Rapid MRSA PCR on respiratory specimens from ventilated patients with suspected pneumonia: a tool to facilitate antimicrobial stewardship

Trevino, Sergio E.; Pence, Morgan A.; Marschall, Jonas; Kollef, Marin H.; Babcock, Hilary M.; Burnham, C-A D

doi:10.1007/s10096-016-2876-5

Cited by 26 publications

(18 citation statements)

References 16 publications

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“…The high sensitivity and negative predictive value we observed is consistent with prior studies of similar PCR technology in lower respiratory tract samples. [20][21][22][23][24] Leone et al 22 reported technical failures in up to 10% using the Cepheid Nasal Complete assay. In the assay validation portion of our study, only 3.2% of the MRSA/SA SSTI assays initially yielded indeterminate results, but an unambiguous result was achieved when run a second time.…”

Section: Discussionmentioning

confidence: 99%

“…Use of RPCR in BAL has been shown to detect both MRSA and methicillin-sensitive S aureus (MSSA) with a high negative predictive value. [20][21][22] Retrospective analyses from two academic medical centers estimated that vancomycin and linezolid utilization in mechanically ventilated patients with pneumonia could be decreased significantly by using RPCR on BAL 23,24 ; however, retrospective analyses cannot accurately predict actual clinical response to diagnostic testing results, particularly if safety is a concern.…”

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confidence: 99%

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Rapid Detection of Methicillin-Resistant Staphylococcus aureus in BAL

Paonessa

Shah

Pickens

et al. 2019

Chest

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BACKGROUND: Guidelines recommend empirical vancomycin or linezolid for patients with suspected pneumonia at risk for methicillin-resistant Staphylococcus aureus (MRSA). Unneeded vancomycin or linezolid use may unnecessarily alter host flora and expose patients to toxicity. We therefore sought to determine if rapid testing for MRSA in BAL can safely decrease use of vancomycin or linezolid for suspected MRSA pneumonia. METHODS: Operating characteristics of the assay were initially validated against culture on residual BAL. A prospective, unblinded, randomized clinical trial to assess the effect of antibiotic management made on the basis of rapid diagnostic testing (RDT) compared with usual care was subsequently conducted, with primary outcome of duration of vancomycin or linezolid administration. Secondary end points focused on safety. RESULTS: Sensitivity of RPCR was 95.7%, with a negative likelihood ratio of 0.04 for MRSA. The clinical trial randomized 45 patients: 22 to antibiotic management made on the basis of RDT and 23 to usual care. Duration of vancomycin or linezolid administration was significantly reduced in the intervention group (32 h [interquartile range, 22-48] vs 72 h [interquartile range, 50-113], P < .001). Proportions with complications and length of stay trended lower in the intervention group. Hospital mortality was 13.6% in the intervention group and 39.1% for usual care (95% CI of difference,-3.3 to 50.3, P ¼ .06). Standardized mortality ratio was 0.48 for the intervention group and 1.18 for usual care. CONCLUSIONS: A highly sensitive BAL RDT for MRSA significantly reduced use of vancomycin and linezolid in ventilated patients with suspected pneumonia. Management made on the basis of RDT had no adverse effects, with a trend to lower hospital mortality.

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Section: Discussionmentioning

confidence: 99%

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Rapid Detection of Methicillin-Resistant Staphylococcus aureus in BAL

Paonessa

Shah

Pickens

et al. 2019

Chest

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“…These tests have the potential to reduce the duration of broad-spectrum empirical antibiotic therapy by identifying pathogenic organisms or specific antibiotic resistance markers 2 to 3 days sooner than routine methods. Specifically, rapid molecular detection of methicillin-resistant S. aureus (MRSA) in respiratory specimens has been associated with a potential 60% to 80% reduction in anti-MRSA antibiotic days and a total savings of Ͼ$60,000 in antibiotic cost annually (10). Multiplexed molecular tests, including the ePlex RP (GenMark Diagnostics) and the BioFire FilmArray Respiratory 2 (RP2) panel (BioFire Diagnostics), enable broad detection of viral pathogens in respiratory specimens but identify only a few bacteria, including Mycoplasma pneumoniae, Chlamydia pneumoniae, and Bordetella species (11).…”

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Practical Comparison of the BioFire FilmArray Pneumonia Panel to Routine Diagnostic Methods and Potential Impact on Antimicrobial Stewardship in Adult Hospitalized Patients with Lower Respiratory Tract Infections

et al. 2020

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Lower respiratory tract infections, including hospital-acquired and ventilator-associated pneumonia, are common in hospitalized patient populations. Standard methods frequently fail to identify the infectious etiology due to the polymicrobial nature of respiratory specimens and the necessity of ordering specific tests to identify viral agents. The potential severity of these infections combined with a failure to clearly identify the causative pathogen results in administration of empirical antibiotic agents based on clinical presentation and other risk factors. We examined the impact of the multiplexed, semiquantitative BioFire FilmArray Pneumonia panel (PN panel) test on laboratory reporting for 259 adult inpatients submitting bronchoalveolar lavage (BAL) specimens for laboratory analysis. The PN panel demonstrated a combined 96.2% positive percent agreement (PPA) and 98.1% negative percent agreement (NPA) for the qualitative identification of 15 bacterial targets compared to routine bacterial culture. Semiquantitative values reported by the PN panel were frequently higher than values reported by culture, resulting in semiquantitative agreement (within the same log10 value) of 43.6% between the PN panel and culture; however, all bacterial targets reported as >105 CFU/ml in culture were reported as ≥105 genomic copies/ml by the PN panel. Viral targets were identified by the PN panel in 17.7% of specimens tested, of which 39.1% were detected in conjunction with a bacterial target. A review of patient medical records, including clinically prescribed antibiotics, revealed the potential for antibiotic adjustment in 70.7% of patients based on the PN panel result, including discontinuation or de-escalation in 48.2% of patients, resulting in an average savings of 6.2 antibiotic days/patient.

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“…A rapid test sensitivity equivalent to culture for pathogen detection is easier to achieve than the molecular diagnosis equivalent of culture-based antibiotic susceptibility. The lowest-hanging fruit may be Staphylococcus aureus, where a single mutation predicts methicillin resistance (26,49). Determining antibiotic susceptibility by a rapid test for Pseudomonas aeruginosa or other MDR pathogens is much more complex (50).…”

Section: The Hope Of Rapid Diagnostics Is Currently Unfulfilledmentioning

confidence: 99%

Antibiotic Stewardship in the Intensive Care Unit. An Official American Thoracic Society Workshop Report in Collaboration with the AACN, CHEST, CDC, and SCCM

Wunderink¹,

Srinivasan²,

Barie³

et al. 2020

Annals ATS

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Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital's use of parenteral antibiotics, especially broad-spectrum, occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is "the right drug at the right time and the right dose for the right bug for the right duration." A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community-and hospitalacquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.

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Rapid MRSA PCR on respiratory specimens from ventilated patients with suspected pneumonia: a tool to facilitate antimicrobial stewardship

Cited by 26 publications

References 16 publications

Rapid Detection of Methicillin-Resistant Staphylococcus aureus in BAL

Rapid Detection of Methicillin-Resistant Staphylococcus aureus in BAL

Practical Comparison of the BioFire FilmArray Pneumonia Panel to Routine Diagnostic Methods and Potential Impact on Antimicrobial Stewardship in Adult Hospitalized Patients with Lower Respiratory Tract Infections

Antibiotic Stewardship in the Intensive Care Unit. An Official American Thoracic Society Workshop Report in Collaboration with the AACN, CHEST, CDC, and SCCM

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