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A stewards guide to Verigene optimization

A stewards guide to Verigene optimization. Jason M. Pogue, PharmD, BCPS, BCIDP Clinical Pharmacist, Infectious Diseases Sinai-Grace Hospital; Detroit Medical Center Clinical Assistant Professor of Medicine Wayne State University School of Medicine. Objectives.

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A stewards guide to Verigene optimization

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  1. A stewards guide to Verigene optimization Jason M. Pogue, PharmD, BCPS, BCIDP Clinical Pharmacist, Infectious Diseases Sinai-Grace Hospital; Detroit Medical Center Clinical Assistant Professor of Medicine Wayne State University School of Medicine

  2. Objectives • List the organisms and resistance mechanisms that are detected by Verigene BC-GP and BC-GN • Discuss strategies for optimizing the use of Verigene within your institution

  3. What is Verigene? • Multiplex PCR test that is run on positive blood cultures • Once blood culture turns positive • Gram stain • Place sample on BC-GP or BC-GN based on results • Results in < 2.5 hours • What do you get? • Organism identification (most common ones) • Key resistance determinants

  4. An example pathway for BC-GP

  5. Verigene BC-GP: Impact • Very straightforward and simple to put together a pathway based on results • Impact on optimizing meaningful outcomes limited (time to appropriate therapy, LOS, mortality) • Everyone gets vancomycin and it is active (even if not optimal) against most things • Previous technologies that gave genus/species would lead to appropriate therapy as resistance predictable based off of it • Even simple things like coagulase test, GPC in pairs and chains can drive to appropriate coverage if acted upon • Time to optimal therapy can be improved • Largely driven by quicker de-escalation off of vancomycin • Impact on safety? Infect Control HospEpidemiol 2016;37:1361–1366; Proc (BaylUniv Med Cent) 2015;28(2):139–143

  6. Can mean different things for different organisms • A. baumannii  OXA-23, 51, 58 • Enterobacteriaceae  OXA-48 like • What it picks up versus what it doesn’t isn’t well defined….

  7. Verigene BC-GN offers a HUGE opportunity to escalate and improve outcomes! Informal pathway at the DMC

  8. J ClinMicrobiol. 2016 Jul;54(7):1789-1796

  9. “Hospital length of stay was decreased in the post BC-GN group (7 (5-15) days versus 9 (4.5 – 21 days); p = 0.001)” Eur J ClinMicrobiol Infect Dis. 2017 36(10):1879-1887

  10. That’s great but…what do you do when resistance determinants are negative? • Enterobacteriaceae • There are non CTX-M ESBLs • P. aeruginosa • Common beta lactam resistance mechanisms not on that list • A. baumannii • Are all oxacillinases detected??

  11. So what would you do? • JJ is a 36 y/o female who presents with urosepsis. She has a history of recurrent UTI, no other details provided. Her vitals and relative lab values in the ED were as follows: • BP: 97/60, Tmax 38.5, HR 110, RR 18 • WBC 17.5, Creatinine 1.4 (baseline 0.8) • Patient is started on Vancopime • 17 hours later the following information comes back • Blood culture GNR, Verigene (+) K. pneumoniae, resistance determinants negative • No significant changes to the above labs, but patient stable on the floor • ESBL rate at your institution in K. pneumoniae is 23% • Who wants to (in addition to stopping vancomycin) • A) Continue cefepime • B) Escalate (kind of) to ertapenem • C) De-escalate to ceftriaxone • D) I do not know enough information to make this decision

  12. Antimicrob Agents Chemother. 2018 Apr 26;62(5).

  13. What did we learn? • At both DMC and UMMC absence of key determinants largely rules out resistance to target agents • One notable exception was P. aeruginosa • Antibiogram and severity of illness should drive decisions • And Ryan might have a solution for you in the next talk • These data should NOT be used to justify a similar pathway at your institution • But you can (and should) do the same thing

  14. There are a few quirks of Verigene BC-GN to be aware of • Off panel organisms • From time to time we will see off panel organisms • Common considerations: Serratia, Morganella, or in the right population Stenotrophomonas • Also, if anaerobic culture only or GI source – think anaerobes • Polymicrobial GN infections limitations • Dominant organism might only be detected • Different pathogen in untested bottle • Impact on care limited (but not zero)

  15. Summary/conclusion • Verigene offers organism ID and the presence/absence of key resistance determinants ~48 hours prior to traditional methodology • Impact on Gram positive BSI is modest • Real benefit is in GNR • Decrease time to appropriate therapy in resistant organisms • Can also allow more rapid de-escalation (or spare unnecessary escalation) • But clinical judgement warranted

  16. A stewards guide to Verigene optimization Jason M. Pogue, PharmD, BCPS, BCIDP Clinical Pharmacist, Infectious Diseases Sinai-Grace Hospital; Detroit Medical Center Clinical Assistant Professor of Medicine Wayne State University School of Medicine

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