Performance and impact of rapid multiplex PCR on diagnosis and treatment of ventilated hospital-acquired pneumonia in patients with extended-spectrum β-lactamase-producing Enterobacterales rectal carriage.

IF 5.7 1区 医学 Q1 CRITICAL CARE MEDICINE Annals of Intensive Care Pub Date : 2024-07-29 DOI:10.1186/s13613-024-01348-5
Pierre Bay, Vincent Fihman, Paul-Louis Woerther, Bastien Peiffer, Ségolène Gendreau, Romain Arrestier, Pascale Labedade, Elsa Moncomble, Antoine Gaillet, Guillaume Carteaux, Nicolas de Prost, Armand Mekontso Dessap, Keyvan Razazi
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Abstract

Background: Antimicrobial stewardship (AMS) for ventilator-associated pneumonia (VAP) or ventilated hospital-acquired pneumonia (vHAP) in extended-spectrum β-lactamase-producing Enterobacterales (ESBL-E) carriers is challenging. BioFire® FilmArray® Pneumonia plus Panel (mPCR) can detect bacteria and antibiotic resistance genes, including blaCTX-M, the most common ESBL-encoding gene.

Methods: This monocentric, prospective study was conducted on a group of ESBL-E carriers from March 2020 to August 2022. The primary objective was to evaluate the concordance between the results of mPCR and conventional culture performed on respiratory samples of ESBL-E carriers to investigate suspected VAP/vHAP. The secondary objective was to appraise the impact of performing or not mPCR on initial antibiotic therapy adequacy in ESBL-E carriers with confirmed VAP/vHAP.

Results: Over the study period, 294 patients with ESBL-E carriage were admitted to the ICU, of who 168 (57%) were mechanically ventilated. (i) Diagnostic performance of mPCR was evaluated in suspected 41 episodes of VAP/vHAP: blaCTX-M gene was detected in 15/41 (37%) episodes, where 9/15 (60%) were confirmed ESBL-E-induced pneumonia. The culture and blaCTX-M were concordant in 35/41 (85%) episodes, and in all episodes where blaCTX-M was negative (n = 26), the culture never detected ESBL-E. (ii) The impact of mPCR on initial antibiotic therapy adequacy was assessed in 95 episodes of confirmed VAP/vHAP (22 episodes were tested with mPCR and 73 without); 47 (49%) episodes were ESBL-E-induced, and 24 (25%) were carbapenem-resistant bacteria-induced. The use of mPCR was significantly associated with higher prescription of adequate empirical antibiotic therapy in the multivariable logistic regression (adjusted odds ratio (aOR) (95% CI) of 7.5 (2.1-35.9), p = 0.004), propensity-weighting (aOR of 5.9 (1.6-22.1), p = 0.008), and matching-cohort models (aOR of 5.8 (1.5-22.1), p = 0.01).

Conclusion: mPCR blaCTX-M showed an excellent diagnostic value to rule out the diagnosis of ESBL-E related pneumonia in ESBL-E carriers with suspected VAP/vHAP. In addition, in patients with confirmed VAP/vHAP, a mPCR-based antibiotic therapy was associated with an increased prescription of adequate empirical antibiotic therapy. Performing mPCR on respiratory samples seems to be a promising tool in ESBL-E carriers with suspected vHAP/VAP. However, if mPCR is used in very low pre-test clinical probability of pneumonia, due to the high sensitivity and the rate of overdiagnosed pneumonia, the risk of overconsumption of carbapenem may prevail. Further studies are warranted.

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快速多重 PCR 在诊断和治疗直肠携带产扩展谱 β-内酰胺酶肠杆菌的通风医院获得性肺炎中的性能和影响。
背景:对产扩展谱β-内酰胺酶肠杆菌(ESBL-E)携带者的呼吸机相关性肺炎(VAP)或呼吸机医院获得性肺炎(vHAP)进行抗菌药物管理(AMS)具有挑战性。BioFire® FilmArray® Pneumonia plus Panel (mPCR) 可检测细菌和抗生素耐药基因,包括最常见的 ESBL 编码基因 blaCTX-M:这项单中心前瞻性研究于 2020 年 3 月至 2022 年 8 月对一组 ESBL-E 携带者进行了研究。主要目的是评估在调查疑似 VAP/vHAP 时,对 ESBL-E 携带者的呼吸道样本进行 mPCR 和传统培养的结果之间的一致性。次要目标是评估是否进行 mPCR 对确诊 VAP/vHAP 的 ESBL-E 携带者初始抗生素治疗充分性的影响:研究期间,294 名携带 ESBL-E 的患者入住重症监护病房,其中 168 人(57%)接受了机械通气治疗。(i) 对 41 例疑似 VAP/vHAP 病例进行了 mPCR 诊断性能评估:15/41(37%)例病例检测到 blaCTX-M 基因,其中 9/15(60%)例确诊为 ESBL-E 引起的肺炎。在 35/41 次(85%)病例中,培养和 blaCTX-M 的结果一致,在 blaCTX-M 呈阴性的所有病例中(n = 26),培养从未检测到 ESBL-E。(ii) 在 95 例确诊 VAP/vHAP 中评估了 mPCR 对初始抗生素治疗充分性的影响(22 例使用 mPCR 进行检测,73 例未使用 mPCR);47 例(49%)由 ESBL-E 引起,24 例(25%)由碳青霉烯耐药菌引起。在多变量逻辑回归(调整赔率(aOR)(95% CI)为 7.5 (2.1-35.9),p = 0.004)、倾向加权(aOR 为 5.结论:mPCR blaCTX-M 对疑似 VAP/vHAP 的 ESBL-E 携带者排除 ESBL-E 相关肺炎的诊断具有很好的诊断价值。此外,在确诊为 VAP/vHAP 的患者中,基于 mPCR 的抗生素疗法可增加适当的经验性抗生素治疗处方。对疑似 VHAP/VAP 的 ESBL-E 携带者的呼吸道样本进行 mPCR 检测似乎是一种很有前途的工具。但是,如果 mPCR 用于检测前肺炎临床概率很低的情况,由于其灵敏度高和肺炎过度诊断率高,可能会出现碳青霉烯类药物用量过多的风险。有必要进行进一步研究。
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来源期刊
Annals of Intensive Care
Annals of Intensive Care CRITICAL CARE MEDICINE-
CiteScore
14.20
自引率
3.70%
发文量
107
审稿时长
13 weeks
期刊介绍: Annals of Intensive Care is an online peer-reviewed journal that publishes high-quality review articles and original research papers in the field of intensive care medicine. It targets critical care providers including attending physicians, fellows, residents, nurses, and physiotherapists, who aim to enhance their knowledge and provide optimal care for their patients. The journal's articles are included in various prestigious databases such as CAS, Current contents, DOAJ, Embase, Journal Citation Reports/Science Edition, OCLC, PubMed, PubMed Central, Science Citation Index Expanded, SCOPUS, and Summon by Serial Solutions.
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