Clinical and Financial Impact of a Diagnostic Stewardship Program for Children with Suspected Central Nervous System Infection.
Clinical and Financial Impact of a Diagnostic Stewardship Program for Children with Suspected Central Nervous System Infection.
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DOI：
10.1016/j.jpeds.2022.02.002
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发表时间：
2022-05
影响因子：
5.1
通讯作者：
Dominguez, Samuel R.
中科院分区：
文献类型：
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作者：
Messacar, Kevin;Palmer, Claire;Gregoire, LiseAnne;Elliott, Audrey;Ackley, Elizabeth;Perraillon, Marcelo C.;Tyler, Kenneth L.;Dominguez, Samuel R.
本研究旨在探讨对疑似中枢神经系统感染的儿童进行脑脊液多重聚合酶链式反应(MEP)检测的最佳实施方案、临床和财务影响。科罗拉多州儿童医院(CHCO)进行了一项前期准实验队列研究，以调查使用快速脑脊液诊断管理计划实施MEP的影响。MEP与EMR适应症选择一起实施，以指导对符合批准使用标准的儿童的测试：I、婴儿和婴儿；2、II。免疫功能受损，III。脑炎，静脉注射。≥5白细胞/μL。积极的结果与抗菌药物管理实时决策支持进行了沟通。所有通过腰椎穿刺术获得的脑脊液病例被送往CHCO微生物学实验室，符合上述四项标准中的任何一项，与实施后病例(2017-2018)相比，纳入实施前控制(2015-2016)。主要结果是使用对数等级检验和Kaplan-Meier分析比较达到最佳抗菌药的时间。达到最佳抗菌药的时间从实施前对照的28小时减少到实施后病例的18小时(p<；0.0001)(72%进行了MEP检测)。实施后，脑脊液结果呈阳性的时间更快(4.8vs.9.6h，p<；0.0001)，IV抗菌药持续时间更短(24vs.36h，p=0.004)，感染性神经诊断更常见(15%vs.10%，p=0.03)。在抗菌药物起效时间、住院时间、开始使用抗菌药物或住院时间方面没有差异。微生物检测的成本增加了，但医院总成本没有变化。MEP与快速中枢神经系统诊断管理计划的实施改善了抗菌药物的使用，结果更快，缩短了经验性治疗。针对高产量适应症的常规MEP测试可以在总体成本不变的情况下实现抗菌药物的优化。
This study sought to investigate the optimal implementation, clinical and financial impacts of FilmArray Meningitis Encephalitis Panel (MEP) multiplex PCR testing of cerebrospinal fluid (CSF) in children with suspected (CNS) infection. A pre-post quasi-experimental cohort study to investigate the impact of implementing MEP using a rapid CSF diagnostic stewardship program was conducted at Children’s Hospital Colorado (CHCO). MEP was implemented with EMR indication selection to guide testing to children meeting approved use criteria: i. infants < 2mo, ii. immunocompromised, iii. encephalitis, iv. ≥5 WBCs/μL of CSF. Positive results were communicated with antimicrobial stewardship real-time decision support. All cases with CSF obtained by lumbar puncture sent to the CHCO microbiology laboratory meeting any of the four criteria above were included with pre-implementation controls (2015–2016) compared to post-implementation cases (2017–2018). Primary outcome was time-to-optimal antimicrobials compared using log-rank test with Kaplan-Meier analysis. Time-to-optimal antimicrobials decreased from 28 hours amongst 1124 pre-implementation controls to 18 hours (p<0.0001) amongst 1127 post-implementation cases (72% with MEP testing conducted). Post-implementation, time-to-positive CSF results was faster (4.8 vs. 9.6 hours, p<0.0001), IV antimicrobial duration was shorter (24 vs 36 hours, p=0.004) with infectious neurologic diagnoses more frequently identified (15% vs. 10%, p=0.03). There were no differences in time-to-effective antimicrobials, hospital admissions, antimicrobial starts or length of stay. Costs of microbiologic testing increased, but total hospital costs were unchanged. Implementation of MEP with a rapid CNS diagnostic stewardship program improved antimicrobial use with faster results shortening empiric therapy. Routine MEP testing for high-yield indications enables antimicrobial optimization with unchanged overall costs.
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