Effect of Rapid Respiratory Virus Testing on Antibiotic Prescribing Among Children Presenting to the Emergency Department With Acute Respiratory Illness

Rao, Suchitra; Lamb, Molly M.; Moss, Angela; Mistry, Rakesh D.; Grice, Kathleen; Ahmed, Wasiu; Santos-Cantú, Daniela; Kitchen, E. A.; Patel, Chandni; Ferrari, Ilaria; Dominguez, Samuel R.

doi:10.1001/jamanetworkopen.2021.11836

Cited by 35 publications

(56 citation statements)

References 24 publications

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“…To further highlight the uncertainties behind the decision to prescribe antibiotics, a recent randomized clinical trial found the unexpected results that the use of rapid respiratory pathogen testing in the ED for children with influenzalike illness did not decrease antibiotic prescribing [28]. Although clear evidence of a viral infection should theoretically reinforce the decision to not prescribe antibiotics, in a cohort of children with respiratory symptoms with a high pre-test probability of having viral infections, previous studies found similar results on how these tests did not affect the prescription practices [29,30].…”

Section: Discussionmentioning

confidence: 99%

“…New resistance mechanisms are emerging and spreading, and a growing list of diseases, including the major global killers-such as pneumonia, tuberculosis, and foodborne diseases-are becoming more and more difficult to treat [1]. Recent estimates from the European Economic Area found that, in 2015, infections with antibiotic-resistant bacteria accounted for an estimated 33,110 (28,430) attributable deaths and 874,541 (768,837-989,068) disability-adjusted life-years (DALYs) [2], and had increased since 2007. Unfortunately, this problem is increasingly recognized in the pediatric population as well, with the highest burden in infants aged < 1 year [2].…”

Section: Introductionmentioning

confidence: 99%

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Determinants of antibiotic prescriptions in a large cohort of children discharged from a pediatric emergency department

et al. 2022

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While there is evidence of high use of wide-spectrum antibiotics in children evaluated in the pediatric emergency departments, determinants of this behavior are still unclear. This study was aimed at defining the demographic, social, clinical, and laboratory factors that affect antibiotic prescriptions in children discharged from the emergency department. We performed a retrospective observational study of children aged younger than 18 years discharged from a pediatric university hospital between Jan. 1, 2015 and Dec. 31, 2020. We determined the proportion and type of antibiotic prescription according to demographic, social, clinical, laboratory, and imaging data, as well as doctor’s expertise. Fifty-one thousand six hundred thirty-three children were included, and 13,167 (25.5%) received an antibiotic prescription. Amoxicilline/clavulanate (Am/Cl) was the most prescribed antibiotic (8453, 64.2% of all prescriptions). Factors independently associated with an antibiotic prescription were older age (OR = 1.62 [1.53–1.73] for age 2–5 years, OR = 1.77 [1.64–1.91] for age 6–10 years, OR = 1.36 [1.25–1.49] for age 11–18 years, p < 0.001 for all groups); being evaluated by a physician with > 3 years of pediatric expertise (OR = 1.22 [1.13–1.31], p < 0.001); fever peak higher than 40 °C (OR = 1.37 [1.21–1.54], p < 0.001); abnormal findings on auscultation (OR = 1.95 [1.75–2.17], p < 0.001), CRP values (OR = 1.63 [1.26–2.10] for CRP < 50 mg/L, and OR = 3.78 (2.75–5.21) for CRP ≥ 50 mg/L with respect to CRP not requested; p < 0.01); CXR results whatever positive (OR = 4.47 [3.62–5.52], p < 0.001) or negative (1.82 [1.62–2.04], p < 0.001); being diagnosed with upper respiratory tract infections (OR = 4.27 [4.04–4.51], p < 0.001), lower respiratory tract infections (OR = 5.35 [4.88–5.85]; p < 0.001), and UTI (OR = 9.33 [8.14–10.71], p < 0.001). Conclusions: Overprescription of antibiotics, including Am/Cl, is relevant in pediatric emergency departments. Factors associated with overprescription are not limited to the clinical characteristics of the treated patients. These findings highlight the need for a new and comprehensive approach to ensure successful antibiotic stewardship initiatives in the emergency departments. What is Known:• Antibiotic resistance is a growing problem in medical practice, including in pediatrics.• Antibiotics are overprescribed in children assessed in the emergency department, but comprehensive and large studies are lacking. What is New:• Factors associated with overprescription are not limited to the clinical characteristics of the patients.• Non-clinical factors such as environmental variables, doctor’s expertise, and attitudes to laboratory and radiological examinations affect prescription.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Determinants of antibiotic prescriptions in a large cohort of children discharged from a pediatric emergency department

et al. 2022

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“…Multiplex upper respiratory viral testing has been described in the literature as a potential approach to aid in antibiotic stewardship 17–19 . In a pediatric randomized control trial led by Rao et al, with respiratory viral panel (RVP) testing as an intervention, there was no impact of testing availability on antibiotic prescribing (RR, 1.1, 95% CI: 0.9–1.4) 20 . However, in an adult study of 2000 patients, availability of rapid PCR testing resulted in change in management occurring in 58% of the cases resulting in a decrease of inappropriate/unsupported antibiotic and anti‐viral prescribing by 24.5% and 9%, respectively.…”

Section: Discussionmentioning

confidence: 99%

“…Numerous diagnostic assays exist to determine co‐infections, including multiplex nucleic acid amplification and microarray‐based assays. A new challenge is understanding the performance evaluation of different assays and testing phase requirements 20,22 . A study by Diaz‐Decaro, which focuses on FDA‐approved respiratory multiplex assays for public health surveillance, identifies rhinovirus and enteroviruses as problematic targets for multiplex due to genetic homology and primer similarity increasing the risk of cross‐amplification and interference during multiplex testing 22 .…”

Section: Discussionmentioning

confidence: 99%

Viral co‐infections are associated with increased rates of hospitalization in those with influenza

Shannon

Osula

Shaw‐Saliba

et al. 2022

Influenza Resp Viruses

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Background: Influenza causes significant morbidity and mortality in the United States. Among patients infected with influenza, the presence of bacterial co-infection is associated with worse clinical outcomes; less is known regarding the clinical importance of viral co-infections. The objective of this study was to determine rates of viral co-infections in emergency department (ED) patients with confirmed influenza and association of co-infection with disease severity.Methods: Secondary analysis of a biorepository and clinical database from a parent study where rapid influenza testing was implemented in four U.S. academic EDs, during the 2014-2015 influenza season. Patients were systematically tested for influenza virus using a validated clinical decision guideline. Demographic and clinical data were extracted from medical records; nasopharyngeal specimens from influenza-positive patients were tested for viral co-infections (ePlex, Genmark Diagnostics). Patterns of viral co-infections were evaluated using chi-square analysis.The association of viral co-infection with hospital admission was assessed using univariate and multivariate regression. Results:The overall influenza A/B positivity rate was 18.1% (1071/5919). Of the 999 samples with ePlex results, the prevalence of viral co-infections was 7.9% (79/999). The most common viral co-infection was rhinovirus/enterovirus (RhV/EV), at 3.9% (39/999). The odds of hospital admission (OR 2.33, 95% CI: 1.01-5.34) increased significantly for those with viral co-infections (other than RhV/EV) versus those with influenza A infection only. Conclusion:Presence of viral co-infection (other than RhV/EV) in ED influenza A/B positive patients was independently associated with increased risk of hospital admission. Further research is needed to determine clinical utility of ED multiplex testing.

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“…The QIAstat-Dx Respiratory SARS-CoV-2 panel RP2.0 (QIAstat-Dx RP2.0) (Qiagen, Germany) and the BioFire FilmArray Respiratory panel RP2.1 (BioFire RP2.1) have recently emerged in the market, generating results from 22 different respiratory targets, including SARS-CoV-2 in approximately 1 h ( Rao et al, 2021 ). While the BioFire RP2.1 offers relatively quicker results (45 vs. 70 min), the QIAstat-Dx RP2.0 also offers direct introduction of the nasopharyngeal swab into the cartridge, reducing hands-on-time.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of the QIAstat-Dx RP2.0 and the BioFire FilmArray RP2.1 for the Rapid Detection of Respiratory Pathogens Including SARS-CoV-2

et al. 2022

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Point-of-care syndromic panels allow for simultaneous and rapid detection of respiratory pathogens from nasopharyngeal swabs. The clinical performance of the QIAstat-Dx Respiratory SARS-CoV-2 panel RP2.0 (QIAstat-Dx RP2.0) and the BioFire FilmArray Respiratory panel RP2.1 (BioFire RP2.1) was evaluated for the detection of SARS-CoV-2 and other common respiratory pathogens. A total of 137 patient samples were retrospectively selected based on emergency department admission, along with 33 SARS-CoV-2 positive samples tested using a WHO laboratory developed test. The limit of detection for SARS-CoV-2 was initially evaluated for both platforms. The QIAstat-Dx RP2.0 detected SARS-CoV-2 at 500 copies/mL and had a positive percent agreement (PPA) of 85%. The BioFire RP2.1 detected SARS-CoV-2 at 50 copies/mL and had a PPA of 97%. Both platforms showed a negative percent agreement of 100% for SARS-CoV-2. Evaluation of analytical specificity from a range of common respiratory targets showed a similar performance between each platform. The QIAstat-Dx RP2.0 had an overall PPA of 82% (67–100%) in clinical samples, with differences in sensitivity depending on the respiratory target. Both platforms can be used to detect acute cases of SARS-CoV-2. While the QIAstat-Dx RP2.0 is suitable for detecting respiratory viruses within a clinical range, it has less analytical and clinical sensitivity for SARS-CoV-2 compared to the BioFire RP2.1.

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Effect of Rapid Respiratory Virus Testing on Antibiotic Prescribing Among Children Presenting to the Emergency Department With Acute Respiratory Illness

Cited by 35 publications

References 24 publications

Determinants of antibiotic prescriptions in a large cohort of children discharged from a pediatric emergency department

Determinants of antibiotic prescriptions in a large cohort of children discharged from a pediatric emergency department

Viral co‐infections are associated with increased rates of hospitalization in those with influenza

Evaluation of the QIAstat-Dx RP2.0 and the BioFire FilmArray RP2.1 for the Rapid Detection of Respiratory Pathogens Including SARS-CoV-2

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