Effectiveness of Practices To Increase Timeliness of Providing Targeted Therapy for Inpatients with Bloodstream Infections: a Laboratory Medicine Best Practices Systematic Review and Meta-analysis

Abstract

SUMMARYBackground.Bloodstream infection (BSI) is a major cause of morbidity and mortality throughout the world. Rapid identification of bloodstream pathogens is a laboratory practice that supports strategies for rapid transition to direct targeted therapy by providing for timely and effective patient care. In fact, the more rapidly that appropriate antimicrobials are prescribed, the lower the mortality for patients with sepsis. Rapid identification methods may have multiple positive impacts on patient outcomes, including reductions in mortality, morbidity, hospital lengths of stay, and antibiotic use. In addition, the strategy can reduce the cost of care for patients with BSIs.Objectives.The purpose of this review is to evaluate the evidence for the effectiveness of three rapid diagnostic practices in decreasing the time to targeted therapy for hospitalized patients with BSIs. The review was performed by applying the Centers for Disease Control and Prevention's (CDC's) Laboratory Medicine Best Practices Initiative (LMBP) systematic review methods for quality improvement (QI) practices and translating the results into evidence-based guidance (R. H. Christenson et al., Clin Chem 57:816–825, 2011, http://dx.doi.org/10.1373/clinchem.2010.157131).Search strategy.A comprehensive literature search was conducted to identify studies with measurable outcomes. A search of three electronic bibliographic databases (PubMed, Embase, and CINAHL), databases containing “gray” literature (unpublished academic, government, or industry evidence not governed by commercial publishing) (CIHI, NIHR, SIGN, and other databases), and the Cochrane database for English-language articles published between 1990 and 2011 was conducted in July 2011.Dates of search.The dates of our search were from 1990 to July 2011.Selection criteria.Animal studies and non-English publications were excluded. The search contained the following medical subject headings: bacteremia; bloodstream infection; time factors; health care costs; length of stay; morbidity; mortality; antimicrobial therapy; rapid molecular techniques, polymerase chain reaction (PCR); in situ hybridization, fluorescence; treatment outcome; drug therapy; patient care team; pharmacy service, hospital; hospital information systems; Gram stain; pharmacy service; and spectrometry, mass, matrix-assisted laser desorption-ionization. Phenotypic as well as the following key words were searched: targeted therapy; rapid identification; rapid; Gram positive; Gram negative; reduce(ed); cost(s); pneumoslide; PBP2; tube coagulase; matrix-assisted laser desorption/ionization time of flight; MALDI TOF; blood culture; EMR; electronic reporting; call to provider; collaboration; pharmacy; laboratory; bacteria; yeast; ICU; and others. In addition to the electronic search being performed, a request for unpublished quality improvement data was made to the clinical laboratory community.Main results.Rapid molecular testing with direct communication significantly improves timeliness compared to standard testing. Rapid ...

Benefits of Adding a Rapid PCR-Based Blood Culture Identification Panel to an Established Antimicrobial Stewardship Program

“…Unfortunately, conventional organism identification and susceptibility reporting require 48 to 72 h to produce final results, leading to a substantial delay in the receipt of appropriate antimicrobial therapy, which has been shown to negatively impact patient outcomes, particularly in the setting of multidrug-resistant organisms (3, 4). That the delay in de-escalation of antimicrobial therapy for infections caused by susceptible organisms can result in longer durations of exposure of these patients to broader-spectrum agents, which may lead to development of resistance, Clostridium difficile infections, microbiome disruption, and increased costs, is equally troubling (5, 6).Several approaches can provide organism identification and detect antimicrobial resistance genes within hours of blood culture positivity, allowing earlier and more effective antimicrobial therapy (7,8). These include fluorescence in situ hybridization, matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) mass spectrometry, and nucleic acid hybridization and amplification assays.…”

Changing Definitions of Sepsis

“…Rapid testing of the microorganisms is needed for reducing the time to targeted therapy for ICU patients (32). In this topic, polymerase chain reaction is an excellent technique for the rapid detection of pathogens for the early diagnosis of culture negative sepsis (33).…”

Real -time PCR for early microbiological diagnosis: is it time?

“…This is an important and relevant quality gap. It is evident that improved identification methods and practices that allow reduction of time to microbiological diagnosis and targeted therapy constitutes a major quality improvement framework in antibiotic use [1].Diagnostic techniques that do not depend on growth of organisms in culture may offer a distinct advantage over current methods. They allow shorter time to results and detection of non-cultivable microorganisms under antibiotic pressure.…”

“…This is an important and relevant quality gap. It is evident that improved identification methods and practices that allow reduction of time to microbiological diagnosis and targeted therapy constitutes a major quality improvement framework in antibiotic use [1].…”

“…Recently, a comprehensive literature search was conducted to identify studies with measurable outcomes to evaluate the evidence for the effectiveness of different rapid diagnostic practices in decreasing time to targeted therapy for hospitalized patients with BSI [1]. The authors concluded that rapid phenotypic techniques with direct communication likely improve the timeliness of targeted therapy and that rapid molecular testing with direct communication significantly improves timeliness and significantly reduces mortality, compared to standard testing.…”