Pneumococcal Urinary Antigen Testing in United States Hospitals: A Missed Opportunity for Antimicrobial Stewardship

Abstract Background The Infectious Diseases Society of America recommends pneumococcal urinary antigen testing (UAT) when identifying pneumococcal infection would allow for antibiotic de-escalation. However, the frequencies of UAT and subsequent antibiotic de-escalation are unknown. Methods We conducted a retrospective cohort study of adult patients admitted with community-acquired or healthcare-associated pneumonia to 170 US hospitals in the Premier database from 2010 to 2015, to describe variation in UAT use, associations of UAT results with antibiotic de-escalation, and associations of de-escalation with outcomes. Results Among 159 894 eligible admissions, 24 757 (15.5%) included UAT performed (18.4% of intensive care unit [ICU] and 15.3% of non-ICU patients). Among hospitals with ≥100 eligible patients, UAT proportions ranged from 0% to 69%. Compared to patients with negative UAT, 7.2% with positive UAT more often had a positive Streptococcus pneumoniae culture (25.4% vs 1.9%, P < .001) and less often had resistant bacteria (5.2% vs 6.8%, P < .05). Of patients initially treated with broad-spectrum antibiotics, most were still receiving broad-spectrum therapy 3 days later, but UAT-positive patients more often had coverage narrowed (38.4% vs 17.0% UAT-negative and 14.6% untested patients, P < .001). Hospital rate of UAT was strongly correlated with de-escalation following a positive test. Only 3 patients de-escalated after a positive UAT result were subsequently admitted to ICU. Conclusions UAT is not ordered routinely in pneumonia, even in ICU. A positive UAT result was associated with less frequent resistant organisms, but usually did not lead to antibiotic de-escalation. Increasing UAT and narrowing therapy after a positive UAT result are opportunities for improved antimicrobial stewardship.

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Healthcare-associated Legionnaires’ disease: Limitations of surveillance definitions and importance of epidemiologic investigation

Journal of Infection Prevention ◽

10.1177/1757177417720999 ◽

2017 ◽

Vol 18 (6) ◽

pp. 307-310 ◽

Cited By ~ 2

Author(s):

Laila M Castellino ◽

Shantini D Gamage ◽

Patti V Hoffman ◽

Stephen M Kralovic ◽

Mark Holodniy ◽

...

Keyword(s):

Legionella Pneumophila ◽

Sequence Type ◽

Significant Morbidity ◽

Urinary Antigen ◽

Epidemiologic Investigation ◽

Urinary Antigen Testing ◽

Legionnaires Disease ◽

Healthcare Associated ◽

Antigen Testing

Healthcare-associated Legionnaires’ disease (HCA LD) causes significant morbidity and mortality, with varying guidance on prevention. We describe the evaluation of a case of possible HCA LD and note the pitfalls of relying solely on an epidemiologic definition for association of a case with a facility. Our detailed investigation led to the identification of a new Legionella pneumophila serogroup 1 sequence type, confirmed a healthcare association and helped build the framework for our ongoing preventive efforts. Our experience highlights the role of routine environmental cultures in the assessment of risk for a given facility. As clinicians increasingly rely on urinary antigen testing for the detection of L. pneumophila, our investigation emphasises the importance of clinical cultures in an epidemiologic investigation.

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A Recurrent Outbreak of Nosocomial Legionnaires' Disease Detected by Urinary Antigen Testing: Evidence for Long-Term Colonization of a Hospital Plumbing System

Infection Control and Hospital Epidemiology ◽

10.1086/647761 ◽

1998 ◽

Vol 19 (12) ◽

pp. 905-910 ◽

Cited By ~ 20

Author(s):

Lisa A. Lepine ◽

Daniel B. Jernigan ◽

Jay C. Butler ◽

Janet M. Pruckler ◽

Robert F. Benson ◽

...

Keyword(s):

Plumbing System ◽

Urinary Antigen ◽

Urinary Antigen Testing ◽

Legionnaires Disease ◽

Antigen Testing

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Legionella pneumonia presenting with bilateral flank pain, hyponatraemia and acute renal failure

Canadian Urological Association Journal ◽

10.5489/cuaj.738 ◽

2013 ◽

Vol 5 (6) ◽

pp. 96

Author(s):

Celia Birkin ◽

Chandra Shekhar Biyani ◽

Anthony J. Browning

Keyword(s):

Gastrointestinal Symptoms ◽

Community Acquired Pneumonia ◽

Flank Pain ◽

High Fever ◽

Urinary Antigen ◽

Legionella Pneumonia ◽

Urinary Antigen Testing ◽

Legionella Species ◽

Legionnaires Disease ◽

Antigen Testing

Legionnaires’ disease (LD) is an often overlooked but a possiblecause of sporadic community acquired pneumonia. High fever,cough and gastrointestinal symptoms are non-specific symptoms.Hyponatremia is more common in LD than pneumonia linkedwith other causes. A definitive diagnosis is usually confirmed byculture, urinary antigen testing for Legionella species. Macolideor quinolone antibiotic is the treatment of choice. We describe acase of Legionella pneumonia presenting with high fever, bilateralflank pain and oliguria. It is important for clinicians to be awareof this diagnosis when managing patients with flank pain. Thecase highlights the problems in differentiating LD from renal colicand the importance of proper history, physical examination withlaboratory tests for appropriate management.

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Evaluation of pneumococcal urinary antigen testing for respiratory tract infection investigations

Médecine et Maladies Infectieuses ◽

10.1016/j.medmal.2019.06.009 ◽

2020 ◽

Vol 50 (1) ◽

pp. 57-62 ◽

Cited By ~ 1

Author(s):

F. Charton ◽

P.L. Conan ◽

H. Le Floch ◽

O. Bylicki ◽

W. Gaspard ◽

...

Keyword(s):

Tract Infection ◽

Respiratory Tract ◽

Respiratory Tract Infection ◽

Urinary Antigen ◽

Urinary Antigen Testing ◽

Antigen Testing

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Environmental Cultures and Hospital-Acquired Legionnaires' Disease: A 5-Year Prospective Study in 20 Hospitals in Catalonia, Spain

Infection Control and Hospital Epidemiology ◽

10.1017/s019594170007750x ◽

2004 ◽

Vol 25 (12) ◽

pp. 1072-1076 ◽

Cited By ~ 10

Author(s):

Miquel Sabrià ◽

Josep M. Mòdol ◽

Marian Garcia-Nuñez ◽

Esteban Reynaga ◽

Maria L. Pedro-Botet ◽

...

Keyword(s):

Prospective Study ◽

Potable Water ◽

Environmental Study ◽

Urinary Antigen ◽

Hospital Acquired Pneumonia ◽

Urinary Antigen Testing ◽

Legionnaires Disease ◽

Hospital Acquired ◽

Antigen Testing

AbstractObjective:To determine whether environmental cultures forLegionellaincrease the index of suspicion for legionnaires' disease (LD).Design:Five-year prospective study.Setting:Twenty hospitals in Catalonia, Spain.Methods:From 1994 to 1996, the potable water systems of 20 hospitals in Catalonia were tested forLegionella, Cases of hospital-acquired LD and availability of an “in-house”Legionellatest in the previous 4 years were assessed. After the hospitals were informed of the results of their water cultures, a prospective 5-year-study was conducted focusing on the detection of new cases of nosocomial legionellosis and the availability and use of Legionella testing.Results:Before environmental cultures were started, only one hospital had conducted active surveillance of hospital-acquired pneumonia and usedLegionellatests includingLegionellaurinary antigen in all pneumonia cases. Only one other hospital had used the latter test at all. In six hospitals,Legionellatests had been completely unavailable. Cases of nosocomial LD had been diagnosed in the previous 4 years in only two hospitals. During prospective surveillance, 12 hospitals (60%) usedLegionellaurinary antigen testing in house and 11 (55%) found cases of nosocomial legionellosis, representing 64.7% (11 of 17) of those with positive water cultures. Hospitals with negative water cultures did not find nosocomial LD.Conclusions:The environmental study increased the index of suspicion for nosocomial LD. The number of cases of nosocomial LD increased significantly during the prospective follow-up period, and most hospitals began using theLegionellaurinary antigen test in their laboratories.

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