timely identification for informed patient care in infectious … · 2018. 12. 13. · dr banerjee:...

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Timely Identification for Informed Patient Care in Infectious Diseases: Acute Respiratory Infection CME / ABIM MOC / ACCENT

medscape.org/cmetv/acute-respiratory-infection


Supported by an independent educational grant from BioFire Diagnostics, LLC

Presented through a collaboration between The American Association for Clinical Chemistry (AACC) and Medscape Education.

www.medscape.org/cmetv/acute-respiratory-infection

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Target AudienceThis activity is intended for physicians who practice infectious disease, critical care, pediatrics, family medicine, internal medicine, hospital medicine, pulmonary medicine, public health, and emergency medicine, as well as laboratory and point-of-care testing professionals.

GoalsThe goal of this activity is to increase awareness of the benefits and limitations of new and emerging diagnostic tests for acute respiratory illnesses.

Learning ObjectivesUpon completion of this activity, participants will:• Have increased knowledge regarding the key distinguishing characteristics among rapid laboratory methods for the

diagnosis of acute respiratory illnesses• Have greater competence related to the clinical implications of rapid moleculardiagnostics for acute respiratory illnesses• Demonstrate greater confidence in their ability to identify key attributes of molecular diagnostic testsin the diagnosis of

acute respiratory illnesses

Credits AvailablePhysicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™ABIM Diplomates - maximum of 0.25 ABIM MOC points Laboratory and Point-of-Care Testing Professionals - maximum of 0.25 ACCENT® credit hours

Accreditation Statements

In support of improving patient care, Medscape, LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

For Physicians Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This article is a CME / ABIM MOC / ACCENT activity.To earn credit for this activity visit:

www.medscape.org/cmetv/acute-respiratory-infection

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For Laboratory and Point-of-Care Testing Professionals

The American Association for Clinical Chemistry (AACC) will designate this activity for a maximum of 0.25 ACCENT® credit hours.

AACC is an approved provider of continuing education (CE) for clinical laboratory scientists licensed in states that require documentation of CE, including California, Florida, Louisiana, Montana, Nevada, North Dakota, Rhode Island, Tennessee, and West Virginia. ACCENT® credit is also recognized by several organizations: AAB, ABCC, ACS, AMT,ASCLS, ASCP, ASM, CAP, IFCC, and NRCC.

ABIM MOCSuccessful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Aggregate participant data will be shared with commercial supporters of this activity.

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Instructions for Participation and Credit

There are no fees for participating in or receiving credit for this online educational activity. For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.

This activity is designed to be completed within the time designated on page 2; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on page 2. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

Follow these steps to earn CME/CE credit*:

1. Read the target audience, learning objectives, and author disclosures. 2. Study the educational content online or printed out. 3. Online, choose the best answer to each test question. To receive a certificate, you must receive a passing score as designated at the top of the test. We encourage you to complete the Activity Evaluation to provide feedback for future programming.

You may now view or print the certificate from your CME/CE Tracker. You may print the certificate but you cannot alter it. Credits will be tallied in your CME/CE Tracker and archived for 6 years; at any point within this time period you can print out the tally as well as the certificates from the CME/CE Tracker.

*The credit that you receive is based on your user profile.

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To access activities, users will need:• A computer with an Internet connection.• Internet Explorer 8.x or higher, the latest versions of Firefox or Safari, or any other W3C standards compliant browser.• Adobe Flash Player and/or an HTML5 capable browser may be required for video or audio playback.• Occasionally other additional software may be required such as PowerPoint or Adobe Acrobat Reader.

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Disclosures

Faculty

Ritu Banerjee, MD, PhDAssociate ProfessorMedical DirectorPediatric Antimicrobial Stewardship ProgramVanderbilt University Medical CenterNashville, Tennessee

Disclosure: Ritu Banerjee, MD, PhD, has disclosed the following relevant financial relationships:

Received grants for clinical research from: Axcellerate Pharma; Biofire; bioMérieux; Roche

Editors

Susan L. Smith, MN, PhD Lead Scientific Director, Medscape, LLCDisclosure: Susan L. Smith, MN, PhD, has disclosed no relevant financial relationships.

CME Reviewer

Amy Bernard, MS, BSN, RN-BC, CHCPLead Nurse Planner, Medscape, LLCDisclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.

Peer ReviewerThis activity has been peer reviewed and the reviewer has disclosed no relevant financial relationships.

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Taryn Brill: Hello, and welcome to the third episode of Diagnosis TV: Timely Identification, Informed Patient Care in Infectious Diseases – Acute Respiratory Infection. I’m Taryn Brill. Before we begin, please take a moment to answer the pre-assessment questions.

Ms Brill: Respiratory tract infection is a broadly defined clinical syndrome -- ranging from the familiar common cold to life-threatening illnesses -- whose etiologies include a wide range of bacteria and viruses. Respiratory viruses, in particular, are one of the most common causes of morbidity and mortality in the United States.[1,2]

And during the respiratory virus season, the influenza viruses A and B and respiratory syncytial virus (or RSV) are among the leading causes, primarily in children, elderly persons, and those with immunocompromising health problems.[3,4]

As with other infectious diseases we’ve discussed in this series, the initial signs and symptoms, regardless of the etiology, are similar -- making the diagnosis and assurance of appropriate and timely treatment challenging. Accurate assessment of the etiology of acute respiratory disease allows providers to deliver timely treatment, whether it be antibiotics or antiviral therapies.

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To help us better understand this common clinical problem, we asked Dr Ritu Banerjee, Associate Professor of Pediatrics and Director of the Vanderbilt Vaccine Research Program at Vanderbilt University School of Medicine, in Nashville, Tennessee, to elaborate.

Ritu Banerjee, MD: Respiratory tract infection is the most frequently occurring acute illness evaluated in outpatient settings. Although the burden of disease is felt by persons of all ages, those at both ends of the spectrum -- young children and older adults -- are particularly vulnerable.

Parents bringing their children to the pediatrician for fever and runny nose is an everyday occurrence, and the overall health and societal burdens are significant. Every year in the United States, children’s colds lead to 22 million missed school days and 20 million related missed days of work by parents.[5]

In adults, uncomplicated upper respiratory tract infections account for 25 million visits to family physicians and 20 to 22 million days of absence from work or school each year.[6]

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Busy providers in pediatric and primary care clinics, and in emergency departments, know all too well the diagnostic challenges they confront when patients present with nonspecific symptoms of a respiratory infection. Their main challenge is that the clinical presentations of bacterial or viral respiratory infections -- regardless of the patient’s age -- often overlap. It is up to providers, usually within a narrow window of time, to determine whether patients have a “common cold,” the flu, or a bacterial infection, and then whether and how to treat them.

Dr Banerjee: Pneumonia is an important problem to consider in this regard because it is a leading cause of hospitalization and death among adults and children.[1,2,7] Although the cause of pneumonia is more often viral than bacterial, providers are frequently unable to determine a specific cause, as was shown in the EPIC study.

The EPIC study highlighted the burden of hospitalizations for community-acquired pneumonia among children and adults in the United States and identified the pathogens associated with these hospitalizations.

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In adults, most of the time no pathogen was detected. But, when a pathogen was detected, viruses were more common than bacteria.[1,2] And in some children, multiple pathogens were codetected. The results of this study underscore the need for rapid, sensitive, and inexpensive diagnostic tests for identifying pathogens that cause pneumonia, in inpatient and outpatient settings.[1]

Taryn Brill: We next asked Dr Banerjee to tell us about the diagnostic testing options for acute respiratory infection that are widely available to providers.

Dr Banerjee: First, there are the rapid influenza diagnostic tests -- or RIDTs -- that are used in outpatient settings. RIDTs are immunoassays that can identify the presence of influenza A and B viral nucleoprotein antigens in respiratory specimens. These tests are very practical. They are simple to perform and approved for use at the point of care. Results are available in 15 minutes or less and are reported as either positive or negative.

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And although RIDTs have high specificity, they are less sensitive than rapid molecular tests or viral culture.[8] Thus, a negative result from an RIDT should be interpreted with caution, especially during times of peak influenza activity in a community. In fact, if a patient presents with a respiratory tract infection during an influenza epidemic in the area, chances are the patient has influenza, so a diagnostic test might not be needed.

According to the Centers for Disease Control and Prevention (CDC), testing of all patients with signs and symptoms of influenza is not needed to make antiviral treatment decisions.[9]

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Once influenza activity has been documented in the community or a geographic area, a clinical diagnosis of influenza can be made for outpatients with signs and symptoms consistent with influenza, especially during periods of peak influenza activity in the community.

Then, there are monoplex molecular tests. These tests detect a single target, usually influenza A, influenza B, or or RSV. These tests detect nucleic acid rather than antigen. In general, they are more sensitive than RIDTs, but they miss common respiratory pathogens, such as adenovirus, parainfluenza virus, and Mycoplasma.

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Taryn Brill: In episodes 1 and 2 of this series, the syndromic approach to diagnosis of meningitis/encephalitis and gastroenteritis -- in particular, the use of multiplex molecular panel tests -- was discussed. In this episode, Dr Banerjee discusses the implications of these technologies for diagnosing acute respiratory infections.

Dr Banerjee: Syndromic testing for multiple agents responsible for acute respiratory infection with a single test has created opportunities to improve patient care by facilitating accurate diagnosis and more timely and targeted treatment.

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The vehicles for this approach are multiplex molecular respiratory panel tests. Newer multiplex molecular panels are highly sensitive -- regardless of the circulating prevalence of the virus -- and provide results in a short amount of time.[10,11] The turnaround time is a matter of hours vs several days for previous methods. Quick access to test results enables providers to make real-time clinical decisions, often while their patients are in front of them.

These panels potentially improve patient care by allowing providers to rapidly identify a broad range of pathogens, some of which may not have otherwise been detected using any conventional tests. In addition, the need for multiple tests to reach a diagnosis is reduced. Many times, by identifying a viral cause of a respiratory infection, both providers and patients feel comfortable not ordering additional blood tests and chest x-rays, and not treating with antibiotics. Also, more rapid detection of a virus, like the influenza virus, enables providers to promptly prescribe antiviral medications.

I believe it is important for providers to be able to place a diagnosis on a patient’s symptoms; in other words to be able to say, “You have a parainfluenza virus infection,” vs telling them they have a cold. When communicated this way, patients are less likely to request an antibiotic. Less use of unnecessary antibiotics, in turn, leads to fewer antibiotic-associated adverse events, less emergence of resistant organisms, and lower healthcare costs. These are significant advantages.

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Taryn Brill: Dr Banerjee went on to describe a typical case.

Dr Banerjee: Upon examination, the patient is noted to have a temperature of 38.7°C, heart rate of 90/min, respiratory rate of 24/min, and normal oxygen saturation on room air. She has rhinorrhea and an intermittent cough, but is breathing comfortably without retractions or other signs of respiratory distress. On auscultation, lungs sounds are coarse throughout, with good air movement and no wheeze or focal findings. The remainder of the examination is normal.

The provider suspects a viral cause of the fever, but the mother is not convinced. A nasopharyngeal specimen is sent for testing using a multiplex molecular respiratory panel, and the child is given acetaminophen for symptomatic management of her fever while waiting in the emergency department for the results. Within 2 hours, her fever has resolved, her heart rate and respiratory rate have slowed, and parainfluenza virus has been identified on the multiplex molecular respiratory panel test.

Based on the child’s reassuring clinical examination and test results, both provider and parent feel comfortable attributing her fever to a parainfluenza infection, and she is discharged home with supportive care and instructions for follow-up with her primary care provider. No additional blood tests are needed, a chest x-ray is not performed, and no antibiotics are prescribed.

Taryn Brill: We’ve heard about the potential applications and benefits of multiplex molecular panel tests for acute respiratory infections. Dr Banerjee summarizes the practicalities and limitations of this technology.

Dr Banerjee: The value of any multiplex molecular panel test depends in part on the setting in which it is used. For example, there are additional costs associated with these tests. More training of laboratory personnel is required, and quality control to assure that the instruments are performing correctly is a very important aspect of using these tests. They also require more space than conventional devices, and because they are molecular tests, they are very sensitive, so ample clean space is necessary to avoid contamination.

Despite the advantages of the multiplex molecular tests, rapid antigen detection tests may be favored in an emergency department or urgent care center during an influenza outbreak because they are readily available, require little storage space, and produce tests results in 15 to 30 minutes. Thus, patients can be tested and treated with an antiviral medication, if needed, and be out the door in a relatively short period of time, not only allowing them to begin convalescence sooner, but also limiting the spread of infectious diseases in outpatient settings.

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In reality, one institution may decide to use a rapid antigen test on every patient who comes into the emergency department with flu symptoms, and if the patient tests negative a follow-up molecular test is done. I work at a large children’s hospital in a big medical center with ready access to a lab and I have easy access to molecular monoplex and multiplex tests. However, if I worked at an off-site clinic, ordering molecular tests would involve transporting specimens to a central lab, which delays turnaround-time; so in this circumstance, rapid antigen detection tests may be useful.

Taryn Brill: How does the use of multiplex molecular panels tests equip providers to be good stewards of antibiotics? Dr Banerjee explains.

Dr Banerjee: Antibiotic overuse in the outpatient treatment of acute respiratory infections, including laboratory-confirmed influenza, is widespread.[12] Acute respiratory tract infections are the most common reason for antibiotic prescriptions in adults,[13] and in children more than 1 in 5 ambulatory visits result in an antibiotic prescription.[14] The CDC found that, overall, 41% of antibiotic prescriptions written for patients with acute respiratory infections were inappropriate.[12]

There are more data on respiratory virus testing than other kinds of testing, in terms of benefits related to antibiotic stewardship. Use of respiratory virus testing in children presenting to the emergency department has shown that detection of a virus leads to fewer antibiotic days, less utilization of chest x-rays, and less ordering of ancillary laboratory tests.[15-17]

What’s more, the collateral damage associated with inappropriate prescribing of antibiotics is astounding. Antibiotics are the most common culprit among children presenting to emergency departments with adverse drug reactions.

By using a syndromic approach to diagnosis via multiplex molecular respiratory panels, unnecessary use of antibiotics can be avoided[18] and timely administration of antiviral medications can be achieved, when indicated. In addition, rapid diagnosis of respiratory infections can lead to decreased length of stay for patients admitted to the hospital.[16,17]

Taryn Brill: This brings us to the close of episode 3. We hope you found it to be informative and helpful to your practice. As Dr Banerjee discussed, one of the greatest unmet needs in infectious diseases is availability of rapid and precise diagnostic tests. In out next episode, we will continue our discussion of the use of multiplex molecular panel tests in patients who present with signs and symptoms of sepsis. To proceed to the online CME/CE test click on the “earn CME/CE credit” link on this page. And thank you for watching.

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AbbreviationsCAP = community-acquired pneumoniaCDC = Centers for Disease Control and PreventionEPIC = Epidemiology of Pneumonia in the CommunityRIDT = rapid influenza diagnostic testRSV = respiratory syncytial virus

References

1. Jain S, Williams DJ, Arnold SR, et al; for the CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. children. N Engl J Med. 2015;372:835-845.

2. Jain S, Self WH, Wunderink RG, et al; for the CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med. 2015;373:415-427.

3. Hall CB, Weinberg GA, Iwane MK, et al. The burden of respiratory syncytial virus infection in young children. N Engl J Med. 2009;360:588-598.

4. Harper SA, Bradley JS, Englund JA, et al; Expert Panel of the Infectious Diseases Society of America. Seasonal influenza in adults and children--diagnosis, treatment, chemoprophylaxis, and institutional outbreak management: clinical practice guidelines of the Infectious Diseases Society of America. Clin Infect Dis. 2009;48:1003-1032.

5. Fendrick AM, Monto AS, Nightengale B, et al. The economic burden of non-influenza-related viral respiratory tract infection in the United States. Arch Intern Med. 2003;163:487-494.

6. Zoorob. R, Sidani MA, Fremont RD, et al. Antibiotic use in acute upper respiratory tract infections. Am Fam Phys. 2012;86:817-822.

7. Centers for Disease Control and Prevention. New CDC study highlights burden of pneumonia hospitalizations among US adults. https://www.cdc.gov/media/releases/2015/p0714-pneumonia-hospitalizations.html. Accessed November 4, 2018.

8. Merckx J, Wali R, Schiller I, et al. Diagnostic accuracy of novel and traditional rapid tests for influenza infection compared with reverse transcriptase polymerase chain reaction: a systematic review and meta-analysis. Ann Intern Med. 2017;167:394-409.

9. Centers for Disease Control and Prevention. Rapid influenza diagnostic tests. https://www.cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm. Accessed November 4, 2018.

10. Gonzalez MD, McElvania E. New developments in rapid diagnostic testing for children. Infect Dis Clin N Am. 2018;32:19-34.

11. Hansen KE, Courturier MR. Multiplexed molecular diagnostics for respiratory, gastrointestinal, and central nervous system infections. Clin Infec Dis. 2016;1361-1367.

12. Havers FP, Hicks LA, Chung JR, et al. Outpatient antibiotic prescribing for acute respiratory infections during influenza seasons. JAMA Network Open. 2018;1:e180243.

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13. Harris AM, Hicks LA, Qaseem A; High Value Care Task Force for the American College of Physicians and the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016;164:425-434.

14. Hersch AL, Shapiro DJ, Pavia AT, et al. Antibiotic prescribing in ambulatory pediatrics in the United States. Pediatrics. 2011;128:1053-1061.

15. Byington CL, Reynolds CC, Korgenski J, et al. Costs and infant outcomes after implementation of a care process model for febrile infants. Pediatrics. 2012;130:e16-24.

16. Burstein B, Dubrovsky AS, Greene AW, et al. National survey on the impact of viral testing for the ED and inpatient management of febrile, young infants. Hosp Ped. 2016;6:226-233.

17. Doan Q, Enarson P, Kissoon N, et al. Rapid viral diagnosis for acute febrile respiratory illness in children in the emergency department. Cochrane Database Syst Rev. 2014(9):CD006452.

18. File TM Jr, Politis P, Tan MJ, et al. Effect of rapid molecular diagnostic testing and antimicrobial stewardship on antimicrobial therapy of respiratory infections. Open Forum Infect Dis. 2017;4(suppl 1):S629.

19. Leber AL, Everhart K, Daly JA, et al. Multicenter evaluation of the Biofire FilmArray Respiratory Panel 2 for the detection of viruses and bacteria in nasopharyngeal swab samples. J Clin Microbiol. 2018;56:(6). pii: e01945-17.

timely identification for informed patient care in infectious … · 2018. 12. 13. · dr banerjee:...

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