Optimization of Empirical Antimicrobial Therapy in Enterobacterales Bloodstream Infection Using the Extended-Spectrum Beta-Lactamase Prediction Score

Haimerl, Brian J.; Encinas, Rodrigo; Justo, Julie Ann; Kohn, Joseph; Bookstaver, P. Brandon; Winders, Hana Rac; Al-Hasan, Majdi N.

doi:10.3390/antibiotics12061003

Cited by 3 publications

(2 citation statements)

References 23 publications

(37 reference statements)

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“…In one systematic review examining scoring tools for predicting ESBL presence and carbapenem resistance in Enterobacterales bloodstream infections, subsequent external validation studies reported a median sensitivity and specificity of 32% and 90% for ESBL prediction, which were lower than that of their original studies (55% and 94%, respectively) ( 12 ). In another study at several community hospitals, the implementation of an ESBL diagnostic scoring tool in Enterobacterales bloodstream infections led to a significant decrease in mean time to appropriate antibiotic administration (78 hours before to 46 hours after implementation) ( 13 ). Altogether, these findings underscore the potential clinical relevance of these tools, particularly for NPV among low incidence settings, and the necessity of local validation of diagnostic scoring tools to ensure effective implementation.…”

Section: Discussionmentioning

confidence: 99%

Comparative analysis of a rapid diagnostic test and scoring tools for ESBL detection in Enterobacterales bloodstream infections for optimizing antimicrobial therapy

Andrews,

Timbrook,

Fisher

et al. 2024

Microbiol Spectr

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Extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales bloodstream infections (BSI) are associated with increased cost, morbidity, and mortality compared with BSI by non-ESBL-producing bacteria. Phenotypic susceptibility data from blood cultures can take up to 72 hours to result, leading to delays in appropriate antimicrobial administration and unnecessary carbapenem usage. We sought to evaluate the performance of a rapid diagnostic test (RDT) and two published diagnostic scoring tools for predicting ceftriaxone resistance in BSI by Enterobacterales . This was a retrospective observational cohort study evaluating adult patients with BSI by select Enterobacterales species ( Escherichia coli , Klebsiella oxytoca , Klebsiella pneumoniae group, Proteus mirabilis , and Salmonella spp.). We compared the performance of a multiplex-PCR panel by BioFire (BCID2) with two diagnostic scoring tools for predicting ceftriaxone resistance. Among 356 patients, ceftriaxone resistance was observed in 41 of 356 (11.5%) isolates. BCID2 accurately predicted ceftriaxone susceptibility in 99.2% of isolates (92.7% sensitivity and 100% specificity), compared with <90% for the two scoring tools ( P < 0.05 for both). In ceftriaxone-resistant isolates ( n = 41), BCID2 led to fewer instances of undertreatment with ceftriaxone compared with scoring tools (7.3% vs 68.3% and 92.7%). In ceftriaxone-susceptible isolates ( n = 315), BCID2 led to no instances of overtreatment with carbapenems compared with 3.8% and 5.7% with the scoring tools. The BCID2 panel outperformed both ESBL scoring tools in our population. Local evaluation of RDT and scoring tools should be performed in conjunction with institutional implementation. IMPORTANCE Our study addresses a significant issue in the medical and scientific community—the delayed administration of appropriate antimicrobial treatments due to the time-consuming process of phenotypic susceptibility data collection in gram-negative bloodstream infections. Our research indicates that a multiplex PCR rapid diagnostic test (RDT) significantly outperformed two clinical scoring tools in predicting ceftriaxone susceptibility. Multiplex PCR also led to reduced instances of undertreatment with ceftriaxone and minimized overtreatment with carbapenems. Furthermore, multiplex PCR demonstrated high sensitivity and specificity in predicting ceftriaxone susceptibility. The results of our study underscore the potential RDTs to reduce the time to appropriate antimicrobial therapy, leading to improved patient outcomes and reduced healthcare costs.

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Section: Discussionmentioning

confidence: 99%

Comparative analysis of a rapid diagnostic test and scoring tools for ESBL detection in Enterobacterales bloodstream infections for optimizing antimicrobial therapy

Andrews,

Timbrook,

Fisher

et al. 2024

Microbiol Spectr

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“…As noted, in the two studies evaluating clinical utility, only the hypothetical undertreatment, overtreatment, and carbapenem use per 1000 patient days was evaluated. However, the collaborators of the Augustine study recently published a separate subsequent study evaluating the implementation of their risk prediction scoring on patient management [ 28 ]. For their implementation, they made the prediction score and algorithm available in print, on their internal website for providers, and through a mobile app.…”

Section: Discussionmentioning

confidence: 99%

Predicting Extended-Spectrum Beta-Lactamase and Carbapenem Resistance in Enterobacteriaceae Bacteremia: A Diagnostic Model Systematic Review and Meta-Analysis

Timbrook,

Fowler

2023

Antibiotics

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Enterobacteriaceae bacteremia, particularly when associated with antimicrobial resistance, can result in increased mortality, emphasizing the need for timely effective therapy. Clinical risk prediction models are promising tools, stratifying patients based on their risk of resistance due to ESBL and carbapenemase-producing Enterobacteriaceae in bloodstream infections (BSIs) and, thereby, improving therapeutic decisions. This systematic review and meta-analysis synthesized the literature on the performance of these models. Searches of PubMed and EMBASE led to the identification of 10 relevant studies with 6106 unique patient encounters. Nine studies concerned ESBL prediction, and one focused on the prediction of carbapenemases. For the two ESBL model derivation studies, the discrimination performance showed sensitivities of 53–85% and specificities of 93–95%. Among the four ESBL model derivation and validation studies, the sensitivities were 43–88%, and the specificities were 77–99%. The sensitivity and specificity for the subsequent external validation studies were 7–37% and 88–96%, respectively. For the three external validation studies, only two models were evaluated across multiple studies, with a pooled AUROC of 65–71%, with one study omitting the sensitivity/specificity. Only two studies measured clinical utility through hypothetical therapy assessments. Given the limited evidence on their interventional application, it would be beneficial to further assess these or future models, to better understand their clinical utility and ensure their safe and impactful implementation.

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Validation of a Stenotrophomonas maltophilia bloodstream infection prediction score in the hematologic malignancy population

Gill,

McEvoy

2024

Ann Hematol

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Stenotrophomonas maltophilia (SM) bloodstream infections (BSIs) contribute to significant mortality in hematologic malignancy (HM) and hematopoietic stem cell transplantation (HSCT) patients. A risk score to predict SM BSI could reduce time to appropriate antimicrobial therapy (TTAT) and improve patient outcomes. A single center cohort study of hospitalized adults with HM/HSCT was conducted. Patients had ≥ 1 blood culture with a Gram-negative (GN) organism. A StenoSCORE was calculated for each patient. The StenoSCORE2 was developed using risk factors for SM BSI identified via logistic regression. Receiver operating characteristic (ROC) curves were plotted. Sensitivity and specificity for the StenoSCORE and StenoSCORE2 were calculated. Thirty-six SM patients and 534 non-SM patients were assessed. A StenoSCORE ≥ 33 points was 80% sensitive, 68% specific, and accurately classified 69% of GN BSIs. StenoSCORE2 variables included acute leukemia, prolonged neutropenia, mucositis, ICU admission, recent meropenem and/or cefepime exposure. The StenoSCORE2 performed better than the StenoSCORE (ROC AUC 0.84 vs. 0.77). A StenoSCORE2 ≥ 4 points was 86% sensitive, 76% specific, and accurately classified 77% of GN BSIs. TTAT was significantly longer for patients with SM BSI compared with non-SM BSI (45.16 h vs. 0.57 h; p < 0.0001). In-hospital and 28-day mortality were significantly higher for patients with SM BSI compared to non-SM BSI (58.3% vs. 18.5% and 66.7% vs. 26.4%; p-value < 0.0001). The StenoSCORE and StenoSCORE2 performed well in predicting SM BSIs in patients with HM/HSCT and GN BSI. Clinical studies evaluating whether StenoSCORE and/or StenoSCORE2 implementation improves TTAT and clinical outcomes are warranted.

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Optimization of Empirical Antimicrobial Therapy in Enterobacterales Bloodstream Infection Using the Extended-Spectrum Beta-Lactamase Prediction Score

Cited by 3 publications

References 23 publications

Comparative analysis of a rapid diagnostic test and scoring tools for ESBL detection in Enterobacterales bloodstream infections for optimizing antimicrobial therapy

Comparative analysis of a rapid diagnostic test and scoring tools for ESBL detection in Enterobacterales bloodstream infections for optimizing antimicrobial therapy

Predicting Extended-Spectrum Beta-Lactamase and Carbapenem Resistance in Enterobacteriaceae Bacteremia: A Diagnostic Model Systematic Review and Meta-Analysis

Validation of a Stenotrophomonas maltophilia bloodstream infection prediction score in the hematologic malignancy population

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