Management of Gram-Negative Bloodstream Infections in the Era of Rapid Diagnostic Testing: Impact With and Without Antibiotic Stewardship

Abstract

Background Verigene Blood-Culture Gram-Negative is a rapid diagnostic test (RDT) that detects GNs and resistance within hours from Gram-stain. The majority of data supports the use of RDTs with antimicrobial stewardship (AMS) intervention in gram-positive BSI; Less is known on for GN BSI. Methods Retrospective quasi-experimental (non-randomized) study of adult patients with RDT-target GN BSI comparing patients pre-RDT/AMS versus post-RDT/pre-AMS versus post-RDT/AMS. Optimal therapy was defined as appropriate coverage with narrowest spectrum, accounting for source and co-infecting organisms. Time to optimal therapy was analyzed using Kaplan-Meier, and multivariable Cox-proportional hazards regression. Results Eight-hundred thirty-two patients were included; 237 pre-RDT/AMS versus 308 post-RDT/pre-AMS versus 237 post-RDT/AMS, respectively. The proportion of patients on optimal antibiotic therapy increased with each intervention (66.5% vs 78.9% vs 83.2%, P & 0.0001). Time to optimal therapy decreased with introduction of RDT; 47h (IQR, 7.9, 67.7) vs 24.9h (IQR 12.4, 55.2) vs 26.5h (IQR 10.3, 66.5), P = 0.09. Using multivariable modelling, ID consult was an effect modifier. Within the ID consult stratum, controlling for source and ICU stay, compared to the pre- RDT/AMS group, both post-RDT/pre-AMS (adjusted hazard ratio (aHR) = 1.34, 95% CI 1.04, 1.72) and post-RDT/AMS (aHR = 1.28, 95% CI 1.01, 1.64) had improved time to optimal therapy. This effect was not seen in the stratum without ID consult. Conclusions With the introduction of RDT and AMS, both proportion and time to optimal therapy optimal antibiotic therapy improved, especially among those with an existing ID consult. This study highlights the beneficial role of RDTs in GN BSI.

Clinical-laboratory characteristics and etiological structure of bloodstream infections: results of a multicenter clinical study

“…The high efficiency and rate of performing microbiological research using an automatic analyzer for hemoculture in comparison with the traditional manual method has been shown. паратов, преобладанием среди пациентов людей пожилого возраста, а также появлением множественной устойчивости микроорганизмов к антибактериальным препаратам [2][3][4].…”

New Microbiological Techniques for the Diagnosis of Bacterial Infections and Sepsis in ICU Including Point of Care

“…The Verigene system (Luminex) uses multiplex PCRs and subsequent microarray hybridisation for detection of 22 bacteria and their resistance determinants from positive BC [ 57 , 58 ], and comprises two different panels, for Gram positives and Gram negatives, whose choice can be driven by the Gram stain results. Verigene has proved able to identify susceptibility to new β-lactam/β-lactamase inhibitors [ 59 ], and when implemented within an AMS program, reduced the time to optimal therapy in bacteraemic patients [ 60 , 61 ].…”

Rapid Antimicrobial Susceptibility Testing Methods for Blood Cultures and Their Clinical Impact

“…These studies have been previously summarized elsewhere and have been incorporated in meta-analyses (67)(68)(69). Limitations of these studies include their varying quality; small sample sizes; single-center, retrospective, and observational designs; and historical or absent control groups (70)(71)(72)(73). A few studies have used the more rigorous study design of a prospective randomized controlled trial (RCT) to evaluate outcomes of rapid blood culture AST methods and are summarized in Table 3.…”

“…It is also notable that with the exception of the study by Kim et al, most of these trials were conducted in areas with low rates of antimicrobial-resistant bacteria, and it is possible that more clinical benefit would be observed in areas with higher rates of resistant infections (19,20). Additionally, most of the studies demonstrate the importance of pairing rapid blood culture diagnostics with antibiotic stewardship team review, as has been emphasized by many others (20,68,69,73,(77)(78)(79)(80). A meta-analysis of primarily observational studies demonstrated mortality benefit when blood culture diagnostics were used with stewardship programs but not without stewardship programs (69).…”

“…These studies have been previously summarized elsewhere and have been incorporated in meta-analyses ( 67 – 69 ). Limitations of these studies include their varying quality; small sample sizes; single-center, retrospective, and observational designs; and historical or absent control groups ( 70 – 73 ).…”