Rapid Rule Out of Culture-Negative Bloodstream Infections by Use of a Novel Approach to Universal Detection of Bacteria and Fungi

Abstract

Background Currently it can take up to 5 days to rule out bloodstream infection. With the low yield of blood cultures (approximately 10%), a significant number of patients are potentially exposed to inappropriate therapy that can lead to adverse events. More rapid rule out can accelerate deescalation or cessation of antimicrobial therapy, improving patient outcomes. Methods A method is described, termed enzymatic template generation and amplification (ETGA), that universally and sensitively detects DNA polymerase activity liberated from viable bacteria and fungi isolated from blood culture samples as a measure of bloodstream infection. ETGA was applied in a diagnostic test format to identify negative blood cultures after an overnight incubation. Performance data for a prototype (Cognitor) and automated (Magnitor) version of the test are presented. Results The Cognitor manual assay displayed analytical reactivity for a panel of the 20 most prevalent causes of bloodstream infection, with a detection range of 28–9050 CFU/mL. Validation with 1457 clinical blood cultures showed a negative predictive value of 99.0% compared to blood culture incubation for 5 days. Magnitor showed an improved detection range of 1–67 CFU/mL, allowing for detection of bacteria-supplemented blood cultures after 2–8 h incubation, and Candida albicans-supplemented blood cultures at 16–22 h, 5–15 h faster than blood culture. Removing an aliquot from a blood culture bottle and replacing the bottle into the incubator was shown not to result in contaminating organisms being introduced. Conclusions The described method displays excellent breadth and detection for microbial cells and demonstrates the capability of confirming negative blood cultures after an overnight incubation in a blood culture instrument.

Cutaneous Mucormycosis After Elective Outpatient Gastrocnemius Recession for Plantar Fasciitis in an Immunocompetent Host

“…Unfortunately, 72% of cultures do not yield a fungus. Therefore, DNA mapping with techniques such as next-generation sequencing or enzymatic template generation and amplification has begun to be used for more rapid diagnosis of the exact microbe especially in culturenegative infections such as mucormycosis or periprosthetic joint infections [33][34][35] .…”

“…Treatment regimens recommend 3 to 5 mg/kg of amphotericin B once per day for 6 to 8 weeks 10,30 . The combination with oral posaconazole 200 mg 4 times per day can be used if renal toxicity occurs, if the patient is unresponsive to amphotericin B, or to facilitate discharge because the medication is oral 30,35 . In a series of 91 patients with invasive disease, there was a 60% response rate at 12 weeks, and 21% achieved a stable disease state with this regimen 30,35 .…”

“…The combination with oral posaconazole 200 mg 4 times per day can be used if renal toxicity occurs, if the patient is unresponsive to amphotericin B, or to facilitate discharge because the medication is oral 30,35 . In a series of 91 patients with invasive disease, there was a 60% response rate at 12 weeks, and 21% achieved a stable disease state with this regimen 30,35 . The duration of treatment is unknown, but case series report administration of posaconazole from 2 to 34 months of treatment 30,36,37 .…”