED shown to be significantly lower during the post-implementation period compared to the pre-implementation period (0.8% vs. 2.1%, P = 0.001, respectively). No significant difference in disease progression was observed (P = 1.000). CONCLUSION Using the GI panel in the ED was shown to decrease broad spectrum antibiotic prescribing practices and reduce revisits or admission at follow up by aiding clinical decisions and improving patient outcome.
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Affiliation(s)
- Hyun Mi Kang
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- College of Medicine, Vaccine Bio Research Institute, The Catholic University of Korea, Seoul, Korea
| | - In Hyuk Yoo
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Dae Chul Jeong
- Department of Pediatrics, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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5
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Pavia AT, Cohen DM, Leber AL, Daly JA, Jackson JT, Selvarangan R, Kanwar N, Bender JM, Bard JD, Festekjian A, Duffy S, Larsen C, Holmberg KM, Bardsley T, Haaland B, Bourzac KM, Stockmann C, Chapin KC, Leung DT. Clinical Impact of Multiplex Molecular Diagnostic Testing in Children with Acute Gastroenteritis Presenting to An Emergency Department: A Multicenter Prospective Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.27.23293208. [PMID: 37577483 PMCID: PMC10418295 DOI: 10.1101/2023.07.27.23293208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Background Multiplex molecular diagnostic panels have greatly enhanced detection of gastrointestinal pathogens. However, data on the impact of these tests on clinical and patient-centered outcomes are limited. Methods We conducted a prospective, multicenter, stepped-wedge trial to determine the impact of multiplex molecular testing at five academic children's hospitals in children presenting to the ED with acute gastroenteritis. Caregivers were interviewed on enrollment and again 7-10 days after enrollment to determine symptoms, risk factors, subsequent medical visits, and impact on family members. During the pre-intervention period, diagnostic testing was performed at the discretion of clinicians. During the intervention period, multiplex molecular testing was performed on all children with results available to clinicians. Primary outcome was return visits to a health care provider within 10 days of enrollment. Results Potential pathogens were identified by clinician ordered tests in 19/571 (3.3%) in the pre-intervention period compared to 434/586 (74%) in the intervention period; clinically relevant pathogens were detected in 2.1% and 15% respectively. In the multivariate model adjusting for potential confounders, the intervention was associated with a 21% reduction in the odds of any return visit (OR 0.79; 95% CI 0.70-0.90). Appropriate treatment was prescribed in 11.3% compared to 19.6% during the intervention period(P=0.22). Conclusions Routine molecular multiplex testing for all children presenting to the ED with AGE detected more clinically relevant pathogens and led to a 21% decrease in return visits. Additional research is needed to define patients most likely to benefit from testing.
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Kakizaki N, Asai K, Kuroda M, Watanabe R, Kujiraoka M, Sekizuka T, Katagiri M, Moriyama H, Watanabe M, Saida Y. Rapid identification of bacteria using a multiplex polymerase chain reaction system for acute abdominal infections. Front Microbiol 2023; 14:1220651. [PMID: 37492262 PMCID: PMC10363666 DOI: 10.3389/fmicb.2023.1220651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 06/23/2023] [Indexed: 07/27/2023] Open
Abstract
Purpose Acute abdominal infections can be fatal if the causative organism (s) are misidentified. The spread of antimicrobial-resistant bacteria has become a serious problem worldwide, making antibiotic selection extremely difficult. Using quantitative metagenomic analysis, we evaluated a commercial multiplex polymerase chain reaction (PCR) system (FilmArray™, bioMérieux, Marcy-l'Étoile, France) for the rapid identification of causative bacteria. Methods The cases of 10 patients with acute abdominal infections were enrolled in this retrospective study. There were six cases of perforated peritonitis and four cases of intraabdominal abscess. Fluid collected from the acute surgical abdominal infections were examined. Results All specimens tested positive for microorganisms in culture, and six involved two or more microorganisms. Using the multiplex PCR system, nine of ten specimens were found to involve at least one microorganism. One specimen was not included in the multiplex PCR system panel. Nineteen of 21 microorganisms (90.5%) isolated by culture were detected by the multiplex PCR system. Microorganisms with very small numbers of reads (19 reads) were detectable. Conclusion This multiplex PCR system showed a high detection rate for causative microorganisms in ascites and intraabdominal abscesses. This system may be suitable as an affordable rapid identification system for causative bacteria in these cases.
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Affiliation(s)
- Nanako Kakizaki
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
- Department of Clinical Oncology, Toho University Graduate School of Medicine, Tokyo, Japan
| | - Koji Asai
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Makoto Kuroda
- Laboratory of Bacterial Genomics, National Institute of Infectious Diseases, Pathogen Genomics Center, Tokyo, Japan
| | - Ryutaro Watanabe
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Manabu Kujiraoka
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Tsuyoshi Sekizuka
- Laboratory of Bacterial Genomics, National Institute of Infectious Diseases, Pathogen Genomics Center, Tokyo, Japan
| | - Miwa Katagiri
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Hodaka Moriyama
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Manabu Watanabe
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yoshihisa Saida
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
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7
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Xie J, Kim K, Berenger BM, Chui L, Vanderkooi OG, Grisaru S, Freedman SB. Comparison of a Rapid Multiplex Gastrointestinal Panel with Standard Laboratory Testing in the Management of Children with Hematochezia in a Pediatric Emergency Department: Randomized Controlled Trial. Microbiol Spectr 2023; 11:e0026823. [PMID: 37039648 PMCID: PMC10269456 DOI: 10.1128/spectrum.00268-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 03/10/2023] [Indexed: 04/12/2023] Open
Abstract
Advances in diagnostic microbiology allow for the rapid identification of a broad range of enteropathogens; such knowledge can inform care and reduce testing. We conducted a randomized, unblinded trial in a tertiary-care pediatric emergency department. Participants had stool (and rectal swabs if stool was not immediately available) tested using routine microbiologic approaches or by use of a device (BioFire FilmArray gastrointestinal panel), which identifies 22 pathogens with a 1-h instrument turnaround time. Participants were 6 months to <18.0 years and had acute bloody diarrhea. Primary outcome was performance of blood tests within 72 h. From 15 June 2018 through 7 May 2022, 60 children were randomized. Patients in the BioFire FilmArray arm had a reduced time to test result (median 3.0 h with interquartile range [IQR] of 3.0 to 4.0 h, versus 42.0 h (IQR 23.5 to 47.3 h); difference of -38.0 h, 95% confidence interval [CI] of -41.0 to -22.0 h). Sixty-five percent (20/31) of participants in the BioFire FilmArray group had a pathogen detected-most frequently enteropathogenic Escherichia coli (19%), Campylobacter (16%), and Salmonella (13%). Blood tests were performed in 52% of children in the BioFire FilmArray group and 62% in the standard-of-care group (difference of -10.5%, 95% CI of -35.4% to 14.5%). There were no between-group differences in the proportions of children administered intravenous fluids, antibiotics, hospitalized, or who had diagnostic imaging performed. Testing with the BioFire FilmArray reduced the time to result availability by 38 h. Although statistical significance was limited by study power, BioFire FilmArray use was not associated with clinically meaningful reductions in health care utilization or improved outcomes. IMPORTANCE Advances in diagnostic microbiology now allow for the faster and more accurate detection of an increasing number of pathogens. We determined, however, that in children with acute bloody diarrhea, these advances did not necessarily translate into improved clinical outcomes. While a greater number of pathogens was identified using a rapid turnaround multiplex stool diagnostic panel, with a reduction in the time to stool test result of over 1.5 days, this did not alter the practice of pediatric emergency medicine physicians, who continued to perform blood tests on a large proportion of children. While our conclusions may be limited by the relatively small sample size, targeted approaches that educate clinicians on the implementation of such technology into clinical care will be needed to optimize usage and maximize benefits.
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Affiliation(s)
- Jianling Xie
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kelly Kim
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Byron M. Berenger
- Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Alberta Precision Laboratories, Alberta Health Services, Calgary, Alberta, Canada
| | - Linda Chui
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, Canada
- Alberta Precision Laboratories, Alberta Health Services, Edmonton, Alberta, Canada
| | - Otto G. Vanderkooi
- Section of Infectious Diseases, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Silviu Grisaru
- Section of Pediatric Nephrology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Stephen B. Freedman
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Section of Pediatric Gastroenterology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Panarelli NC. Infectious Mimics of Inflammatory Bowel Disease. Mod Pathol 2023:100210. [PMID: 37172904 DOI: 10.1016/j.modpat.2023.100210] [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: 03/28/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023]
Abstract
Distinguishing inflammatory bowel disease (IBD) from its mimics remains a diagnostic challenge for surgical pathologists. Several gastrointestinal infections produce inflammatory patterns that overlap with typical findings of IBD. Although stool culture, PCR, and other clinical assays may identify infectious enterocolitides, these tests may not be performed or the results may be unavailable at the time of histologic evaluation. Furthermore, some clinical tests, including stool PCR, may reflect past exposure rather than ongoing infection. It is important for surgical pathologists to be knowledgeable about infections that simulate IBD in order to generate an accurate differential diagnosis, perform appropriate ancillary studies, and prompt clinical follow-up. This review covers bacterial, fungal, and protozoal infections in the differential diagnosis of IBD.
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Affiliation(s)
- Nicole C Panarelli
- Department of Pathology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY.
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Carmon D, Rohana H, Azrad M, Peretz A. The Impact of a Positive Biofire® FilmArray® Gastrointestinal Panel Result on Clinical Management and Outcomes. Diagnostics (Basel) 2023; 13:diagnostics13061094. [PMID: 36980402 PMCID: PMC10046972 DOI: 10.3390/diagnostics13061094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
The gold standard diagnostic method for gastrointestinal infections is stool culture, which has limited sensitivity and long turnaround time. Infection diagnosis recently shifted to syndrome-based panel assays. This study employed the FilmArray® Gastrointestinal Panel, which detects 22 pathogens simultaneously, to investigate gastrointestinal infection and pathogen distribution in 91 stool samples of patients hospitalized at the Tzafon Medical Center, Israel, during 2020, and to compare the clinical and demographic data of negative vs. positive samples. Among the 61 positive samples (67%), the most common pathogen was Campylobacter (34.4%). Positive test results were associated with a slightly younger patient age (p = 0.012), significantly higher post-diagnosis use of antibiotics (63.9% vs. 36.7%; p = 0.014), and shorter length of stay and time to discharge (p = 0.035, p = 0.003, respectively) than negative test results. To conclude, the FilmArray® Gastrointestinal Panel enabled the early identification of causative infectious agents and enhanced clinical management and outcomes.
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Affiliation(s)
- David Carmon
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Hanan Rohana
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
- The Clinical Microbiology Laboratory, Tzafon Medical Center, Poriya, Tiberias 1528001, Israel
| | - Maya Azrad
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
- The Clinical Microbiology Laboratory, Tzafon Medical Center, Poriya, Tiberias 1528001, Israel
| | - Avi Peretz
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
- The Clinical Microbiology Laboratory, Tzafon Medical Center, Poriya, Tiberias 1528001, Israel
- Correspondence: ; Tel.: +972-4-665-2322
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Relationship between Diagnostic Method and Pathogen Detection, Healthcare Resource Use, and Cost in U.S. Adult Outpatients Treated for Acute Infectious Gastroenteritis. J Clin Microbiol 2023; 61:e0162822. [PMID: 36645308 PMCID: PMC9945572 DOI: 10.1128/jcm.01628-22] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
A retrospective observational study was performed to assess the relationship between diagnostic method (traditional work-up [TW], multiplex PCR panel with < 12 target pathogens [PCR < 12], or multiplex PCR panel with ≥ 12 target pathogens [PCR12]), and diagnostic yield, health care resource use (HRU), and cost in adult outpatients visiting U.S. hospitals for acute infectious gastroenteritis (AGE). Using data from PINC AI Healthcare Database during January 1, 2016-June 30, 2021, we analyzed adult patients with an AGE diagnosis and stool testing performed during an outpatient visit. Detection rates for different pathogens were analyzed for those with microbiology data available. Among 36,787 patients, TW was most often performed (57.0%). PCR12 testing was more frequent in patients from large, urban, and teaching hospitals, compared to TW (all P < 0.01). PCR12 was associated with a higher mean index visit cost (by $97) but lower mean 30-day AGE-related follow-up cost (by $117) than TW. Patients with PCR12 had a lower 30-day AGE-related hospitalization risk than TW (1.7% versus 2.7% P < 0.01). Among the 8,451 patients with microbiology data, PCR12 was associated with fewer stool tests per patient (mean 1.61 versus 1.26), faster turnaround time (mean 6.3 versus 25.7 h) and lower likelihood of receiving in-hospital antibiotics (39.4% versus 47.1%, all P < 0.01) than TW. A higher percentage of patients with PCR12 had a target pathogen detected (73.1%) compared to PCR < 12 (63.6%) or TW (45.4%, P < 0.01). Thus, we found that large multiplex PCR panels were associated with lower 30-day AGE-related follow-up cost and risk of AGE-related hospitalization, and increased diagnostic yield compared to TW.
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BD MAX Enteric Bacterial, Bacterial Plus, and Virus Panels for Diagnosis of Acute Infectious Gastroenteritis: a Cost-Benefit Analysis. Microbiol Spectr 2022; 10:e0088022. [PMID: 36069590 PMCID: PMC9603360 DOI: 10.1128/spectrum.00880-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Economic assessment is required to gauge the value of implementing PCR syndromic platforms in the microbiology laboratory for the diagnosis of community-acquired acute gastroenteritis (AGE) in pediatric and adult in- and outpatients. A cost-benefit analysis was conducted from a health care system perspective using BD MAX Enteric Bacterial, Bacterial Plus, and Virus panels. Two 6-month periods were selected, in which either conventional procedures (in 2017) or BD MAX PCR multiplex panels (in 2018) were used. We retrospectively reviewed medical records of all patients with positive results and a representative sample of negative ones. A Markov model was used to represent transition probabilities between different health care states from time of stool microbiological study until completion of AGE-episode-associated health care. A total of 1,336 medical records were reviewed (829 in 2018 and 507 in 2017), showing overall a significantly higher positivity rate in 2018 than in 2017 (26% versus 6%, P < 0.001). The total cost per individual associated with health care for AGE was €314 in 2018 and €341 in 2017; when we only considered the pediatric cohort, the figures were €271 and €456, respectively. Using Tornado sensitivity analyses, we found that the three variables that most influenced the model in descending order of weight were the probability of longer hospital stays, the probability of returning to the emergency room (ER), and the probability of hospitalization from the ER. Use of BD MAX enteric PCR platforms for the diagnosis of community-acquired AGE instead of a non-PCR-based conventional approach results in an incremental benefit from a health care perspective in the general population, particularly children. IMPORTANCE The implementation of multiplex molecular panels allows microbiological laboratories to quickly, sensitively, and accurately diagnose acute infectious gastroenteritis. This methodology therefore allows faster decisions regarding treatment and infection control measures. Economic evaluations are required to gauge the value of implementing these syndromic PCR platforms in a community-based acute gastroenteritis setting. We studied the potential clinical and cost benefits, in terms of both their impact on laboratory costs and the subsequent costs of managing patients.
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DiDiodato G, Allen A, Bradbury N, Brown J, Cruise K, Jedrzejko C, MacDonald V, Pigeon J, Sturgeon A, Yellenik D. The Efficacy of the BioFire FilmArray Gastrointestinal Panel to Reduce Hospital Costs Associated With Contact Isolation: A Pragmatic Randomized Controlled Trial. Cureus 2022; 14:e27931. [PMID: 36120274 PMCID: PMC9464456 DOI: 10.7759/cureus.27931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2022] [Indexed: 11/05/2022] Open
Abstract
Background: Molecular syndromic panels can rapidly detect common pathogens responsible for acute gastroenteritis in hospitalized patients. Their impact on both patient and healthcare system outcomes is uncertain compared to conventional stool testing. This randomized trial evaluates the impact of molecular testing on in-hospital resource utilization compared to conventional stool testing. Methods: Hospitalized patients with acute diarrheal illness were randomized 1:1 to either conventional or molecular stool testing with the BioFire FilmArray gastrointestinal panel (FGP). The primary outcome was the duration of contact isolation, and secondary outcomes included other in-hospital resource utilization such as diagnostic imaging and antimicrobial use. Results: A total of 156 patients were randomized. Randomization resulted in a balanced allocation of patients across all three age strata (<18, 18-69, ≥70 years old). The proportion of positive stools was 20.5% vs 29.5% in the control and FGP groups, respectively (p=0.196). The median duration of contact isolation was 51 hours (interquartile range [iqr] 66) and 69 hours (iqr 81) in the conventional and FGP groups, respectively (p=0.0513). There were no significant differences in other in-hospital resource utilization between groups. Conclusions: There were no differences in in-hospital resource utilization observed between the FGP and conventional stool testing groups.
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13
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Lakhan C, Badrie N, Ramsubhag A, Indar L. Detection of Foodborne Pathogens in Acute Gastroenteritis Patient’s Stool Samples Using the BioFire® FilmArray® Gastrointestinal PCR Panel in the Republic of Trinidad and Tobago, West Indies. Microorganisms 2022; 10:microorganisms10081601. [PMID: 36014019 PMCID: PMC9416176 DOI: 10.3390/microorganisms10081601] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 07/29/2022] [Indexed: 11/16/2022] Open
Abstract
In 2009, the burden of illness study for acute gastroenteritis in Trinidad and Tobago highlighted that ~10% of stool samples tested were positive for a foodborne pathogen. The study also noted that limited laboratory screening for pathogens contributed to a lack of etiology as public health hospitals only routinely tested for Salmonella and Shigella, and sometimes for Escherichia coli and Campylobacter. To better understand the foodborne pathogens responsible for acute gastroenteritis, enhanced testing using the BioFire® FilmArray® Gastrointestinal PCR panel was used to screen diarrheal stool samples for 22 pathogens from patients in 2018. The five general public health hospitals (San Fernando, Mt. Hope, Port of Spain, Sangre Grande, and Tobago) were notified of research activities and diarrheal stool samples were collected from all acute gastroenteritis patients. A total of 66 stools were screened and ~30% of samples tested positive for a foodborne pathogen. The current study showed that a much wider range of enteric pathogens were associated with acute gastroenteritis in Trinidad and Tobago than previously reported in 2009. These findings can be used by health officials to guide appropriate interventions, as well as to provide evidence for adoption of the PCR panel detection method at public health hospitals to benefit patient care.
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Affiliation(s)
- Carelene Lakhan
- Department of Food Production, University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Neela Badrie
- Department of Food Production, University of the West Indies, St. Augustine, Trinidad and Tobago
- Correspondence: ; Tel.: +1868-662-2002 (ext. 83211); Fax: +1868-663-9684
| | - Adash Ramsubhag
- Department of Life Sciences, University of the West Indies, St. Augustine, Trinidad and Tobago
| | - Lisa Indar
- The Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago
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14
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Ching CK, Nobel YR, Pereira MR, Verna EC. The role of gastrointestinal pathogen PCR testing in liver transplant recipients hospitalized with diarrhea. Transpl Infect Dis 2022; 24:e13873. [PMID: 35748886 DOI: 10.1111/tid.13873] [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: 02/26/2022] [Revised: 04/22/2022] [Accepted: 05/16/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Diarrhea is a common symptom among liver transplant (LT) recipients and can result in significant morbidity. The utility of PCR-based multiplex gastrointestinal (GI) pathogen panels in this population is unknown. METHODS We assessed incidence, predictors, and outcomes of GI PCR positivity among inpatients who underwent stool pathogen testing with the FilmArray multiplex GI PCR panel at our institution within 1 year following LT from April 2015 to December 2019. RESULTS 112 patients were identified. 14 (12.5%) had a positive PCR for any pathogen. Escherichia coli (n = 9) and Norovirus (n = 5) were the most common pathogens detected. Recipients with a positive PCR were significantly further from LT (median 74.5 vs 15.5 days, p < 0.01) and tested earlier during hospitalization (median 1.0 vs 9.0 days, p < 0.01). C. difficile was positive in 20.0% of patients with a positive PCR and 11.4% with a negative PCR. CMV viremia was observed in 11.6% of patients, all in the negative PCR group. Following a positive PCR, patients were more likely to have a change in antimicrobial regimen (71.4% vs 28.6%, p = 0.02), a shorter length of stay (median 7.5 vs. 17.5 days, p < 0.01), and a trend toward lower rates of readmission and colonoscopy within 30 days. CONCLUSIONS In hospitalized LT recipients with diarrhea, GI PCR pathogen identification was associated with the use of targeted antimicrobial therapy and a shorter length of stay. GI PCR testing should be considered early during admission and later in the post-LT period. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Charlotte K Ching
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Yael R Nobel
- Division of Digestive and Liver Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Marcus R Pereira
- Division of Infectious Diseases, Columbia University Irving Medical Center, New York, New York, USA
| | - Elizabeth C Verna
- Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, New York, USA
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15
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Gerace E, Mancuso G, Midiri A, Poidomani S, Zummo S, Biondo C. Recent Advances in the Use of Molecular Methods for the Diagnosis of Bacterial Infections. Pathogens 2022; 11:pathogens11060663. [PMID: 35745518 PMCID: PMC9229729 DOI: 10.3390/pathogens11060663] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/31/2022] [Accepted: 06/05/2022] [Indexed: 12/14/2022] Open
Abstract
Infections caused by bacteria have a major impact on public health-related morbidity and mortality. Despite major advances in the prevention and treatment of bacterial infections, the latter continue to represent a significant economic and social burden worldwide. The WHO compiled a list of six highly virulent multidrug-resistant bacteria named ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) responsible for life-threatening diseases. Taken together with Clostridioides difficile, Escherichia coli, Campylobacter spp., (C. jejuni and C. coli), Legionella spp., Salmonella spp., and Neisseria gonorrhoeae, all of these microorganisms are the leading causes of nosocomial infections. The rapid and accurate detection of these pathogens is not only important for the early initiation of appropriate antibiotic therapy, but also for resolving outbreaks and minimizing subsequent antimicrobial resistance. The need for ever-improving molecular diagnostic techniques is also of fundamental importance for improving epidemiological surveillance of bacterial infections. In this review, we aim to discuss the recent advances on the use of molecular techniques based on genomic and proteomic approaches for the diagnosis of bacterial infections. The advantages and limitations of each of the techniques considered are also discussed.
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Affiliation(s)
| | - Giuseppe Mancuso
- Department of Human Pathology, University of Messina, 98125 Messina, Italy; (G.M.); (A.M.); (S.P.); (S.Z.)
| | - Angelina Midiri
- Department of Human Pathology, University of Messina, 98125 Messina, Italy; (G.M.); (A.M.); (S.P.); (S.Z.)
| | - Stefano Poidomani
- Department of Human Pathology, University of Messina, 98125 Messina, Italy; (G.M.); (A.M.); (S.P.); (S.Z.)
| | - Sebastiana Zummo
- Department of Human Pathology, University of Messina, 98125 Messina, Italy; (G.M.); (A.M.); (S.P.); (S.Z.)
| | - Carmelo Biondo
- Department of Human Pathology, University of Messina, 98125 Messina, Italy; (G.M.); (A.M.); (S.P.); (S.Z.)
- Correspondence: ; Tel.: +39-090-2213322
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16
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Truong J, Cointe A, Le Roux E, Bidet P, Michel M, Boize J, Mariani-Kurkdjian P, Caseris M, Hobson CA, Desmarest M, Titomanlio L, Faye A, Bonacorsi S. Clinical impact of a gastrointestinal PCR panel in children with infectious diarrhoea. Arch Dis Child 2022; 107:601-605. [PMID: 34921002 DOI: 10.1136/archdischild-2021-322465] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 11/28/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Multiplex gastrointestinal PCR (GI-PCR) allows fast and simultaneous detection of 22 enteric pathogens (including Campylobacter, Salmonella, Shigella/enteroinvasive Escherichia coli (EIEC), among other bacteria, parasites and viruses). However, its impact on the management of children with infectious diarrhoea remains unknown. PATIENTS/DESIGN All children eligible for stool culture from May to October 2018 were prospectively included in a monocentric study at Robert-Debré University-Hospital. INTERVENTION A GI-PCR (BioFire FilmArray) was performed on each stool sample. MAIN MEASURES Data on the children's healthcare management before and after GI-PCR results were collected. Stool culture results were also reported. RESULTS 172 children were included. The main criteria for performing stool analysis were mucous/bloody diarrhoea and/or traveller's diarrhoea (n=130). GI-PCR's were positive for 120 patients (70%). The main pathogens were enteroaggregative E. coli (n=39; 23%), enteropathogenic E. coli (n=34; 20%), Shigella/EIEC (n=27; 16%) and Campylobacter (n=21; 12%). Compared with stool cultures, GI-PCR enabled the detection of 21 vs 19 Campylobacter, 12 vs 10 Salmonella, 27 Shigella/EIEC vs 13 Shigella, 2 vs 2 Yersinia enterocolitica, 1 vs 1 Plesiomonas shigelloides, respectively. Considering the GI-PCR results and before stool culture results, the medical management was revised for 40 patients (23%): 28 initiations, 2 changes and 1 discontinuation of antibiotics, 1 hospitalisation, 2 specific room isolations related to Clostridioides difficile infections, 4 additional test prescriptions and 2 test cancellations. CONCLUSION The GI-PCR's results impacted the medical management of gastroenteritis for almostone-fourth of the children, and especially the prescription of appropriate antibiotic treatment before stool culture results.
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Affiliation(s)
- Jeanne Truong
- General Paediatrics, Robert Debré University Hospital, AP-HP, Paris, France .,Université de Paris, UFR de médecine Paris-Nord, Paris, Île-de-France, France
| | - Aurélie Cointe
- Microbiology Laboratory, Robert-Debré University Hospital, AP-HP, Paris, Île-de-France, France.,IAME UMR 1137, INSERM, Paris, Île-de-France, France
| | - Enora Le Roux
- Unité d'Epidémiologie Clinique, Robert Debré University Hospital, AP-HP, Paris, France.,ECEVE UMR-1123, INSERM, Paris, Île-de-France, France
| | - Philippe Bidet
- Microbiology Laboratory, Robert-Debré University Hospital, AP-HP, Paris, Île-de-France, France.,IAME UMR 1137, INSERM, Paris, Île-de-France, France
| | - Morgane Michel
- ECEVE UMR-1123, INSERM, Paris, Île-de-France, France.,URC Eco, Hôtel-Dieu, AP-HP, Paris, France
| | - Julien Boize
- Department of Paediatric Emergency Care, Robert Debré University Hospital, AP-HP, Paris, Île-de-France, France
| | | | - Marion Caseris
- General Paediatrics, Robert Debré University Hospital, AP-HP, Paris, France
| | - Claire Amaris Hobson
- Université de Paris, UFR de médecine Paris-Nord, Paris, Île-de-France, France.,IAME UMR 1137, INSERM, Paris, Île-de-France, France
| | - Marie Desmarest
- Department of Paediatric Emergency Care, Robert Debré University Hospital, AP-HP, Paris, Île-de-France, France
| | - Luigi Titomanlio
- Université de Paris, UFR de médecine Paris-Nord, Paris, Île-de-France, France.,Department of Paediatric Emergency Care, Robert Debré University Hospital, AP-HP, Paris, Île-de-France, France.,U1141, INSERM, Paris, France
| | - Albert Faye
- General Paediatrics, Robert Debré University Hospital, AP-HP, Paris, France.,Université de Paris, UFR de médecine Paris-Nord, Paris, Île-de-France, France.,ECEVE UMR-1123, INSERM, Paris, Île-de-France, France
| | - Stéphane Bonacorsi
- Microbiology Laboratory, Robert-Debré University Hospital, AP-HP, Paris, Île-de-France, France.,IAME UMR 1137, INSERM, Paris, Île-de-France, France
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17
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Bassetti S, Tschudin-Sutter S, Egli A, Osthoff M. Optimizing antibiotic therapies to reduce the risk of bacterial resistance. Eur J Intern Med 2022; 99:7-12. [PMID: 35074246 DOI: 10.1016/j.ejim.2022.01.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 01/02/2023]
Abstract
The incidence of infections caused by bacteria that are resistant to antibiotics is constantly increasing. In Europe alone, it has been estimated that each year about 33'000 deaths are attributable to such infections. One important driver of antimicrobial resistance is the use and abuse of antibiotics in human medicine. Inappropriate prescribing of antibiotics is still very frequent: up to 50% of all antimicrobials prescribed in humans might be unnecessary and several studies show that at least 50% of antibiotic treatments are inadequate, depending on the setting. Possible strategies to optimize antibiotic use in everyday clinical practice and to reduce the risk of inducing bacterial resistance include: the implementation of rapid microbiological diagnostics for identification and antimicrobial susceptibility testing, the use of inflammation markers to guide initiation and duration of therapies, the reduction of standard durations of antibiotic courses, the individualization of antibiotic therapies and dosing considering pharmacokinetics/pharmacodynamics targets, and avoiding antibiotic classes carrying a higher risk for induction of bacterial resistance. Importantly, measures to improve antibiotic prescribing and antibiotic stewardship programs should focus on facilitating clinical reasoning and improving prescribing environment in order to remove any barriers to good prescribing.
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Affiliation(s)
- Stefano Bassetti
- Division of Internal Medicine, University Hospital Basel and University of Basel, Switzerland; Department of Clinical Research, University Hospital Basel and University of Basel, Switzerland.
| | - Sarah Tschudin-Sutter
- Department of Clinical Research, University Hospital Basel and University of Basel, Switzerland; Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel and University of Basel, Switzerland
| | - Adrian Egli
- Division of Clinical Bacteriology and Mycology, University Hospital Basel and University of Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Switzerland
| | - Michael Osthoff
- Division of Internal Medicine, University Hospital Basel and University of Basel, Switzerland; Department of Clinical Research, University Hospital Basel and University of Basel, Switzerland
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18
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Meltzer AC, Newton S, Lange J, Hall NC, Vargas NM, Huang Y, Moran S, Ma Y. A randomized control trial of a multiplex gastrointestinal PCR panel versus usual testing to assess antibiotics use for patients with infectious diarrhea in the emergency department. J Am Coll Emerg Physicians Open 2022; 3:e12616. [PMID: 35072157 PMCID: PMC8760946 DOI: 10.1002/emp2.12616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This study analyzed physician treating behavior through the use of a multiplex gastrointestinal polymerase chain reaction (GI PCR) test compared with usual testing in emergency department (ED) patients with suspected acute infectious diarrhea to assess differences in antibiotic management. METHODS A prospective, single-center, randomized control trial was designed to investigate antibiotic use in ED patients with moderate to severe suspected infectious diarrhea, comparing those who received GI PCR to those who received usual testing. ED patients with signs of dehydration, inflammation, or persistent symptoms were randomized to either the experimental arm (GI PCR) or the control arm (usual testing or no testing). RESULTS A total of 74 patients met study criteria and were randomized to either the experimental GI PCR arm (n = 38) or to the control arm (n = 36). Participants in the GI PCR arm received antibiotics in 87% of bacterial or protozoal diarrheal infections (13/15) whereas those in the control arm received antibiotics in 46% of bacterial or protozoal infections (6/13) (P value 0.042) with 2-proportion difference 0.41 (95% confidence interval 0.07 and 0.68). CONCLUSIONS ED use of multiplex GI PCR led to an increase in antibiotic use for bacterial and protozoal causes of infectious diarrhea compared to usual testing. This increase in antibiotics appears to be appropriate given patients' moderate to severe symptoms and a definitive identification of a likely bacterial or protozoal cause of symptoms. Results should be interpreted with caution because of the small sample size.
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Affiliation(s)
- Andrew C. Meltzer
- Department of Emergency MedicineGeorge Washington University (GWU) School of Medicine & Health SciencesWashingtonDistrict of ColumbiaUSA
| | - Sophia Newton
- Department of Emergency MedicineGeorge Washington University (GWU) School of Medicine & Health SciencesWashingtonDistrict of ColumbiaUSA
| | - Joel Lange
- Department of Emergency MedicineGeorge Washington University (GWU) School of Medicine & Health SciencesWashingtonDistrict of ColumbiaUSA
| | - Nicole C. Hall
- Department of Emergency MedicineGeorge Washington University (GWU) School of Medicine & Health SciencesWashingtonDistrict of ColumbiaUSA
| | - Nataly Montano Vargas
- Department of Emergency MedicineGeorge Washington University (GWU) School of Medicine & Health SciencesWashingtonDistrict of ColumbiaUSA
| | - Yihe Huang
- Department of Biostatistics and BioinformaticsGeorge Washington University (GWU) Milken Institute School of Public HealthWashingtonDistrict of ColumbiaUSA
| | - Seamus Moran
- Department of Emergency MedicineGeorge Washington University (GWU) School of Medicine & Health SciencesWashingtonDistrict of ColumbiaUSA
| | - Yan Ma
- Department of Biostatistics and BioinformaticsGeorge Washington University (GWU) Milken Institute School of Public HealthWashingtonDistrict of ColumbiaUSA
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19
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Adler AV, Ciccotti HR, Trivitt SJH, Watson RCJ, Riddle MS. What's new in travellers' diarrhoea: updates on epidemiology, diagnostics, treatment and long-term consequences. J Travel Med 2022; 29:6316240. [PMID: 34230966 DOI: 10.1093/jtm/taab099] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/23/2021] [Accepted: 06/24/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Travellers' diarrhoea (TD) is the most common clinical syndrome affecting travellers. This narrative review summarizes key discoveries reported in the last two years related to TD and suggests areas for future research. METHODS A PubMed literature search was conducted for novel data in TD research published between 12 January 2018 and 12 January 2020. Inclusion was based on contribution to epidemiology, aetiology, diagnostics, management and long-term consequences and relevance to public health, discovery and clinical practice. RESULTS The initial literature search yielded 118 articles. We retrieved 72 and reviewed 31 articles for inclusion. The findings support our understanding that TD incidence varies by traveller group and environment with students and military-travel remaining moderately high risk, and control of food and water in mass gathering events remain an important goal. The growth of culture-independent testing has led to a continued detection of previously known pathogens, but also an increased detection frequency of norovirus. Another consequence is the increase in multi-pathogen infections, which require consideration of clinical, epidemiological and diagnostic data. Fluoroquinolone resistant rates continue to rise. New data on non-absorbable antibiotics continue to emerge, offering a potential alternative to current recommendations (azithromycin and fluoroquinolones), but are not recommended for febrile diarrhoea or dysentery or regions/itineraries where invasive pathogens are likely to cause illness. Recent studies investigated the interaction of the microbiome in TD prevention and consequences, and while discriminating features were identified, much uncertainty remains. The prevalence of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) acquisition and carriage is increasing. Finally, continued research documents the post-infectious consequences, whereas mechanisms of reactive arthritis and post-infectious IBS necessitate further investigation. CONCLUSIONS Globally, TD remains an important travel health issue and advances in our understanding continue. More research is needed to mitigate risk factors where possible and develop risk-based management strategies to reduce antibiotic usage and its attendant consequences.
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Maldonado-Garza HJ, Garza-González E, Bocanegra-Ibarias P, Flores-Treviño S. Diagnostic syndromic multiplex approaches for gastrointestinal infections. Expert Rev Gastroenterol Hepatol 2021; 15:743-757. [PMID: 33682566 DOI: 10.1080/17474124.2021.1899807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Gastrointestinal diseases due to infectious pathogens currently represent an important global health concern, especially in children and developing countries. Early and accurate detection of gastrointestinal pathogens is important to initiate the appropriate type of therapy. Multiplex molecular gastrointestinal panels rapidly detect several gastrointestinal pathogens at once with high sensitivity.Areas covered: We assess the scope and limitations of several multiplex gastrointestinal panels approved by the Food and Drug Administration or marked by Conformité Européenne-in vitro diagnostic. We compare 10 syndromic gastrointestinal panels, 14 bacteria-specific multiplex panels, seven parasite-specific multiplex panels, and eight virus-specific multiplex panels.Expert opinion: Thanks to the advances made in the diagnostic approaches for gastrointestinal infections, there are various panels to choose. The choice of a specific syndromic gastrointestinal multiplex panel should be made to improve patient care. Diagnostic syndromic multiplex approaches for gastrointestinal infections should be customized; each hospital should develop its diagnostic algorithm for gastrointestinal infections tailored to its setting, study population, and geographical site. Current multiplex gastrointestinal panels could be improved by including the detection of antimicrobial resistance, toxigenic Clostridioides difficile, and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the virus responsible for the COVID-19 pandemic).
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Affiliation(s)
- Héctor Jesús Maldonado-Garza
- Departamento de Medicina Interna, Universidad Autónoma De Nuevo León, Hospital Universitario Dr. José Eleuterio González Y Facultad De Medicina, Servicio De Gastroenterología, Monterrey, Nuevo León, Mexico
| | - Elvira Garza-González
- Departamento de Medicina Interna, Universidad Autónoma De Nuevo León, Hospital Universitario Dr. José Eleuterio González Y Facultad De Medicina, Servicio De Gastroenterología, Monterrey, Nuevo León, Mexico
| | - Paola Bocanegra-Ibarias
- Departamento de Medicina Interna, Universidad Autónoma De Nuevo León, Hospital Universitario Dr. José Eleuterio González Y Facultad De Medicina, Servicio De Gastroenterología, Monterrey, Nuevo León, Mexico
| | - Samantha Flores-Treviño
- Departamento de Medicina Interna, Universidad Autónoma De Nuevo León, Hospital Universitario Dr. José Eleuterio González Y Facultad De Medicina, Servicio De Gastroenterología, Monterrey, Nuevo León, Mexico
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21
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Yoo IH, Kang HM, Suh W, Cho H, Yoo IY, Jo SJ, Park YJ, Jeong DC. Quality Improvements in Management of Children with Acute Diarrhea Using a Multiplex-PCR-Based Gastrointestinal Pathogen Panel. Diagnostics (Basel) 2021; 11:diagnostics11071175. [PMID: 34203426 PMCID: PMC8303787 DOI: 10.3390/diagnostics11071175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 11/16/2022] Open
Abstract
Conventional methods for etiologic diagnoses of acute gastroenteritis (AGE) are time consuming and have low positive yield leading to limited clinical value. This study aimed to investigate quality improvements in patient management, antibiotic stewardship, and in-hospital infection transmission prevention using BioFire® FilmArray® Gastrointestinal Panel (GI Panel) in children with acute diarrhea. This was a prospective study recruiting children < 19 years old with new onset diarrhea during the study period, and a matched historical cohort study of children diagnosed with AGE during the 4 years prior. Patients in the prospective cohort underwent stool testing with GI Panel and conventional methods. A total of 182 patients were included in the prospective cohort, of which 85.7% (n = 156) had community-onset and 14.3% (n = 26) had hospital-onset diarrhea. A higher pathogen positivity rate for community-onset diarrhea was observed by the GI Panel (58.3%, n = 91) compared to conventional studies (42.3%, n = 66) (p = 0.005) and historical cohort (31.4%, n = 49) (p < 0.001). The stool tests reporting time after admission was 25 (interquartile range, IQR 17-46) hours for the GI Panel, and 72 (IQR 48-96) hours for the historical cohort (p < 0.001). A significant reduction in antibiotic use was observed in the prospective cohort compared to historical cohort, 35.3% vs. 71.8%; p < 0.001), respectively. Compared to the GI Panel, norovirus ICT was only able to detect 4/11 (36.4%) patients with hospital-onset and 14/27 (51.8%) patients with community-onset diarrhea. The high positivity rate and rapid reporting time of the GI Panel had clinical benefits for children admitted for acute diarrhea, especially by reducing antibiotic use and enabling early adequate infection precaution and isolation.
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Affiliation(s)
- In Hyuk Yoo
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
| | - Hyun Mi Kang
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
- Correspondence: (H.M.K.); (D.C.J.); Tel.: +82-2-2258-6273 (H.M.K.); +82-2-2258-6180 (D.C.J.); Fax: +82-2-537-4544 (H.M.K. & D.C.J.)
| | - Woosuk Suh
- Uijeongbu Eulji Medical Center, Department of Pediatrics, Eulji University School of Medicine, Seongnam 11759, Korea;
| | - Hanwool Cho
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.C.); (I.Y.Y.); (S.J.J.); (Y.J.P.)
| | - In Young Yoo
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.C.); (I.Y.Y.); (S.J.J.); (Y.J.P.)
| | - Sung Jin Jo
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.C.); (I.Y.Y.); (S.J.J.); (Y.J.P.)
| | - Yeon Joon Park
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea; (H.C.); (I.Y.Y.); (S.J.J.); (Y.J.P.)
| | - Dae Chul Jeong
- Department of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul 06591, Korea;
- Correspondence: (H.M.K.); (D.C.J.); Tel.: +82-2-2258-6273 (H.M.K.); +82-2-2258-6180 (D.C.J.); Fax: +82-2-537-4544 (H.M.K. & D.C.J.)
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The effect of gastrointestinal pathogen panel (GIP) on antibiotic management. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY 2021; 1:e5. [PMID: 36168483 PMCID: PMC9495426 DOI: 10.1017/ash.2021.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/20/2021] [Indexed: 11/15/2022]
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O'Neal M, Murray H, Dash S, Al-Hasan MN, Justo JA, Bookstaver PB. Evaluating appropriateness and diagnostic stewardship opportunities of multiplex polymerase chain reaction gastrointestinal testing within a hospital system. Ther Adv Infect Dis 2020; 7:2049936120959561. [PMID: 33014363 PMCID: PMC7513010 DOI: 10.1177/2049936120959561] [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: 07/03/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022] Open
Abstract
Objective: This single-center, retrospective, observational cohort study evaluates the
appropriateness of the BioFire® FilmArray® Gastrointestinal (GI) multiplex
PCR panel testing at a community-teaching hospital. Methods: All adult, hospitalized patients at Prisma Health Richland Hospital with a
documented GI multiplex PCR panel from 1 April 2015 through 28 February 2018
were included in the analysis. Inappropriate use of the GI panel was defined
as a test obtained without documented diarrhea, greater than 2 days of
hospitalization, redundant use with other diagnostic tests (e.g.
Clostridioides difficile PCR), or laxative use in the
preceding 48 h. Antibiotic use and host variables were compared between
groups with positive and negative results. Results: During the study period, 442 GI panels were obtained, among which 268 (61%)
were deemed inappropriate. Primary reasons for inappropriate testing were
lack of documented diarrhea (n = 92), greater than 2 days
of hospitalization (n = 116), having a duplicate C.
difficile PCR test ordered (n = 118), or
laxative use in the 48 h before testing (n = 36). A total
of 141 (32%) GI panels were positive. The most frequently identified
pathogens were C. difficile (51.1%,
n = 72), Enteropathogenic Escherichia coli
(17.7%, n = 25), and Norovirus GI/GII (12.1%,
n = 17). Patients with negative GI panel results were
initiated on antibiotics significantly less frequently than those with
positive GI panels (62.5% versus 80.2%,
p < 0.00001). Conclusion: Stewardship opportunities exist to optimize the diagnostic application of the
GI multiplex PCR panel.
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Affiliation(s)
- Melissa O'Neal
- University of South Carolina College of Pharmacy, 715 Sumter Street, Columbia, SC 29208, USA
| | - Hanna Murray
- University of South Carolina College of Pharmacy, Columbia, SC, USA
| | - Sangita Dash
- University of South Carolina School of Medicine, Columbia, SC, USA
| | - Majdi N Al-Hasan
- University of South Carolina School of Medicine, Columbia, SC, USA
| | - Julie Ann Justo
- University of South Carolina College of Pharmacy, Columbia, SC, USA
| | - P Brandon Bookstaver
- University of South Carolina College of Pharmacy, 715 Sumter Street, Columbia, SC 29208, USA
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