53. Effect of rapid identification of bloodstream isolates on antibiotic management using a pharmacist-based treatment algorithm

Abstract Background The use of rapid molecular diagnostic testing to identify microorganisms and resistance markers has great potential to optimize medical care and assist with antimicrobial stewardship. We implemented the Verigene bloodstream infection testing panel along with a pharmacy notification system to clinicians and assessed efficacy of the system. Methods In November 2019, we implemented the Verigene gram positive and negative panels for patients with positive blood cultures. Our antimicrobial stewardship committee developed a recommended treatment algorithm for pharmacists to use when notified of Verigene results. The first positive bottle per patient and per admission was tested. Subsequent positive bottles were not tested on the Verigene unless a different morphology was noted on the gram stain. A gram stain was performed on all positive cultures and this result was called to the patient’s nurse (if inpatient) and the covering physician was notified of the result. After the Verigene result was available, an assigned pharmacist was notified of these results (organism identification and resistance markers if identified). Pharmacists notified covering physicians of the test results and the recommended antibiotic management. Pharmacists documented the frequency that the test result changed the antibiotic management, including escalation, de-escalation or no change in therapy. The data from the first six months was summarized. Results From 11/19/19-5/18/20, a total of 575 test results were called into the pharmacist (average 3.2/day). Among these, 165 (28.7%) were considered likely contaminants, 106 had no change in therapy and 59 had antibiotic de-escalation. Among the remaining 410 patients, 156 had de-escalation, 53 had escalation, 30 were not on any antibiotics and appropriate antibiotics were started. Overall, antibiotic management changed in 298/575 (51.8%) of isolates run by Verigene in our institution including 215 (37.4%) de-escalations. The most frequent antibiotics that were stopped included vancomycin (142) and cefepime (53). Conclusion Our pharmacist-based algorithm for notification and treatment recommendation based on Verigene results was highly successful in optimizing antibiotic management and improving antimicrobial stewardship in our institution. Disclosures All Authors: No reported disclosures

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Intensivists’ beliefs about rapid multiplex molecular diagnostic testing and its potential role in improving prescribing decisions and antimicrobial stewardship: a qualitative study

Antimicrobial Resistance and Infection Control ◽

10.1186/s13756-021-00961-4 ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Alyssa M. Pandolfo ◽

Robert Horne ◽

Yogini Jani ◽

Tom W. Reader ◽

Natalie Bidad ◽

...

Keyword(s):

Molecular Diagnostics ◽

Antimicrobial Stewardship ◽

Diagnostic Tests ◽

Pathogenic Bacteria ◽

Point Of Care ◽

Diagnostic Testing ◽

Molecular Diagnostic ◽

Antibiotic Prescribing ◽

Test Results ◽

Structured Interviews

Abstract Background Rapid molecular diagnostic tests to investigate the microbial aetiology of pneumonias may improve treatment and antimicrobial stewardship in intensive care units (ICUs). Clinicians’ endorsement and uptake of these tests is crucial to maximise engagement; however, adoption may be impeded if users harbour unaddressed concerns or if device usage is incompatible with local practice. Accordingly, we strove to identify ICU clinicians’ beliefs about molecular diagnostic tests for pneumonias before implementation at the point-of-care. Methods We conducted semi-structured interviews with 35 critical care doctors working in four ICUs in the United Kingdom. A clinical vignette depicting a fictitious patient with signs of pneumonia was used to explore clinicians’ beliefs about the importance of molecular diagnostics and their concerns. Data were analysed thematically. Results Clinicians’ beliefs about molecular tests could be grouped into two categories: perceived potential of molecular diagnostics to improve antibiotic prescribing (Molecular Diagnostic Necessity) and concerns about how the test results could be implemented into practice (Molecular Diagnostic Concerns). Molecular Diagnostic Necessity stemmed from beliefs that positive results would facilitate targeted antimicrobial therapy; that negative results would signal the absence of a pathogen, and consequently that having the molecular diagnostic results would bolster clinicians’ prescribing confidence. Molecular Diagnostic Concerns included unfamiliarity with the device’s capabilities, worry that it would detect non-pathogenic bacteria, uncertainty whether it would fail to detect pathogens, and discomfort with withholding antibiotics until receiving molecular test results. Conclusions Clinicians believed rapid molecular diagnostics for pneumonias were potentially important and were open to using them; however, they harboured concerns about the tests’ capabilities and integration into clinical practice. Implementation strategies should bolster users’ necessity beliefs while reducing their concerns; this can be accomplished by publicising the tests’ purpose and benefits, identifying and addressing clinicians’ misconceptions, establishing a trial period for first-hand familiarisation, and emphasising that, with a swift (e.g., 60–90 min) test, antibiotics can be started and refined after molecular diagnostic results become available.

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293. Influence of a Pharmacist Led Treatment Algorithm for the Management of Staphylococcus Bacteremia

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.336 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S146-S146

Author(s):

Jessica Lomanno ◽

Salwa Elarabi ◽

Jorge Fleisher

Keyword(s):

Blood Culture ◽

Antimicrobial Stewardship ◽

Retrospective Cohort ◽

Average Length ◽

Diagnostic Testing ◽

Treatment Algorithm ◽

Intervention Group ◽

Length Of Hospital Stay ◽

Negative Blood Culture ◽

Recommended Treatment

Abstract Background Staphylococcus bacteremia is a major healthcare burden and currently there is no widely recommended treatment algorithm. Our institution adopts all elements of antimicrobial stewardship including rapid diagnostic testing. Despite these efforts, management of staphylococcus bacteremia continues to be problematic. The objective of this project is to evaluate implementation of a pharmacist-driven algorithm to guide treatment selection for staphylococcus bacteremia. Methods This is a single center, IRB-approved cohort study with a retrospective and prospective phase. The algorithm was designed in collaboration with the infectious disease (ID) service. Retrospective data was collected from June 2019 through September 2019. The algorithm was implemented on October 1, 2019 and prospective data was collected through January 2020. Prospectively a pharmacy resident identified positive blood cultures and recommended treatment based on the algorithm. Patients 18 years of age or older with a positive blood culture for staphylococcus were included. Patients were excluded if treatment was initiated at an outside hospital. The primary outcome is algorithm adherence. Secondary outcomes include days to negative blood culture, days to de-escalation, length of hospital stay and whether ID was consulted. Treatment Algorithm Results A total of 64 patients were identified in the retrospective cohort and 46 in the intervention group. There were no significant differences in baseline characteristics. Algorithm adherence increased from 45% to 72% upon implementation (p=0.006). The algorithm resulted in a shorter time to de-escalation from 2.1 to 1.3 days (p=0.04). There were no statistically significant differences in days to negative blood culture, 2.3 vs. 2.2 days, or in average length of stay, 12.1 vs. 10.6 days in the retrospective and intervention groups, respectively. ID was consulted on 50% of patients in the retrospective cohort and 48% in the intervention group. Conclusion Implementation of a staphylococcus bacteremia treatment algorithm optimizes management. Additional layers of pharmacy involvement also result in a shorter time to de-escalation. These results highlight the importance of continuity of antimicrobial stewardship efforts. Disclosures All Authors: No reported disclosures

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The Use of Saliva as a Diagnostic Specimen for SARS CoV-2 Molecular Diagnostic Testing for Pediatric Patients

10.1101/2020.11.11.20223800 ◽

2020 ◽

Author(s):

Meghan Delaney ◽

Joelle Simpson ◽

Bobbe Thomas ◽

Christal Ralph ◽

Michael Evangalista ◽

...

Keyword(s):

Diagnostic Testing ◽

Molecular Diagnostic ◽

Test Results ◽

Sample Collection ◽

Specimen Collection ◽

Collection Device ◽

Viral Transport Medium ◽

Study Population ◽

Saliva Collection ◽

Pcr Assays

ABSTRACTBackgroundChildren are an important population to test for COVID-19 infection, particularly because they may shed the virus without displaying symptoms. Testing children for COVID-19 via sensitive molecular methods is important, although collecting nasopharyngeal (NP) specimens can be challenging. A less invasive mode of specimen collection that yields test results comparable to those from NP specimens would be beneficial to simplify sample collection.MethodsTo demonstrate that saliva is a suitable specimen for collection from children, the clinical usability/acceptability and the analytic performance of saliva were compared to NP specimens suspended in viral transport medium. Four different FDA EUA-approved real-time RT-PCR assays and one EUA approved saliva collection device were investigated.ResultsThe study population included 526 patients between the ages of 3 and 61 years, 461 (88%) were <18 years, 425 were asymptomatic (81.1%), 92 were symptomatic (17.6%). Saliva mixed with saliva stabilizing buffer was found to yield comparable sensitivity to NP specimens when tested on the AllPlex SARS-CoV-2 molecular test (Seegene Inc). The analytic sensitivity of the AllPlex assay during testing of spiked saliva mixed with SpectrumDNA saliva stabilizer was found to be 250 genomic copies/mL.ConclusionsOf the four FDA EUA-approved SARS-CoV-2 PCR assays studied, we found the AllPlex assay to be best suited for testing saliva specimens collected from children 5 years of age or older. The sensitivity of viral detection was equivalent to NP specimens when saliva specimens were mixed with the saliva stabilizer.

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The DOOR to Antibiotic Stewardship: Refining Assessments of Interventions With Desirability of Outcome Ranking

Journal of Pharmacy Practice ◽

10.1177/0897190020987130 ◽

2021 ◽

pp. 089719002098713

Author(s):

Steven M. Smoke ◽

Vishal V. Patel ◽

Nicole I. Leonida

Keyword(s):

Quality Improvement ◽

Antimicrobial Stewardship ◽

Antibiotic Stewardship ◽

Diagnostic Testing ◽

Intervention Group ◽

Molecular Diagnostic ◽

Post Intervention ◽

Appropriate Therapy ◽

The Impact ◽

Post Intervention Group

Background: Limited sample size and disparate outcome measures can hinder the ability of antimicrobial stewardship programs to assess the utility of their quality improvement interventions. Desirability of outcome ranking (DOOR) is a novel methodology that incorporates multiple outcomes into a single value to more comprehensively compare therapeutic strategies. The objective of this study was to apply DOOR to a single center antibiotic stewardship intervention. Methods: A pre- and post-interventional study was conducted evaluating the impact of prospective pharmacist review of rapid molecular diagnostic testing (RDT) of blood cultures on antibiotic optimization. Outcomes included the percentage of patients who were switched to appropriate therapy, the time to appropriate therapy, and the percentage of patients who had missed de-escalation opportunities. Results: A total of 19 and 29 patients were included in the final analysis. The percentage of patients reaching appropriate therapy was 84% (16/19) and 97% ([28/29], p = 0.16) in the pre-intervention and post-intervention groups respectively. Median time to appropriate therapy was 26 hours and 36 minutes (IQR 13:05-50:45) and 22:40 (IQR 3:42-48:23, p = 0.32), respectively. One missed de-escalation opportunity was identified in the post-intervention group (0% vs 3%, p = 1.00). DOOR analysis indicated that the probability of a better outcome for the post-intervention group than the pre-intervention group was 58% (95% CI 54-62). Conclusion: In this analysis, DOOR revealed a benefit that would not have been apparent with traditional outcomes assessments. Antimicrobial stewardship programs conducting quality improvement studies should consider incorporating DOOR into their methodology.

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Effect of Rapid Molecular Diagnostic Testing and Antimicrobial Stewardship on Antimicrobial Therapy of Respiratory Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.1668 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S628-S629 ◽

Cited By ~ 2

Author(s):

Thomas M File ◽

Paula Politis ◽

Michael J Tan ◽

George Kallstrom

Keyword(s):

Antimicrobial Stewardship ◽

Antimicrobial Therapy ◽

Respiratory Infections ◽

Diagnostic Testing ◽

Molecular Diagnostic ◽

Molecular Diagnostic Testing

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Performance of Verigene Rapid Diagnostic Testing for Detection of Inpatient Pediatric Bacteremia

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-26.5.472 ◽

2021 ◽

Vol 26 (5) ◽

pp. 472-477

Author(s):

Amy Kruger Howard ◽

Kimberly Claeys ◽

Jessica M. Biggs ◽

Kristine A. Parbuoni ◽

Kristie Johnson ◽

...

Keyword(s):

Diagnostic Testing ◽

Decision Support Tool ◽

Clinical Decision ◽

Gram Stain ◽

Support Tool ◽

Rapid Diagnostic Testing ◽

Children's Hospital ◽

Percent Agreement ◽

Children’S Hospital ◽

Resistance Markers

OBJECTIVE Verigene blood culture panels comprise rapid diagnostic testing, which aids in early bacteremia species identification. This study determined the concordance of Verigene rapid diagnostic results compared with the Vitek reference standard in patients admitted to a children's hospital. METHODS This was a 3-year retrospective observational study of neonatal and pediatric patients ≤18 years admitted to a children's hospital with confirmed bacteremia for whom Verigene testing was performed. Verigene testing was conducted on cultures with reported growth on Gram stain and final organism speciation confirmed via Vitek. Percent concordance and positive percent agreement with 95% CIs were calculated for Verigene panel-identifiable organisms. Negative percent agreement with 95% CIs was calculated for non-panel organisms. Time-to-result was calculated from Gram stain reporting to both Verigene and Vitek final organism susceptibility. RESULTS One hundred thirty-five Gram-positive (GP) and 51 Gram-negative (GN) isolates were identified through Vitek. Verigene GP panel-detectable organisms were correctly identified 96.9% (125/129) at the genus level and 95.3% (123/129) at the species level. Overall positive percent agreement was 95.3 (CI: 90.2–98.3). Negative percent agreement was 83.3 (CI: 35.9–99.6) for the 6 non-panel GP organisms. All GN isolates were correctly identified on Verigene. Median time-to-result was 2.9 hours (IQR 2.6, 3.2) and 44.4 hours (IQR: 35.4, 52.5) for Verigene and final susceptibilities, respectively. There was a statistically significant time savings of 41.5 hours (CI: 29.8–53.2) for identification and detection of resistance markers (p < 0.0001). CONCLUSION Verigene concordance at our institution aligns with results from previously published studies and can be considered a reliable clinical decision-support tool.

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Implementation of Rapid Molecular Infectious Disease Diagnostics: the Role of Diagnostic and Antimicrobial Stewardship

Journal of Clinical Microbiology ◽

10.1128/jcm.02264-16 ◽

2016 ◽

Vol 55 (3) ◽

pp. 715-723 ◽

Cited By ~ 104

Author(s):

Kevin Messacar ◽

Sarah K. Parker ◽

James K. Todd ◽

Samuel R. Dominguez

Keyword(s):

Infectious Disease ◽

Antimicrobial Stewardship ◽

Molecular Diagnostic ◽

Test Results ◽

Improved Outcomes ◽

Disease Diagnostics ◽

Infectious Disease Diagnostics ◽

Clinical Action ◽

Diagnostic Technologies

ABSTRACT New rapid molecular diagnostic technologies for infectious diseases enable expedited accurate microbiological diagnoses. However, diagnostic stewardship and antimicrobial stewardship are necessary to ensure that these technologies conserve, rather than consume, additional health care resources and optimally affect patient care. Diagnostic stewardship is needed to implement appropriate tests for the clinical setting and to direct testing toward appropriate patients. Antimicrobial stewardship is needed to ensure prompt appropriate clinical action to translate faster diagnostic test results in the laboratory into improved outcomes at the bedside. This minireview outlines the roles of diagnostic stewardship and antimicrobial stewardship in the implementation of rapid molecular infectious disease diagnostics.

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458. Molecular SARS-CoV-2 Testing During the COVID-19 Outbreak: Experiences of a Hospital in Southeast Michigan, USA

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.651 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S296-S297

Author(s):

Trini A Mathew ◽

Jonathan Hopkins ◽

Diane Kamerer ◽

Shagufta N Ali ◽

Daniel Ortiz ◽

...

Keyword(s):

Clinical Features ◽

Diagnostic Testing ◽

Beaumont Hospital ◽

High Capacity ◽

Turnaround Time ◽

Molecular Diagnostic ◽

The Novel ◽

Repeat Testing ◽

Asymptomatic Patients ◽

Novel Coronavirus

Abstract Background The novel Coronavirus SARS CoV-2 (COVID-19) outbreak was complicated by the lack of diagnostic testing kits. In early March 2020, leadership at Beaumont Hospital, Royal Oak Michigan (Beaumont) identified the need to develop high capacity testing modalities with appropriate sensitivity and specificity and rapid turnaround time. We describe the molecular diagnostic testing experience since initial rollout on March 16, 2020 at Beaumont, and results of repeat testing during the peak of the COVID-19 pandemic in MI. Methods Beaumont is an 1100 bed hospital in Southeast MI. In March, testing was initially performed with the EUA Luminex NxTAG CoV Extended Panel until March 28, 2020 when testing was converted to the EUA Cepheid Xpert Xpress SARS-CoV-2 for quicker turnaround times. Each assay was validated with a combination of patient samples and contrived specimens. Results During the initial week of testing there was > 20 % specimen positivity. As the prevalence grew the positivity rate reached 68% by the end of March (Figure 1). Many state and hospital initiatives were implemented during the outbreak, including social distancing and screening of asymptomatic patients to increase case-finding and prevent transmission. We also adopted a process for clinical review of symptomatic patients who initially tested negative for SARS-CoV-2 by a group of infectious disease physicians (Figure 2). This process was expanded to include other trained clinicians who were redeployed from other departments in the hospital. Repeat testing was performed to allow consideration of discontinuation of isolation precautions. During the surge of community cases from March 16 to April 30, 2020, we identified patients with negative PCR tests who subsequently had repeat testing based on clinical evaluation, with 7.1% (39/551) returning positive for SARS- CoV2. Of the patients who expired due to COVID-19 during this period, 4.3% (9/206) initially tested negative before ultimately testing positive. Figure 1 BH RO testing Epicurve Figure 2: Screening tool for repeat COVID19 testing and precautions Conclusion Many state and hospital initiatives helped us flatten the curve for COVID-19. Our hospital testing experience indicate that repeat testing may be warranted for those patients with clinical features suggestive of COVID-19. We will further analyze these cases and clinical features that prompted repeat testing. Disclosures All Authors: No reported disclosures

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Implementation of Rapid Molecular Diagnostic Tests and Antimicrobial Stewardship Involvement in Acute-Care Hospitals

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.847 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s278-s279

Author(s):

Maiko Kondo ◽

Matthew Simon ◽

Esther Babady ◽

Angela Loo ◽

David Calfee

Keyword(s):

Antimicrobial Stewardship ◽

Diagnostic Tests ◽

New Technology ◽

Clinical Care ◽

Bloodstream Infections ◽

Clinical Decision ◽

Research Network ◽

Molecular Diagnostic ◽

Financial Outcomes ◽

Stewardship Program

Background: In recent years, several rapid molecular diagnostic tests (RMDTs) for infectious diseases diagnostics, such as bloodstream infections (BSIs), have become available for clinical use. The extent to which RMDTs have been adopted and how the results of these tests have been incorporated into clinical care are currently unknown. Methods: We surveyed members of the Society for Healthcare Epidemiology of America Research Network to characterize utilization of RMDT in hospitals and antimicrobial stewardship program (ASP) involvement in result communication and interpretation. The survey was administered using Qualtrics software, and data were analyzed using Stata and Excel software. Results: Overall, 57 responses were received (response rate, 59%), and 72% were from academic hospitals; 50 hospitals (88%) used at least 1 RMDT for BSI (Fig. 1). The factors most commonly reported to have been important in the decision to adopt RMDT were improvements in antimicrobial usage (82%), clinical outcomes (74%), and laboratory efficiency (52%). Among 7 hospitals that did not use RMDT for BSI, the most common reason was cost of new technology. In 50 hospitals with RMDT for BSI, 54% provided written guidelines for optimization or de-escalation of antimicrobials based upon RMDT results. In 40 hospitals (80%), microbiology laboratories directly notified a healthcare worker of the RMDT results: 70% provided results to a physician, nurse practitioner, or physician assistant; 48% to the ASP team; and 33% to a nurse. Furthermore, 11 hospitals (22%) had neither guidelines nor ASP intervention. In addition, 24 hospitals (48%) reported performing postimplementation evaluation of RMDT impact. Reported findings included reduction in time to antibiotic de-escalation (75%), reduction in length of stay (25%), improved laboratory efficiency (20%), and reduction in mortality and overall costs (12%). Among the 47 hospitals with both RMDT and ASP, 79% reported that the ASP team routinely reviewed blood culture RMDT results, and 53.2% used clinical decision support software to do so. Finally, 53 hospitals (93%) used 1 or more RMDT for non–bloodstream infections (Fig. 1). Fewer than half of hospitals provided written guidelines to assist clinicians in interpreting these RMDT results. Conclusions: RMDTs have been widely adopted by participating hospitals and are associated with positive self-reported clinical, logistic, and financial outcomes. However, nearly 1 in 4 hospitals did not have guidelines or ASP interventions to assist clinicians with optimization of antimicrobial prescribing based on RMDT results for BSI. Also, most hospitals did not have guidelines for RMDT results for non-BSI. These findings suggest that opportunities exist to further enhance the potential benefits of RMDT.Funding: NoneDisclosures: None

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