1. Kaylee Wentworth, PharmD PGY-1 Pharmacy Resident April 2017
Implementation of FilmArray blood culture identification panel: Assessment of time to appropriate antimicrobial therapy and subsequent impact on patient outcomes
Kaylee Wentworth, PharmD
PGY-1 Pharmacy Resident
April 2017

2. The speaker has no actual or potential conflict of interest in relation to this presentation

3. Background

4. Bloodstream Infections (BSI)
Associated with a high risk of mortality
Sepsis: 20%
Severe sepsis: 40%
Septic shock: >60%
Delays in appropriate antimicrobial therapy have been shown to:
Increase mortality
Increase hospital length of stay
Increase costs
Promote antimicrobial resistance
Chang H, et al. JAMA. 2010: 304 (16); 1856.
Wisplinghoff H, et al. Clin Infect Dis. 2004: 39;
Kumar A, et al. Chest. 2009: 136;
Fraser A, et al. Am J Med. 2006: 119;
Lehman LE, et al. Crit Care. 2010: 14; R186.
Cameron DR, et al. Clin Infect Dis. 2011: 53;

5. Blood Culture Results Positive Culture Pathogen
Gram-positive cocci (staph-like)
Staphylococcus aureus
1 or multiple
Methicillin-sensitive
Beta-lactam
Methicillin-resistant
Vancomycin
Coagulase-negative staphylococcus
1 out of 2
Likely a contaminant
No Therapy
Positive Culture
Pathogen
Number of Positive Cultures
Identification
Appropriate Therapy

6. FilmArray Blood Culture Identification (BCID) Panel
Multiplex polymerase chain reaction (PCR) system
Tests simultaneously for:
19 gram positive and gram negative bacteria
5 yeast
3 antibiotic resistance genes
Identifies pathogens in ~1 hour

7. Current Process at MCHS
BCID Panel:
Organism & Resistance Gene Identification
Positive Blood Culture
Gram Stain
Culture Plate
Organism Identification & Susceptibility
~1hr
~24-48hr
18-24hr
6-18hr

8. Kaylee M. Wentworth, PharmD
Implementation of FilmArray blood culture identification panel: Assessment of time to appropriate antimicrobial therapy and subsequent impact on patient outcomes
Kaylee M. Wentworth, PharmD
Co-Investigators: Theresa Koski, BS, PharmD, Patient Care Pharmacist, Antimicrobial Stewardship; Katrina Reynolds, PharmD, Patient Care Pharmacist; Andrew Caputo, PharmD, BCPS, Patient Care Pharmacist; Dr. Joy Voorhees, BS, DVM

9. Purpose
Analyze the effects of the BCID panel on appropriate antimicrobial use, including duration of vancomycin therapy, and patient outcomes 9

10. Study Overview Multi-center Retrospective IRB approved
Mount Carmel West
Mount Carmel East
Mount Carmel St. Ann’s
Retrospective
January 1, 2016 through January 31, 2017
All outcomes were compare 6 months pre- and post-implementation of the BCID panel
IRB approved

11. Inclusion and Exclusion Criteria
≥18 years of age
Positive blood culture for Methicillin-sensitive Staphylococcus aureus (MSSA) OR
1 positive culture out of 2 for Coagulase-negative Staphylococcus (CoNS)
Positive blood cultures for pathogens other than MSSA or CoNS
Vancomycin for indications other than sepsis or bacteremia
Patients who expired, left against medical advice, or transferred to palliative care within 24 hours of the positive culture

12. Outcomes Primary Secondary Length of vancomycin therapy
Time to appropriate antimicrobial therapy
MSSA: de-escalation to a beta-lactam
CoNS: no therapy
Hospital length of stay (LOS)
Length of vancomycin therapy
Measured in hours
Length of intensive care unit (ICU) stay
Time to negative blood culture
Adverse drug events
30-day mortality
30-day readmission

13. Results

14. Results 406 Patients included Pre-BCID panel n=182 CoNS n=128
MSSA n=54
Post-BCID panel n=224
CoNS n=173
MSSA n=51
p=0.138

15. Blood Stream Infections: MSSA

16. MSSA: Baseline Characteristics
Pre-BCID Panel
Post-BCID Panel
P-value
Age**
54.2 (19.3, 23 – 89)
57.4 (14.1, 26-88)
0.4509
Male*
30 (55.6%)
29 (56.9%)
1.000
Antibiotic allergies*
13 (24.1%)
10 (19.6%)
0.6417
Baseline SCr**
2.23 (2.26, 0.43 – 12.27)
1.78 (2.1, 0.44 – 12.01)
0.1946
History of IV drug abuse*
9 (16.7%)
5 (9.8%)
0.3930
Nephrotoxic Agents*
Contrast dye
53 (24.4%)
65 (27.2%)
0.5220
Aminoglycosides
7 (3.2%)
11 (4.6%)
NSAIDs
39 (17.7%)
30 (12.4%)
Loop diuretics
62 (28.2%)
72 (29.9%)
Hospital*
MCW
 19 (35.2%)
 25 (49.0%)
0.2504
MCE
 20 (37.0%)
 12 (23.5%)
MCSA
 15 (27.8%)
 14 (27.5%)
*reported in hours; mean (SD, range)
**reported as n (%)

17. MSSA: Baseline Characteristics
Pre-BCID Panel
Post-BCID Panel
P-value
Charlson Comorbidity Index
12 (22.2%)
14 (27.5%)
0.0275 1
16 (29.6%)
20 (39.2%) 2
9 (16.7%)
8 (15.7%) 3
2 (3.7%)
6 (11.8%) 4
1 (2.0%) ≥5
6 (11.1%)
2 (3.9%)
Pre-BCID Panel
Post-BCID Panel
P-value
Pitt Bacteremia Score
4 (7.4%)
10 (19.6%)
0.6102 1
10 (18.5%)
7 (13.7%) 2
14 (25.9%)
8 (15.7%) 3
13 (25.5%) 4
7 (13.0%)
4 (7.8%) 5
0 (0%)
2 (3.9%) ≥6
5 (9.3%)
reported as n (%)
reported as n (%)

18. MSSA: Primary Outcomes
Pre-BCID Panel
Post-BCID Panel
P-value
Time to appropriate therapy
82.6 (59.6, 5 – 367)
71.4 (73.9, 1 – 312)
0.0045
Hospital length of stay (LOS)
241 (115, )
281 (192, 38 – 992)
0.5357
reported in hours; mean (SD, range)

19. MSSA: Secondary Outcomes
Pre-BCID Panel
Post-BCID Panel
P-value
Time on vancomycin*
39.8 (24.6, 0 – 113)
29.8 (27.2, 0 – 99)
0.0441
Received ≥1 dose of vancomycin*
50 (90.9%)
44 (81.5%)
0.1751
Time to negative culture*
94.2 (85.4, 5-319)
62.8 (56.7, 2-242)
0.0543
Length of ICU stay*
105 (107, 15 – 400)
158 (120, 14 – 461)
0.1359
30-day mortality**
5 (9.1%)
3 (5.6%)
0.7161
30-day readmission**
8 (14.6%)
6 (11.1%)
0.7758
*reported in hours; mean (SD, range)
**reported as n (%)

20. MSSA: Adverse Events Pre-BCID Panel Post-BCID Panel P-value
Change in Serum Creatinine
No change
41 (85.4%)
40 (93.0%)
0.5395
Risk
4 (8.3%)
1 (2.3%)
Injury
1 (2.1%)
0 (0%)
Failure
2 (4.2%)
2 (4.7%)
reported as n (%)

21. Contaminants: CoNS

22. CoNS: Baseline Characteristics
Pre-BCID Panel
Post-BCID Panel
P-value
Age**
65.4 (14.8, 27 – 97)
67.7 (16.1, 18 – 99)
0.0985
Male*
68 (53.1%)
84 (48.6%)
0.4845
Antibiotic allergies*
34 (26.6%)
60 (34.7%)
0.1663
Baseline SCr**
1.74 (1.71, 0.32 – 10.63)
2.04 (1.85, 0.54 – 8.63)
0.3983
History of IV drug abuse*
4 (3.2%)
6 (3.6%)
1.000
Nephrotoxic Agents*
Contrast dye
53 (24.4%)
65 (27.2%)
0.5220
Aminoglycosides
7 (3.2%)
11 (4.6%)
NSAIDs
39 (17.7%)
30 (12.4%)
Loop diuretics
62 (28.2%)
72 (29.9%)
Hospital*
MCW
65 (50.8%)
67 (38.7%)
0.07
MCE
54 (42.2%)
MCSA
9 (7.1%)
22 (12.7%)
*reported in hours; mean (SD, range)
**reported as n (%)

23. CoNS: Baseline Characteristics
Pre-BCID Panel
Post-BCID Panel
P-value
Charlson Comorbidity Index
24 (18.8%)
22 (12.7%)
0.0291 1
21 (16.4%)
56 (32.4%) 2
29 (22.7%)
31 (17.9%) 3
20 (11.6%) 4
17 (13.3%)
17 (9.8%) ≥5
16 (12.5%)
27 (15.6%)
Pre-BCID Panel
Post-BCID Panel
P-value
Pitt Bacteremia Score
38 (29.7%)
69 (39.9%)
0.1013 1
9 (7.0%)
22 (12.7%) 2
35 (27.3%)
35 (20.2%) 3
17 (13.3%)
13 (7.5%) 4
15 (11.7%)
15 (8.7%) 5
7 (5.5%)
8 (4.6%) ≥6
11 (6.4%)
reported as n (%)
reported as n (%)

24. CoNS: Primary Outcomes
Pre-BCID Panel
Post-BCID Panel
P-value
Time to appropriate therapy
94.2 (97.6, 4 – 660)
69.6 (103, 3 – 875)
<0.0001
Hospital length of stay (LOS)
209 (177, )
163 (128, 21 – 886)
0.0377
reported in hours; mean (SD, range)

25. CoNS: Secondary Outcomes
Pre-BCID Panel
Post-BCID Panel
P-value
Time on vancomycin*
42.9 (71.3, 0 – 659)
26.2 (61.6, 0 – 478)
<0.0001
Received ≥1 dose of vancomycin*
112 (67.9%)
92 (49.2%)
0.0005
Hospital
MCW
60 (73.2%)
40 (54.1%)
0.0189
MCE
44 (63.8%)
38 (42.2%)
0.0102
MCSA
8 (57.1%)
14 (60.9%)
1.00
Length of ICU stay*
133 (110, 13 – 442)
113 (119, 14 – 540)
0.1460
30-day mortality**
10 (7.8%)
16 (9.3%)
0.8360
30-day readmission**
17 (13.3%)
24 (13.9%)
1.000
*reported in hours; mean (SD, range)
**reported as n (%)

26. CoNS: Adverse Events Pre-BCID Panel Post-BCID Panel P-value
Change in Serum Creatinine
No change
102 (94.4%)
68 (90.7%)
0.0962
Risk
3 (2.8%)
7 (9.3%)
Injury
1 (0.9%)
0 (0%)
Failure
2 (1.9%)
reported as n (%)

27. Overall Results

28. Results: Primary Outcomes

29. Results: Vancomycin

30. Conclusions

31. Conclusions Reduced time to appropriate therapy
Reduction in unnecessary antibiotic use
Trend toward decrease in hospital length of stay in CoNS subgroup
Reduction in time on vancomycin and overall vancomycin use

32. Study Limitations Time to appropriate therapy calculation
Serum creatinine was only collected on patients who received vancomycin
Potential for variation in reaction time
Bias and consistency of data collection

33. Future Implications Ongoing education
Provided pocket guide in addition to electronic link
Room for improvement regarding vancomycin use
Implementation of other panels
Respiratory
Meningitis/Encephalitis
Gastrointestinal

34. References Chang H, et al. Sepsis. JAMA. 2010: 304 (16); 1856.
Wisplinghoff H, et al. Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis. 2004: 39;
Kumar A, et al. Initiation of inappropriate antimicrobial therapy results in a fivefold reduction of survival in human septic shock. Chest. 2009: 136;
Fraser A, et al. Benefit of appropriate empirical antibiotic treatment: thirty-day mortality and duration of hospital stay. Am J Med. 2006: 119;
Lehman LE, et al. Cost and mortality predication using polymerase chain reaction pathogen detection in sepsis: evidence from three observational trials. Crit Care. 2010: 14; R186.
Cameron DR, et al. The interface between antibiotic resistance and virulence in Staphylococcus aureus and its impact upon clinical outcomes. Clin Infect Dis. 2011: 53;
Huang AM, et al. Impact of rapid organism identification via matrix-assisted laser desorption/ionization time-of-flight combined with antimicrobial stewardship team intervention in adult patients with bacteremia and candidemia. Clin Infect Dis. 2013: 57;
Biofire. Products: The Filmarray Panels .Accessed 18 Mar
Southern TR, et al. Implementation and performance of the BioFire FilmArray® Blood Culture Identification panel with antimicrobial treatment recommendations for bloodstream infections at a midwestern academic tertiary hospital. Diagn Microbiol Infect Dis. 2015: 81 (2);

35. Kaylee M. Wentworth, PharmD
Implementation of FilmArray blood culture identification panel: Assessment of time to appropriate antimicrobial therapy and subsequent impact on patient outcomes
Kaylee M. Wentworth, PharmD
Co-Investigators: Theresa Koski, BS, PharmD, Patient Care Pharmacist, Antimicrobial Stewardship; Katrina Reynolds, PharmD, Patient Care Pharmacist; Andrew Caputo, PharmD, BCPS, Patient Care Pharmacist; Dr. Joy Voorhees, BS, DVM