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

ABSTRACT: Background:Rapid 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. Methods:We 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. Results:RDT 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). Conclusions:RDTs 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.

SUBMITTER: Burrowes SAB

PROVIDER: S-EPMC7060900 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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

Burrowes Shana A B SAB Rader Alec A Ni Pengsheng P Drainoni Mari-Lynn ML Barlam Tamar F TF

Open forum infectious diseases 20200303 3

<h4>Background</h4>Rapid 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.<h4>Methods</h4>We 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 Decem ...[more]

PMID: 32166096

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Project description: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.

Project description:The only licensed dengue vaccine, Dengvaxia®, increases risk of severe dengue when given to individuals without prior dengue virus (DENV) infection but is protective against future disease in those with prior DENV immunity. The World Health Organization has recommended using rapid diagnostic tests (RDT) to determine history of prior DENV infection and suitability for vaccination. Dengue experts recommend that these assays be highly specific (≥98%) to avoid erroneously vaccinating individuals without prior DENV infection, as well as be sensitive enough (≥95%) to detect individuals with a single prior DENV infection. We evaluated one existing and two newly developed anti-flavivirus RDTs using samples collected >6 months post-infection from individuals in non-endemic and DENV and ZIKV endemic areas. We first evaluated the IgG component of the SD BIOLINE Dengue IgG/IgM RDT, which was developed to assist in confirming acute/recent DENV infections (n=93 samples). When evaluated following the manufacturer's instructions, the SD BIOLINE Dengue RDT had 100% specificity for both non-endemic and endemic samples but low sensitivity for detecting DENV seropositivity (0% non-endemic, 41% endemic). Sensitivity increased (53% non-endemic, 98% endemic) when tests were allowed to run beyond manufacturer recommendations (0.5 up to 3 hours), but specificity decreased in endemic samples (36%). When tests were evaluated using a quantitative reader, optimal specificity could be achieved (≥98%) while still retaining sensitivity at earlier timepoints in non-endemic (44-88%) and endemic samples (31-55%). We next evaluated novel dengue and Zika RDTs developed by Excivion to detect prior DENV or ZIKV infections and reduce cross-flavivirus reactivity (n=207 samples). When evaluated visually, the Excivion Dengue RDT had sensitivity and specificity values of 79%, but when evaluated with a quantitative reader, optimal specificity could be achieved (≥98%) while still maintaining moderate sensitivity (48-75%). The Excivion Zika RDT had high specificity (>98%) and sensitivity (>93%) when evaluated quantitatively, suggesting it may be used alongside dengue RDTs to minimize misclassification due to cross-reactivity. Our findings demonstrate the potential of RDTs to be used for dengue pre-vaccination screening to reduce vaccine-induced priming for severe dengue and show how assay design adaptations as well quantitative evaluation can further improve RDTs for this purpose.

Project description:Early diagnosis is important for the clinical management of diseases caused by dengue virus (DENV) infections. We investigated the performance of three commercially available DENV nonstructural protein 1 (NS1) rapid diagnostic tests (RDTs) using 173 acute-phase sera collected from dengue fever-suspected patients during the 2012-2013 DENV outbreak in Taiwan. The results of the NS1 RDTs were compared with those of qRT-PCR to calculate the sensitivity and specificity of the NS1 RDTs. The anti-DENV IgM and IgG RDT results were included to increase the probability of detecting acute DENV infection. The anti-DENV IgM/IgG RDT results were also compared with those of IgM/IgG captured ELISA. The sera from DENV qRT-PCR-positive patients were subjected to NS1 RDTs, as well as IgM/IgG captured ELISA. These results suggested that there was no significant difference in the sensitivities of the three commercially available DNEV NS1 RDTs; the SD NS1 RDT results showed the highest agreement with the qRT-PCR reference results, followed in order by the Bio-Rad and CTK NS1 RDT results when the specificity was considered. Inclusion of the IgM or IgG RDT results increased the likelihood of diagnosing either a primary or secondary DENV infection. NS1 RDTs were more sensitive for the detection of primary infections than secondary infections, related to DENV viremia levels determined by qRT-PCR. These results suggested that anti-DENV antibodies reduced the sensitivity of NS1 rapid tests. We also analyzed the sensitivity for the detection of different DENV serotypes, and the results suggested that the NS1 RDTs used in this study were valuable for rapid screening of acute DENV infection with DENV-1, DENV-2 and DENV-3. Our results suggest that the NS1 RDT is a good alternative to qRT-PCR analysis for timely dengue disease management and prevention in dengue-endemic regions where medical resources are lacking or during large dengue outbreaks. However, the relatively low sensitivity for DENV-4 might miss the detection of DENV-4-infected cases.

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

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

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