Highlights
- •The first randomised trial of rapid syndromic molecular testing in pneumonia.
- •Molecular testing for pneumonia detected more pathogens.
- •Molecular results were generated much more rapidly than culture.
- •More patients had early appropriate antibiotic de-escalation and escalation.
- •There were no major differences in clinical and safety outcomes.
Summary
Background
Effective treatment of pneumonia requires timely administration of appropriate antimicrobials
but standard diagnostic tests take around 48 h to generate results. Highly accurate,
rapid molecular tests have been developed for identifying organisms in lower respiratory
tract samples, however their impact on antibiotic use is unknown. The aim of this
study was to assess the impact of syndromic molecular point-of-care testing compared
to conventional diagnostic testing, on antibiotic use.
Methods
In this pragmatic, randomised controlled trial, we enrolled critically ill adults
with pneumonia. Patients were assigned (1:1) to molecular testing of samples at the
point-of-care or routine clinical care. The primary outcome was the proportion of
patients who received results-directed antimicrobial therapy.
Results
200 patients were randomly assigned to point-of-care testing (n = 100) or the control group (n = 100). 85 patients had community acquired pneumonia (42 in the mPOCT group and 43
in the control group), 69 hospital acquired pneumonia (30 in mPOCT and 39 in control)
and 46 ventilator associated pneumonia (28 in mPOCT and 18 in control). The median
[IQR] time to results was 1.7 [1.6-1.9] hours for point-of-care testing and 66.7 [56.7-88.5]
hours for standard diagnostics (difference of -65.0 h, 95%CI -68.0 to -62.0; p < 0.0001). 71 (71%) patients in the point-of-care testing arm had pathogens detected
compared to 51 (51%) in the control arm (difference of 20%, 95%CI 7 to 33; p = 0.004). 80 (80%) of patients in the point-of-care group received results-directed
therapy, compared with 29 (29%) of 99 in the control group (difference of 51%, 95%CI
39-63; p < 0.0001). Time to results-directed therapy was 2.3 [1.8-7.2] hours in the mPOCT
group and 46.1 [23.0-51.5] hours in the control group (difference of -43.8 h, 95%
CI -48.9 to -38.6; p < 0.0001). 42 (42%) patients in mPOCT group had antibiotics de-escalated compared
with 8 (8%) of 98 in the control group (difference of 34%, 95%CI 23-45; p < 0.0001). Time to de-escalation was 4.8 [2.4-13.0] hours in the mPOCT group compared
with 46.5 [26.3-48.6] hours in the control group (difference of -41.4 h, 95%CI -53
to -29.7; p < 0.0001). There was no major difference in antibiotic duration or in clinical or
safety outcomes between the two groups.
Conclusions
Use of molecular point-of-care testing in patients with pneumonia returned results
more rapidly and identified more pathogens than conventional testing. This was associated
with improvements in appropriate antimicrobial use and appeared safe.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of InfectionAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of disease study 2019.Lancet. 2020; 396: 1204-1222
- Surviving sepsis campaign guidelines for management of severe sepsis and septic shock.Crit Care Med. 2004; 32: 858-873
- Time to first antibiotic and mortality in adults hospitalised with community-acquired pneumonia: a matched-propensity analysis.Thorax. 2016; 71: 568-570
- Administration of first hospital antibiotics for community-acquired pneumonia: does timeliness affect outcomes?.Curr Opin Infect Dis. 2005; 18: 151-156
- Community-acquired pneumonia requiring hospitalization among U.S. adults.N Engl J Med. 2015; 373: 415-427
- Epidemiology, antibiotic therapy, and clinical outcomes in health care-associated pneumonia: a UK cohort study.Clin Infect Dis. 2011; 53: 107-113
- Diagnostic value of microscopic examination of gram-stained sputum and sputum cultures in patients with bacteremic pneumococcal pneumonia.Clin Infect Dis. 2004; 39: 165-169
- Impact of inappropriate antibiotic therapy on mortality in patients with ventilator-associated pneumonia and blood stream infection: a meta-analysis.J Crit Care. 2008; 23: 91-100
- Comprehensive molecular testing for respiratory pathogens in community-acquired pneumonia.Clin Infect Dis. 2016; 62: 817-823
- Multinational evaluation of the BioFire® FilmArray® Pneumonia plus Panel as compared to standard of care testing.Eur J Clin Microbiol Infect Dis. 2021; 40: 1609-1622
- Clinical impact of molecular point-of-care testing for suspected COVID-19 in hospital (COV-19POC): a prospective, interventional, non-randomised, controlled study.Lancet Respir Med. 2020; 8: 1192-1200
- Clinical impact of a routine, molecular, point-of-care, test-and-treat strategy for influenza in adults admitted to hospital (FluPOC): a multicentre, open-label, randomised controlled trial.Lancet Respir Med. 2021; 9: 419-429
- Routine molecular point-of-care testing for respiratory viruses in adults presenting to hospital with acute respiratory illness (ResPOC): a pragmatic, open-label, randomised controlled trial.Lancet Respir Med. 2017; 5: 401-411
Tackling drug-resistant infections globally: final report and recommendations chaired by Jim O'Neill. Available at https://amr-review.org/sites/default/files/160525_Finalpaper_withcover.pdf. Accessed February 12, 2019.
- Clinical evaluation of a semi-quantitative multiplex molecular assay for the identification of bacteria, viruses and fungi in lower respiratory specimens.in: Proceedings of the Poster at Clinical Virology Symposium 2017. 2021 (Available at) (Accessed December 17)
- Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the infectious diseases society of america and the american thoracic society.Clin Infect Dis. 2016; 63: e61-111
- Multicenter evaluation of the biofire filmarray pneumonia/pneumonia plus panel for detection and quantification of agents of lower respiratory tract infection.J Clin Microbiol. 2020; 58
- Biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and process evaluation.Lancet Respir Med. 2020; 8: 182-191
- Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial.Lancet. 2010; 375: 463-474
- Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial.Lancet Infect Dis. 2016; 16: 819-827
Article info
Publication history
Published online: September 08, 2022
Accepted:
September 5,
2022
Received in revised form:
September 1,
2022
Received:
June 23,
2022
Identification
Copyright
© 2022 The British Infection Association. Published by Elsevier Ltd. All rights reserved.
