Examining the clinical impact of rapid multiplex polymerase chain reaction‐based diagnostic testing for bloodstream infections in a national cohort of the Veterans Health Administration

Abstract

Study Objective Bloodstream infections (BSIs) are a significant cause of mortality. Use of a rapid multiplex polymerase chain reaction‐based blood culture identification panel (BCID) may improve antimicrobial utilization and clinical outcomes by shortening the time to appropriate therapy and de‐escalating antibiotics among patients on overly broad‐spectrum empiric therapy. The effect of BCID on clinical outcomes across varying institutional antimicrobial stewardship program (ASP) practices is unclear. This study evaluated clinical outcomes associated with the “real‐world” implementation of BCID in a national health system with varying ASP practices. Design National, multicenter, retrospective, pre–post quasi‐experimental study of hospitalized patients admitted from 2015 to 2020 to VHA facilities, which introduced the BCID for ≥1 year. Setting United States Veterans Health Administration (VHA) hospitals with BCID. Patients Hospitalized VHA patients with ≥1 blood culture positive for bacteria featured on the BCID panel. Intervention Comparison of outcomes between the pre‐ and post‐BCID implementation groups. Measurements Outcomes evaluated included early antimicrobial de‐escalation within 48 h, defined as reduction in antimicrobial spectrum scores, time to appropriate therapy, and 30‐day mortality. Main Results A total of 4138 patients (pre‐BCID, n = 2100; post‐BCID, n = 2038) met the study criteria. Implementation of BCID was associated with significant improvements in early antimicrobial de‐escalation (34.6%: pre‐BCID vs. 38.1%: post‐BCID; p = 0.022), which persisted after adjusting for other covariates (adjusted risk ratio [aRR], 1.11; 95% confidence interval [CI], 1.02–1.20; p = 0.011). Median time to appropriate therapy was shorter in the post‐BCID implementation group relative to the pre‐BCID group (9 h: pre‐BCID vs. 8 h: post‐BCID, respectively, p = 0.005), and a greater percentage of patients received early appropriate antimicrobial therapy within 48 h in the post‐BCID implementation group (91.7%: pre‐BCID vs. 93.8%: post‐BCID; p = 0.008). In the multivariable regression analysis, BCID implementation was significantly associated with a higher likelihood of appropriate therapy within 48 h (aRR, 1.02; 95% CI, 1.01–1.08; p = 0.020). There was no difference in 30‐day mortality between groups overall (12.6% pre‐BCID vs. 11.2% post‐BCID; p = 0.211). Conclusions In a “real‐world” clinical setting, the implementation of BCID was associated with clinical improvements in antimicrobial utilization. The BCID platform may serve as a useful adjunct for BSI management in facilities with ASP.

Large-Scale Clinical Evaluation of Rapid Blood Culture Identification Panels for Bloodstream Infections at a Tertiary Hospital

“…Therefore, further evaluations are warranted for rare target organisms. Second, several previous studies have shown that improving turnaround time through BCID has a positive clinical effect on shortening the time to optimize antibacterial treatment for patients with BSIs, especially those requiring antibiotic susceptibility testing and subsequent molecular screening [ 9 , 25 , 26 ]. However, this study has yet to evaluate the impact of this rapid reporting of results on patient health and health service outcomes in clinical settings, which remains a subject of further research.…”

“…Multiplex polymerase chain reaction (mPCR) panels, also known as syndrome panels, are considered a principal technology in the many strategies that integrate tests for multiple pathogens and/or antimicrobial resistance genes into a single test, providing rapid results for multiple targets [ 6 , 7 ]. The introduction of the mPCR panel in clinical microbiology laboratories is expected to improve patient care and clinical workflow, as well as reduce hospitalization costs by reducing diagnosis and decision-making time [ 8 , 9 , 10 , 11 ].…”

From bottle to bedside: Implementation considerations and antimicrobial stewardship considerations for bloodstream infection rapid diagnostic testing

“…5 A recent large retrospective cohort of over 4000 patients within the Veterans Health Administration failed to demonstrate beneficial clinical outcomes. 73 Two RCTs evaluating the clinical impact of mRDTs also failed to detect a difference in mortality, LOS, or hospital readmission; however, the studies were not powered to detect these differences. 38,40 A prospective, randomized, open-label trial (NCT03744728) evaluating the Accelerate Pheno platform compared with the Verigene® BC-GP/GN is ongoing.…”

“…Overall, antimicrobial consumption will not likely provide the necessary insight into the success of the implementation, nor will review clinical outcomes such as hospital LOS or inpatient mortality. As recently demonstrated within a large Veteran's Affairs population of over 4000 patients with BSI, changes to process metrics such as time to appropriate antimicrobials can be impacted by mRDTs, but 30‐day mortality remained relatively unchanged 73 . Therefore, it is within the AMS program's best interest to evaluate the intervention success based on process metrics such as adherence to guideline recommendations and time to appropriate and optimal therapy.…”

“…As mentioned above, a systematic review of 5920 patients found statistically significant decreases in both mortality and hospital LOS with mRDT in BSI 5 . A recent large retrospective cohort of over 4000 patients within the Veterans Health Administration failed to demonstrate beneficial clinical outcomes 73 . Two RCTs evaluating the clinical impact of mRDTs also failed to detect a difference in mortality, LOS, or hospital readmission; however, the studies were not powered to detect these differences 38,40 .…”