Baylor University Medical Center Proceedings October 2017 - 397

Table 3. Distribution of Gram-negative organisms across three
Baylor Scott & White Health hospitals
Targets

BUMC

BAS

IRV

Total

Escherichia coli

284

133

141

558

Klebsiella pneumoniae

94

31

26

151

Enterobacter spp.

37

12

4

53

Klebsiella oxytoca

8

2

4

14

Citrobacter spp.

4

5

0

9

ESBL producers
E. coli (% ESBLs)

55
(19.4%)

14
25
94
(10.5%) (17.7%) (16.9%)

K. pneumoniae (% ESBLs)

16
(17.0%)

2
(6.5%)

0
(0%)

18
(11.9%)

K. oxytoca (% ESBLs)

1
(12.5%)

0
(0%)

0
(0%)

1
(7.1%)

1
(2.7%)

0
(0%)

0
(0%)

1
(1.9%)

500

199

200

899

Carbapenamase producers
Enterobacter spp.
(% carbapenamase
producers)
Total

BAS indicates Baylor All Saints; BUMC, Baylor University Medical Center; ESBL, extended
spectrum beta-lactamases; IRV, Baylor Irving.

which constituted 20.5% of the isolates, with 10.3% of the
Klebsiella spp. harboring ESBLs.
The timeline of antibiotic adjustment in response to stewardship recommendations on the rapid BC-GN report is shown
in Figure 1. Across all three sites combined, 29.1% (262/899)
of patients were transitioned from empiric to targeted therapy
and made the expected change to antibiotics in response to
stewardship recommendations within 24 hours. In the subset
where an intervention was made, the switch to appropriate

targeted antibiotics was made at 12.2 ± 13.5 hours in response
to BC-GN results, which was significantly earlier (P < 0.001)
than when results by conventional methods became available
(73.6 ± 40.0 hours).
After accounting for patients already on recommended targeted therapy, polymicrobial infections, and patients deceased or
lost to follow-up, we found antibiotic stewardship opportunities
in ∼28% of GN infections. Further subanalysis demonstrated
site-specific differences in the uptake of stewardship recommendations, whereby 32.4% of cases at Baylor University Medical
Center, 50.5% at Baylor All Saints, and 15.0% at Baylor Irving
demonstrated the expected change in antibiotics (Table 4). We
also noticed overuse of carbapenem/quinolone drug categories
(only 9.6% of patients on carbapenem/quinolone were ESBL
producers) at the Baylor Irving site.
DISCUSSION
Rapid identification of GN bacteremia and key susceptibility markers can lead to many benefits, such as earlier deescalation
of empiric therapy and switch to appropriate targeted antimicrobials that can lead to better patient outcomes, decreased length
of hospital stay, and decreased overall hospital costs (9-12). The
Verigene BC-GN assay has two major advantages favoring its
routine use: a random-access format with very limited handson time and the ability to rapidly provide clinically actionable
therapeutic information to physicians.
Our study demonstrated that implementation of the BCGN panel across a multisite facility led to earlier deescalation of
empiric therapy and switch to appropriate targeted antibiotics in
approximately 29% of the cases. Multiple patients were shown
to be on targeted antibiotic therapy from initial dosing (i.e.,
before organism identification was available by Verigene BCGN). The initial postulation was that the choice of antibiotics
may be driven by order sets in the EHR, for which physicians
may be directed to empiric therapy other than vancomycin and

Figure 1. Overall timeline comparison between the following groups: response to final blood culture results by conventional identification and susceptibility methods
as surrogate for adjustment of antibiotics in the conventional group vs. response to the preliminary identification and resistance marker reporting after BC-GN panel
implementation. All times are listed as mean ± standard deviation in hours. ID indicates identification; GS, Gram stain; BC-GN, Gram-negative blood culture.
October 2017

Rapid diagnosis of Gram-negative bacteremia and outcomes

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