Baylor University Medical Center Proceedings October 2017 - 398

Table 4. Blood culture Gram-negative report utilization across three Baylor Scott & White Health hospitals
BUMC
(n = 500)

BAS
(n = 199)

IRV
(n = 200)

Total
(n = 899)

Expected change in antibiotics*

132 (26.4%)

100 (50.5%)

30 (15.0%)

262 (29.1%)

No change/change other than recommended

368 (73.6%)

99 (49.5%)

170 (85.0%)

637 (70.9)

Reasons for no change in GP coverage Not on dedicated GP coverage

Parameter

Category

170 (34.0%)

26 (13.0%)

133 (66.5%)

329 (36.6%)

Died/ED/discharged

35 (7.0%)

4 (2.0%)

0 (0.0%)

39 (4.3%)

Polymicrobial cultures

31 (6.2%)

1 (0.5%)

2 (1.0%)

34 (3.8%)

Continued empiric GP

132 (26.4%)

68 (34.0%)

35 (17.5%)

235 (26.1%)

53 (10.6%)

24 (12.0%)

82 (41.0%)

159 (17.7%)

55 (11.0%)

22 (11.0%)

Reasons for no change in GN coverage On recommended antibiotics
On other targeted antibiotics (carbapenem/quinolone)
N (%) ESBLs

47/55 (85.5%) 16/22 (72.7%)

Died/ED/discharged

35 (7.0%)

4 (2.0%)

73 (36.5%)

150 (16.7%)

7/73 (9.6%)

70/150 (46.7%)

0 (0.0%)

39 (4.3%)

Polymicrobial cultures

31 (6.2%)

1 (0.5%)

2 (1.0%)

34 (3.8%)

Continued empiric GN

194 (38.8%)

48 (24.0%)

13 (6.5%)

255 (28.4%)

BAS indicates Baylor All Saints; BUMC, Baylor University Medical Center; ED, emergency department; ESBL, extended spectrum beta-lactamases; GN, Gram-negative; GP, Gram-positive;
IRV, Baylor Irving.
*Expected change was defined as deescalation of empiric therapy (vancomycin and piperacillin/tazobactam) for patients with Citrobacter spp., Enterobacter spp., Klebsiella spp., and
Escherichia coli bacteremia to the appropriate targeted coverage per institutional guidelines within 24 hours in response to the stewardship recommendations on the Verigene report.

piperacillin/tazobactam, as it is not needed in all cases. However,
further subset analysis by order sets demonstrated that there was
no association between use of order sets to prescribe antibiotic
therapy and changes in therapy in response to BC-GN result.
There was also no association of patient location (i.e., within or
outside of the intensive care unit) and response to the BC-GN
results (data not shown).
We determined that there were site-specific differences
in antibiotic stewardship practices. Of interest, we identified
high empiric use of carbapenem/quinolone drug classes despite
low identification of ESBL on the BC-GN result at the Baylor
Irving site. Although carbapenems are active in this setting,
these high-cost agents should be reserved for the additional
coverage of drug-resistant organisms (13, 14). The outcome
of this study will allow concentration of antimicrobial stewardship efforts at this site. Confidence in the rapid results on
non-ESBL producers on the BC-GN panel combined with
education should minimize the use of carbapenem/quinolone
drug categories when not indicated. Further opportunities
for discontinuation of empiric coverage and earlier switch to
targeted therapy were identified for approximately one-fourth
of the cases.
Our study is comparable to previously published outcome
studies on BC-GN rapid testing. Hill et al (10) evaluated the
performance of the Verigene BC-GN assay and potential impact of rapid antibiotic interventions in 54 patients. BC-GN
identified the organism approximately 24 hours faster than conventional methods. Upon retrospective evaluation of medical
records by the stewardship team, it was concluded that antibiotic
management could have been modified for 31.8% of patients
an average of 33 hours sooner. Walker et al (12) did a retrospective review of GN bacteremia cases before (n = 98) and after
(n = 97) Verigene BC-GN implementation and demonstrated
398

that rapid implementation of effective therapy was statistically
significant for postintervention cases of ESBL-producing organisms (P = 0.049) but not overall (P = 0.12).
The study was limited, as it did not evaluate the economic
savings to the hospital in terms of antibiotic usage, length of
hospitalization, and mortality. Another limitation is that underlying diagnosis and associated complications were not evaluated.
Larger prospective studies are warranted to support the findings
of our study and to address other important aspects influencing
the routine use of this assay.
1.

Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH. The influence of
inadequate antimicrobial treatment of bloodstream infections on patient
outcomes in the ICU setting. Chest 2000;118(1):146-155.
2. Kim SH, Kim KH, Kim HB, Kim NJ, Kim EC, Oh MD, Choe KW.
Outcome of vancomycin treatment in patients with methicillin-susceptible Staphylococcus aureus bacteremia. Antimicrob Agents Chemother
2008;52(1):192-197.
3. Perez KK, Olsen RJ, Musick WL, Cernoch PL, Davis JR, Land GA,
Peterson LE, Musser JM. Integrating rapid pathogen identification and
antimicrobial stewardship significantly decreases hospital costs. Arch Pathol
Lab Med 2013;137(9):1247-1254.
4. Tojo M, Fujita T, Ainoda Y, Nagamatsu M, Hayakawa K, Mezaki
K, Sakurai A, Masui Y, Yazaki H, Takahashi H, Miyoshi-Akiyama
T, Totsuka K, Kirikae T, Ohmagari N. Evaluation of an automated
rapid diagnostic assay for detection of Gram-negative bacteria and
their drug-resistance genes in positive blood cultures. PLoS One
2014;9(4):e94064.
5. Tziolos N, Giamarellos-Bourboulis EJ. Contemporary approaches
to the rapid molecular diagnosis of sepsis. Expert Rev Mol Diagn
2016;16(11):1201-1207.
6. Ledeboer NA, Lopansri BK, Dhiman N, Cavagnolo R, Carroll KC,
Granato P, Thomson R Jr., Butler-Wu SM, Berger H, Samuel L,
Pancholi P, Swyers L, Hansen GT, Tran NK, Polage CR, Thomson
KS, Hanson ND, Winegar R, Buchan BW. Identification of Gramnegative bacteria and genetic resistance determinants from positive
blood culture broths by use of the Verigene Gram-negative blood

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