Measuring clinical outcomes of highly multiplex molecular diagnostics for respiratory infections: A systematic review and conceptual framework

Objectives

To review methodologies and outcomes reporting among these studies and to develop a conceptual framework of outcomes to assist in guiding studies and production of clinical metrics.

Data sources

PubMed and Embase from January 1, 2012, thru December 1, 2021.

Study eligibility criteria

Studies evaluating highly multiplex molecular respiratory diagnostics and their impact on either clinical or economic outcomes.

Methods

A systematic literature review (SLR) of methodologies and outcomes reporting was performed. A qualitative synthesis of identified SLRs and associated primary studies was conducted to develop conceptual framework for outcomes.

Results

Ultimately, 4 systemic literature reviews and their 12 associated primary studies were selected for review. Most primary studies included patient outcomes focusing on antimicrobial exposure changes such as antibiotic (80%) and antiviral use (50%) or occupancy changes such as hospital length of stay (60%). Economic outcomes were infrequently reported, and societal outcomes, such as antibiotic resistance impact, were absent from the reviewed literature. Qualitative evidence synthesis of reported outcomes yielded a conceptual framework of outcomes to include operational, patient, economic, and societal domains.

Conclusions

Our review highlights the significant heterogeneity in outcomes reporting among clinical impact studies for highly multiplex molecular respiratory diagnostics. Furthermore, we developed a conceptual framework of outcomes domains that may act as a guide to improve considerations in outcomes selection and reporting when evaluating clinical impact of these tests. These improvements may be important in synthesizing the evidence for informing clinical decision making, guidelines, and financial reimbursement.

Administration of taurolidine-citrate lock solution for prevention of central venous catheter infection in adult neutropenic haematological patients: a randomised, double-blinded, placebo-controlled trial (TAURCAT)

Background

Catheter-related bloodstream infection (CRBSI) is one of the most frequent complications in patients with cancer who have central venous catheters (CVCs) implanted and is associated with substantial morbidity and mortality. Taurolidine is a non-antibiotic agent with broad-spectrum antimicrobial activity, which has been used as a lock solution to prevent CRBSI in some settings. However, little is known about its usefulness in high-risk adult neutropenic patients with cancer. This prospective randomised clinical trial aims to test the hypothesis that taurolidine-citrate lock solution is more effective than placebo for preventing catheter infection in neutropenic haematological patients.

Methods

This study is a prospective, multicentre, randomised, double-blinded, parallel, superiority, placebo-controlled trial. Patients with haematological cancer who are expected to develop prolonged neutropenia (> 7 days) and who have a non-tunnelled CVC implanted will be randomised to receive prophylactic taurolidine-citrate-heparin solution using a lock technique (study group) or heparin alone (placebo group). The primary endpoint will be bacterial colonisation of the CVC hubs. The secondary endpoints will be the incidence of CRBSI, CVC removal, adverse events, and 30-day case-fatality rate.

Discussion

The lock technique is a preventive strategy that inhibits bacterial colonisation in the catheter hubs, which is the initial step of endoluminal catheter colonisation and the development of infection. Taurolidine is a nontoxic agent that does not develop antibiotic resistance because it acts as an antiseptic rather than an antibiotic. Taurolidine has shown controversial results in the few trials conducted in cancer patients. These studies have important limitations due to the lack of data on adult and/or high-risk neutropenic patients, the type of catheters studied (tunnelled or ports), and the lack of information regarding the intervention (e.g. dwelling of the solution, time, and periodicity of the lock technique). If our hypothesis is proven, the study could provide important solid evidence on the potential usefulness of this preventive procedure in a population at high risk of CRBSI, in whom this complication may significantly impair patient outcome.

Trial registration

ISRCTN, ISRCTN47102251. Registered on 9 September 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2647-y) contains supplementary material, which is available to authorized users.

Teaming Up to Take Down Community-Acquired Bloodstream Infections: A Program Aimed at Educating and Training Nurses in the Community

Background: Advances in medical technology have allowed pediatric patients to be discharged home with complex devices, including central venous catheters (CVCs). For these patients to be safely discharged, families require training to care for these catheters. At a large children's hospital, extensive family education and training for CVCs was already established. However, community caregivers were not receiving the same training. In an effort to target these caregivers, an education program was designed and implemented in 2011.

Methods: The program was originally designed and implemented by nurses on a gastroenterology unit and has expanded to include instructors from the vascular access team, hematology/oncology department, and pulmonary department. All community nurses providing care for pediatric patients in the region are welcome to attend the free class with education hours offered. The class is structured with lecture time and skills practice through simulation.

Results: Since the program began in 2011, 34 classes have been offered and 305 nurses have attended from multiple home health companies and school districts in the region. Community-acquired central line-associated bloodstream infection (CLABSI) rates for the pediatric gastroenterology and oncology patient populations have decreased significantly since the class began.

Conclusions: An education program targeting nurses in the community who care for complex patients with CVCs can decrease community-acquired infection rates and complications. This program can be designed and tailored for multiple patient populations with varying complexities and medical devices.

Reducing Central Line-Associated Bloodstream Infections on Inpatient Oncology Units Using Peer Review

The purpose of this article is to describe a peer-to-peer program and the outcomes of interventions to reduce the incidence of central line-associated bloodstream infections in patients in bone marrow transplantation, medical, and surgical oncology units. The article reviews the process and describes tools used to achieve success in a Magnet®-designated academic medical center.

Attributable cost and length of stay for central line-associated bloodstream infections

BACKGROUND AND OBJECTIVE

Central line-associated bloodstream infections (CLABSI) are common types of hospital-acquired infections associated with high morbidity. Little is known about the attributable cost and length of stay (LOS) of CLABSI in pediatric inpatient settings. We determined the cost and LOS attributable to pediatric CLABSI from 2008 through 2011.

METHODS

A propensity score-matched case-control study was performed. Children <18 years with inpatient discharges in the Nationwide Inpatient Sample databases from the Healthcare Cost and Utilization Project from 2008 to 2011 were included. Discharges with CLABSI were matched to those without CLABSI by age, year, and high dimensional propensity score (obtained from a logistic regression of CLABSI status on patient characteristics and the presence or absence of 262 individual clinical classification software diagnoses). Our main outcome measures were estimated costs obtained from cost-to-charge ratios and LOS for pediatric discharges.

RESULTS

The mean attributable cost and LOS between matched CLABSI cases (1339) and non-CLABSI controls (2678) was $55 646 (2011 dollars) and 19 days, respectively. Between 2008 and 2011, the rate of pediatric CLABSI declined from 1.08 to 0.60 per 1000 (P < .001). Estimates of mean costs of treating patients with CLABSI declined from $111 852 to $98 621 (11.8%; P < .001) over this period, but cost of treating matched non-CLABSI patients remained constant at ∼$48 000.

CONCLUSIONS

Despite significant improvement in rates, CLABSI remains a burden on patients, families, and payers. Continued attention to CLABSI-prevention initiatives and lower-cost CLABSI care management strategies to support high-value pediatric care delivery is warranted.

The increased risks of death and extra lengths of hospital and ICU stay from hospital-acquired bloodstream infections: a case-control study

OBJECTIVES

Hospital-acquired bloodstream infections are known to increase the risk of death and prolong hospital stay, but precise estimates of these two important outcomes from well-designed studies are rare, particularly for non-intensive care unit (ICU) patients. We aimed to calculate accurate estimates, which are vital for estimating the economic costs of hospital-acquired bloodstream infections.

DESIGN

Case-control study.

SETTING

9 Australian public hospitals.

PARTICIPANTS

All the patients were admitted between 2005 and 2010.

PRIMARY AND SECONDARY OUTCOME MEASURES

Risk of death and extra length of hospital stay associated with nosocomial infection.

RESULTS

The greatest increase in the risk of death was for a bloodstream infection with methicillin-resistant Staphylococcus aureus (HR=4.6, 95% CI 2.7 to 7.6). This infection also had the longest extra length of stay to discharge in a standard bed (12.8 days, 95% CI 6.2 to 26.1 days). All the eight bloodstream infections increased the length of stay in the ICU, with longer stays for the patients who eventually died (mean increase 0.7-6.0 days) compared with those who were discharged (mean increase: 0.4-3.1 days). The three most common organisms associated with Gram-negative infection were Escherichia coli, Pseudomonas aeruginosa and Klebsiella pneumonia.

CONCLUSIONS

Bloodstream infections are associated with an increased risk of death and longer hospital stay. Avoiding infections could save lives and free up valuable bed days.

Hospital-acquired infections--appropriate statistical treatment is urgently needed!

Research on hospital-acquired infections (HAIs) requires the highest methodological standards to minimize the risk of bias and to avoid misleading interpretation. There are two major issues related specifically to studies in this area, namely the timing of infection and the occurrence of so-called competing risks, which deserve special attention. Just as a patient who acquires a serious infection during hospital admission needs appropriate antibiotic treatment, data being collected in studies on hospital-acquired infections need appropriate statistical analysis. We illustrate the urgent need for appropriate statistical treatment of hospital-acquired infections with some examples from recently conducted studies.The considerations presented are relevant for investigations on risk factors for HAIs as well as for outcome studies.

Modern trends in infection control practices in intensive care units

Hospital-acquired infections (HAIs) are common in intensive care unit (ICU) patients and are associated with increased morbidity and mortality. There has been an increasing effort to prevent HAIs, and infection control practices are paramount in avoiding these complications. In the last several years, numerous developments have been seen in the infection prevention strategies in various health care settings. This article reviews the modern trends in infection control practices to prevent HAIs in ICUs with a focus on methods for monitoring hand hygiene, updates in isolation precautions, new methods for environmental cleaning, antimicrobial bathing, prevention of ventilator-associated pneumonia, central line-associated bloodstream infections, catheter-associated urinary tract infections, and Clostridium difficile infection.

Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection

BACKGROUND

Catheter hub decontamination requires a thorough scrub and compliance varies. This study evaluates the effectiveness of a disinfection cap with 70% alcohol in preventing contamination/infection.

METHODS

A 3-phased, multifacility, quasi-experimental study of adult patients with central lines divided into P1 (baseline), when the standard scrub was used; P2, when the cap was used on all central lines; and P3, when standard disinfection was reinstituted. House-wide central-line associated bloodstream infection (CLABSI) rates are reported with catheter-associated urinary tract infections (CAUTI) as a control measure. Adults with peripherally inserted central catheters inserted during hospitalization having 5+ consecutive line-days gave consent and were enrolled, and 1.5 mL of blood was withdrawn from each lumen not in use and quantitatively cultured.

RESULTS

Contamination was 12.7% (32/252) during P1; 5.5% (20/364) in P2 (P = .002), and 12.0% (22/183; P = 0.88 vs P1 and P = .01 vs P2) in P3 (P = .001 vs P2). The median colony-forming units per milliliter was 4 for P1, 1 for P2 (P = .009), and 2 for P3 (P = .05 vs P2). CLABSI rates declined from 1.43 per 1,000 line-days (16/11,154) to 0.69 (13/18,972) in P2 (P = .04) and increased to 1.31 (7/5,354) in P3. CAUTI rates remained stable between P1 and P2 (1.42 and 1.41, respectively, P = .90) but declined in P3 (1.04, P = .03 vs P1 and P2).

CONCLUSION

Disinfecting caps reduce line contamination, organism density, and CLABSIs.

Time-dependent analysis of extra length of stay and mortality due to ventilator-associated pneumonia in intensive-care units of ten limited-resources countries: findings of the International Nosocomial Infection Control Consortium (INICC)

Ventilator-associated pneumonias (VAPs) are a worldwide problem that significantly increases patient morbidity, mortality, and length of stay (LoS), and their effects should be estimated to account for the timing of infection. The purpose of the study was to estimate extra LoS and mortality in an intensive-care unit (ICU) due to a VAP in a cohort of 69 248 admissions followed for 283 069 days in ICUs from 10 countries. Data were arranged according to the multi-state format. Extra LoS and increased risk of death were estimated independently in each country, and their results were combined using a random-effects meta-analysis. VAP prolonged LoS by an average of 2·03 days (95% CI 1·52–2·54 days), and increased the risk of death by 14% (95% CI 2–27). The increased risk of death due to VAP was explained by confounding with patient morbidity.

Open versus closed IV infusion systems: a state based model to predict risk of catheter associated blood stream infections

Objectives To quantify the change in risk of central line associated blood stream infection (CLABSI) following the introduction of a closed infusion container in intensive care units (ICUs) in two Latin American cities. Design A state-space model was used to describe the flow of admissions through the ICU. This approach correctly treats infection as a time-dependent covariate. Results A closed system reduced the risk of CLABSI. The hazard ratios for the closed versus open container were between 0.15 and 0.31 (p values<0.001), indicating a clinically significant reduction in the risk of admissions having a CLABSI. A simulation study showed that a closed system reduced the number of infections, costs and deaths. Conclusions The data reveal costs are saved and health benefits gained from fewer cases of CLABSI after adoption of a closed infusion system. Information is required on the costs of implementing the closed system widely in these settings.