Stewardship Approach for Optimizing Antimicrobial Therapy through Use of a Rapid Microarray Assay on Blood Cultures Positive for Enterococcus Species

Sango, Aaron; McCarter, Yvette S.; Johnson, Donald W.; Ferreira, Jason; Guzman, Nilmarie; Jankowski, Christopher A.

doi:10.1128/jcm.01951-13

Cited by 89 publications

(66 citation statements)

References 10 publications

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“…Despite having the ability to obtain blood culture results up to 1.5 days faster than traditional identification methods, this study shows that without real-time AMS intervention, treatment optimization was significantly delayed. Several studies have established that the use of mRDT in settings with ASPs and microbiology result analysis improves the time to antimicrobial streamlining and various patient outcomes compared to traditional methods of organism identification (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19).…”

Section: Discussionmentioning

confidence: 99%

Effect of Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry (MALDI-TOF MS) Alone versus MALDI-TOF MS Combined with Real-Time Antimicrobial Stewardship Interventions on Time to Optimal Antimicrobial Therapy in Patients with Positive Blood Cultures

Beganovic

Costello²,

Wieczorkiewicz

2017

J Clin Microbiol

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Matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) decreases the time to organism identification and improves clinical and financial outcomes. The purpose of this study was to evaluate the impact of MALDI-TOF MS alone versus MALDI-TOF MS combined with real-time, pharmacist-driven, antimicrobial stewardship (AMS) intervention on patient outcomes. This single-center, pre-post, quasiexperimental study evaluated hospitalized patients with positive blood cultures identified via MALDI-TOF MS combined with prospective AMS intervention compared to a control cohort with MALDI-TOF MS identification without AMS intervention. AMS intervention included: real-time MALDI-TOF MS pharmacist notification and prospective AMS provider feedback. The primary outcome was the time to optimal therapy (TTOT). A total of 252 blood cultures, 126 in each group, were included in the final analysis. MALDI-TOF MS plus AMS intervention significantly reduced the overall TTOT (75.17 versus 43.06 h; P Ͻ 0.001), the Gram-positive contaminant TTOT (48.21 versus 11.75 h; P Ͻ 0.001), the Gramnegative infection (GNI) TTOT (71.83 versus 35.98 h; P Ͻ 0.001), and the overall hospital length of stay (LOS; 15.03 versus 9.02 days; P ϭ 0.021). The TTOT for Grampositive infection (GPI) was improved (64.04 versus 41.61 h; P ϭ 0.082). For GPI, the hospital LOS (14.64 versus 10.31 days; P ϭ 0.002) and length of antimicrobial therapy 24.30 versus 18.97 days; P ϭ 0.018) were reduced. For GNI, the time to microbiologic clearance (51.13 versus 34.51 h; P Ͻ 0.001), the hospital LOS (15.40 versus 7.90 days; P ϭ 0.027), and the intensive care unit LOS (5.55 versus 1.19 days; P ϭ 0.035) were reduced. To achieve optimal outcomes, rapid identification with MALDI-TOF MS combined with real-time AMS intervention is more impactful than MALDI-TOF MS alone.KEYWORDS MALDI-TOF MS, antimicrobial stewardship, rapid molecular diagnostics D espite advances in antimicrobial therapy, bloodstream infections (BSIs) remain a threat to hospitalized patients. A significant proportion of health care-associated infections result from multidrug-resistant organisms (MDROs). These infection rates continue to uptrend, posing a substantial public health risk by driving providers to utilize broad-spectrum antimicrobials and potentiating the cycle that creates MDROs

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Section: Discussionmentioning

confidence: 99%

Effect of Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry (MALDI-TOF MS) Alone versus MALDI-TOF MS Combined with Real-Time Antimicrobial Stewardship Interventions on Time to Optimal Antimicrobial Therapy in Patients with Positive Blood Cultures

Beganovic

Costello²,

Wieczorkiewicz

2017

J Clin Microbiol

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“…The use of molecular methods to identify culture-isolated organisms decreases the overall time to identification, resulting in improved patient outcomes and significantly decreasing hospital costs (54)(55)(56)(57). This is a strong step forward but requires time for culture and is not useful when cultures from truly infected patients are negative (58,59).…”

Section: Discussionmentioning

confidence: 99%

Improved Sensitivity for Molecular Detection of Bacterial and Candida Infections in Blood

et al. 2014

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The rapid identification of bacteria and fungi directly from the blood of patients with suspected bloodstream infections aids in diagnosis and guides treatment decisions. The development of an automated, rapid, and sensitive molecular technology capable of detecting the diverse agents of such infections at low titers has been challenging, due in part to the high background of genomic DNA in blood. PCR followed by electrospray ionization mass spectrometry (PCR/ESI-MS) allows for the rapid and accurate identification of microorganisms but with a sensitivity of about 50% compared to that of culture when using 1-ml wholeblood specimens. Here, we describe a new integrated specimen preparation technology that substantially improves the sensitivity of PCR/ESI-MS analysis. An efficient lysis method and automated DNA purification system were designed for processing 5 ml of whole blood. In addition, PCR amplification formulations were optimized to tolerate high levels of human DNA. An analysis of 331 specimens collected from patients with suspected bloodstream infections resulted in 35 PCR/ESI-MS-positive specimens (10.6%) compared to 18 positive by culture (5.4%). PCR/ESI-MS was 83% sensitive and 94% specific compared to culture. Replicate PCR/ESI-MS testing from a second aliquot of the PCR/ESI-MS-positive/culture-negative specimens corroborated the initial findings in most cases, resulting in increased sensitivity (91%) and specificity (99%) when confirmed detections were considered true positives. The integrated solution described here has the potential to provide rapid detection and identification of organisms responsible for bloodstream infections.

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“…It was previously shown that during empirical treatment up to 58% of the patients were found to receive inadequate therapy (37), which was associated with increased mortality (37,38) and a prolonged hospital stay after Gram-negative BSI (39). Thus, faster identification of blood culture pathogens was associated with a shorter time for adequate therapy (40) and decreased mortality in combination with antibiotic stewardship programs (ASP) (41). In addition, another study showed that the introduction of PCR-based blood culture identification in combination with ASP enabled an earlier de-escalation of antibiotic therapy compared to ASP alone (23).…”

Section: (S)mentioning

confidence: 99%

Evaluation of the Accelerate Pheno System for Fast Identification and Antimicrobial Susceptibility Testing from Positive Blood Cultures in Bloodstream Infections Caused by Gram-Negative Pathogens

et al. 2017

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Bloodstream infections (BSI) are an important cause of morbidity and mortality. Increasing rates of antimicrobial-resistant pathogens limit treatment options, prompting an empirical use of broad-range antibiotics. Fast and reliable diagnostic tools are needed to provide adequate therapy in a timely manner and to enable a de-escalation of treatment. The Accelerate Pheno system (Accelerate Diagnostics, USA) is a fully automated test system that performs both identification and antimicrobial susceptibility testing (AST) directly from positive blood cultures within approximately 7 h. In total, 115 episodes of BSI with Gram-negative bacteria were included in our study and compared to conventional culture-based methods. The Accelerate Pheno system correctly identified 88.7% (102 of 115) of all BSI episodes and 97.1% (102 of 105) of isolates that are covered by the system's identification panel. The Accelerate Pheno system generated an AST result for 91.3% (95 of 104) samples in which the Accelerate Pheno system identified a Gram-negative pathogen. The overall category agreement between the Accelerate Pheno system and culture-based AST was 96.4%, the rates for minor discrepancies 1.4%, major discrepancies 2.3%, and very major discrepancies 1.0%. Of note, ceftriaxone, piperacillintazobactam, and carbapenem resistance was correctly detected in blood culture specimens with extended-spectrum beta-lactamase-producing Escherichia coli (n ϭ 7) and multidrug-resistant Pseudomonas aeruginosa (n ϭ 3) strains. The utilization of the Accelerate Pheno system reduced the time to result for identification by 27.49 h (P Ͻ 0.0001) and for AST by 40.39 h (P Ͻ 0.0001) compared to culture-based methods in our laboratory setting. In conclusion, the Accelerate Pheno system provided fast, reliable results while significantly improving turnaround time in blood culture diagnostics of Gramnegative BSI.KEYWORDS antimicrobial susceptibility testing, bloodstream infections, rapid tests B loodstream infections (BSI) are an important cause of morbidity and mortality, associated with prolonged hospital stays, as well as high costs for health care systems (1-3). Increasing rates of antimicrobial-resistant pathogens, in particular Gramnegative bacteria, limit treatment options, often prompting the empirical use of broad-range antibiotics. Therefore, we need fast and reliable diagnostic tools to speed up both identification (ID) and antimicrobial susceptibility testing (AST) from blood cultures in order to provide adequate therapy in a timely manner and to enable effective antibiotic stewardship interventions (4).

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Stewardship Approach for Optimizing Antimicrobial Therapy through Use of a Rapid Microarray Assay on Blood Cultures Positive for Enterococcus Species

Cited by 89 publications

References 10 publications

Effect of Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry (MALDI-TOF MS) Alone versus MALDI-TOF MS Combined with Real-Time Antimicrobial Stewardship Interventions on Time to Optimal Antimicrobial Therapy in Patients with Positive Blood Cultures

Effect of Matrix-Assisted Laser Desorption Ionization–Time of Flight Mass Spectrometry (MALDI-TOF MS) Alone versus MALDI-TOF MS Combined with Real-Time Antimicrobial Stewardship Interventions on Time to Optimal Antimicrobial Therapy in Patients with Positive Blood Cultures

Improved Sensitivity for Molecular Detection of Bacterial and Candida Infections in Blood

Evaluation of the Accelerate Pheno System for Fast Identification and Antimicrobial Susceptibility Testing from Positive Blood Cultures in Bloodstream Infections Caused by Gram-Negative Pathogens

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