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Retrospective review of a blood culture identification panel implementation and its impact on antimicrobial therapy by organism morphology Colton Michael Taylor PGY1 Pharmacy Resident Providence Alaska Medical Center IRB Approval Received

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Retrospective review of a blood culture identification panel implementation and its impact on antimicrobial therapy by

rganism morphology

Colton Michael Taylor PGY1 Pharmacy Resident Providence Alaska Medical Center

IRB Approval Received 9/2019

SLIDE 2

Disclosure Statement

I, Colton Michael Taylor, have no conflict of interest and have received

no funding to support this project in its entirety.

This research is subject to different interpretation and is being

presented solely for educational purposes.

SLIDE 3

Learning Objectives

At the conclusion of this presentation, the reader should be able to:

1). Recognize the utility of a polymerase chain reaction (PCR)-based blood

pathogen panel in conjunction with an antimicrobial stewardship program.

2). Understand opportunities for appropriate management of antimicrobial

regimens following implementation of a blood pathogen panel

SLIDE 4

Institution

Providence Alaska Medical Center is a tertiary care community medical center located in Anchorage, Alaska

403 beds
36 ICU beds
Level II trauma center
Largest hospital in Alaska
Antimicrobial stewardship program

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Pre-test assessment Questions

1). Blood culture identification (BCID) panels have been shown to be best utilized as part of a(n)?

A). Hospital system
B). Intensive care unit
C). Antimicrobial stewardship program
D). None of the above

2). BCID panels aid clinicians in making what decisions (select all that apply)?

A). Empiric antimicrobial regimens prior to blood being drawn
B). Discontinuation of antimicrobial regimens
C). De-escalation of empiric antimicrobial regimens, when used in conjunction with stewardship program
D). De-escalation/escalation of empiric antimicrobial regimens, when used in conjunction with stewardship

program

3). A negative BCID result could indicate which of the following (Select all that apply)?

A). The patient doesn’t have bacteremia/fungemia
B). The patient has bacteremia/fungemia with an organisms that aren’t detected by the BCID
C). The BCID is falsely negative, repeat the whole test
D). There was an error when processing the sample

SLIDE 6

Background

Polymerase chain reaction (PCR) based blood culture identification

(BCID) is a rapid diagnostic tool utilized for patients with positive blood cultures

The BCID panel takes around two hours to identify microbes in positive blood

samples

It has the potential to reduce
Total antimicrobial doses
Duration of therapy
The time from blood draw to microbe identification when compared to traditional

culture methods

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Background

Blood sample

btained

Blood sample (+) in tube

Patient

(+) sample analyzed by BCID BCID Result (+) sample plated for incubation Finalization of cultures with sensitivities /susceptibilities ~12-24h ~1-2h Days ~0.5-1.5d 2-6d

Figure 1.

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Gram-Positive Enterococcus

L. monocytogenes

Staphylococcus spp. Staphylococcus aureus Streptococcus spp. Streptococcus agalactiae Streptococcus pneumoniae Streptococcus pyogenes Gram-Negative Acinetobacter baumannii Haemophilus influenzae Neisseria meningitidis Pseudomonas aeruginosa Enterobacteriaceae Enterobacter cloacae complex Escherichia coli Klebsiella oxytoca Klebsiella pneumoniae Proteus spp. Serratia marcescens Yeast Candida glabrata Candid krusei Candid parapsilosis Candida tropicalis Antimicrobial Resistance Genes MecA – Methicillin resistance VanA/B – Vancomycin resistance KPC – Carbapenem resistance

Figure 2. Organisms on BCID panel

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Study Objectives

Primary outcome measure
Time from positive blood culture identification to appropriate antimicrobial

therapy.

Secondary outcome measures
Time from initial blood culture to appropriate antimicrobial

therapy/escalation/de-escalation for gram positive and gram negative

rganisms separately
Percent of patients receiving effective therapy within 24 hours of a positive

blood culture

Hospital length of stay.

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Methodology - Design

Study Design
Two cohorts: Pre-BCID implementation & Post-BCID Implementation
Retrospective review of patients with positive blood cultures for:
Gram positive cocci
Gram negative rods
Candida species

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Methodology – Inclusion/Exclusion

Inclusion Criteria:
≥18yo
Hospitalized during the time of PCR analysis
Length of stay was ≥48hrs
Only first positive set of blood cultures
Exclusion Criteria:
Did not meet inclusion criteria
Had blood cultures drawn after antibiotics were administered
Patient didn’t have two separate sets of blood cultures drawn appropriately
Patients who had been discharged prior to blood culture positivity

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1,259 Patients Total Npre-BCID = 775 Npost-BCID = 484 Inclusion/Exclusion Npre-BCID = 230 Npost-BCID = 340

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DEMOGRAPHICS Group # Controls # Treatment 18-29 yo 16 (6.95%) 10 (2.94 %) 30-59yo

82 (35.65 %)

122 (35.88 %) 60-79 yo

89 (38.70 %)

156 (48.88 %) >/=80yo

43 (18.70 %)

52 (15.29 %) AVG AGE 61.6 61.9 Male

121 (52.61%)

173 (50.88 %) Female

109 (47.39 %)

167 (49.12 %) TOTAL # patients per group 230 340

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Pre-BCID Post-BCID Average Duration of Therapy (Days) 8.6 6.4 Average total doses 18.4 15.8 Total “No changes” from empiric to final antibiotic decision 127 (55.2%) 264 (77.6%) GPC 99 (77.95%) 174 (65.9%) GNR 27 (21.3%) 85 (32.2%)

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Conclusion

The BCID can help reduce the following for patients with positive

blood cultures

Time to organism identification
Number of total doses
Total duration of antimicrobial therapy

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Discussion

Initial provider education was delayed
May require follow-up data
Overnight BCID samples
Increased time to result in some patients
Gram negative rods vs Gram positive cocci
Likely need more data to assess impact on antimicrobial regimens

SLIDE 17

Post-test Assessment Questions

1). Blood culture identification panels have been shown to be best utilized as part of a(n)?

A). Hospital system B). Intensive care unit C). Antimicrobial stewardship program D). None of the above

SLIDE 18

Post-test Assessment Questions

2). BCID panels aid clinicians in making what decisions (select all that apply)?

A). Empiric antimicrobial regimens prior to blood being drawn B). Discontinuation of antimicrobial regimens C). De-escalation of empiric antimicrobial regimens, when used in conjunction with stewardship program D). De-escalation/escalation of empiric antimicrobial regimens, when used in conjunction with stewardship program

SLIDE 19

Post-test Assessment Questions

3). A negative BCID result could indicate which of the following (Select all that apply)?

A). The patient doesn’t have bacteremia/fungemia B). The patient has bacteremia/fungemia with an organisms that aren’t detected by the BCID C). The BCID is falsely negative, repeat the whole test D). There was an error when processing the sample