Comprehensive Respiratory Panel Research Articles

Cold agglutinin syndrome secondary to Mycoplasma pneumoniae

A 47-year-old female presented with dyspnea, dry cough, and fatigue for ten days. On examination, she had severe pallor and bilateral crepts in the lungs. Complete blood count (CBC) showed a hemoglobin of 7.3 g/dL, reticulocyte count of 5.6%, and chest X-ray was normal. Her extended Direct Coombs test (DCT) showed C3d +3 and cold agglutinin titer of 1:256 at 4°C. A comprehensive respiratory panel showed positivity for Mycoplasma pneumonia. Thus, a diagnosis of cold agglutinin syndrome secondary to M. pneumonia was made, and she was started on injection doxycycline 100 mg IV twice a day, following which her symptoms and anemia improved without transfusion support.

Use and Cost Analysis of Comprehensive Respiratory Panel Testing in a Pediatric Emergency Department.

Fever and respiratory infections are among the leading causes of pediatric emergency department visits and hospitalizations. Although typically self-resolving, clinicians may perform diagnostic tests to determine microbial etiologies of these illnesses. Although comprehensive respiratory viral panels can quickly identify causative organisms, cost to the hospital and patient may be significant. The objective of this study was to analyze the financial impact of comprehensive respiratory viral panel use in relation to associated clinical outcomes. This study was a single-center, retrospective chart review of pediatric emergency department patients who were evaluated between October 1, 2016, and April 30, 2018, with International Classification of Diseases, Tenth Revision (ICD-10) code diagnoses of acute upper respiratory infection, fever unspecified, and/or bronchiolitis. Our primary outcome was the effect of comprehensive respiratory viral panel testing and results on the total health care charge to patients. Secondary outcomes were the effect of comprehensive respiratory viral panel testing and results on emergency department length of stay and antimicrobial use. A total of 5766 visits were included for primary analysis, with 229 (4%) undergoing comprehensive respiratory viral panel testing. Of these, 163 had a positive result (71%) for at least 1 organism. The total cost was significantly higher in the group that underwent comprehensive respiratory viral panel testing ($643.39 [$534.18-$741.15] vs $295.15 [$249.72-$353.92]; P < 0.001). There was no decrease in emergency department length of stay or significant change in antimicrobial use associated with comprehensive respiratory viral panel use. This study demonstrates that the utilization of comprehensive respiratory viral panels in pediatric emergency department patients with bronchiolitis, unspecified fever, and/or acute upper respiratory infection adds significant cost to patient care without a decrease in their length of stay or antimicrobial use. Further studies are needed to determine the appropriate targeted use of comprehensive respiratory viral panels.

Provider views on rapid diagnostic tests and antibiotic prescribing for respiratory tract infections: A mixed methods study.

BackgroundRespiratory tract infections (RTIs) are often inappropriately treated with antibiotics. Rapid diagnostic tests (RDTs) have been developed with the aim of improving antibiotic prescribing but uptake remains low. The aim of this study was to examine provider knowledge, attitudes and behaviors regarding RDT use and their relationship to antibiotic prescribing decisions across multiple clinical departments in an urban safety-net hospital.MethodsWe conducted a mixed methods sequential explanatory study. Providers with prescribing authority (attending physicians, nurse practitioners and physician assistants) who had at least 20 RTI encounters from January 1, 2016 to December 31, 2018. Eighty-five providers completed surveys and 16 participated in interviews. We conducted electronic surveys via RedCap from April to July 2019, followed by semi-structured individual interviews from October to December 2019, to ascertain knowledge, attitudes and behaviors related to RDT use and antibiotic prescribing.ResultsSurvey findings indicated that providers felt knowledgeable about antibiotic prescribing guidelines. They reported high familiarity with the rapid streptococcus and rapid influenza tests. Familiarity with comprehensive respiratory panel PCR (RPP-respiratory panel PCR) and procalcitonin differed by clinical department. Qualitative interviews identified four main themes: providers trust their clinical judgment more than rapid test results; patient-provider relationships play an important role in prescribing decisions; there is patient demand for antibiotics and providers employ different strategies to address the demand and providers do not believe RDTs are implemented with sufficient education or evidence for clinical practice.ConclusionPrescribers are knowledgeable about prescribing guidelines but often rely on clinical judgement to make final decisions. The utility of RDTs is specific to the type of RDT and the clinical department. Given the low familiarity and clinical utility of RPP and procalcitonin, providers may require additional education and these tests may need to be implemented differently based on clinical department.

Does common cold coronavirus infection protect against severe SARS-CoV-2 disease?

The coronavirus disease 2019 (COVID-19) pandemic continues to cause morbidity and mortality. Since SARS coronavirus 2 (SARS-CoV-2) was identified as the cause for COVID-19, some have questioned whether exposure to seasonal common cold coronaviruses (CCCs) could provide tangible protection against SARS-CoV-2 infection or disease. In this issue of the JCI, Sagar et al. examined SARS-CoV-2 infections and outcomes of patients who had previously tested positive or negative for CCC infection (CCC+ or CCC-) by a comprehensive respiratory panel using PCR. No differences were seen between groups in terms of susceptibility to SARS-CoV-2 infection. However, hospitalized patients with a documented history of CCC infection had lower rates of intensive care unit (ICU) admissions and higher rates of survival than hospitalized CCC- patients. While these findings are associative and not causative, they highlight evidence suggesting that previous CCC infection may influence the disease course of SARS-CoV-2 infection.

SWEET HYDROTHORAX: A RARE COMPLICATION OF PERITONEAL DIALYSIS

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hydrothorax is a rare complication of continuous ambulatory peritoneal dialysis (CAPD) with an incidence of approximately 2%(1). We present a case of hydrothorax secondary to CAPD. CASE PRESENTATION: 72-year-old female with past medical history of end-stage renal disease requiring peritoneal dialysis 4 times a day and type 2 diabetes mellitus presented with shortness of breath, productive cough, chest congestion and nausea for 2 days. She denied any fevers or chills. Vitals were stable with oxygen saturation of 97% on 2 L nasal cannula. Physical exam was significant for diminished breath sounds at the base of the right lung on auscultation. Electrocardiogram showed normal sinus rhythm with no ST changes. Laboratory results were significant for an elevated creatinine of 6.4 mg/dL whereas white blood cell count, lactic acid and troponins were unremarkable. A comprehensive respiratory panel including Influenza A & B, urine antigen testing for streptococcus pneumonia and legionella were also negative. Chest x-ray PA and lateral showed middle to lower lung lobe infiltrate with pleural effusion. Blood cultures that were obtained on admission did not grow any organisms. Patient was started on antibiotics for presumed community acquired pneumonia. Pulmonology performed right sided thoracentesis and 1600 mL of colorless clear fluid was drained. Patient experienced significant symptomatic relief post thoracentesis. Pleural fluid analysis revealed a pH of 7.3 and a high glucose concentration of 438 mg/dL (simultaneous blood glucose level of 103 mg/dL). Additionally, LDH and protein were suggestive of a transudative effusion as per Light’s criteria. Pleural fluid cultures remained negative. Given that pleural effusion was transudative with an elevated glucose level, the diagnosis of sweet hydrothorax was established. Antibiotics were discontinued. The patient was then transitioned to hemodialysis (HD). DISCUSSION: Sweet hydrothorax most commonly occurs on the right as compared to the left side and is more prevalent in women. Mechanisms of this phenomenon include pleuro-peritoneal pressure gradient, congenital diaphragmatic defects and lymphatic drainage disorders (2). Diagnoses involves thoracentesis with pleural fluid analysis revealing a marked elevation of glucose when compared to serum levels. This finding is pathognomonic for sweet hydrothorax. Imaging modalities used for diagnosis involve demonstrating the transfer of radiopaque dye across the diaphragm e.g. peritoneal scintigraphy, CT and MR Peritoneography, or direct visualization with video-assisted thoracoscopic surgery (VATS) (3). CONCLUSIONS: Management involves temporary cessation of CAPD, therapeutic thoracentesis, short dwell periods or dry days. Video-assisted thoracoscopic pleurodesis may be performed for patients who have failed conservative management. Most patients however end up switching permanently to HD. Reference #1: Szeto CC, Chow KM. Pathogenesis and management of hydrothorax complicating peritoneal dialysis. Current Opinion in Pulmonary Medicine. 2004 Jul;10(4):315-319. DOI: 10.1097/01.mcp.0000127901.60693.d0. Reference #2: Chow, K.M., Szeto, C.C. and Li, P.K.-T. (2003), Review Articles: Management Options for Hydrothorax Complicating Peritoneal Dialysis. Seminars in Dialysis, 16: 389-394. doi:10.1046/j.1525-139X.2003.16080.x Reference #3: Sydney Tang, Wing Hung Chui, Anthony W. C. Tang, Fu Keung Li, Wing Shun Chau, Yiu Wing Ho, Tak Mao Chan, Kar Neng Lai, Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis, Nephrology Dialysis Transplantation, Volume 18, Issue 4, April 2003, Pages 804–808, https://doi.org/10.1093/ndt/gfg042 DISCLOSURES: No relevant relationships by Muhammad Hamza, source=Web Response No relevant relationships by Travis Hanson, source=Web Response No relevant relationships by Touba Naim, source=Web Response No relevant relationships by Muhammad Omar, source=Web Response

Low Uptake of Rapid Diagnostic Tests for Respiratory Tract Infections in an Urban Safety Net Hospital.

BackgroundRapid diagnostic tests (RDTs) have been developed with the aim of providing accurate results in a timely manner. Despite this, studies report that provider uptake remains low.MethodsWe conducted a retrospective analysis of ambulatory, urgent care, and emergency department (ED) encounters at an urban safety net hospital with a primary diagnosis of an upper or lower respiratory tract infection (eg, bronchitis, pharyngitis, acute sinusitis) from January 1, 2016, to December 31, 2018. We collected RDT type and results, antibiotics prescribed, demographic and clinical patient information, and provider demographics.ResultsRDT use was low; a test was performed at 29.5% of the 33 494 visits. The RDT most often ordered was the rapid Group A Streptococcus (GAS) test (n = 7352), predominantly for visits with a discharge diagnosis of pharyngitis (n = 5818). Though antibiotic prescription was more likely if the test was positive (relative risk [RR], 1.68; 95% confidence interval [CI], 1.58–1.8), 92.46% of streptococcal pharyngitis cases with a negative test were prescribed an antibiotic. The Comprehensive Respiratory Panel (CRP) was ordered in 2498 visits; influenza was the most commonly detected pathogen. Physicians in the ED were most likely to order a CRP. Antibiotic prescription was lower if the CRP was not ordered compared with a negative CRP result (RR, 0.77; 95% CI, 0.7–0.84). There was no difference in prescribing by CRP result (negative vs positive).ConclusionsRDTs are used infrequently in the outpatient setting, and impact on prescribing was inconsistent. Further work is needed to determine barriers to RDT use and to address potential solutions.

2622. Multiplex Polymerase Chain Reaction (PCR) Panels in Pediatric Hospital Care: New Insights into Factors Driving Antimicrobial Use

BackgroundMultiplex PCR panels are diagnostic tools that first became available in 2011. They have rapid turnaround time and excellent sensitivity and specificity for a wide spectrum of microbial targets. However, it remains controversial whether its widespread use leads to optimal use of antimicrobials. We aimed to determine whether use of these tests was associated with appropriate antimicrobial therapy (AAT).MethodsWe conducted a single-center, retrospective study of hospitalized pediatric patients from 2015 to 2018 looking at 4 different respiratory panels and 1 meningoencephalitis panel (MEP). We analyzed test results and compared them to antimicrobial treatment. Using logistic regression, we analyzed the clinical and laboratory factors associated with AAT (defined as directed antimicrobial therapy based on clinical assessment and tests results).ResultsThere were 1,002 encounters in 951 patients. Mean length of stay was 7 days. 53.2% encounters had intensive care unit (ICU) admission. 77.1% of respiratory panels and 17.3% of MEP were positive. Co-detection in respiratory samples was 44.2%. Enterovirus was the most common virus detected while H. influenza was the most frequent bacteria. Respiratory Syncytial Virus was commonly detected with bacteria when compared with other common viruses. 13.4% patients were intubated, concordance with sputum culture was 63%. Patients admitted to the floor were more likely to have AAT than ICU patients (82.5% vs. 71.7%). ICU admission increased the odds of unnecessary antimicrobials (OR 1.6; 95% CI 1.1–2.5). Positive result from a comprehensive respiratory panel (bacteria + virus) decreased the odds of AAT (odds ratio: 0.4, 95% CI 0.3–0.8). Age, season, comorbidity, and intubation were not significantly associated with AAT. Only 0.5% of blood cultures in patients tested for respiratory infection were positive (3/579).ConclusionWe present new insights into factors driving antimicrobial use in pediatric hospital care. ICU admission was significantly associated with unnecessary antimicrobial use after adjusting for clinical findings and diagnostics. Frequently PCR results were not acted upon or caused additional use of antimicrobials. Further investigation is warranted to understand factors influencing antimicrobial use in pediatric care. Disclosures All authors: No reported disclosures.