A key component of antimicrobial stewardship programs (ASPs) is streamlining antimicrobial therapy based on culture and susceptibility testing results. Traditional culture methods may take 72 hours to finalize, and test interpretation may be influenced by microbiologists’ expertise. Technological advances have reduced causative organism identification time.Reference Goff, Jankowski and Tenover 1 Implementation of rapid diagnostic tests (RDTs) combined with active ASP interventions is associated with reduced time to appropriate antimicrobial therapy, decreased length of stay (LOS) and healthcare costs, and improved clinical outcomes, including mortality.Reference Timbrook, Morton and McConeghy 2 , Reference Bauer, Perez, Forrest and Goff 3
ASP members may not be aware of the breadth or scope of RDTs available, including pharmacists. According to the 2014 National Healthcare Safety Network Hospital (NHSN) survey, pharmacists are most commonly responsible for improving inpatient antimicrobial use.Reference Pollack, van Santen and Weiner 4 To our knowledge, familiarity with RDTs has not been previously reported. We sought to evaluate pharmacists’ familiarity with and utilization of available RDTs designed to aid in ASP activities.
METHODS
This cross-sectional electronic survey targeting pharmacists involved in ASP activities was approved by the institutional review board. A 19-item RedCap electronic survey (Online Supplementary Material) examined the respondents’ RDT knowledge and institutional utilization. The survey was pilot tested by 3 clinical pharmacists and was distributed via e-mail to members of the Society of Infectious Diseases Pharmacists (SIDP) and the Infectious Diseases Practice and Research Network (ID-PRN) of the American College of Clinical Pharmacy (ACCP). Respondents had 4 weeks to complete the survey. A reminder e-mail was sent at 2 weeks, participation was optional, and responses were anonymous.
The primary objectives of this study were to evaluate respondents’ familiarity with and institutional use of RDT in ASP activities: polymerase chain reaction (PCR), multiplex PCR, nucleic acid extraction/PCR amplification (NA PCR), peptide nucleic acid fluorescent in situ hybridization (PNA FISH), and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS). All surveys with at least 33% completion (including 5 items regarding familiarity with and utilization of RDTs) were analyzed. Demographics, actions secondary to positive RDTs, and reported RDT outcomes were evaluated. Familiarity with various RDTs was assessed via a 5-point Likert scale from 1 (completely unfamiliar) to 5 (very familiar). Survey results were summarized, and Likert-scale responses were reported with descriptive statistics. Respondent results were further grouped by formal infectious diseases (ID) training (yes/no) and institution type (academic medical center, community hospital, other) for analysis of potential differences in RDT familiarity. Formal ID training was defined as completion of an ID post-graduate year 2 pharmacy residency or fellowship. Differences between groups were analyzed using χ2 tests (α=0.05). Multivariate logistic regressions were conducted to assess risk factors associated with respondents’ familiarity status.
RESULTS
We received a total of 224 responses representing 46 states and 9 countries. Respondents most commonly had <10 years in practice and worked at a community hospital. Overall, 101 of 224 respondents (45.1%) reported formal ID training, and 81 of 224 respondents (36.2%) had completed stewardship-related certificate programs. In addition, 152 of 173 respondents (87.9%) worked at a facility with ≥0.5 ASP-dedicated FTE, and 127 of 174 respondents (73.0%) had RDT for <3 years. Full demographics are shown in Table 1.
TABLE 1 Respondent Demographics
NOTE. FTE, full-time equivalent; AQ-ID, board-certified pharmacotherapy specialist with added qualifications in infectious diseases; SIDP, Society of Infectious Diseases Pharmacists; MAD ID, Making a Difference in Infectious Diseases.
a Other: rural referral/critical access hospital (n=5), ambulatory care/outpatient clinic (n=1), long-term care/rehabilitation (n=1), long-term acute-care facility (n=1), or unspecified (n=9).
Self-reported utilization of RDTs varied: multiplex PCR was used in 94 institutions (42.1%), MALDI-TOF was used in 74 institutions (33.2%), PCR was used in 67 institutions (30.0%), PNA FISH was used in 29 institutions (13%), and NA PCR was used in 24 institutions (10.8%). Furthermore, 44 respondents (19.7%) indicated no current use of RDTs. The most notable discrepancy was among the 74 MALDI-TOF users, where 44 teaching hospitals (59%) utilized this RDT, compared to 22 community hospitals (30%) and 8 other institutions (11%). Respondent’s self-reported familiarity (defined as somewhat familiar or very familiar) with RDT types was ranked. In decreasing order of familiarity, 211 respondents (94%) reported familiarity with PCR, 176 respondents (79%) reported familiarity with MALDI-TOF, 154 respondents (70%) reported familiarity with NA PCR, and 158 respondents (70%) reported familiarity with PNA FISH. Familiarity with multiplex PCR was lowest, with only 130 respondents (58%) reporting familiarity. Different factors were associated with respondent’s selecting “very familiar” with RDTs. Formal ID training was the only statistically significant factor across all familiarities surveyed (Table 2).
TABLE 2 Factors Associated with Respondent’s Familiarity (Defined as Very Familiar) With Different Rapid Diagnostic Tests
NOTE. PCR, polymerase chain reaction; OR, odds ratio; CI, confidence interval; NA, nucleic acid; PNA FISH, peptide nucleic acid fluorescent in situ hybridization, MALDI-TOF, matrix-assisted laser desorption/ionization time-of-flight; ID, infectious diseases.
Respondents indicated a variety of personnel receiving RDT alerts. Of 260 responses, 81 (31.2%) were pharmacists, followed by 60 (23.1%) nurses. A total of 162 respondents commented on timing of alerts received: 86 respondents (53.1%) reported receiving alerts in real time. The rest were limited to day and/or evening shifts. Of 166 respondents, 112 (67.5%) had not assessed institutional outcomes secondary to RDT implementation. Only 47 (28.3%) reported decreased time to de-escalation/targeted therapy. Measurement of RDT impact on length of stay was reported by 16 respondents (9.6%) impact on mortality was reported by 5 respondents (3.0%), and impact of RDT on antimicrobial use was reported by 26 respondents (15.7%) and impact on hospital-associated costs reported by 15 respondents (9.0%)
DISCUSSION
The RDT most familiar to respondents was PCR, yet multiplex PCR was most often used. This finding may reflect confusion with regard to nuances in RDT types. Most institutions reported familiarity and use of a PCR-type RDT, which reflects the length of time this technology has been available. Familiarity with RDT type did not vary by institution type. Formal ID training was associated with higher rates of RDT familiarity compared to those without formal training. However, formal ID training programs are lacking,Reference Collins, Miller and Kenney 5 and pharmacists without formal ID-training are increasingly more involved with ASPs than those with formal training.Reference Gauthier, Worley and Laboy 6 Approximately one-third of respondents reported completing an ASP certificate program (eg, SIDP’s Antimicrobial Stewardship Certificate, Making a Difference in Infectious Diseases (MAD-ID’s) Antimicrobial Stewardship Programs) that included RDT education as part of the curriculum. 7 , 8 The use of RDT in ASP activities is becoming commonplace; therefore, it is imperative that clinicians are familiar with these technologies and certification and training programs maintain current and adequate content. Similar to the medication formulary review process, each ASP, in collaboration with microbiology, should consider a proactive review of new and emerging RDTs to determine feasibility, utility and priority in its facility.
Additionally, nurses often reported receiving alerts. Basic information about RDT and the benefit of timely action should be incorporated into other health sciences curricula and postgraduate residency programs.
Our results corroborate those of the recent NHSN survey demonstrating that pharmacists receive RDT results most frequently.Reference Pollack, van Santen and Weiner 4 However, only approximately half of the respondents reported that alerts were received or acted upon in real time. Achieving maximal benefit from RDT requires prompt communication and understanding the patient management implications. 10 Furthermore, most respondents (67.5%) had not evaluated the impact of these technologies since employing them, highlighting a great opportunity to assess the added benefit of combined RDT results with stewardship interventions in real time. Quality outcomes and cost-effectiveness research surrounding implementation of RDTs in combination with ASPs is critical, especially given the significant initial financial investment required as well as the heterogeneity of health systems employing them. Future research should identify barriers to routinely measuring clinical outcomes for RDTs as ASP metrics.Reference Moehring, Anderson and Cochran 9 Organizations such as the Society for Healthcare Epidemiology of America support programmatic training on antimicrobial stewardship research, including assessment of both process and outcomes measures. 10
Several limitations exist in our study. The survey was sent to pharmacist groups with specific ID interest, which may confer selection bias and may overestimate positive results. Furthermore, only 166 of 224 respondents completed the section assessing outcomes to RDTs, which could have influenced results. The survey was not controlled for duplicate institutions. Questions were geared toward identifying pharmacists’ current knowledge of RDTs and were not designed to assess whether this knowledge was obtained at a previous institution. Lastly, causality cannot be fully determined.
The results of this survey demonstrate the opportunity for pharmacists to improve their knowledge surrounding utilization and implementation of RDTs, with additional opportunity to educate other professions, including nursing and medical staff. Efforts are needed to improve communication of alerts to fully realize the benefit of timely results. Continued research in various practice settings is needed to evaluate the impact of RDT on patient and ASP-associated outcomes.
Acknowledgments
We acknowledge the Society of Infectious Diseases Pharmacists (SIDP) and the American College of Clinical Pharmacy Infectious Diseases Practice and Research Network (ACCP ID PRN) for allowing distribution of our survey. We acknowledge Brandon Hill, PharmD, for his assistance in manuscript editing.
Financial support. None reported.
Potential conflicts of interest. P.B.B. reports service as a content developer for and has received honorarium from Rockpointe and FreeCe.com, and he has received grant support from the Centers for Disease Control and Prevention. C.M.B. reports having received grant support from ALK Abello and an honorarium from Merck. All other authors report no conflicts of interest.
SUPPLEMENTARY MATERIALS
To view supplementary material for this article, please visit https:/doi.org/10.1017/ice.2017.67
