Fellows journal Club
Article: Association of the FilmArray Meningitis/Encephalitis Panel with Clinical Management
Nabower AM, Miller S, Biewen B, et al. Association of the FilmArray Meningitis/Encephalitis Panel With Clinical Management. Hosp Pediatr. 2019;9(10):763-769.
Summary: PCR to rapidly detect suspected bacterial vs. viral pediatric meningitis could lead to decreased resource utilization. This study compared management practices in patients who had CSF meningitis/encephalitis (ME) panels performed versus those who had CSF cultures with enterovirus and/or HSV PCR. The authors concluded that use of the ME panel led to decreased LOS, time to antibiotic narrowing, and acyclovir dosing. The ME panel’s strengths included a high NPV for bacterial organisms and higher sensitivity for pretreated samples, but discrepant results between the ME panel and standard CSF culture required clinical judgment.
Key Strengths: The demonstration of decreased resources (acyclovir, LOS, antibiotic narrowing) shows the potential utility of the ME panel. The quick turnaround time of the panel seems to be the largest contributor to this decreased utilization. There also seems to be good clinical utility in sending the ME panel on pretreated samples to help with decision-making.
Limitations/Flaws: As PCR panels can be expensive, a cost-benefit analysis would have greatly added to the strength of this study if able to show that, despite the cost of the panel, there was overall benefit in decreased resource utilization. Perhaps an algorithmic approach such as sending an enterovirus PCR (as it typically has a short turnaround time and was the most common viral cause in this study) followed by sending the full ME panel only if the enterovirus PCR is negative would be even more cost-effective than sending the full panel as the first and only test. Another factor that could have influenced the results was the hospital’s concurrent project to discharge low-risk febrile infants in <30h.
Major Takeaway: PCR testing for viral or bacterial meningitis can help reduce resource utilization, but overall cost/benefit is unclear and likely dependent on testing cost and turnaround time. It may be most helpful for HSV/acyclovir use and in clinical decision-making for pretreated CSF cultures.
How should this article impact our practice? Sending a viral and bacterial PCR panel on pretreated CSF samples could help with decision-making in suspected pediatric meningitis. Depending on a hospital’s local resources (availability of PCR testing, cost, and turnaround time), utilization of a PCR test for viral and/or bacterial pathogens may be useful in decreasing acyclovir use, time to narrowing antibiotics, and LOS. However, additional information including a cost-benefit analysis is needed.
Nabower AM, Miller S, Biewen B, et al. Association of the FilmArray Meningitis/Encephalitis Panel With Clinical Management. Hosp Pediatr. 2019;9(10):763-769.
Summary: PCR to rapidly detect suspected bacterial vs. viral pediatric meningitis could lead to decreased resource utilization. This study compared management practices in patients who had CSF meningitis/encephalitis (ME) panels performed versus those who had CSF cultures with enterovirus and/or HSV PCR. The authors concluded that use of the ME panel led to decreased LOS, time to antibiotic narrowing, and acyclovir dosing. The ME panel’s strengths included a high NPV for bacterial organisms and higher sensitivity for pretreated samples, but discrepant results between the ME panel and standard CSF culture required clinical judgment.
Key Strengths: The demonstration of decreased resources (acyclovir, LOS, antibiotic narrowing) shows the potential utility of the ME panel. The quick turnaround time of the panel seems to be the largest contributor to this decreased utilization. There also seems to be good clinical utility in sending the ME panel on pretreated samples to help with decision-making.
Limitations/Flaws: As PCR panels can be expensive, a cost-benefit analysis would have greatly added to the strength of this study if able to show that, despite the cost of the panel, there was overall benefit in decreased resource utilization. Perhaps an algorithmic approach such as sending an enterovirus PCR (as it typically has a short turnaround time and was the most common viral cause in this study) followed by sending the full ME panel only if the enterovirus PCR is negative would be even more cost-effective than sending the full panel as the first and only test. Another factor that could have influenced the results was the hospital’s concurrent project to discharge low-risk febrile infants in <30h.
Major Takeaway: PCR testing for viral or bacterial meningitis can help reduce resource utilization, but overall cost/benefit is unclear and likely dependent on testing cost and turnaround time. It may be most helpful for HSV/acyclovir use and in clinical decision-making for pretreated CSF cultures.
How should this article impact our practice? Sending a viral and bacterial PCR panel on pretreated CSF samples could help with decision-making in suspected pediatric meningitis. Depending on a hospital’s local resources (availability of PCR testing, cost, and turnaround time), utilization of a PCR test for viral and/or bacterial pathogens may be useful in decreasing acyclovir use, time to narrowing antibiotics, and LOS. However, additional information including a cost-benefit analysis is needed.
Fellow: Britanny Winckler, MD, MBA,
Pediatric Hospital Medicine Fellow PGY-5
UC San Diego/Rady Children’s Hospital San Diego
Fellowship accomplishments and current research or work: My main research project utilizes spatial analysis (for those unfamiliar with this concept, the Johns Hopkins COVID map is a good example) to look at geographic associations of mental health utilization of the hospital and ED. I have also been able to participate in a QI project implementing inpatient food insecurity screening and lead a PDSA cycle.
Goals/Plans: During medical school, I also completed an MBA as I wanted to be better able to affect patient care from a systems-level. In my career, I endeavor to combine clinical and administrative work to truly improve population health with particular emphasis on social determinants of health and mental health care.
Fun fact: I’m a former Disneyland Cast Member and operated the rides in Fantasyland during college. That probably should have been my first clue that I would become a pediatrician, but I didn’t even consider Pediatrics until after I did my third-year clinical rotation in medical school!
Pediatric Hospital Medicine Fellow PGY-5
UC San Diego/Rady Children’s Hospital San Diego
Fellowship accomplishments and current research or work: My main research project utilizes spatial analysis (for those unfamiliar with this concept, the Johns Hopkins COVID map is a good example) to look at geographic associations of mental health utilization of the hospital and ED. I have also been able to participate in a QI project implementing inpatient food insecurity screening and lead a PDSA cycle.
Goals/Plans: During medical school, I also completed an MBA as I wanted to be better able to affect patient care from a systems-level. In my career, I endeavor to combine clinical and administrative work to truly improve population health with particular emphasis on social determinants of health and mental health care.
Fun fact: I’m a former Disneyland Cast Member and operated the rides in Fantasyland during college. That probably should have been my first clue that I would become a pediatrician, but I didn’t even consider Pediatrics until after I did my third-year clinical rotation in medical school!
Previous Articles:
- Hannah Neubauer - HHFNC vs. low flow
- Amanda Messer - UTIs and renal scarring
- Christiane Lenzen - procalcitonin and CAP
- Melanie Rudnick - dexamethasone and parapneumonic effusions
- Jane Im - empiric antibiotic therapy in infants
- Ashley Jenkins - AKI with vancomycin and piperacillin/tazobactam therapy
- Fatuma Barqadle - US for LPs
- Marni Shear - Hypotonic IV fluids and bronchiolitis
- Ivy Tam - Ipratropium and IV magnesium in asthmatics
- Daniela Burger - HSV in Infants
- Lindsay Weiss - macrolides in pneumonia
- Tiranun Rungvivatjarus - High Flow Nasal Cannula
- Karisa Grizzle - Empiric Antibiotics in Osteomyelitis
- Mike Fenster - Bacterial meningitis in positive UA
- Courtney Charvat - CSF bioplex assay
- Audrey Uong - Complex Care Discharges
- Adam Cohen - Early Master Clinician Traits
- Alice Lee - Variation in Orbital Cellulitis Care
- Joy Solano - Family centered interventions to improve education
- Sunita Hemani - Discharging after q3 albuterol in asthma
- Jennifer Chen - Discharge Instruction Literacy
- John Morrison - Readmission Models for Complex Care
- Hanna Siddiqui - Fever, PEWS, and deterioration
- Kate Kyler - Reducing Safety Events in Suicidal Patients via QI
- Sonya Tang Girwood - Antibiotics in RSV Related Respiratory Failure
- Maria Santos - Positive UA and Meningitis
- Chionye Ossai - Parent Perception of Patient Portal
- Sarah Bram - Predictors of bacteremia in CAP
- Kris Chang - Note Bloat
- Risa Bochner - SBI with fever alone <60 days
- Alexandra Kilinsky - Promoting Fellow Autonomy
- Sasha Wee - Somatic Symptom Pathway
- Kate Donowitz - Predicting High Risk BRUE
- Caleb Hancock - Imaging Cervical Lymphadenitis
- Nathan Money - Duration of Antibiotics in Pyelonephritis
- Alison Carroll - Criteria for Invasive Bacterial Infections
- Scarlett Johnson - Deimplementation of Interventions in Bronchiolitis
- Brandon Palmer - HFNC in Bronchiolitis
- Lea Bornstein and Amelia Castro - Rebound Hyperbili Prediction