Impact of clinical guidance and rapid molecular pathogen detection on evaluation and outcomes of febrile or hypothermic infants

Abstract

Objective: To quantify the impact of clinical guidance and rapid respiratory and meningitis/encephalitis multiplex polymerase chain reaction (mPCR) testing on the management of infants. Design: Before-and-after intervention study. Setting: Tertiary-care children’s hospital. Patients: Infants ≤90 days old presenting with fever or hypothermia to the emergency department (ED). Methods: The study spanned 3 periods: period 1, January 1, 2011, through December 31, 2014; period 2, January 1, 2015, through April 30, 2018; and period 3, May 1, 2018, through June 15, 2019. During period 1, no standardized clinical guideline had been established and no rapid pathogen testing was available. During period 2, a clinical guideline was implemented, but no rapid testing was available. During period 3, a guideline was in effect, plus mPCR testing using the BioFire FilmArray respiratory panel 2 (RP 2) and the meningitis encephalitis panel (MEP). Outcomes included antimicrobial and ancillary test utilization, length of stay (LOS), admission rate, 30-day mortality. Outcomes were compared across periods using Kruskal-Wallis and Pearson tests and interrupted time series analysis. Results: Overall 5,317 patients were included: 2,514 in period 1, 2,082 in period 2, and 721 in period 3. Over the entire study period, we detected reductions in the use of chest radiographs, lumbar punctures, LOS, and median antibiotic duration. After adjusting for temporal trends, we observed that the introduction of the guideline was associated with reductions in ancillary tests and lumbar punctures. Use of mPCR testing with the febrile infant clinical guideline was associated with additional reductions in ancillary testing for all patients and a higher proportion of infants 29–60 days old being managed without antibiotics. Conclusions: Use of mPCR testing plus a guideline for young infant evaluation in the emergency department was associated with less antimicrobial and ancillary test utilization compared to the use of a guideline alone.

Diagnostic Stewardship—The Impact of Rapid Diagnostic Testing for Paediatric Respiratory Presentations in the Emergency Setting: A Systematic Review

“…Included studies were published between 2002 [ 28 ] and 2021 [ 13 , 25 ]. Eight of eighteen studies were randomised control trials [ 17 , 18 , 19 , 20 , 22 , 23 , 24 , 25 ], three were prospective cohort studies [ 14 , 15 , 26 ], five were retrospective cohort studies [ 8 , 12 , 21 , 27 , 28 ], one was a before and after interventional study [ 16 ], and one was a pragmatic AB single subject study [ 13 ]. The studies were conducted in several different countries, the majority being in the United States [ 8 , 12 , 16 , 18 , 20 , 22 , 24 , 25 , 26 , 27 , 28 ], but also other countries including United Kingdom [ 13 ], Canada [ 17 ], Australia [ 21 ], Belgium [ 14 ], Brazil [ 15 ], Italy [ 19 ] and Turkey [ 23 ].…”

“…All included studies were conducted in the ED of a paediatric hospital or within the paediatric population of a general hospital, however, the number of hospitals varied between studies. Fifteen of eighteen studies reported outcomes from the paediatric population only [ 8 , 12 , 13 , 15 , 16 , 17 , 19 , 20 , 21 , 23 , 24 , 25 , 26 , 27 , 28 ], and three studies extracted paediatric data from a general hospital [ 14 , 18 , 22 ].…”

“…Bird et al combined the use of a rapid GAS detection test with McIsaac’s clinical score as the intervention [ 13 ]. Similarly, Crook et al also combined the use of a standardised clinical guideline with BioRP2 but were able to pool the data to measure the effects of these components separately [ 16 ].…”

Diagnostic Stewardship as a Team Sport: Interdisciplinary Perspectives on Improved Implementation of Interventions and Effect Measurement

“…Another example of this concept occurred in a recent study from Crook et al [ 5 ]. In this study, the investigators evaluated the impact of clinical guidance and of a multiplex respiratory PCR and a multiplex PCR for meningitis/encephalitis on clinical outcomes among febrile or hypothermic infants ≤90 days of age presenting to the emergency department.…”

“…Performing and plotting interrupted time series analysis of respiratory and CNS testing reflected increasing effectiveness over time [ 5 ]…”