WP8 Branka Bedenic, University Hospital Zagreb, Croatia Valentino D Onofrio, Jessa hospital and Hasselt University, Belgium

Transcription

1 WP8 Branka Bedenic, University Hospital Zagreb, Croatia Valentino D Onofrio, Jessa hospital and Hasselt University, Belgium Inge Gyssens, Jessa hospital and Hasselt University and Radboud University Medical Center, Nijmegen, The Netherlands

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3 Sepsis Antibiotic Treatment Pathogen Detection Molecular pathogen detection in whole blood Systematic literature Review Clinical Evaluation preparation and logistics Ethical Aspects Phase 1 Phase 2

4 Systemic inflammatory response to bloodstream infection Rapidly progressing High mortality (ICU: 60%)

5 Start as soon as possible Preferably within the first hour Take blood culture before starting treatment, without causing a delay Septic Shock: 7.6% decrease in survival for each hour of delay within 6hrs after onset of hypotension* *Kumar A. et. Al. 2006

6 Blood culture Gold standard Grow bacteria on medium Results: 2 3 days, 5 days for negativity Only40% is positive No (or later) susceptibility testing Difficult for intracellular bacteria, viruses,

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10 Search strategy t The following search strategy was used for Medline. 1. Pathology Pathology, Molecular Mesh (all synonyms) 2. Sepsis Mesh (all synonyms and subheadings) 3. 1 AND 2 4. whole blood AND (culture OR detection OR sample) 5. 2 AND 4 6. ( Rapid AND Identifiaction AND PCR (and all related terms)) AND AND AND AND 8 This resulted in 234 abstracts

11 Molecular pathogen detection in whole blood for sepsis patients Records identified in PubMed Search: PRISMA (n = 234) checklist Records excluded (n = 128) Excluded: malaria, Not in humans (n= 52) Language (n= 10) viral, or other Exclusion Criteria (n= 67) Records screened by title o Specimen (n= 37) (protozoan) infections and abstract o Technique (n= 13) (n = 234) o Case Report (n= 2) Yield: 19 articles o Epidemiology reports (n= 11) o Other (n= 4) Only 5 test systems CE/FDA approved Full-text articles assessed for eligibility (n = 106) Studies included (n = 19) Full-text articles excluded (n = 87) Full Text not found (n= 4) Protozoan Infection (n= 50) Exclusion Criteria (n= 33) o Analytical testing (n= 6) o Specimen (n= 9) o Case Report (n= 3) o No Pathogen identification (n= 8) o Technique (n= 4) o Not in humans (n= 2) o Not Sepsis (n= 1)

12 Molecular test Targets Susceptibility genes Virulence factors SeptiFast, Roche 25 Pathogens: S. aureus, CoNS, Streptococcus pneumoniae, Streptococcus spp. (S. pyogenes, S. agalactiae, S. mitis), E. faecium, E. faecalis, E. coli, K. pneumoniae, K. oxytoca, Proteus mirabilis, E. cloacae, E. aerogenes, Serratia marcescens, Acinetobacter baumannii, Pseudomonas aeruginosa, Stenotrophomonas maltophilia, C. albicans, C. tropicalis, C. parapsilosis, C. glabrata, C. krusei, Aspergillus fumigatus meca None SepsiTest, Molzym >300 different pathogens None None Vyoo, SIRS lab 40 different pathogens: S. pyogenes, S. pneumoniae, S. agalactiae, viridans group streptococci species, S. aureus, CoNS, E. faecalis, E. faecium, Clostridium perfringens, Bacillus cereus, E. coli, E. aerogenes, E. cloacae, K. oxytoca, K. pneumoniae, P. mirabilis, S. marcescens, Morganella morganii, P. aeruginosa, S. maltophilia, A. baumannii, Burkholderia cepacia, H. infuenzae, Neisseria meningitidis, Bacteroides fragilis, Prevotella buccae, P. melaninogenica, P. intermedia, C. albicans, C. parapsilosis, C. tropicalis, C. glabrata, C. krusei, Aspergillus fumigatus meca, vana, vanb, vanc, bla SHV None MagicPlex, Seegene 73 gram positive organisms: 30 Staphylococcus spp., 40 Streptococcus t spp., 3 Enterococcus spp., Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, Serratia marcescens, Bacteroides fragilis, Salmonella typhi, Klebsiella oxytoca, Proteus mirabilis, E. coli, E. cloacae, E. aerogenes, C. albicans, C. tropicalis, C. parapsilosis, C. glabrata, C. krusei, Aspergillus fumigatus. vana, vanb, meca None T2 Candida MR 5 Candida species: C. albicans, C. tropicalis, C. glabrata, C. krusei, C. parapsilosis None None

13 Faster results (TAT 3 30h) Only selected pathogens (bacteria and few fungi) are detected Sensitivity too low (60 95%) Specificity too low (77 99%) Limit of detection too high (1 100CFU/ml) Little susceptibility testing Expensive Complex laboratory handlings No proven effect on hospital stay or mortality Only used in complement to blood culture

14 PHASE 1: PROSPECTIVE BLOOD COLLECTION 250 PATIENTS Performance of diagnostic systems Prospective blood sample collection Comparison with gold standard Sensitivity analysis PHASE 2: INTERVENTIONAL RANDOMIZED CLINICAL TRIAL 1000 PATIENTS (2 CENTRES) Impact of diagnostic systems on clinical practice Interventional, randomized Primary Endpoint Median time to first change of therapy (hours) Secondary Endpoints: Median time to specific pathogen directed antibiotic therapy In hospital mortality, Length of hospital stay Time to optimal therapy, Number of patients with 30 day all cause mortality

15 Rights of the patient: To ask questions and receive understandable answers before making a decision To know the degree of risk and burden involved in participation To know if there are any benefits involved in participation To know how their data will be collected, protected during the project and either destroyed or re used at the end of the research, if plans to re use the data exist it participants i t will also be duly informed, and consented for further usage To know of any potential commercial exploitation of the research Informed Consent process/ Researcher obligations: Oral explanation of the study goals and handlings, the patient t rights, Written information Written approval; signing of informed consent document by patient and researcher Explicitly state that participation is voluntary and that anyone has the right to refuse to participate and to withdraw their participation, samples or data at any time, without any consequences.

16 Severely ill patients Drawing of blood for blood culture should be done BEFORE antibiotic treatment Start antibiotic treatment as soon as possible ICU patientsnot t t always fullyconscious No time/possibility for written informed consent before taking samples Solution: Delayed informed consent Regulated by MEC As soon as possible after arrival of samples in the lab Patient or his legal representative

17 Jessa Hospital Blood cultures in 2013: 12% positive Emergency Department: n = 500 sets ICU: n = 800 sets Inclusion of 250 patients in 12 months 3 departments: Intensive Care, Emergency Department, Department of Infectious Diseases SOPs will be provided

18 Presentation of patient with suspected bacteremia Routine: set of 1 aerobic + 1 anaerobic bottle Sample collection Sample collection: EDTA blood tube AFTER sampling the bottles Same venipuncture

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20 Collect clinical and laboratory data, Aliquot samples for system anonymize and store evaluation and biobank storage 3 ml 5 ml 1 ml Biobank storage Laboratory evaluation of systems

21 Randomized, d interventional ti study Time Control periods Only blood culture results are communicated to physician Test periods FAPIC diagnostic system results AND blood culture results are communicated Antimicrobial stewardship applied by microbiology/id teams FAPIC Blood Cultures Test Test Test Control Control

22 Dl Delay of 3 months to appoint PhD student speed up the preparation of the prospective blood collection and clinical data: protocol, SOPs, MEC forms Need for acceptance of a delayed informed consent procedure in principle accepted by MEC Recruitment in emergency department Jessa : support from management needed medical director supportive, ICU department taking the lead Identical protocol and forms in Zagreb University Hospital good communication and visit