Clinical Infectious Diseases Advance Access published May 20, 2015
0 MAY
Correspondence When Diagnostic Technology Is Ahead of the Hospital Budget: What Is Antimicrobial Stewardship to Do?
Note Potential conflict of interest. Both authors: No reported conflicts. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Karri A. Bauer and Debra A. Goff Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus
References 1. Mylonakis E, Clancy CJ, Ostrosky-Zeichner L, et al. T2 magnetic resonance assay for the rapid diagnosis of candidemia in whole blood: a clinical trial. Clin Infect Dis 2015; 60:892–9. 2. The White House National Action Plan for Combating Antibiotic-Resistant Bacteria, 2015. Available at: https://www.whitehouse.gov/sites/ default/files/docs/national_action_plan_for_ combating_antibotic-resistant_bacteria.pdf. Accessed 30 March 2015. 3. Garey KW, Rege M, Pai MP, et al. Time to initiation of fluconazole therapy impacts mortality in patients with candidemia: a multi-institutional study. Clin Infect Dis 2006; 43:433–5. 4. Morrell M, Fraser VJ, Kollef MH. Delaying the empiric treatment of candida bloodstream infection until positive blood culture results are obtained: a potential risk factor for hospital mortality. Antimicrob Agents Chemother 2005; 49:3640–5. 5. Kuehn B. IDSA: better, faster diagnostics for infectious diseases needed to curb overtreatment, antibiotic resistance. JAMA 2013; 310:2385–6. 6. Bartlett JG. John Bartlett’s game changers in infectious diseases: 2011. Medscape 2011. Available at: http://www.medscape.com. Accessed 30 March 2015. Correspondence: Karri A. Bauer, PharmD, BCPS, Specialty Practice Pharmacist Infectious Diseases, The Ohio State University Wexner Medical Center, Department of Pharmacy, 410 West 10th Ave, Rm 368 Doan Hall, Columbus, OH 43210 ([email protected]). Clinical Infectious Diseases® © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/civ355
CORRESPONDENCE
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Downloaded from http://cid.oxfordjournals.org/ at Simon Fraser University on May 31, 2015
TO THE EDITOR—We read with great interest the study by Mylonakis et al that describes a new rapid diagnostic test that detects Candida species directly from blood in 3 hours [1]. The T2 magnetic resonance (T2MR) assay is the first fully automated technology to analyze whole blood specimens in order to identify Candida species without the need for growth from a blood culture. The authors state that the T2MR assay represents a breakthrough shift into a new era of molecular diagnostics. While we agree with their statement, we observe that with new technology comes new challenges, specifically economic challenges, for antimicrobial stewardship programs (ASPs). Rapid diagnostic tests represent one of the few advances to address some of the most severe and costly infectious diseases, including candidemia. Recently, the White House released the executive summary for their report, National Action Plan for Combating Antibiotic-Resistance Bacteria. In that report, it is estimated that each case of Candida infection results in 3–13 days of additional hospitalization and $6000– $29 000 in direct healthcare costs per patient [2]. Numerous studies have demonstrated that a delay in the initiation of antifungal therapy is associated with significant increases in both in-hospital mortality and the cost of care for patients with candidemia [3, 4]. The Infectious Diseases Society of America states that improvements in diagnostic tests that reduce delays in getting test results have the potential to save lives and curb healthcare costs [5]. The economic value of the T2MR assay could be great if the patients at greatest risk for candidemia can be identified.
Currently, infectious diseases clinicians watch as oncologists prescribe expensive chemotherapy regimens to extend a patient’s life by months. If that same oncology patient develops candidemia and treatment is delayed, the mortality rate is upwards of 40%. Does it make sense to confirm a diagnosis of candidemia in 3 hours instead of 3 days? Absolutely, but what price is hospital administration willing to accept for a rapid diagnostic test? ASPs are tasked with the implementation and subsequent cost justification of new rapid diagnostic tests. ASPs must evaluate patients in their respective institutions in order to determine if the population considered at risk for candidemia is high enough to offset the expense of the instrument. In this era of escalating healthcare costs, ASPs will have a paramount task convincing hospital administration to move away from the “silo” cost mentality and recognize the broader picture in the implementation and justification of a new rapid diagnostic test. It is evident that the clinical microbiology laboratory will experience a budget increase with implementation of the T2MR assay. The pharmacy budget could also potentially increase as antifungal therapy is started sooner and is used on more patients as a result of the T2MR assay. We welcome the potential impact of this new rapid diagnostic test on patients with candidemia. We concur with Dr John Bartlett, retired infectious diseases physician, who stated in 2010 that rapid diagnostic tests are “game changing” in the management of infectious diseases [6]. However, in 2015, we suggest a modification to his statement that rapid diagnostic tests and antimicrobial stewardship economics will “change the game” of managing patients with infectious diseases.
0 MAY
Correspondence When Diagnostic Technology Is Ahead of the Hospital Budget: What Is Antimicrobial Stewardship to Do?
Note Potential conflict of interest. Both authors: No reported conflicts. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Karri A. Bauer and Debra A. Goff Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus
References 1. Mylonakis E, Clancy CJ, Ostrosky-Zeichner L, et al. T2 magnetic resonance assay for the rapid diagnosis of candidemia in whole blood: a clinical trial. Clin Infect Dis 2015; 60:892–9. 2. The White House National Action Plan for Combating Antibiotic-Resistant Bacteria, 2015. Available at: https://www.whitehouse.gov/sites/ default/files/docs/national_action_plan_for_ combating_antibotic-resistant_bacteria.pdf. Accessed 30 March 2015. 3. Garey KW, Rege M, Pai MP, et al. Time to initiation of fluconazole therapy impacts mortality in patients with candidemia: a multi-institutional study. Clin Infect Dis 2006; 43:433–5. 4. Morrell M, Fraser VJ, Kollef MH. Delaying the empiric treatment of candida bloodstream infection until positive blood culture results are obtained: a potential risk factor for hospital mortality. Antimicrob Agents Chemother 2005; 49:3640–5. 5. Kuehn B. IDSA: better, faster diagnostics for infectious diseases needed to curb overtreatment, antibiotic resistance. JAMA 2013; 310:2385–6. 6. Bartlett JG. John Bartlett’s game changers in infectious diseases: 2011. Medscape 2011. Available at: http://www.medscape.com. Accessed 30 March 2015. Correspondence: Karri A. Bauer, PharmD, BCPS, Specialty Practice Pharmacist Infectious Diseases, The Ohio State University Wexner Medical Center, Department of Pharmacy, 410 West 10th Ave, Rm 368 Doan Hall, Columbus, OH 43210 ([email protected]). Clinical Infectious Diseases® © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals. [email protected]. DOI: 10.1093/cid/civ355
CORRESPONDENCE
•
CID
•
1
Downloaded from http://cid.oxfordjournals.org/ at Simon Fraser University on May 31, 2015
TO THE EDITOR—We read with great interest the study by Mylonakis et al that describes a new rapid diagnostic test that detects Candida species directly from blood in 3 hours [1]. The T2 magnetic resonance (T2MR) assay is the first fully automated technology to analyze whole blood specimens in order to identify Candida species without the need for growth from a blood culture. The authors state that the T2MR assay represents a breakthrough shift into a new era of molecular diagnostics. While we agree with their statement, we observe that with new technology comes new challenges, specifically economic challenges, for antimicrobial stewardship programs (ASPs). Rapid diagnostic tests represent one of the few advances to address some of the most severe and costly infectious diseases, including candidemia. Recently, the White House released the executive summary for their report, National Action Plan for Combating Antibiotic-Resistance Bacteria. In that report, it is estimated that each case of Candida infection results in 3–13 days of additional hospitalization and $6000– $29 000 in direct healthcare costs per patient [2]. Numerous studies have demonstrated that a delay in the initiation of antifungal therapy is associated with significant increases in both in-hospital mortality and the cost of care for patients with candidemia [3, 4]. The Infectious Diseases Society of America states that improvements in diagnostic tests that reduce delays in getting test results have the potential to save lives and curb healthcare costs [5]. The economic value of the T2MR assay could be great if the patients at greatest risk for candidemia can be identified.
Currently, infectious diseases clinicians watch as oncologists prescribe expensive chemotherapy regimens to extend a patient’s life by months. If that same oncology patient develops candidemia and treatment is delayed, the mortality rate is upwards of 40%. Does it make sense to confirm a diagnosis of candidemia in 3 hours instead of 3 days? Absolutely, but what price is hospital administration willing to accept for a rapid diagnostic test? ASPs are tasked with the implementation and subsequent cost justification of new rapid diagnostic tests. ASPs must evaluate patients in their respective institutions in order to determine if the population considered at risk for candidemia is high enough to offset the expense of the instrument. In this era of escalating healthcare costs, ASPs will have a paramount task convincing hospital administration to move away from the “silo” cost mentality and recognize the broader picture in the implementation and justification of a new rapid diagnostic test. It is evident that the clinical microbiology laboratory will experience a budget increase with implementation of the T2MR assay. The pharmacy budget could also potentially increase as antifungal therapy is started sooner and is used on more patients as a result of the T2MR assay. We welcome the potential impact of this new rapid diagnostic test on patients with candidemia. We concur with Dr John Bartlett, retired infectious diseases physician, who stated in 2010 that rapid diagnostic tests are “game changing” in the management of infectious diseases [6]. However, in 2015, we suggest a modification to his statement that rapid diagnostic tests and antimicrobial stewardship economics will “change the game” of managing patients with infectious diseases.
