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Peri AM, Chatfield MD, Ling W, Furuya-Kanamori L, Harris PNA, Paterson DL. Rapid Diagnostic Tests and Antimicrobial Stewardship Programs for the Management of Bloodstream Infection: What Is Their Relative Contribution to Improving Clinical Outcomes? A Systematic Review and Network Meta-analysis. Clin Infect Dis 2024; 79:502-515. [PMID: 38676943 PMCID: PMC11327801 DOI: 10.1093/cid/ciae234] [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: 01/24/2024] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Evidence about the clinical impact of rapid diagnostic tests (RDTs) for the diagnosis of bloodstream infections is limited, and whether RDT are superior to conventional blood cultures (BCs) embedded within antimicrobial stewardship programs (ASPs) is unknown. METHODS We performed network meta-analyses using results from studies of patients with bloodstream infection with the aim of comparing the clinical impact of RDT (applied on positive BC broth or whole blood) to conventional BC, both assessed with and without ASP with respect to mortality, length of stay (LOS), and time to optimal therapy. RESULTS Eighty-eight papers were selected, including 25 682 patient encounters. There was an appreciable amount of statistical heterogeneity within each meta-analysis. The network meta-analyses showed a significant reduction in mortality associated with the use of RDT + ASP versus BC alone (odds ratio [OR], 0.72; 95% confidence interval [CI], .59-.87) and with the use of RDT + ASP versus BC + ASP (OR, 0.78; 95% CI, .63-.96). No benefit in survival was found associated with the use of RDT alone nor with BC + ASP compared to BC alone. A reduction in LOS was associated with RDT + ASP versus BC alone (OR, 0.91; 95% CI, .84-.98) whereas no difference in LOS was shown between any other groups. A reduced time to optimal therapy was shown when RDT + ASP was compared to BC alone (-29 hours; 95% CI, -35 to -23), BC + ASP (-18 hours; 95% CI, -27 to -10), and to RDT alone (-12 hours; 95% CI, -20 to -3). CONCLUSIONS The use of RDT + ASP may lead to a survival benefit even when introduced in settings already adopting effective ASP in association with conventional BC.
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Affiliation(s)
- Anna Maria Peri
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Mark D Chatfield
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Weiping Ling
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Luis Furuya-Kanamori
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Patrick N A Harris
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
- Herston Infectious Diseases Institute, Herston, Brisbane, Queensland, Australia
- Central Microbiology, Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - David L Paterson
- The University of Queensland, UQ Centre for Clinical Research, Brisbane, Queensland, Australia
- ADVANCE-ID, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Infectious Diseases Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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2
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Wilde AM, Song M, Allen WP, Junkins AD, Frazier JM, Moore SE, Schulz PS. Implementation of a pharmacy-driven rapid bacteremia response program. Am J Health Syst Pharm 2024; 81:74-82. [PMID: 37658845 DOI: 10.1093/ajhp/zxad211] [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: 08/31/2023] [Indexed: 09/05/2023] Open
Abstract
PURPOSE This report describes a comprehensive pharmacy-driven rapid bacteremia response program. SUMMARY This novel program positioned the pharmacy department at a large, community health system to receive and respond to critical microbiologic diagnostic testing results, 24/7/365. The program empowered pharmacists to provide centralized, comprehensive care including assessing blood culture Gram stain results, adjusting antibiotic therapy per protocol, ordering repeat blood cultures, analyzing and interpreting rapid molecular diagnostic test results, placing orders for contact isolation, and communicating antibiotic recommendations to the treatment team. In the first year after program implementation, 2,282 blood culture Gram stains and 2,046 rapid diagnostic test results were called in to the pharmacy department. The program reduced the median time to effective therapy in patients who did not already have active antimicrobial orders from over 10 hours to less than 1 hour. Based on the Gram stain results, antibiotics were started per protocol in 34.2% of patients. Based on the rapid molecular diagnostic test results, adjustments were made to antibiotic regimens in 55.7% of cases after discussion with a provider. Of these adjustments, 39.9% were for escalation of antibiotics and 37.7% were for de-escalation of antibiotics. CONCLUSION By expanding the scope of pharmacy practice, barriers to optimizing clinical care were overcome.
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Affiliation(s)
- Ashley M Wilde
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - Matthew Song
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - W Paul Allen
- Pharmacy Services, Norton Healthcare, Louisville, KY, USA
| | - Alan D Junkins
- Department of Microbiology, Norton Healthcare, Louisville, KY, USA
| | | | - Sarah E Moore
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
| | - Paul S Schulz
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, KY, USA
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3
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Attia Hussein Mahmoud H, Parekh R, Dhandibhotla S, Sai T, Pradhan A, Alugula S, Cevallos-Cueva M, Hayes BK, Athanti S, Abdin Z, K B. Insight Into Neonatal Sepsis: An Overview. Cureus 2023; 15:e45530. [PMID: 37868444 PMCID: PMC10585949 DOI: 10.7759/cureus.45530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
There are approximately 1.3 million cases of neonatal sepsis reported worldwide with deaths occurring more commonly in preterm and low-weight newborns. Neonatal sepsis is the third major cause of neonatal deaths resulting in 203,000 deaths per year. It is divided into two subtypes based on time of occurrence: early-onset neonatal sepsis (ENS), occurring within the first 72 hours of birth usually due to perinatal risk factors, and late-onset neonatal sepsis (LOS) usually occurring after the first week of life and up to 28th day of life. There are many complications associated with neonatal sepsis including septic shock, multiple organ failure, and death. It is vital for clinicians to know the signs and symptoms of neonatal sepsis in order to diagnose it early. Preventive measures, early diagnosis, appropriate antibiotic administration, timely supportive management, and the establishment of efficient management are vital in the prevention of severe complications or death. In this review, we aim to provide the most up-to-date information regarding risk factors, pathophysiology, signs and symptoms, diagnosis, and treatment of neonatal sepsis. We discuss the maternal and neonatal risk factors involved in the pathogenesis of neonatal sepsis and the signs and symptoms of early and late neonatal sepsis. We focus on the different pathogens involved and the markers used in the diagnosis and treatments available for each.
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Affiliation(s)
| | - Ritika Parekh
- Community Health, K. J. Somaiya Medical College and Research Centre, Mumbai, IND
| | | | - Tarun Sai
- Pediatrics, Sri Balaji Medical College Hospital and Research Institute, Tirupati, IND
| | - Aayush Pradhan
- Pediatric Emergency, International Friendship Children's Hospital, Kathmandu, NPL
| | - Shiny Alugula
- Pediatric Surgery, New Vision University, Eluru, IND
| | | | - Barbara K Hayes
- Pediatric Intensive Care Unit, Suburbio Hospital, Salvador, BRA
| | - Saranya Athanti
- Pediatrics, Employees' State Insurance Corporation Medical College and Hospital, Hyderabad, IND
| | - Zain Abdin
- Critical Care Medicine, IMG (International Medical Graduate) Helping Hands, Albuquerque, USA
| | - Basant K
- Medicine, Tanta University, Tanta, EGY
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4
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Lapin JS, Smith RD, Hornback KM, Johnson JK, Claeys KC. From bottle to bedside: Implementation considerations and antimicrobial stewardship considerations for bloodstream infection rapid diagnostic testing. Pharmacotherapy 2023; 43:847-863. [PMID: 37158053 DOI: 10.1002/phar.2813] [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: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/03/2023] [Indexed: 05/10/2023]
Abstract
Antimicrobial stewardship (AMS) programs have been quick to adopt novel molecular rapid diagnostic technologies (mRDTs) for bloodstream infections (BSIs) to improve antimicrobial management. As such, most of the literature demonstrating the clinical and economic benefits of mRDTs for BSI is in the presence of active AMS intervention. Leveraging mRDTs to improve antimicrobial therapy for BSI is increasingly integral to AMS program activities. This narrative review discusses available and future mRDTs, the relationship between the clinical microbiology laboratory and AMS programs, and practical considerations for optimizing the use of these tools within a health system. Antimicrobial stewardship programs must work closely with their clinical microbiology laboratories to ensure that mRDTs are used to their fullest benefit while remaining cognizant of their limitations. As more mRDT instruments and panels become available and AMS programs continue to expand, future efforts must consider the expansion beyond traditional settings of large academic medical centers and how combinations of tools can further improve patient care.
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Affiliation(s)
- Jonathan S Lapin
- Department of Pharmacy Practice, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Richard D Smith
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Krutika M Hornback
- Department of Pharmacy Practice, Medical University of South Carolina (MUSC) Health, Charleston, South Carolina, USA
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kimberly C Claeys
- Department of Pharmacy Science and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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5
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Cairns KA, Udy AA, Peel TN, Abbott IJ, Dooley MJ, Peleg AY. Therapeutics for Vancomycin-Resistant Enterococcal Bloodstream Infections. Clin Microbiol Rev 2023; 36:e0005922. [PMID: 37067406 PMCID: PMC10283489 DOI: 10.1128/cmr.00059-22] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Vancomycin-resistant enterococci (VRE) are common causes of bloodstream infections (BSIs) with high morbidity and mortality rates. They are pathogens of global concern with a limited treatment pipeline. Significant challenges exist in the management of VRE BSI, including drug dosing, the emergence of resistance, and the optimal treatment for persistent bacteremia and infective endocarditis. Therapeutic drug monitoring (TDM) for antimicrobial therapy is evolving for VRE-active agents; however, there are significant gaps in the literature for predicting antimicrobial efficacy for VRE BSIs. To date, TDM has the greatest evidence for predicting drug toxicity for the three main VRE-active antimicrobial agents daptomycin, linezolid, and teicoplanin. This article presents an overview of the treatment options for VRE BSIs, the role of antimicrobial dose optimization through TDM in supporting clinical infection management, and challenges and perspectives for the future.
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Affiliation(s)
- Kelly A. Cairns
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew A. Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Trisha N. Peel
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Iain J. Abbott
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Microbiology Unit, Alfred Health, Melbourne, Victoria, Australia
| | - Michael J. Dooley
- Pharmacy Department, Alfred Health, Melbourne, Victoria, Australia
- Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
| | - Anton Y. Peleg
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Infection Program, Monash Biomedicine Discovery Institute, Department of Microbiology, Monash University, Clayton, Victoria, Australia
- Centre to Impact AMR, Monash University, Clayton, Victoria, Australia
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6
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The role of Nucleic Acid Mimics (NAMs) on FISH-based techniques and applications for microbial detection. Microbiol Res 2022; 262:127086. [PMID: 35700584 DOI: 10.1016/j.micres.2022.127086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 06/01/2022] [Accepted: 06/03/2022] [Indexed: 01/07/2023]
Abstract
Fluorescent in situ hybridization (FISH) is a powerful tool that for more than 30 years has allowed to detect and quantify microorganisms as well as to study their spatial distribution in three-dimensional structured environments such as biofilms. Throughout these years, FISH has been improved in order to face some of its earlier limitations and to adapt to new research objectives. One of these improvements is related to the emergence of Nucleic Acid Mimics (NAMs), which are now employed as alternatives to the DNA and RNA probes that have been classically used in FISH. NAMs such as peptide and locked nucleic acids (PNA and LNA) have provided enhanced sensitivity and specificity to the FISH technique, as well as higher flexibility in terms of applications. In this review, we aim to cover the state-of-the-art of the different NAMs and explore their possible applications in FISH, providing a general overview of the technique advancement in the last decades.
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7
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Dare RK, Lusardi K, Pearson C, McCain KD, Daniels B, Van S, Rico JC, Painter J, Lakkad M, Rosenbaum ER, Bariola JR. Clinical Impact of Accelerate PhenoTM Rapid Blood Culture Detection System in Bacteremic Patients. Clin Infect Dis 2020; 73:e4616-e4626. [PMID: 32463864 DOI: 10.1093/cid/ciaa649] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/22/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Accelerate Pheno blood culture detection system (AXDX) provides identification (ID) and antimicrobial susceptibility testing (AST) results within 8h of blood culture growth. Limited data exists regarding its clinical impact. Other rapid platforms coupled with antimicrobial stewardship program (ASP) real-time notification (RTN) have shown improved length of stay (LOS) in bacteremia. METHODS A single-center, quasi-experimental study of adult bacteremic inpatients before/after AXDX implementation was conducted comparing clinical outcomes from 1 historical and 2 intervention cohorts (AXDX and AXDX+RTN). Primary outcome was LOS. RESULTS Of 830 bacteremic episodes, 188 (77%) of 245 historical and 308 (155 AXDX, 153 AXDX+RTN; 65%) of 585 intervention episodes were included. Median LOS was shorter with AXDX (6.3d) and AXDX+RTN (6.7d) compared to historical (8.1d; P=0.001). Achievement of optimal therapy (AOT) was more frequent (93.6% and 95.4%) and median time to optimal therapy (TTOT) was faster (1.3d and 1.4d) in AXDX and AXDX+RTN compared to historical (84.6%, P≤0.001 and 2.4d; P≤0.001) respectively. Median antimicrobial days of therapy (DOT) was shorter in both intervention arms compared to historical (6d each vs 7d; P=0.011). Median LOS benefit was most pronounced in patients with coagulase negative Staphylococcus bacteremia (5.5d and 4.5d vs 7.2d; P=0.003) in AXDX, AXDX+RTN, and historical cohorts respectively. CONCLUSIONS LOS, AOT, TTOT, and total DOT significantly improved after AXDX implementation. Addition of RTN did not show further improvement over AXDX and an already active ASP. These results suggest AXDX can be integrated into healthcare systems with an active ASP even without the resources to include RTN.
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Affiliation(s)
- R K Dare
- Division of Infectious Diseases, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - K Lusardi
- Hospital Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - C Pearson
- Division of Infectious Diseases, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - K D McCain
- Hospital Pharmacy, Wadley Regional Medical Center, Texarkana, TX, USA
| | - B Daniels
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - S Van
- College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - J C Rico
- Division of Infectious Diseases, Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - J Painter
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - M Lakkad
- Division of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - E R Rosenbaum
- Department of Pathology and Laboratory Services, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - J R Bariola
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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8
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Rapid microbiological tests for bloodstream infections due to multidrug resistant Gram-negative bacteria: therapeutic implications. Clin Microbiol Infect 2019; 26:713-722. [PMID: 31610299 DOI: 10.1016/j.cmi.2019.09.023] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/20/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Treating severe infections due to multidrug-resistant Gram-negative bacteria (MDR-GNB) is one of the most important challenges for clinicians worldwide, partly because resistance may remain unrecognized until identification of the causative agent and/or antimicrobial susceptibility testing (AST). Recently, some novel rapid test for identification and/or AST of MDR-GNB from positive blood cultures or the blood of patients with bloodstream infections (BSIs) have become available. OBJECTIVES The objective of this narrative review is to discuss the advantages and limitations of different rapid tests for identification and/or AST of MDR-GNB from positive blood cultures or the blood of patients with BSI, as well as the available evidence on their possible role to improve therapeutic decisions and antimicrobial stewardship. SOURCES Inductive PubMed search for publications relevant to the topic. CONTENT The present review is structured in the following way: (a) rapid tests on positive blood cultures; (b) rapid tests directly on whole blood; (c) therapeutic implications. IMPLICATIONS Novel molecular and phenotypic rapid tests for identification and AST show the potential for favourably influencing patients' outcomes and results of antimicrobial stewardship interventions by reducing both the time to effective treatment and the misuse of antibiotics, although the interpretation about their impact on actual therapeutic decisions and patients' outcomes is still complex. Factors such as feasibility and personnel availability, as well as the detailed knowledge of the local microbiological epidemiology, need to be considered very carefully when implementing novel rapid tests in laboratory workflows and algorithms. Providing high-level, comparable evidence on the clinical impact of rapid identification and AST is becoming of paramount importance for MDR-GNB infections, since in the near future rapid identification of specific resistance mechanisms could be crucial for guiding rapid, effective, and targeted therapy against specific resistance mechanisms.
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Comparison of rapid BACpro® II, Sepsityper® kit and in-house preparation methods for direct identification of bacteria from blood cultures by MALDI-TOF MS with and without Sepsityper® module analysis. Eur J Clin Microbiol Infect Dis 2019; 38:2133-2143. [PMID: 31494828 PMCID: PMC6800852 DOI: 10.1007/s10096-019-03654-4] [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: 06/11/2019] [Accepted: 07/21/2019] [Indexed: 01/24/2023]
Abstract
There are several approaches available for purifying microorganisms prior to matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) analysis. In the present study, rapid BACpro® II (Nittobo Medical Co., Ltd., Tokyo, Japan), a new application, has been compared with Sepsityper® kit (Bruker Daltonics, Billerica, USA) and an in-house method. Samples were also tested with two modules, standard and Sepsityper®, identified in the Bruker MALDI-TOF MS. The bottles having monomicrobial growth were included in the study according to Gram staining results. In total, two hundred blood culture bottles were included but there was no growth in one of the subcultures so 199 blood culture bottles were studied prospectively. With the standard MALDI-TOF MS analysis, rapid BACpro® II could successfully identify microorganisms in 174/199 (87.4%) of the bottles where Sepsityper® kit and in-house method were successful in 136/199 (68.3%) and 114/199 (57.3%), respectively. When the MALDI-TOF MS data were analysed by Sepsityper® module, the identification rates were increased to 94.4%, 82.1% and 69.8% (p < 0.001), respectively. In the Sepsityper® module, 72/73 (98.6%) of Gram-negative and 97/106 (91.5%) of Gram-positive microorganisms were detected by rapid BACpro® II method. The present study shows that rapid BACpro® II is a reliable preparation procedure and has higher rates of identification compared with Sepsityper® kit and in-house method. The use of the Sepsityper® module in blood cultures increases the chance of identification for all three methods studied.
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10
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Antisense peptide nucleic acids as a potential anti-infective agent. J Microbiol 2019; 57:423-430. [PMID: 31054136 DOI: 10.1007/s12275-019-8635-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/25/2019] [Accepted: 01/28/2019] [Indexed: 01/25/2023]
Abstract
Antibiotics have long been used for anti-infective control of bacterial infections, growth promotion in husbandry, and prophylactic protection against plant pathogens. However, their inappropriate use results in the emergence and spread of multiple drug resistance (MDR) especially among various bacterial populations, which limits further administration of conventional antibiotics. Therefore, the demand for novel anti-infective approaches against MDR diseases becomes increasing in recent years. The peptide nucleic acid (PNA)-based technology has been proposed as one of novel anti-infective and/or therapeutic strategies. By definition, PNA is an artificially synthesized nucleic acid mimic structurally similar to DNA or RNA in nature and linked one another via an unnatural pseudo-peptide backbone, rendering to its stability in diverse host conditions. It can bind DNA or RNA strands complimentarily with high affinity and sequence specificity, which induces the target-specific gene silencing by inhibiting transcription and/or translation. Based on these unique properties, PNA has been widely applied for molecular diagnosis as well as considered as a potential anti-infective agent. In this review, we discuss the general features of PNAs and their application to various bacterial pathogens as new anti-infective or antimicrobial agents.
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11
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Antibiotic stewardship in the intensive care unit: Challenges and opportunities. Infect Control Hosp Epidemiol 2019; 40:693-698. [PMID: 31046851 DOI: 10.1017/ice.2019.74] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Infections due to antibiotic-resistant organisms are increasing in prevalence and represent a major public health threat. Antibiotic overuse is a major driver of this epidemic, and antibiotic stewardship an important means of limiting antibiotic resistance. The intensive care unit (ICU) setting presents an intersection of opportunities and challenges for effective antibiotic stewardship, but limited data inform optimal stewardship interventions in this setting. In this review, we present unique considerations for stewardship interventions the ICU setting and summarize available data evaluating the impact of prospective audit and feedback, diagnostic test stewardship, rapid molecular diagnostic tests, and procalcitonin-guided algorithms for antibiotic discontinuation. The existing knowledge gaps ripe for future research are emphasized.
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12
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Lam SW, Bass SN. Advancing Infectious Diseases Diagnostic Testing and Applications to Antimicrobial Therapy in the ICU. J Pharm Pract 2019; 32:327-338. [PMID: 30808257 DOI: 10.1177/0897190019831162] [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] [Indexed: 01/05/2023]
Abstract
Treatment of suspected infections in critically ill patients requires the timely initiation of appropriate antimicrobials and rapid de-escalation of unnecessary broad-spectrum coverage. New advances in rapid diagnostic tests can now offer earlier detection of pathogen and potential resistance mechanisms within hours of initial culture growth. These technologies, combined with pharmacist antimicrobial stewardship efforts, may result in shorten time to adequate coverage or earlier de-escalation of unnecessary broad spectrum antimicrobials, which could improve patient outcomes and lower overall treatment cost. Furthermore, de-escalation of antimicrobials may lead to decreased emergence of resistant organisms and adverse events associated with antimicrobials. Clinical pharmacists should be aware of new rapid diagnostic tests, including their application, clinical evidence, and limitations, in order to implement the most appropriate clinical treatment strategy when patients have positive cultures. This review will focus on commercially available rapid diagnostic tests for infections that are routinely encountered by critically ill patients, including gram-positive and gram-negative bacterial blood stream infections, Candida, and Clostridioides difficile.
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Affiliation(s)
- Simon W Lam
- 1 Department of Pharmacy, Pharmacoeconomics and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Stephanie N Bass
- 2 Department of Pharmacy, Medical Intensive Care Unit, Cleveland Clinic, Cleveland, OH, USA
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13
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Affiliation(s)
- Marilynn Ransom Fairfax
- Department of Pathology, Wayne State University School of Medicine, 540 East Canfield Street, Detroit, MI 48201, USA; Clinical Microbiology Laboratories, DMC University Laboratories, 4201 St. Antoine Street, Detroit, MI 48201, USA.
| | - Martin H Bluth
- Department of Pathology, Wayne State University School of Medicine, 540 East Canfield Street, Detroit, MI 48201, USA; Pathology Laboratories, Michigan Surgical Hospital, 21230 Dequindre Road, Warren, MI 48091, USA
| | - Hossein Salimnia
- Department of Pathology, Wayne State University School of Medicine, 540 East Canfield Street, Detroit, MI 48201, USA; Clinical Microbiology Laboratories, DMC University Laboratories, 4201 St. Antoine Street, Detroit, MI 48201, USA
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Accelerated bacterial detection in blood culture by enhanced acoustic flow cytometry (AFC) following peptide nucleic acid fluorescence in situ hybridization (PNA-FISH). PLoS One 2019; 14:e0201332. [PMID: 30735489 PMCID: PMC6368374 DOI: 10.1371/journal.pone.0201332] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 01/16/2019] [Indexed: 11/23/2022] Open
Abstract
Bacteraemia is a risk factor for subsequent clinical deterioration and death. Current reliance on culture-based methods for detection of bacteraemia delays identification and assessment of this risk until after the optimal period for positively impacting treatment decisions has passed. Therefore, a method for rapid detection and identification of bacterial infection in the peripheral bloodstream in acutely ill patients is crucial for improved patient survival through earlier targeted antibiotic treatment. The turnaround time for current clinical laboratory methods ranges from 12 to 48 hours, emphasizing the need for a faster diagnostic test. Here we describe a novel assay for accelerated generic detection of bacteria in blood culture (BC) using peptide nucleic acid fluorescence in situ hybridization enhanced acoustic flow cytometry (PNA-FISH-AFC). For assay development, we used simulated blood cultures (BCs) spiked with one of three bacterial species at a low starting concentration of 10 CFU/mL: Escherichia coli, Klebsiella pneumoniae or Pseudomonas aeruginosa. Under current clinical settings, it takes a minimum of 12 hours incubation to reach positivity on the BacTEC system, corresponding to a bacterial concentration of 107−109 CFU/mL optimal for further analyses. In contrast, our PNA-FISH-AFC assay detected 103–104 CFU/mL bacteria in BC following a much shorter culture incubation of 5 to 10 hours. Using either PCR-based FilmArray assay or MALDI-TOF for bacterial detection, it took 7–10 and 12–24 hours of incubation, respectively, to reach the positive result. These findings indicate a potential time advantage of PNA-FISH-AFC assay for rapid bacterial detection in BC with significantly improved turnaround time over currently used laboratory techniques.
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15
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Wolk DM, Johnson JK. Rapid Diagnostics for Blood Cultures: Supporting Decisions for Antimicrobial Therapy and Value-Based Care. J Appl Lab Med 2018; 3:686-697. [PMID: 31639736 DOI: 10.1373/jalm.2018.028159] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/07/2018] [Indexed: 01/05/2023]
Abstract
Bacteremia and sepsis are critically important syndromes with high mortality, morbidity, and associated costs. Bloodstream infections and sepsis are among the top causes of mortality in the US, with >600 deaths each day. Most septic patients can be found in emergency medicine departments or critical care units, settings in which rapid administration of targeted antibiotic therapy can reduce mortality. Unfortunately, routine blood cultures are not rapid enough to aid in the decision of therapeutic intervention at the onset of bacteremia. As a result, empiric, broad-spectrum treatment is common-a costly approach that may fail to target the correct microbe effectively, may inadvertently harm patients via antimicrobial toxicity, and may contribute to the evolution of drug-resistant microbes. To overcome these challenges, laboratorians must understand the complexity of diagnosing and treating septic patients, focus on creating algorithms that rapidly support decisions for targeted antibiotic therapy, and synergize with existing emergency department and critical care clinical practices put forth in the Surviving Sepsis Guidelines.
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Affiliation(s)
- Donna M Wolk
- Laboratory Medicine, Geisinger Diagnostic Medicine Institute, Danville, PA;
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD
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Tseng AS, Kasule SN, Rice F, Mi L, Chan L, Seville MT, Grys TE. Is It Actionable? An Evaluation of the Rapid PCR-Based Blood Culture Identification Panel on the Management of Gram-Positive and Gram-Negative Blood Stream Infections. Open Forum Infect Dis 2018; 5:ofy308. [PMID: 30555850 PMCID: PMC6288766 DOI: 10.1093/ofid/ofy308] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 12/03/2018] [Indexed: 01/02/2023] Open
Abstract
Background There is growing interest in the use of rapid blood culture identification (BCID) in antimicrobial stewardship programs (ASPs). Although many studies have looked at its clinical and economic utility, its comparative utility in gram-positive and gram-negative blood stream infections (BSIs) has not been as well characterized. Methods The study was a quasi-experimental retrospective study at the Mayo Clinic in Phoenix, Arizona. All adult patients with positive blood cultures before BCID implementation (June 2015 to December 2015) and after BCID implementation (June 2016 to December 2016) were included. The outcomes of interest included time to first appropriate antibiotic escalation, time to first appropriate antibiotic de-escalation, time to organism identification, length of stay, infectious diseases consultation, discharge disposition, and in-hospital mortality. Results In total, 203 patients were included in this study. There was a significant difference in the time to organism identification between the pre- and post-BCID cohorts (27.1 hours vs 3.3 hours, P < .0001). BCID did not significantly reduce the time to first appropriate antimicrobial escalation or de-escalation for either gram-positive BSIs (GP-BSIs) or gram-negative BSIs (GN-BSIs). Providers were more likely to escalate antimicrobial therapy in GP-BSIs after gram stain and more likely to de-escalate therapy in GN-BSIs after susceptibilities. Although there were no significant differences in changes in antimicrobial therapy for organism identification by BCID vs traditional methods, more than one-quarter of providers (28.1%) made changes after organism identification. There were no differences in hospital length of stay or in-hospital mortality comparing pre- vs post-BCID. Conclusions Although BCID significantly reduced the time to identification for both GP-BSIs and GN-BSIs, BCID did not reduce the time to first appropriate antimicrobial escalation and de-escalation.
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Affiliation(s)
- Andrew S Tseng
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Sabirah N Kasule
- Department of Internal Medicine, Mayo Clinic, Scottsdale, Arizona
| | - Felicia Rice
- Division of Laboratory Medicine, Mayo Clinic, Phoenix, Arizona
| | - Lanyu Mi
- Division of Health Sciences Research, Department of Biomedical Statistics and Informatics, Mayo Clinic, Scottsdale, Arizona
| | - Lynn Chan
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona
| | - Maria T Seville
- Division of Infectious Diseases, Mayo Clinic, Phoenix, Arizona
| | - Thomas E Grys
- Division of Laboratory Medicine, Mayo Clinic, Phoenix, Arizona
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She RC, Bender JM. Advances in Rapid Molecular Blood Culture Diagnostics: Healthcare Impact, Laboratory Implications, and Multiplex Technologies. J Appl Lab Med 2018; 3:617-630. [PMID: 31639730 DOI: 10.1373/jalm.2018.027409] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Accepted: 09/28/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND For far too long, the diagnosis of bloodstream infections has relied on time-consuming blood cultures coupled with traditional organism identification and susceptibility testing. Technologies to define the culprit in bloodstream infections have gained sophistication in recent years, notably by application of molecular methods. CONTENT In this review, we summarize the tests available to clinical laboratories for molecular rapid identification and resistance marker detection in blood culture bottles that have flagged positive. We explore the cost-benefit ratio of such assays, covering aspects that include performance characteristics, effect on patient care, and relevance to antibiotic stewardship initiatives. SUMMARY Rapid blood culture diagnostics represent an advance in the care of patients with bloodstream infections, particularly those infected with resistant organisms. These diagnostics are relatively easy to implement and appear to have a positive cost-benefit balance, particularly when fully incorporated into a hospital's antimicrobial stewardship program.
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Affiliation(s)
- Rosemary C She
- Department of Pathology, Keck School of Medicine of the University of Southern California, Los Angeles, CA;
| | - Jeffrey M Bender
- Division of Infectious Diseases of the Department of Pediatrics, Keck School of Medicine of the University of Southern California, Los Angeles, CA
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18
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Kamboj M, Cohen N, Huang YT, Kerpelev M, Jakubowski A, Sepkowitz KA, Papanicolaou GA, Seo SK. Impact of Empiric Treatment for Vancomycin-Resistant Enterococcus in Colonized Patients Early after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2018; 25:594-598. [PMID: 30448456 DOI: 10.1016/j.bbmt.2018.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 11/08/2018] [Indexed: 01/07/2023]
Abstract
In recent years, vancomycin-resistant Enterococcus (VRE) colonization is being increasingly encountered in transplant recipients, and VRE has become one of the leading causes of bacteremia early after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Data are sparse on the effect of empiric VRE therapy for febrile, neutropenic allo-HSCT recipients colonized with VRE. All allo-HSCT recipients aged ≥18years who developed VRE bacteremia (VREB) between 2005 and 2014 were identified and categorized as to whether they received empiric or directed VRE therapy. There were 434 (33%) VRE-colonized and 872 (67%) non-VRE-colonized patients during the study period, and 172 of the 434 (40%) VRE-colonized patients received empiric therapy. There was no significant difference in incidence of VREB among colonized patients who did or did not receive empiric therapy (28 of 172 [16%] vs 55 of 262 [21%]; P = .22). There were 95 patients with VREB, of which the majority (83 of 95; 87%) was known to be VRE-colonized. Of the 95 VREB episodes, 29 (31%) were treated with empiric VRE therapy, whereas 66 (69%) were treated with directed therapy. No significant differences in clinical outcomes, including median duration of bacteremia (2 days vs 2 days; P = .39), recurrent VREB (3 of 29 [10%] vs 5 of 66 [8%]; P = .65), 30-day all-cause mortality (1 of 29 [3%] vs 4 of 66 [6%]; P = .62), or VRE-attributable mortality (1 of 29 [3%] vs 1 of 66 [2%]; P = .55), were observed between the empiric therapy and directed therapy groups. Kaplan-Meier curve analysis showed no significant difference in survival at 30days in allo-HSCT recipients with VREB who received empiric therapy and those who received directed therapy (97% vs 94%; P = .62). Based on our data, we recommend against empiric use of VRE-active agents for fever and neutropenia in VRE-colonized patients undergoing allo-HSCT.
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Affiliation(s)
- Mini Kamboj
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Infection Control, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Joan and Sanford Weill Cornell Medical College, New York, New York
| | - Nina Cohen
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yao-Ting Huang
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marina Kerpelev
- Information Systems, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ann Jakubowski
- Department of Medicine, Joan and Sanford Weill Cornell Medical College, New York, New York; Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kent A Sepkowitz
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Infection Control, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Joan and Sanford Weill Cornell Medical College, New York, New York
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Joan and Sanford Weill Cornell Medical College, New York, New York
| | - Susan K Seo
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Joan and Sanford Weill Cornell Medical College, New York, New York.
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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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20
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Prudent E, Lepidi H, Angelakis E, Raoult D. Fluorescence In Situ Hybridization (FISH) and Peptide Nucleic Acid Probe-Based FISH for Diagnosis of Q Fever Endocarditis and Vascular Infections. J Clin Microbiol 2018; 56:e00542-18. [PMID: 29899006 PMCID: PMC6113452 DOI: 10.1128/jcm.00542-18] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 06/11/2018] [Indexed: 01/07/2023] Open
Abstract
Endocarditis and vascular infections are common manifestations of persistent localized infection due to Coxiella burnetii, and recently, fluorescence in situ hybridization (FISH) was proposed as an alternative tool for their diagnosis. In this study, we evaluated the efficiency of FISH in a series of valve and vascular samples infected by C. burnetii We tested 23 C. burnetii-positive valves and thrombus samples obtained from patients with Q fever endocarditis. Seven aneurysms and thrombus specimens were retrieved from patients with Q fever vascular infections. Samples were analyzed by culture, immunochemistry, and FISH with oligonucleotide and PNA probes targeting C. burnetii-specific 16S rRNA sequences. The immunohistochemical analysis was positive for five (17%) samples with significantly more copies of C. burnetii DNA than the negative ones (P = 0.02). FISH was positive for 13 (43%) samples and presented 43% and 40% sensitivity compared to that for quantitative PCR (qPCR) and culture, respectively. PNA FISH detected C. burnetii in 18 (60%) samples and presented 60% and 55% sensitivity compared to that for qPCR and culture, respectively. Immunohistochemistry had 38% and 28% sensitivity compared to that for FISH and PNA FISH, respectively. Samples found positive by both immunohistochemistry and PNA FISH contained significantly more copies of C. burnetii DNA than the negative ones (P = 0.03). Finally, PNA FISH was more sensitive than FISH (60% versus 43%, respectively) for the detection of C. burnetii We provide evidence that PNA FISH and FISH are important assays for the diagnosis of C. burnetii endocarditis and vascular infections.
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Affiliation(s)
- Elsa Prudent
- Aix Marseille Université, IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Hubert Lepidi
- Aix Marseille Université, IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, Marseille, France
| | - Emmanouil Angelakis
- Aix Marseille Université, IRD, AP-HM, VITROME, IHU-Méditerranée Infection, Marseille, France
- French Reference Center for the Diagnosis and Study of Rickettsioses, Q fever and Bartonelloses, IHU-Méditerranée Infection, Marseille, France
| | - Didier Raoult
- Aix Marseille Université, IRD, AP-HM, MEPHI, IHU-Méditerranée Infection, Marseille, France
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21
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Clinical Evaluation of the iCubate iC-GPC Assay for Detection of Gram-Positive Bacteria and Resistance Markers from Positive Blood Cultures. J Clin Microbiol 2018; 56:JCM.00485-18. [PMID: 29899000 PMCID: PMC6113461 DOI: 10.1128/jcm.00485-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 06/01/2018] [Indexed: 01/06/2023] Open
Abstract
The iC-GPC Assay (iCubate, Huntsville, AL) is a qualitative multiplex test for the detection of five of the most common Gram-positive bacteria (Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, Enterococcus faecalis, and Enterococcus faecium) responsible for bacterial bloodstream infections, performed directly from positive blood cultures. The assay also detects the presence of the mecA, vanA, and vanB resistance determinants. The iC-GPC Assay (iCubate, Huntsville, AL) is a qualitative multiplex test for the detection of five of the most common Gram-positive bacteria (Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pneumoniae, Enterococcus faecalis, and Enterococcus faecium) responsible for bacterial bloodstream infections, performed directly from positive blood cultures. The assay also detects the presence of the mecA, vanA, and vanB resistance determinants. This study comparatively evaluated the performance of the iC-GPC Assay against the Verigene Gram-positive blood culture (BC-GP) assay (Luminex Corp., Austin, TX) for 1,134 patient blood culture specimens positive for Gram-positive cocci. The iC-GPC Assay had an overall percent agreement with the BC-GP assay of 95.5%. Discordant specimens were further analyzed by PCR and a bidirectional sequencing method. The results indicate that the iC-GPC Assay together with the iCubate system is an accurate and reliable tool for the detection of the five most common Gram-positive bacteria and their resistance markers responsible for bloodstream infections.
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22
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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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Wenzler E, Timbrook TT, Wong JR, Hurst JM, MacVane SH. Implementation and optimization of molecular rapid diagnostic tests for bloodstream infections. Am J Health Syst Pharm 2018; 75:1191-1202. [PMID: 29970407 DOI: 10.2146/ajhp170604] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE The implementation and optimization of molecular rapid diagnostic tests (mRDTs) as an antimicrobial stewardship intervention for patients with bloodstream infections (BSIs) are reviewed. SUMMARY All U.S. acute care hospitals accredited by the Joint Commission are required to implement an antimicrobial stewardship program (ASP). Of the many interventions available to ASPs, mRDTs have demonstrated consistent, meaningful results on antimicrobial optimization and patient outcomes. Even among infectious diseases and antimicrobial stewardship-trained pharmacists, significant knowledge and familiarity gaps exist regarding available mRDTs and how best to implement and optimize them. Given the paucity of infectious diseases and/or antimicrobial stewardship-trained pharmacists, the mandates for establishing ASPs will require non-infectious diseases/antimicrobial stewardship-trained pharmacists to implement stewardship interventions, which may include mRDTs, within their institution. Optimization of mRDTs requires adequate diagnostic stewardship, specifically evaluating how mRDT implementation may decrease costs and assist in meeting antimicrobial stewardship regulatory requirements. Knowledge of how these technologies will augment existing microbiology and antimicrobial stewardship workflow is essential. Finally, selecting the right mRDT necessitates familiarity with the instrument's capabilities and with the institutional antibiogram. CONCLUSION mRDTs have demonstrated the ability to be one of the most powerful antimicrobial stewardship interventions. Pharmacists required to implement an ASP in their institution should consider mRDTs as standard of care for patients with BSIs.
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Affiliation(s)
- Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL.
| | | | - Jordan R Wong
- Department of Pharmacy, Grady Health System, Atlanta, GA
| | - John M Hurst
- Department of Antibiotic Stewardship, St. Anthony Hospital, Oklahoma City, OK
| | - Shawn H MacVane
- Department of Pharmacy and Division of Infectious Diseases, Medical University of South Carolina, Charleston, SC
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24
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Foolad F, Nagel JL, Eschenauer G, Patel TS, Nguyen CT. Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management. J Antimicrob Chemother 2018; 72:3232-3244. [PMID: 29177489 DOI: 10.1093/jac/dkx266] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.
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Affiliation(s)
- Farnaz Foolad
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
| | - Jerod L Nagel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Gregory Eschenauer
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA.,College of Pharmacy, University of Michigan, 428 Church St., Ann Arbor, MI 48109, USA
| | - Twisha S Patel
- Department of Pharmacy, Michigan Medicine, 1500 E. Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Cynthia T Nguyen
- Department of Pharmacy, University of Chicago Medicine, 5841 S. Maryland Ave. MC0010, Chicago, IL 60637, USA
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25
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Avdic E, Wang R, Li DX, Tamma PD, Shulder SE, Carroll KC, Cosgrove SE. Sustained impact of a rapid microarray-based assay with antimicrobial stewardship interventions on optimizing therapy in patients with Gram-positive bacteraemia. J Antimicrob Chemother 2018; 72:3191-3198. [PMID: 28961942 DOI: 10.1093/jac/dkx267] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 07/06/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives To compare antibiotic optimization and outcomes of patients before implementation of the Verigene Gram-Positive Blood Culture (Verigene BC-GP) nucleic acid microarray assay to after implementation with antimicrobial stewardship (AS) interventions and after discontinuation of AS interventions. Methods A retrospective pre-post-post quasi-experimental study was conducted to compare the three periods. AS interventions consisted of real-time guidance to clinicians on antibiotic selection. The primary outcome was median time from Gram stain to optimal therapy. Secondary outcomes included median time to effective therapy, median duration of therapy for contaminant organisms, median length of stay after blood cultures were collected, and all-cause in-hospital mortality. Results Out of a total of 923 patients, 390 (125 baseline, 134 intervention, 131 post-intervention) who were not on optimal therapy at the time of Gram stain or had contaminated blood cultures were assessed. Compared with baseline, only the median time to optimal therapy for MSSA bacteraemia was reduced in both the intervention and post-intervention periods (17 versus 17 versus 50 h; P < 0.001), respectively. In an analysis adjusted for baseline differences among the groups using quantile regression models, use of the Verigene BC-GP assay in both periods significantly reduced time to optimal therapy by 14-22 h in patients who would achieve optimal therapy at ≥ 26 h without the assay. There were no differences in in-hospital mortality or hospital length of stay between study periods. Conclusions A real-time AS intervention implemented alongside introduction of the Verigene BC-GP assay led to improvements in antibiotic therapy for patients with bacteraemia due to Gram-positive cocci, even after the AS intervention was discontinued.
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Affiliation(s)
- Edina Avdic
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ruibin Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David X Li
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Karen C Carroll
- Department of Pathology, Division of Medical Microbiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sara E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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26
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Abdul-Aziz MH, Driver E, Lipman J, Roberts JA. New paradigm for rapid achievement of appropriate therapy in special populations: coupling antibiotic dose optimization rapid microbiological methods. Expert Opin Drug Metab Toxicol 2018; 14:693-708. [PMID: 29865877 DOI: 10.1080/17425255.2018.1484452] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Some special patient populations (e.g. critically ill, burns, hematological malignancy, post-major surgery, post-major trauma) have characteristics that lead to higher rates of failure and mortality associated with infection. Choice of effective antibiotics and optimized doses are challenging in these patients that are commonly infected by multidrug-resistant pathogens. Areas covered: A review of the importance of diagnosis and the place of newer microbiological methods (e.g. whole-genome sequencing) to ensure rapid transition from empiric to directed antibiotic therapy is provided. The effects of pathophysiological changes on antibiotic pharmacokinetics are also provided. Expert opinion: Product information dosing regimens do not address the pharmacokinetic alterations that can occur in special patient populations and increase the likelihood of therapeutic failure and the emergence of bacterial resistance. Altered dosing approaches, supplemented with the use of dosing software and therapeutic drug monitoring, may be needed to ensure optimal antibiotic exposure and better therapeutic outcomes in these patients with severe infection. Dose optimization needs to be coupled with advanced microbiological techniques that enable rapid microbiological identification and characterization of resistance mechanism to ensure that maximally effective directed therapy can be chosen.
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Affiliation(s)
- Mohd H Abdul-Aziz
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia
| | - Elicia Driver
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia
| | - Jeffrey Lipman
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia.,b Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia
| | - Jason A Roberts
- a Faculty of Medicine , University of Queensland Centre for Clinical Research, The University of Queensland , Brisbane , Queensland , Australia.,b Department of Intensive Care Medicine , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,c Department of Pharmacy , Royal Brisbane and Women's Hospital , Brisbane , Queensland , Australia.,d School of Pharmacy, Centre for Translational Anti-infective Pharmacodynamics , The University of Queensland , Brisbane , Queensland , Australia
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27
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The Cost-Effectiveness of Rapid Diagnostic Testing for the Diagnosis of Bloodstream Infections with or without Antimicrobial Stewardship. Clin Microbiol Rev 2018; 31:31/3/e00095-17. [PMID: 29848775 DOI: 10.1128/cmr.00095-17] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Bloodstream infections are associated with considerable morbidity and health care costs. Molecular rapid diagnostic tests (mRDTs) are a promising complement to conventional laboratory methods for the diagnosis of bloodstream infections and may reduce the time to effective therapy among patients with bloodstream infections. The concurrent implementation of antimicrobial stewardship programs (ASPs) may reinforce these benefits. The aim of this study was to evaluate the cost-effectivenesses of competing strategies for the diagnosis of bloodstream infection alone or combined with an ASP. To this effect, we constructed a decision-analytic model comparing 12 strategies for the diagnosis of bloodstream infection. The main arms compared the use of mRDT and conventional laboratory methods with or without an ASP. The baseline strategy used as the standard was the use of conventional laboratory methods without an ASP, and our decision-analytic model assessed the cost-effectivenesses of 5 principal strategies: mRDT (with and without an ASP), mRDT with an ASP, mRDT without an ASP, conventional laboratory methods with an ASP, and conventional laboratory methods without an ASP. Furthermore, based on the availability of data in the literature, we assessed the cost-effectivenesses of 7 mRDT subcategories, as follows: PCR with an ASP, matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) analysis with an ASP, peptide nucleic acid fluorescent in situ hybridization (PNA-FISH) with an ASP, a blood culture nanotechnology microarray system for Gram-negative bacteria (BC-GP) with an ASP, a blood culture nanotechnology microarray system for Gram-positive bacteria (BC-GN) with an ASP, PCR without an ASP, and PNA-FISH without an ASP. Our patient population consisted of adult inpatients in U.S. hospitals with suspected bloodstream infection. The time horizon of the model was the projected life expectancy of the patients. In a base-case analysis, cost-effectiveness was determined by calculating the numbers of bloodstream infection deaths averted, the numbers of quality-adjusted life years gained, and incremental cost-effectiveness ratios (ICERs). In a probabilistic analysis, uncertainty was addressed by plotting cost-effectiveness planes and acceptability curves for various willingness-to-pay thresholds. In the base-case analysis, MALDI-TOF analysis with an ASP was the most cost-effective strategy, resulting in savings of $29,205 per quality-adjusted life year and preventing 1 death per 14 patients with suspected bloodstream infection tested compared to conventional laboratory methods without an ASP (ICER, -$29,205/quality-adjusted life year). BC-GN with an ASP (ICER, -$23,587/quality-adjusted life year), PCR with an ASP (ICER, -$19,833/quality-adjusted life year), and PCR without an ASP (ICER, -$21,039/quality-adjusted life year) were other cost-effective options. In the probabilistic analysis, mRDT was dominant and cost-effective in 85.1% of simulations. Importantly, mRDT with an ASP had an 80.0% chance of being cost-effective, while mRDT without an ASP had only a 41.1% chance. In conclusion, our findings suggest that mRDTs are cost-effective for the diagnosis of patients with suspected bloodstream infection and can reduce health care expenditures. Notably, the combination of mRDT and an ASP can result in substantial health care savings.
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Invasive pulmonary aspergillosis: current diagnostic methodologies and a new molecular approach. Eur J Clin Microbiol Infect Dis 2018; 37:1393-1403. [DOI: 10.1007/s10096-018-3251-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Accepted: 04/05/2018] [Indexed: 12/11/2022]
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Otašević S, Momčilović S, Stojanović NM, Skvarč M, Rajković K, Arsić-Arsenijević V. Non-culture based assays for the detection of fungal pathogens. J Mycol Med 2018; 28:236-248. [PMID: 29605542 PMCID: PMC7110445 DOI: 10.1016/j.mycmed.2018.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/05/2018] [Accepted: 03/05/2018] [Indexed: 01/05/2023]
Abstract
Traditional, culture based methods for the diagnosis of fungal infections are still considered as gold standard, but they are time consuming and low sensitive. Therefore, in order to overcome the limitations, many researchers have focused on the development of new immunological and molecular based rapid assays that could enable early diagnosis of infection and accurate identification of fungal pathogens causing superficial and invasive infection. In this brief review, we highlighted the advantages and disadvantages of conventional diagnostic methods and possibility of non-culture based assays in diagnosis of superficial fungal infections and presented the overview on currently available immunochromatographic assays as well as availability of biomarkers detection by immunodiagnostic procedures in prompt and accurate diagnosis of invasive fungal infections. In addition, we presented diagnostic efficiency of currently available molecular panels and researches in this area.
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Affiliation(s)
- S Otašević
- Center of Microbiology and Parasitology, Public Health Institute Niš, Serbia, boulevard Zorana Djindjica 50, 18000 Niš, Serbia; Department of Microbiology and Immunology, Faculty of Medicine, University of Niš, Serbia, boulevard Zorana Djindjica 81, 18000 Niš, Serbia.
| | - S Momčilović
- Department of Microbiology and Immunology, Faculty of Medicine, University of Niš, Serbia, boulevard Zorana Djindjica 81, 18000 Niš, Serbia
| | - N M Stojanović
- Faculty of Medicine, University of Niš, Serbia, boulevard Zorana Djindjica 81, 18000 Niš, Serbia
| | - M Skvarč
- University of Ljubljana, Faculty of Medicine, Institute of Microbiology and Immunology, Zaloska 4, Ljubljana, Slovenia
| | - K Rajković
- High Chemical and Technological School for Professional Studies, Kosančićeva 36, 37000 Kruševac, Serbia
| | - V Arsić-Arsenijević
- Department for Microbiology and Immunology, Faculty of Medicine, University of Belgrade, Serbia, Dr Subotića 1, 11000 Belgrade, Serbia
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Multicenter Evaluation of the Accelerate PhenoTest BC Kit for Rapid Identification and Phenotypic Antimicrobial Susceptibility Testing Using Morphokinetic Cellular Analysis. J Clin Microbiol 2018; 56:JCM.01329-17. [PMID: 29305546 PMCID: PMC5869823 DOI: 10.1128/jcm.01329-17] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 12/19/2017] [Indexed: 12/29/2022] Open
Abstract
We describe results from a multicenter study evaluating the Accelerate Pheno system, a first of its kind diagnostic system that rapidly identifies common bloodstream pathogens from positive blood cultures within 90 min and determines bacterial phenotypic antimicrobial susceptibility testing (AST) results within ∼7 h. A combination of fresh clinical and seeded blood cultures were tested, and results from the Accelerate Pheno system were compared to Vitek 2 results for identification (ID) and broth microdilution or disk diffusion for AST. The Accelerate Pheno system accurately identified 14 common bacterial pathogens and two Candida spp. with sensitivities ranging from 94.6 to 100%. Of fresh positive blood cultures, 89% received a monomicrobial call with a positive predictive value of 97.3%. Six common Gram-positive cocci were evaluated for ID. Five were tested against eight antibiotics, two resistance phenotypes (methicillin-resistant Staphylococcus aureus and Staphylococcus spp. [MRSA/MRS]), and inducible clindamycin resistance (MLSb). From the 4,142 AST results, the overall essential agreement (EA) and categorical agreement (CA) were 97.6% and 97.9%, respectively. Overall very major error (VME), major error (ME), and minor error (mE) rates were 1.0%, 0.7%, and 1.3%, respectively. Eight species of Gram-negative rods were evaluated against 15 antibiotics. From the 6,331 AST results, overall EA and CA were 95.4% and 94.3%, respectively. Overall VME, ME, and mE rates were 0.5%, 0.9%, and 4.8%, respectively. The Accelerate Pheno system has the unique ability to identify and provide phenotypic MIC and categorical AST results in a few hours directly from positive blood culture bottles and support accurate antimicrobial adjustment.
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Seo SK, Gedrimaite Z, Paskovaty A, Seier K, Morjaria S, Cohen N, Riedel E, Tang YW, Babady NE. Impact of QuickFISH in addition to antimicrobial stewardship on vancomycin use and resource utilization in cancer patients with coagulase-negative staphylococcal blood cultures. Clin Microbiol Infect 2018; 24:1339.e7-1339.e12. [PMID: 29549061 DOI: 10.1016/j.cmi.2018.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/26/2018] [Accepted: 03/04/2018] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate the impact of rapidly identifying coagulase-negative staphylococci (CoNS) from positive blood cultures combined with an established antimicrobial stewardship (AS) programme at a tertiary cancer centre. METHODS We compared cancer patients ≥18 years old who between 01/1/13 and 12/31/13 had one or more positive CoNS blood culture(s) identified by Staphylococcus QuickFISH® (a peptide nucleic acid fluorescence in situ hybridization assay) with cancer patients ≥18 years old who had CoNS identified by standard microbiological techniques between 01/01/11 and 12/31/11 (baseline). Positive blood culture results were reported to the clinician by microbiology staff; restricted antibiotics (e.g., vancomycin) required approval by the AS team. RESULTS There were 196 baseline and 103 QuickFISH patients. Faster median time to organism identification (33 (IQR 27-46) versus 49 (IQR 39-63) hours, p < 0.001), more vancomycin avoidance (51/103 (50%) versus 60/196 (31%), p 0.002), shorter median antibiotic duration (1 (IQR 0-3) versus 2 (IQR 0-6) days, p 0.019), fewer central venous catheter (CVC) removals (14/78 (18%) versus 57/160 (36%), p 0.004), and reduced vancomycin level monitoring (16/52 (31%) versus 71/136 (52%), p 0.009) were observed in the QuickFISH group. QuickFISH implementation was predictive of a lower likelihood of antibiotic therapy prescription (OR 0.35, 95%CI 0.20-0.62, p < 0.001). Prior transplant (RR 1.47, 95%CI 1.13-1.92, p 0.004), neutropenia (RR 1.47, 95%CI 1.09-1.99, p 0.012), multiple positive blood cultures (RR 4.23, 95%CI 3.23-5.54, p < 0.001), and CVC (RR 1.60, 95%CI 1.02-2.53, p 0.043) were independent factors for antibiotic duration. CONCLUSIONS QuickFISH implementation plus AS support leads to greater avoidance of vancomycin therapy and improved resource utilization in cancer patients with CoNS blood cultures.
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Affiliation(s)
- S K Seo
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Weill Cornell Medical College, New York, NY, USA.
| | - Z Gedrimaite
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - A Paskovaty
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - K Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - S Morjaria
- Infectious Disease Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - N Cohen
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - E Riedel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Y W Tang
- Clinical Microbiology Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Pathology and Laboratory Medicine, Weill Cornell Medical College, New York, NY, USA
| | - N E Babady
- Clinical Microbiology Service, Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Experience With Rapid Microarray-Based Diagnostic Technology and Antimicrobial Stewardship for Patients With Gram-Positive Bacteremia. Infect Control Hosp Epidemiol 2018; 37:1361-1366. [PMID: 27767002 DOI: 10.1017/ice.2016.175] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To describe the impact of rapid diagnostic microarray technology and antimicrobial stewardship for patients with Gram-positive blood cultures. DESIGN Retrospective pre-intervention/post-intervention study. SETTING A 1,200-bed academic medical center. PATIENTS Inpatients with blood cultures positive for Staphylococcus aureus, Enterococcus faecalis, E. faecium, Streptococcus pneumoniae, S. pyogenes, S. agalactiae, S. anginosus, Streptococcus spp., and Listeria monocytogenes during the 6 months before and after implementation of Verigene Gram-positive blood culture microarray (BC-GP) with an antimicrobial stewardship intervention. METHODS Before the intervention, no rapid diagnostic technology was used or antimicrobial stewardship intervention was undertaken, except for the use of peptide nucleic acid fluorescent in situ hybridization and MRSA agar to identify staphylococcal isolates. After the intervention, all Gram-positive blood cultures underwent BC-GP microarray and the antimicrobial stewardship intervention consisting of real-time notification and pharmacist review. RESULTS In total, 513 patients with bacteremia were included in this study: 280 patients with S. aureus, 150 patients with enterococci, 82 patients with stretococci, and 1 patient with L. monocytogenes. The number of antimicrobial switches was similar in the pre-BC-GP (52%; 155 of 300) and post-BC-GP (50%; 107 of 213) periods. The time to antimicrobial switch was significantly shorter in the post-BC-GP group than in the pre-BC-GP group: 48±41 hours versus 75±46 hours, respectively (P<.001). The most common antimicrobial switch was de-escalation and time to de-escalation, was significantly shorter in the post-BC-GP group than in the pre-BC-GP group: 53±41 hours versus 82±48 hours, respectively (P<.001). There was no difference in mortality or hospital length of stay as a result of the intervention. CONCLUSIONS The combination of a rapid microarray diagnostic test with an antimicrobial stewardship intervention improved time to antimicrobial switch, especially time to de-escalation to optimal therapy, in patients with Gram-positive blood cultures. Infect Control Hosp Epidemiol 2016;1-6.
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Tang YW, Stratton CW. Multiplex PCR for Detection and Identification of Microbial Pathogens. ADVANCED TECHNIQUES IN DIAGNOSTIC MICROBIOLOGY 2018. [PMCID: PMC7121544 DOI: 10.1007/978-3-319-95111-9_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Multiplexed nucleic acid-based tests for infectious disease have become a standard part of clinical laboratory practice. These tests provide a comprehensive syndrome-based approach to determine the etiological agent of disease. The technology underlying these different systems is reviewed here with a special focus on the BioFire FilmArray® platform. The literature on the clinical utility and cost-effectiveness of these platforms for respiratory, blood culture, and gastrointestinal infections is discussed. Although there are reports showing a clear benefit to the patient or to the healthcare system from adopting a syndromic molecular approach, it is also apparent that clinical laboratories and healthcare providers are still learning how to take full advantage of the new systems. Finally, some improvements to this technology that should appear in the next few years are discussed. These include automated pathogen-specific surveillance based on aggregating the data from these systems, a move toward point-of-care syndromic testing, and further decreases in time to result of the tests.
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Affiliation(s)
- Yi-Wei Tang
- Departments of Laboratory Medicine and Internal Medicine, Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Charles W. Stratton
- Department of Pathology, Microbiology and Immunology and Medicine, Vanderbilt University Medical Center, Nashville, TN USA
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Tsalik EL, Petzold E, Kreiswirth BN, Bonomo RA, Banerjee R, Lautenbach E, Evans SR, Hanson KE, Klausner JD, Patel R. Advancing Diagnostics to Address Antibacterial Resistance: The Diagnostics and Devices Committee of the Antibacterial Resistance Leadership Group. Clin Infect Dis 2017; 64:S41-S47. [PMID: 28350903 DOI: 10.1093/cid/ciw831] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Diagnostics are a cornerstone of the practice of infectious diseases. However, various limitations frequently lead to unmet clinical needs. In most other domains, diagnostics focus on narrowly defined questions, provide readily interpretable answers, and use true gold standards for development. In contrast, infectious diseases diagnostics must contend with scores of potential pathogens, dozens of clinical syndromes, emerging pathogens, rapid evolution of existing pathogens and their associated resistance mechanisms, and the absence of gold standards in many situations. In spite of these challenges, the importance and value of diagnostics cannot be underestimated. Therefore, the Antibacterial Resistance Leadership Group has identified diagnostics as 1 of 4 major areas of emphasis. Herein, we provide an overview of that development, highlighting several examples where innovation in study design, content, and execution is advancing the field of infectious diseases diagnostics.
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Affiliation(s)
- Ephraim L Tsalik
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, and.,Emergency Medicine Service, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Elizabeth Petzold
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, and
| | - Barry N Kreiswirth
- Public Health Research Institute Tuberculosis Center, New Jersey Medical School-Rutgers University, Newark
| | - Robert A Bonomo
- Department of Medicine, Case Western Reserve University School of Medicine, and.,Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, Ohio
| | - Ritu Banerjee
- Division of Pediatric Infectious Diseases, Vanderbilt University, Nashville, Tennessee
| | - Ebbing Lautenbach
- Department of Medicine, Division of Infectious Diseases, the University of Pennsylvania School of Medicine, Philadelphia
| | - Scott R Evans
- Center for Biostatistics in AIDS Research and the Department of Biostatistics, Harvard University, Boston, Massachusetts
| | - Kimberly E Hanson
- Departments of Medicine and Pathology, Divisions of Infectious Diseases and Clinical Microbiology, University of Utah, Salt Lake City
| | - Jeffrey D Klausner
- UCLA David Geffen School of Medicine and Fielding School of Public Health, Los Angeles, California
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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Chang D, Okulicz JF, Nielsen LE, White BK. A Tertiary Care Center’s Experience with Novel Molecular Meningitis/Encephalitis Diagnostics and Implementation with Antimicrobial Stewardship. Mil Med 2017; 183:e24-e27. [DOI: 10.1093/milmed/usx025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 10/21/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- David Chang
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Dr, JBSA Fort Sam Houston, San Antonio TX 78234
| | - Jason F Okulicz
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Dr, JBSA Fort Sam Houston, San Antonio TX 78234
| | - Lindsey E Nielsen
- Department of Microbiology, Brooke Army Medical Center, 3551 Roger Brooke Dr, JBSA Fort Sam Houston, San Antonio TX 78234
| | - Brian K White
- Infectious Disease Service, Brooke Army Medical Center, 3551 Roger Brooke Dr, JBSA Fort Sam Houston, San Antonio TX 78234
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Florio W, Morici P, Ghelardi E, Barnini S, Lupetti A. Recent advances in the microbiological diagnosis of bloodstream infections. Crit Rev Microbiol 2017; 44:351-370. [PMID: 29185372 DOI: 10.1080/1040841x.2017.1407745] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Rapid identification (ID) and antimicrobial susceptibility testing (AST) of the causative agent(s) of bloodstream infections (BSIs) are essential for the prompt administration of an effective antimicrobial therapy, which can result in clinical and financial benefits. Immediately after blood sampling, empirical antimicrobial therapy, chosen on clinical and epidemiological data, is administered. When ID and AST results are available, the clinician decides whether to continue or streamline the antimicrobial therapy, based on the results of the in vitro antimicrobial susceptibility profile of the pathogen. The aim of the present study is to review and discuss the experimental data, advantages, and drawbacks of recently developed technological advances of culture-based and molecular methods for the diagnosis of BSI (including mass spectrometry, magnetic resonance, PCR-based methods, direct inoculation methods, and peptide nucleic acid fluorescence in situ hybridization), the understanding of which could provide new perspectives to improve and fasten the diagnosis and treatment of septic patients. Although blood culture remains the gold standard to diagnose BSIs, newly developed methods can significantly shorten the turnaround time of reliable microbial ID and AST, thus substantially improving the diagnostic yield.
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Affiliation(s)
- Walter Florio
- a Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia , Università di Pisa , Pisa , Italy
| | - Paola Morici
- a Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia , Università di Pisa , Pisa , Italy
| | - Emilia Ghelardi
- a Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia , Università di Pisa , Pisa , Italy
| | - Simona Barnini
- b U.O. Microbiologia Universitaria Azienda Ospedaliero-Universitaria Pisana , Pisa , Italy
| | - Antonella Lupetti
- a Dipartimento di Ricerca Traslazionale e delle Nuove Tecnologie in Medicina e Chirurgia , Università di Pisa , Pisa , Italy
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Same-day Detection of Methicillin Resistance in Staphylococcus aureus Isolates by StaResMet® Kit. Jundishapur J Microbiol 2017. [DOI: 10.5812/jjm.14937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Zhou M, Yang Q, Kudinha T, Sun L, Zhang R, Liu C, Yu S, Xiao M, Kong F, Zhao Y, Xu YC. An Improved In-house MALDI-TOF MS Protocol for Direct Cost-Effective Identification of Pathogens from Blood Cultures. Front Microbiol 2017; 8:1824. [PMID: 29033904 PMCID: PMC5625089 DOI: 10.3389/fmicb.2017.01824] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 09/06/2017] [Indexed: 11/23/2022] Open
Abstract
Background: Bloodstream infection is a major cause of morbidity and mortality in hospitalized patients worldwide. Delays in the identification of microorganisms often leads to a poor prognosis. The application of matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) directly to blood culture (BC) broth can potentially identify bloodstream infections earlier, and facilitate timely management. Methods: We developed an “in-house” (IH) protocol for direct MALDI-TOF MS based identification of organisms in positive BCs. The IH protocol was initially evaluated and improved with spiked BC samples, and its performance was compared with the commercial Sepsityper™ kit using both traditional and modified cut-off values. We then studied in parallel the performance of the IH protocol and the colony MS identifications in positive clinical BC samples using only modified cut-off values. All discrepancies were investigated by “gold standard” of gene sequencing. Results: In 54 spiked BC samples, the IH method showed comparable results with Sepsityper™ after applying modified cut-off values. Specifically, accurate species and genus level identification was achieved in 88.7 and 3.9% of all the clinical monomicrobial BCs (284/301, 94.4%), respectively. The IH protocol exhibited superior performance for Gram negative bacteria than for Gram positive bacteria (92.8 vs. 82.4%). For anaerobes and yeasts, accurate species identification was achieved in 80.0 and 90.0% of the cases, respectively. For polymicrobial cultures (17/301, 5.6%), MALDI-TOF MS correctly identified a single species present in all the polymicrobial BCs under the Standard mode, while using the MIXED method, two species were correctly identified in 52.9% of the samples. Comparisons based on BC bottle type, showed that the BACTEC™ Lytic/10 Anaerobic/F culture vials performed the best. Conclusion: Our study provides a novel and effective sample preparation method for MALDI-TOF MS direct identification of pathogens from positive BC vials, with a lower cost ($1.5 vs. $ 7) albeit a slightly more laborious extracting process (an extra 15 min) compared with Sepsityper™ kit.
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Affiliation(s)
- Menglan Zhou
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Qiwen Yang
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Timothy Kudinha
- Charles Sturt University, Leeds Parade, Orange, NSW, Australia
| | - Liying Sun
- Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Rui Zhang
- Becton Dickinson Medical Devices Company, Shanghai, China
| | - Chang Liu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Shuying Yu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Graduate School, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Meng Xiao
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
| | - Fanrong Kong
- Centre for Infectious Diseases and Microbiology Laboratory Services, Westmead Hospital, Westmead, NSW, Australia
| | - Yupei Zhao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Ying-Chun Xu
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China.,Beijing Key Laboratory for Mechanisms Research and Precision Diagnosis of Invasive Fungal Diseases, Beijing, China
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Hayakawa K, Mezaki K, Kobayakawa M, Yamamoto K, Mutoh Y, Tsuboi M, Hasimoto T, Nagamatsu M, Kutsuna S, Takeshita N, Katanami Y, Ishikane M, Ohmagari N. Impact of rapid identification of positive blood cultures using the Verigene system on antibiotic prescriptions: A prospective study of community-onset bacteremia in a tertiary hospital in Japan. PLoS One 2017; 12:e0181548. [PMID: 28742143 PMCID: PMC5524366 DOI: 10.1371/journal.pone.0181548] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/03/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Rapid identification of positive blood cultures is important for initiation of optimal treatment in septic patients. Effects of automated, microarray-based rapid identification systems on antibiotic prescription against community-onset bacteremia (COB) remain unclear. METHODS We prospectively enrolled 177 patients with 185 COB episodes (occurring within 72 h of admission) over 17 months. Bacteremia episodes due to gram-positive bacteria (GP) and gram-negative bacteria (GN) in the same patient were counted separately. For GP bacteremia, patients with ≥2 sets of positive blood cultures were included. The primary study objective was evaluating the rates of antibiotic prescription changes within 2 days of rapid identification using the Verigene system. RESULTS Bacteremia due to GN and GP included 144/185 (77.8%) and 41/185 (22.2%) episodes, respectively. Antibiotic prescription changes occurred in 51/185 cases (27.6% [95%CI:21.3-34.6%]) after Verigene analysis and 70/185 cases (37.8% [30.8-45.2%]) after conventional identification and susceptibility testing. Prescription changes after Verigene identification were more frequent in GP (17/41[41.5%]) than in GN (34/144[23.5%]). Among bacteremia due to single pathogen targeted by Verigene test, bacterial identification agreement between the two tests was high (GP: 38/39[97.4%], GN: 116/116[100%]). The Verigene test correctly predicted targeted antimicrobial resistance. The durations between the initiation of incubation and reporting of the results for the Verigene system and conventional test was 28.3 h (IQR: 25.8-43.4 h) and 90.6 h (68.3-118.4 h), respectively. In only four of the seven episodes of COB in which two isolates were identified by conventional tests, the Verigene test correctly identified both organisms. CONCLUSION We observed a high rate of antibiotic prescription changes after the Verigene test in a population with COB especially in GP. The Verigene test would be a useful tool in antimicrobial stewardship programs among patients with COB.
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Affiliation(s)
- Kayoko Hayakawa
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kazuhisa Mezaki
- Department of Clinical Laboratory, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masao Kobayakawa
- Department of Gastroenterology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kei Yamamoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshikazu Mutoh
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Motoyuki Tsuboi
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takehiro Hasimoto
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Maki Nagamatsu
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Satoshi Kutsuna
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Nozomi Takeshita
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yuichi Katanami
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Masahiro Ishikane
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
- Division of Global infectious diseases, Department of Infection and Epidemiology, Graduate School of Medicine, Tohoku University, Miyagi, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
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Doernberg SB, Chambers HF. Antimicrobial Stewardship Approaches in the Intensive Care Unit. Infect Dis Clin North Am 2017; 31:513-534. [PMID: 28687210 DOI: 10.1016/j.idc.2017.05.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Antimicrobial stewardship programs aim to monitor, improve, and measure responsible antibiotic use. The intensive care unit (ICU), with its critically ill patients and prevalence of multiple drug-resistant pathogens, presents unique challenges. This article reviews approaches to stewardship with application to the ICU, including the value of diagnostics, principles of empirical and definitive therapy, and measures of effectiveness. There is good evidence that antimicrobial stewardship results in more appropriate antimicrobial use, shorter therapy durations, and lower resistance rates. Data demonstrating hard clinical outcomes, such as adverse events and mortality, are more limited but encouraging; further studies are needed.
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Affiliation(s)
- Sarah B Doernberg
- Division of Infectious Diseases, Department of Medicine, University of California, 513 Parnassus Avenue, Box 0654, San Francisco, CA 94143, USA.
| | - Henry F Chambers
- Division of Infectious Diseases, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California, Room 3400, Building 30, 1001 Potrero Avenue, San Francisco, CA 94110, USA
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41
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de With K, Allerberger F, Amann S, Apfalter P, Brodt HR, Eckmanns T, Fellhauer M, Geiss HK, Janata O, Krause R, Lemmen S, Meyer E, Mittermayer H, Porsche U, Presterl E, Reuter S, Sinha B, Strauß R, Wechsler-Fördös A, Wenisch C, Kern WV. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2017; 44:395-439. [PMID: 27066980 PMCID: PMC4889644 DOI: 10.1007/s15010-016-0885-z] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction In the time of increasing resistance and paucity of new drug development there is a growing need for strategies to enhance rational use of antibiotics in German and Austrian hospitals. An evidence-based guideline on recommendations for implementation of antibiotic stewardship (ABS) programmes was developed by the German Society for Infectious Diseases in association with the following societies, associations and institutions: German Society of Hospital Pharmacists, German Society for Hygiene and Microbiology, Paul Ehrlich Society for Chemotherapy, The Austrian Association of Hospital Pharmacists, Austrian Society for Infectious Diseases and Tropical Medicine, Austrian Society for Antimicrobial Chemotherapy, Robert Koch Institute. Materials and methods A structured literature research was performed in the databases EMBASE, BIOSIS, MEDLINE and The Cochrane Library from January 2006 to November 2010 with an update to April 2012 (MEDLINE and The Cochrane Library). The grading of recommendations in relation to their evidence is according to the AWMF Guidance Manual and Rules for Guideline Development. Conclusion The guideline provides the grounds for rational use of antibiotics in hospital to counteract antimicrobial resistance and to improve the quality of care of patients with infections by maximising clinical outcomes while minimising toxicity. Requirements for a successful implementation of ABS programmes as well as core and supplemental ABS strategies are outlined. The German version of the guideline was published by the German Association of the Scientific Medical Societies (AWMF) in December 2013.
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Affiliation(s)
- K de With
- Division of Infectious Diseases, University Hospital Carl Gustav Carus at the TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - F Allerberger
- Division Public Health, Austrian Agency for Health and Food Safety (AGES), Vienna, Austria
| | - S Amann
- Hospital Pharmacy, Munich Municipal Hospital, Munich, Germany
| | - P Apfalter
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - H-R Brodt
- Department of Infectious Disease Medical Clinic II, Goethe-University Frankfurt, Frankfurt, Germany
| | - T Eckmanns
- Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin, Germany
| | - M Fellhauer
- Hospital Pharmacy, Schwarzwald-Baar Hospital, Villingen-Schwenningen, Germany
| | - H K Geiss
- Department of Hospital Epidemiology and Infectiology, Sana Kliniken AG, Ismaning, Germany
| | - O Janata
- Department for Hygiene and Infection Control, Danube Hospital, Vienna, Austria
| | - R Krause
- Section of Infectious Diseases and Tropical Medicine, Medical University of Graz, Graz, Austria
| | - S Lemmen
- Division of Infection Control and Infectious Diseases, University Hospital RWTH Aachen, Aachen, Germany
| | - E Meyer
- Institute of Hygiene and Environmental Medicine, Charité, University Medicine Berlin, Berlin, Germany
| | - H Mittermayer
- Institute for Hygiene, Microbiology and Tropical Medicine (IHMT), National Reference Centre for Nosocomial Infections and Antimicrobial Resistance, Elisabethinen Hospital Linz, Linz, Austria
| | - U Porsche
- Department for Clinical Pharmacy and Drug Information, Landesapotheke, Landeskliniken Salzburg (SALK), Salzburg, Austria
| | - E Presterl
- Department of Infection Control and Hospital Epidemiology, Medical University of Vienna, Vienna, Austria
| | - S Reuter
- Clinic for General Internal Medicine, Infectious Diseases, Pneumology and Osteology, Klinikum Leverkusen, Leverkusen, Germany
| | - B Sinha
- Department of Medical Microbiology and Infection Prevention, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - R Strauß
- Department of Medicine 1, Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Erlangen, Germany
| | - A Wechsler-Fördös
- Department of Antibiotics and Infection Control, Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - C Wenisch
- Medical Department of Infection and Tropical Medicine, Kaiser Franz Josef Hospital, Vienna, Austria
| | - W V Kern
- Division of Infectious Diseases, Department of Medicine, Freiburg University Medical Center, Freiburg, Germany
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Riedel S, Carroll KC. Early Identification and Treatment of Pathogens in Sepsis: Molecular Diagnostics and Antibiotic Choice. Clin Chest Med 2017; 37:191-207. [PMID: 27229637 DOI: 10.1016/j.ccm.2016.01.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Sepsis and septic shock are serious conditions associated with high morbidity and mortality. Rapid molecular methods for detection of microorganisms and antimicrobial resistance genes from positive blood cultures or whole blood have evolved over the past 10 years. Such diagnostic methods coupled with therapeutic interventional programs are desirable to improve the overall clinical outcome and mortality. This article discusses the usefulness of current molecular test methods for the diagnosis of sepsis and their potential to enhance the success of antimicrobial stewardship programs. Clinicians and laboratories alike must appreciate key factors influencing the appropriate use and potential impact of these methods.
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Affiliation(s)
- Stefan Riedel
- Department of Pathology, Harvard Medical School, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - Karen C Carroll
- Division of Medical Microbiology, Department of Pathology, The Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer B1-193, Baltimore, MD 21287, USA
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43
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Frickmann H, Zautner AE, Moter A, Kikhney J, Hagen RM, Stender H, Poppert S. Fluorescence in situ hybridization (FISH) in the microbiological diagnostic routine laboratory: a review. Crit Rev Microbiol 2017; 43:263-293. [PMID: 28129707 DOI: 10.3109/1040841x.2016.1169990] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Early identification of microbial pathogens is essential for rational and conservative antibiotic use especially in the case of known regional resistance patterns. Here, we describe fluorescence in situ hybridization (FISH) as one of the rapid methods for easy identification of microbial pathogens, and its advantages and disadvantages for the diagnosis of pathogens in human infections in the laboratory diagnostic routine. Binding of short fluorescence-labeled DNA or nucleic acid-mimicking PNA probes to ribosomes of infectious agents with consecutive analysis by fluorescence microscopy allows identification of bacterial and eukaryotic pathogens at genus or species level. FISH analysis leads to immediate differentiation of infectious agents without delay due to the need for microbial culture. As a microscopic technique, FISH has the unique potential to provide information about spatial resolution, morphology and identification of key pathogens in mixed species samples. On-going automation and commercialization of the FISH procedure has led to significant shortening of the time-to-result and increased test reliability. FISH is a useful tool for the rapid initial identification of microbial pathogens, even from primary materials. Among the rapidly developing alternative techniques, FISH serves as a bridging technology between microscopy, microbial culture, biochemical identification and molecular diagnostic procedures.
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Affiliation(s)
- Hagen Frickmann
- a German Armed Forces Hospital of Hamburg, Department of Tropical Medicine at the Bernhard Nocht Institute , Hamburg , Germany
| | - Andreas Erich Zautner
- b Department of Medical Microbiology, University Medical Center Göttingen , Göttingen , Germany
| | - Annette Moter
- c University Medical Center Berlin, Biofilmcenter at the German Heart Institute Berlin , Berlin , Germany
| | - Judith Kikhney
- c University Medical Center Berlin, Biofilmcenter at the German Heart Institute Berlin , Berlin , Germany
| | - Ralf Matthias Hagen
- a German Armed Forces Hospital of Hamburg, Department of Tropical Medicine at the Bernhard Nocht Institute , Hamburg , Germany
| | | | - Sven Poppert
- e Institute for Medical Microbiology, Justus-Liebig-University Giessen , Giessen , Germany
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44
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Abstract
Antimicrobial stewardship is a bundle of integrated interventions employed to optimize the use of antimicrobials in health care settings. While infectious-disease-trained physicians, with clinical pharmacists, are considered the main leaders of antimicrobial stewardship programs, clinical microbiologists can play a key role in these programs. This review is intended to provide a comprehensive discussion of the different components of antimicrobial stewardship in which microbiology laboratories and clinical microbiologists can make significant contributions, including cumulative antimicrobial susceptibility reports, enhanced culture and susceptibility reports, guidance in the preanalytic phase, rapid diagnostic test availability, provider education, and alert and surveillance systems. In reviewing this material, we emphasize how the rapid, and especially the recent, evolution of clinical microbiology has reinforced the importance of clinical microbiologists' collaboration with antimicrobial stewardship programs.
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45
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Veesenmeyer AF, Olson JA, Hersh AL, Stockmann C, Korgenski K, Thorell EA, Pavia AT, Blaschke AJ. A Retrospective Study of the Impact of Rapid Diagnostic Testing on Time to Pathogen Identification and Antibiotic Use for Children with Positive Blood Cultures. Infect Dis Ther 2016; 5:555-570. [PMID: 27832502 PMCID: PMC5125139 DOI: 10.1007/s40121-016-0136-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Indexed: 12/20/2022] Open
Abstract
Introduction Rapid identification of bloodstream pathogens provides crucial information that can improve the choice of antimicrobial therapy for children. Previous impact studies have primarily focused on adults. Our objective was to evaluate the impact of rapid testing in a children’s hospital on time to organism identification and antibiotic use in the setting of an established antimicrobial stewardship program. Methods We conducted a retrospective study over three consecutive time periods (spanning January 2013–August 2015) as our hospital sequentially introduced two rapid testing methods for positive blood cultures. An antimicrobial stewardship program was active throughout the study. In the baseline period, no rapid diagnostic methods were routinely utilized. In the second period (PNAFISH), a fluorescent in situ hybridization test was implemented for gram-positive organisms and in the third a rapid multiplex PCR (rmPCR) test was employed. For children with positive blood cultures, time to organism identification use and duration of select antimicrobial therapies were compared between periods. Results Positive blood cultures were analyzed. Median overall time to organism identification was 23, 11, and 0 h in the baseline, PNAFISH, and rmPCR periods, respectively (p < 0.001 for both PNAFISH and rmPCR vs. baseline). For gram-negative organisms, only rmPCR performed significantly faster than baseline (p < 0.001). The duration of vancomycin use for coagulase-negative staphylococci was shorter in both the PNAFISH and rmPCR periods (mean 31 h in the baseline period, 12 and 14 h in the PNAFISH and rmPCR periods, respectively). For MSSA bacteremia, use of vancomycin was significantly decreased only in the rmPCR period (32% of patients vs. 64 and 72% in the baseline and PNAFISH periods; mean duration of 9 h vs. 30 and 26 h). There was no difference in use or duration of broad-spectrum gram-negative therapy across the three time periods. Conclusion Rapid diagnostic testing for children with positive blood cultures results in faster time to identification and can influence antibiotic prescribing in the setting of active antimicrobial stewardship particularly for gram-positive pathogens. Funding Merck.
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Affiliation(s)
| | - Jared A Olson
- Primary Children's Hospital, Salt Lake City, UT, USA
| | - Adam L Hersh
- Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Chris Stockmann
- Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Kent Korgenski
- Pediatric Clinical Program, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Emily A Thorell
- Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Andrew T Pavia
- Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Anne J Blaschke
- Department of Pediatrics, University of Utah Health Sciences Center, Salt Lake City, UT, USA.
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Intra J, Sala M, Falbo R, Cappellini F, Brambilla P. Reducing time to identification of aerobic bacteria and fastidious micro-organisms in positive blood cultures. Lett Appl Microbiol 2016; 63:400-405. [DOI: 10.1111/lam.12682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 09/25/2016] [Accepted: 09/28/2016] [Indexed: 12/15/2022]
Affiliation(s)
- J. Intra
- Department of Laboratory Medicine; Desio Hospital; University Milano Bicocca; Desio Italy
| | - M.R. Sala
- Department of Laboratory Medicine; Desio Hospital; University Milano Bicocca; Desio Italy
| | - R. Falbo
- Department of Laboratory Medicine; Desio Hospital; University Milano Bicocca; Desio Italy
| | - F. Cappellini
- Department of Laboratory Medicine; Desio Hospital; University Milano Bicocca; Desio Italy
| | - P. Brambilla
- Department of Laboratory Medicine; Desio Hospital; University Milano Bicocca; Desio Italy
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Timbrook TT, Morton JB, McConeghy KW, Caffrey AR, Mylonakis E, LaPlante KL. The Effect of Molecular Rapid Diagnostic Testing on Clinical Outcomes in Bloodstream Infections: A Systematic Review and Meta-analysis. Clin Infect Dis 2016; 64:15-23. [PMID: 27678085 DOI: 10.1093/cid/ciw649] [Citation(s) in RCA: 317] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/08/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Previous reports on molecular rapid diagnostic testing (mRDT) do not consistently demonstrate improved clinical outcomes in bloodstream infections (BSIs). This meta-analysis seeks to evaluate the impact of mRDT in improving clinical outcomes in BSIs. METHODS We searched PubMed, CINAHL, Web of Science, and EMBASE through May 2016 for BSI studies comparing clinical outcomes between mRDT and conventional microbiology methods. RESULTS Thirty-one studies were included with 5920 patients. The mortality risk was significantly lower with mRDT than with conventional microbiology methods (odds ratio [OR], 0.66; 95% confidence interval [CI], .54-.80), yielding a number needed to treat of 20. The mortality risk was slightly lower with mRDT in studies with antimicrobial stewardship programs (ASPs) (OR, 0.64; 95% CI, .51-.79), and non-ASP studies failed to demonstrate a significant decrease in mortality risk (0.72; .46-1.12). Significant decreases in mortality risk were observed with both gram-positive (OR, 0.73; 95% CI, .55-.97) and gram-negative organisms (0.51; .33-.78) but not yeast (0.90; .49-1.67). Time to effective therapy decreased by a weighted mean difference of -5.03 hours (95% CI, -8.60 to -1.45 hours), and length of stay decreased by -2.48 days (-3.90 to -1.06 days). CONCLUSIONS For BSIs, mRDT was associated with significant decreases in mortality risk in the presence of a ASP, but not in its absence. mRDT also decreased the time to effective therapy and the length of stay. mRDT should be considered as part of the standard of care in patients with BSIs.
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Affiliation(s)
- Tristan T Timbrook
- Rhode Island Infectious Diseases Research Program, Providence Veterans Affairs Medical Center.,College of Pharmacy, University of Rhode Island, Kingston
| | - Jacob B Morton
- Rhode Island Infectious Diseases Research Program, Providence Veterans Affairs Medical Center.,College of Pharmacy, University of Rhode Island, Kingston
| | - Kevin W McConeghy
- Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center
| | - Aisling R Caffrey
- Rhode Island Infectious Diseases Research Program, Providence Veterans Affairs Medical Center.,Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center.,College of Pharmacy, University of Rhode Island, Kingston
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence
| | - Kerry L LaPlante
- Rhode Island Infectious Diseases Research Program, Providence Veterans Affairs Medical Center.,Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center.,College of Pharmacy, University of Rhode Island, Kingston
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48
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Banerjee R, Özenci V, Patel R. Individualized Approaches Are Needed for Optimized Blood Cultures. Clin Infect Dis 2016; 63:1332-1339. [PMID: 27558570 DOI: 10.1093/cid/ciw573] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 08/14/2016] [Indexed: 01/12/2023] Open
Abstract
Many strategies and technologies are available to improve blood culture (BC)-based diagnostics. The ideal approach to BCs varies between healthcare institutions. Institutions need to examine clinical needs and practices in order to optimize BC-based diagnostics for their site. Before laboratories consider offering rapid matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-ToF MS) or expensive rapid panel-based molecular BC diagnostics, they should optimize preanalytical, analytical, and postanalytical processes and procedures surrounding BC systems. Several factors need to be considered, including local resistance rates, antibiotic prescribing patterns, patient- and provider-types, laboratory staffing, and personnel available to liaise with clinicians to optimize antibiotic use. While there is much excitement surrounding new high-technology diagnostics, cost-neutral benefits can be realized by optimizing existing strategies and using available tools in creative ways. Rapid BC diagnostics should be implemented in a manner that optimizes impact. Strategies to optimize these BC diagnostics in individual laboratories are presented here.
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Affiliation(s)
- Ritu Banerjee
- Department of Pediatric Infections Diseases, Vanderbilt University, Nashville, Tennessee
| | - Volkan Özenci
- Division of Clinical Microbiology, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Robin Patel
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology.,Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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49
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The Confounding Role of Antimicrobial Stewardship Programs in Understanding the Impact of Technology on Patient Care. J Clin Microbiol 2016; 54:2420-3. [PMID: 27535682 DOI: 10.1128/jcm.01484-16] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Numerous studies have demonstrated the benefit of the combination of antimicrobial stewardship program (ASP) intervention and rapid diagnostic testing (RDT). However, few studies have attempted to study the incremental benefit of ASP and RDT, making it difficult to understand the true benefits of each intervention. This issue is discussed in the context of an article by S. H. McVane and F. S. Nolte (J Clin Microbiol 54:2476-2484, 2016, http://dx.doi.org/doi:10.1128/JCM.00996-16), with suggestions about how the findings of this study can be applied to other areas of clinical microbiology.
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50
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Felsenstein S, Bender JM, Sposto R, Gentry M, Takemoto C, Bard JD. Impact of a Rapid Blood Culture Assay for Gram-Positive Identification and Detection of Resistance Markers in a Pediatric Hospital. Arch Pathol Lab Med 2016; 140:267-75. [PMID: 26927722 DOI: 10.5858/arpa.2015-0119-oa] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Molecular diagnostics allow for rapid identification and detection of resistance markers of bloodstream infection, with a potential for accelerated antimicrobial optimization and improved patient outcomes. Although the impact of rapid diagnosis has been reported, studies in pediatric patients are scarce. OBJECTIVE To determine the impact of a molecular blood-culture assay that identifies a broad-spectrum of pathogens and resistance markers in pediatric patients with gram-positive bloodstream infections. DESIGN Data on the time to antimicrobial optimization, the length of hospitalization, and the hospital cost following implementation of a rapid assay were prospectively collected and compared with corresponding preimplementation data. RESULTS There were 440 episodes from 383 patients included, 221 preimplementation episodes and 219 postimplementation episodes. Overall time to antimicrobial optimization was shortened by 12.5 hours (P = .006), 11.9 hours (P = .005) for bloodstream infections of Staphylococcus aureus specifically. Duration of antibiotics for those with probable blood-culture contamination with coagulase-negative staphylococci was reduced by 36.9 hours (P < .001). Median length of stay for patients admitted to general pediatric units was 1.5 days shorter (P = .04), and median hospital cost was $3757 (P = .03) less after implementation. For S aureus bloodstream infections, median length of stay and hospital cost were decreased by 5.6 days (P = .01) and $13,341 (P = .03), respectively. CONCLUSIONS Implementation of molecular assay for the detection of gram-positive pathogens and resistance markers significantly reduced time to identification and resistance detection, resulting in accelerated optimization of therapy, shorter length of stay, and decreased health care cost.
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Affiliation(s)
- Susanna Felsenstein
- From the Departments of Pediatrics, Division of Infectious Diseases (Drs Felsenstein and Bender)
| | | | - Richard Sposto
- Pharmacy (Drs Gentry and Takemoto), and Pathology and Laboratory Medicine (Dr Dien Bard)
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