Impact of Rapid Diagnostic Testing for Chlamydia and Gonorrhea on Appropriate

Antimicrobial Utilization in the Emergency Department

Kaitlyn R. Rivard, Lisa E. Dumkow, Heather M. Draper, Kasey L. Brandt , David

W.Whalen, Nnaemeka E. Egwuatu

A. Department of Pharmaceutical Services, Mercy Health Saint Mary's, Grand

Rapids, MI 49503, USA
B. Department of Emergency Medicine, Mercy Health Saint Mary's, Grand Rapids,
MI 49503, USA
C. Department of Infectious Diseases, Mercy Health Saint Mary's, Grand Rapids,
MI 49503, USA

Abstract
Background: Prolonged turnaround time of Neisseria gonorrhoeae (NG) and
Chlamydia trachomatis (CT) test results may delay time to notification and treatment of
test-positive patients and result in unnecessary antimicrobial use in test negative
patients. This quasiexperimental study evaluated the impact of NG/CT rapid diagnostic
testing (RDT) in an urban emergency department (ED) on treatment appropriateness,
time to notification, and cost. Patients tested in December 2013January 2014
(traditional group, n = 200) were compared with those in December 2014January 2015
(RDT group, n = 200). There was a significant increase in treatment appropriateness in
the RDT group, 72.5% versus 60% (P = 0.008) and time to results notification was
significantly faster (median 17.4 versus 51.5 hours, P = 0.010). Availability of test
result prior to discharge was associated with increased treatment appropriateness (odds
ratio, 22.65 [95% confidence interval, 2.86179.68]). The RDT would save
approximately $37,000 annually. These results support the use of NG/CT RDT to
expand antimicrobial stewardship efforts within the ED.
Introduction

N. gonorrhoeae (NG) and C. trachomatis (CT) are the most common bacterial
sexually transmitted infections (STI) which can result in serious complications if left
untreated.(Centers for Disease Control and Prevention; Centers for Disease Control and
Prevention, 2015a) In 2014, there were more than 350,000 cases of NG and 1.4 million
cases of CT reported in the United States alone (Centers for Disease Control and
Prevention). Nonculture methods, including nucleic acid amplification tests (NAAT),
arewidely available for the detection of genital NG/CT and are the preferred diagnostic
tests recommended by the Centers for Disease Control and Prevention (CDC) (Centers
for Disease Control and Prevention, 2014). With traditional NAAT, many health care
facilities have a turnaround time between 1 and 4 days for results of NG/CT. This
prolonged time to results impacts time to patient and partner notification as well as
treatment for test-positive patients who do not receive empiric therapy. Meanwhile,
excessive empiric antimicrobial use in test-negative patients may contribute to
increasing rates of antimicrobial resistance (U.S. Department of Health and Human
Services Centers for Disease Control and Prevention, 2014).
The emergence of widespread antimicrobial resistance is a threat to public
health. The CDC considers drug-resistant NG as an immediate public health threat that
requires urgent and aggressive action (U.S. Department of Health and Human Services
Centers for Disease Control and Prevention, 2014). Since 1986, the CDC's Gonococcal
Isolate Surveillance Project has monitored NG susceptibility to different antimicrobial
therapies. Ceftriaxone and azithromycin, 2 of the last remaining antimicrobials with
reliable coverage against NG, now demonstrate elevated MICs (Centers for Disease
Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention).While the percentage of NG isolates with decreased susceptibility to
ceftriaxone peaked at 0.4% in 2011 and stabilized in 2013 at 0.05%, continued
surveillance is warranted (Centers for Disease Control and Prevention National Center
for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention; Centers for Disease Control
and Prevention, 2015b). The CDC Sexually Transmitted Diseases treatment guidelines
recommend combination therapy for the treatment of NG to prevent the selective
pressure for resistance to the remaining treatment options (Centers for Disease Control
and Prevention, 2015b).
Antimicrobial stewardship programs have been developed within hospitals to
promote optimal prescribing of antimicrobial agents in an effort to increase efficacy,
improve patient safety, and reduce antimicrobial resistance (Dellit et al., 2007; Society
for Healthcare Epidemiology of America et al., 2012). The development of rapid
diagnostic tests (RDTs) can help to achieve these goals by providing timely detection of
infectious organisms and allowing for targeted antibiotic therapy. The Infectious
Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of
America (SHEA) advocate for the use of RDT to improve detection capabilities and to
guide appropriate treatment as part of an antimicrobial stewardship program. SHEA and
the IDSA also agree that investigations evaluating the development and cost-
effectiveness of RDT are a priority. A RDT NAAT for the detection of genital NG/CT
was approved in 2012. Independent analyses of the RDT have reported equivalent
sensitivity and specificity as compared with traditional NAAT (Gaydos et al., 2013;
Goldenberg et al., 2012; Tabrizi et al., 2013). A recently published open-label,
randomized, controlled trial in emergency department (ED) patients found that use of
the RDT for NG/CT resulted in decreased unnecessary antibiotic exposure in test-
negative patients (May et al., 2016). Subjects randomized to the RDT arm were required
to wait in the ED for 90 minutes following sample collection, increasing the likelihood
that the patient would be present at the time the test results became available (May et
al., 2016). This may not be feasible in a real-world setting. Additionally, the impact of
the RDT on time to patient notification of test results or time to appropriate treatment
was not evaluated.
The purpose of this studywas to determine if implementation of NG/CT RDT as
the standard of care in the ED would improve treatment appropriateness by decreasing
antimicrobial exposure in test-negative patients while increasing treatment rate in test-
positive patients. We hypothesized that the implementation of the RDT would result in
increased treatment appropriateness for NG/CT as well as improved time to patient
notification and decreased cost of care.

Material and Methods

1. Study design and setting
This single-center, quasi-experimental study was conducted at an urban
community teaching hospital with approximately 70,000 ED visits per year and
more than 1500 NG/CT tests performed annually in the ED. Patients 15 years
of age who were tested for NG/CT via the RDT (December 2014January 2015)
were compared to a historical control group tested using a traditional NAAT
(December 2013January 2014). Patients were excluded if they were tested at a
satellite facility or admitted to the hospital following testing. Patients who left
the ED prior to examination were excluded, as a provider was unable to evaluate
the patient for empiric therapy. Patients diagnosed with pelvic inflammatory
disease (PID) were also excluded, as treatment of PID may overlap with NG/CT
treatment despite negative test results. Institutional review board approval with
waiver of informed consent was obtained prior to study initiation.

2. Preintervention testing process

Traditional testing was performed using the Gen-Probe Aptima Combo 2
for NG/CT Assay (Hologic, Bedford, MA). Samples utilized by the ED included
male urine or urethral samples and female endocervical samples. Once received
by the microbiology laboratory, samples were placed in transport media and
then couriered to an off-site laboratory for testing. The expected turnaround time
from collection to results was 2472 hours. Results were posted by the off-site
laboratory 24 hours per day as they became available. A report of all results was
reviewed once daily by ED staff.

3. RDT validation and intervention testing process

RDT was performed using the GeneXpert CT/NG assay (Cepheid,
Sunnyvale, CA). The RDT was validated compared with the traditional testing
method with sensitivity and specificity consistent with that reported by the
manufacturer (Cepheid, 2015). A total of 53 patient specimens were collected
and tested including male and female first-catch urine samples, patient-collected
vaginal swabs, and provider-collected endocervical swabs. Additionally, a
NG/CT verification panel was tested containing 17 samples: 4 strains of C.
trachomatis, 2 strains of N. gonorrhoeae, 1 strain of N. cinerea, and 1 strain of
 N. flavenscens. The sensitivity for CT was 100% and specificity was 100%. The
sensitivity for GC was 94% and specificity was 100%.
Samples utilized by the ED included urine specimens for males and
females, self-collected vaginal swabs, and provider-collected endocervical
swabs. Once received by the microbiology laboratory, samples were tested
immediately using the RDT. The expected time from collection of specimen to
results was approximately 120180 minutes. Providers were responsible for
assessing if results were available prior to patient discharge and decision to treat.
Additionally, an electronic report was generated for review once daily by ED
staff displaying all results from the previous 24 hours.

4. Selection of participants
A computer-generated report from the electronic medical record was
used to retrospectively identify all patients tested for NG/CT during the study
period. Data collected included patient characteristics, testing characteristics,
antimicrobial therapy administered, initial treatment appropriateness, time to test
results, time to patient notification of positive test results, time to appropriate
treatment, and ED length of stay.
The traditional testing group consisted of 200 consecutive patients
presenting to the ED between December 1, 2013 and January 31, 2014. Patients
tested for NG/CT were considered for empiric treatment prior to discharge at
provider discretion (Centers for Disease Control and Prevention, 2015b). Once
test results returned, ED staff notified patients who tested positive for NG/CT of
their results and provided counseling and education by telephone. Patients who
did not receive empiric treatment were provided with treatment either by a
telephone prescription or by request to return to the ED for parenteral
antimicrobial administration. If a patient was unable to be contacted after 3
telephone attempts, a certified letter wasmailed to the patient and patient
information was forwarded to the county health department for follow up.
The RDT was implemented for ED use in October 2014. The RDT group
consisted of 200 consecutive patients presenting to the ED between December 1,
2014 and January 31, 2015. If results were available prior to discharge, patients
with positive results were provided notification, counseling, and treatment for
NG/CT while in the ED. Test-negative patients were notified and spared
unnecessary antimicrobial administration. If patients were ready for discharge
prior to the completion of RDT results, providers had the option to provide
patients with empiric treatment and allow follow-up of results after discharge.
Providers were not encouraged to delay patient discharge in order to await RDT
results. ED staff would contact patients with positive results for notification,
counseling, and treatment following the same process as the traditional test. In
both groups, patients were also screened and treated for additional STIs (e.g.,
trichomonas) if indicated.

5. Outcomes
The primary end point of this study was to compare the percentage of
patients who received appropriate treatment during their index ED visit using the
traditional test versus the RDT for NG/CT. Appropriate treatment was defined
as the combined end point of test-positive patients receiving antimicrobial
therapy in concordance with the CDC 176 K.R. Rivard et al. / Diagnostic
 Microbiology and Infectious Disease 87 (2017) 175-179 guidelines and test-
negative patients not receiving antimicrobial treatment.
Secondary end points included time to test results, time to patient
notification of positive test results, and time to appropriate treatment. Time to
test result was calculated as the time the laboratory received the sample to the
time that test results were uploaded to the medical record. Time to patient
notification of positive test results was calculated as the time the NG/CT results
became available to the time that patient notification was documented in the
medical record. Time to appropriate treatment for test-positive patients was
calculated as the time the NG/CT results became available to the time that
appropriate antimicrobial therapy was provided. Provision of appropriate
antimicrobial therapy included initial medication administration in the ED,
readmission to the ED for treatment, or a telephone prescription. A cost analysis
was performed using institutional financial data to determine the average cost of
appropriate and inappropriate treatment in both groups. Costs were derived
using the direct cost to the institution of the test, cost of the ED visit and revisit
based on diagnosis code, and cost of antimicrobials
.
6. Analysis
The studywas powered to detect a 15% absolute difference in appropriate
initial antimicrobial treatment using a 2-sided testwith =0.05 and = 0.2. A
15% effect size was chosen based on previous literature evaluating the
integration of RDTs into antimicrobial stewardship programs (Clerc et al., 2013;
Parta et al., 2010). It was determined that 167 patients in each arm would need
to be included in this study. Pilot data from the study site found that
approximately 125 patients per month were tested, therefore, 2 months were
included in each group with a maximum enrollment of 200 patients per group
(n=400).
For all baseline characteristics and study end points, categorical data
were compared using chi square or Fisher exact test; continuous data were
compared using Student's t test or theMannWhitney U test. Multivariate
logistic regression analysis was performed to determine clinically relevant
variables that were independently associated with treatment appropriateness. All
variables associated with appropriate therapy in bivariate analysis (P b 0.2) were
considered for inclusion in the multivariate model. Forward entry was used to
derive the final model for appropriate therapy. Significant variables in the final
model had a P b 0.05. Statistical testing was conducted using SPSS 21.0 (SPSS,
Chicago, IL)

Result

1. Characteristics of study subjects

A total of 400 patients (200 per group) were included in the analysis.
Baseline characteristics were similar between groups (Table 1). There were
more females (80% versus 71.5%, P = 0.047) and more pregnant patients (21%
versus 12%, P=0.022) in the traditional group compared with the RDT group,
respectively. Nineteen patients (9.5%) tested positive for NG/CT in the
traditional group and 20 patients (10%) tested positive in the RDT group. The
overall prevalence of CT infection, NG infection, and coinfection with NG/CT
 was 6.0% (n = 12), 2.0% (n = 4), and 1.5% (n = 3) in the traditional group and
7.0% (n = 14), 1.5% (n = 3), and 1.5% (n = 3) in the RDT group, respectively.

2. Main results
Initial treatment was considered appropriate in 60% of patients in the
traditional group compared with 72.5% in the RDT group (P = 0.008, Table 1).
This difference was driven by test-negative patients being spared unnecessary
antimicrobial therapy. For test-positive patients, empiric treatment was
appropriately administered at the index ED visit in 15 patients (78.9%) in the
traditional group and 18 patients (90%) in the RDT group (P=0.407). Median
time to test results was significantly decreased in the RDT group compared with
the traditional group (2.4 [1.412.0] versus 31.7 [9.7105.9] hours, P b 0.001),
as was time to patient notification of positive results (17.4 [0.093.0] versus
53.7 [26.979.9] hours, P = 0.010). Of note, there were 2 patients in the
traditional group (all treated empirically) and 7 in the RDT group (5 treated
empirically) who were unable to be notified of their positive test results via
telephone (P=0.092). There were no statistically significant differences in time
to test order or in ED length of stay (Table 1).

Mean time to appropriate treatment for test-positive patients in

the traditional group was 23.0 56.3 hours. Fifteen patients (78.9%)
were treated empirically at the initial ED visit and 4 (21.1%) required
 follow-up for provision of treatment. Of those that required treatment
after discharge, 2 (10.5%) patients were asked to return to the ED for
treatment of NG. The mean time to appropriate treatment in the RDT
group was 4.9 21.3 hours. All patients in the RDT group were treated
prior to ED discharge orwere lost to follow-up; 5 (25%)were definitively
treated at the initial ED visit (positive results were available prior to
discharge and used to direct therapy), 13 (65%) were empirically treated
at the initial ED visit, and 2 (10%) were unable to be contacted via
telephone and required follow-up by the county health department. No
patient in the RDT group required readmission for treatment. Testing via
RDT was associated with $4891 in cost savings ($24.46 per patient)
compared with traditional testing over the course of the study ($343,566
versus $348,457).
Ten variables were chosen for multivariate logistic regression to
test for factors independently associated with appropriate treatment
(Table 2). The only factor positively associated with treatment
appropriateness was availability of the NG/CT test results prior to
discharge (odds ratio [OR], 22.65 [95% confidence interval {CI}, 2.86
179.68, P= 0.003]). In total, 40 patients in the RDT group were able to be
notified of their test results prior to discharge. Of these patients, 5were
testpositive and 100% of these patients received appropriate treatment.
Of the 35 test-negative patients, 34 were spared unnecessary
antimicrobial use. One patient was treated despite having negative results
because the patient was a self-reported commercial sex worker. Patients
reporting the symptom of genital discharge were more likely to receive
inappropriate treatment (OR, 0.42 [95% CI, 0.260.68, P b 0.001]).

Discussion

The ED presents an important area for the implementation of RDTs to promote

appropriate antibiotic use as antibiotics are prescribed frequently and their downstream
effects can be far-reaching. This study found that the implementation of an RDT as the
standard of care for NG/CT testing was associated with a significant increase in
antimicrobial treatment appropriateness. Over the course of the study period, the
number of patients needed to test with the RDT to prevent 1 patient from receiving
inappropriate therapy was 8 patients. In light of the increasing antimicrobial resistance
of NG, these results are important as prior literature have shown initial treatment
appropriateness of NG/CT to be low. A literature review comparing 13 studies
evaluating NG/CT testing and empiric treatment in several EDs found that 4384% of
test-positive patients were not provided with initial empiric treatment while 7.931.9%
of test-negative patients were treated empirically (Jenkins et al., 2013). A retrospective
cohort evaluating 1260 women for NG/CT in an inner city, county ED discovered that
88.3% of test negative patients received empiric treatment while 38.3% who tested
positive were untreated on their initial visit (Levitt et al., 2003).
There is a paucity of literature evaluating the use of RDT to improve
antimicrobial utilization in patients tested for NG/CT in any setting, including the ED.
Three studies have been published evaluating hypothetical models of NG/CT RDT in
the outpatient clinic setting and its effect on patient outcomes and cost of care. These
studies showed that implementation of the RDT could likely decrease the prevalence of
disease, reduce complications, and provide significant cost savings (Huang et al., 2013;
Hui et al., 2013; Turner et al., 2014). Recently, a randomized, controlled trial was
published comparing the use of the RDT to a standard of care NAAT in 70 ED patients
and demonstrated improved utilization of antimicrobials (May et al., 2016). Our study
demonstrated not only improved appropriate antimicrobial utilization, but also
improved time to patient notification for positive results and decreased cost of care. It is
important to note that ED length of stay was similar between the traditional and RDT
groups; therefore, utilization of the RDT did not impact ED throughput. Additionally,
the RDT resulted in cost savings. This was driven by differences in traditional testing
and RDT costs ($26 versus $19, respectively), decreased antimicrobial utilization, and
decreased need for ED readmission. Extrapolated over 12 months, the RDT would save
approximately $37,000 annually. These cost savings do not account for adverting PID
or other complications. Of note, this was a retrospective study, which relies on the
accuracy of documentation.
The results of this study additionally suggest that process improvement should
be made to optimize the utilization of the RDT within the ED. Of the 200 patients tested
in the RDT group, only 40 (20%) were present in the ED at the time their results
became available. In the multivariate logistic regression, the only factor found to
positively impact treatment appropriateness was having test results available prior to
discharge fromthe ED. Of note, use of the RDT alone was not independently associated
with treatment appropriateness. There is often a delay in reaching a patient for follow-
up after discharge from the ED. This could potentially result in a delay of treatment if
the patient is not treated empirically, as well as a delay to notification and treatment of
affected partners. The implications of this underscore the need for rapid test results as a
matter of public health. Based on the results of this analysis, the authors have suggested
targeted interventions to increase the proportion of test results available prior to
discharge, including the improved utilization of a nursing triage order for NG/CT
testing to increase the number of tests performed before examination with a provider.
Utilization of this order for patients meeting certain criteria during the triage process
may allow for faster time to test order and processing which would increase the
likelihood of test results becoming available during the ED visit.We hypothesize that
improved utilization of the RDT will result in more patients receiving results prior to
discharge, which will translate into more patients being treated appropriately and
partners being notified sooner.
The only factor found to negatively impact treatment appropriateness were
patients presenting to the ED with the symptom of genital discharge, likely due to a
large number of test-negative patients receiving empiric antimicrobial therapy.While we
recognize that the standard of care is to provide symptomatic patients with treatment for
NG/CT, these patients were classified as inappropriately treated for the purposes of
our evaluation to demonstrate the number of patients who could have been spared
unnecessary antimicrobial use if RDT results were available prior to ED discharge.
Additionally, there is a potential for bias anytime a new process is implemented. As
there were many educational updates on the NG/CT testing process, providers may have
had heightened vigilance in the RDT phase to provide empiric treatment. The impact of
temporal differences between study periods was minimized because the study
intervention was the only change made to the standard of care during this time period.
Furthermore, comparing the same time period for 2 consecutive years minimized
seasonal variation in the number of patients tested for NG/CT.
In conclusion, implementation of a RDT for NG/CT in the ED significantly
improved initial treatment appropriateness by sparing unnecessary antimicrobial use,
decreased time to patient notification, and resulted in cost savings. Having test results
prior to patient discharge from the ED was independently associated with receiving
appropriate treatment. Interventions to increase the proportion of tests resulted prior to
discharge are warranted to improve utilization of the RDT. The findings of this
evaluation support the use of the NG/CT RDT as a component of antimicrobial
stewardship in the ED

Acknowledgements

The authors wish to acknowledge G. Robert DeYoung, PharmD, BCPS, for his
administrative and data management support as well as Cora Manby, Microbiology
Technical Specialist for her support with testing validation and implementation.

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 Dampak Uji Diagnostik Cepat untuk Klamidia dan Gonore pada Pemanfaatan
Antimikroba yang Tepat di Departemen Gawat Darurat

Kaitlyn R. Rivard, Lisa E. Dumkow, Heather M. Draper, Kasey L. Brandt , David

W.Whalen, Nnaemeka E. Egwuatu

D. Department Pelayanan Farmasi, Mercy Health Saint Mary's, Grand Rapids, MI

49503, USA
E. Department Obat Gawat Darurat, Mercy Health Saint Mary's, Grand Rapids, MI
49503, USA
F. Department Penyakit Infeksi, Mercy Health Saint Mary's, Grand Rapids, MI
49503, USA

Abstrak
Latar Belakang: Hasil test Neisseria gonorrhea (NG) dan Chlamydia trachomantis
(CT) yang berlangsung lama dan berulang dapt memperlambat pemberitahuan dan
pengobatan pada pasien tes-positif dan mengakibatkan penggunaan antimikrobial tidak
dibutuhkan pada pasien dengan hasil tes-negatif. Studi kuasi eksperimental ini
mengevaluasi dampak dari uji diagnostik cepat atau rapid diagnostic test (RDT) NG/CT
di departemen gawat darurat atau emergency department (ED) perkotaan mengenai
kesesuaian pengobatan, waktu pemberitahuan, dan biaya. Pasien diuji pada Desember
2013-Januari 2014 (kelompok tradisional, n = 200) dibandingkan dengan pasien pada
Desember 2014-Januari 2015 (kelompok RDT, n = 200). Terdapat peningkatan yang
signifikan pada kesesuaian pengobatan di kelompok RDT, 72.5% melawan 60% (P =
0.008) dan waktu untuk hasil pemberitahuan lebih cepat secara signifikan (median 17.4
dibanding 51.5 jam, P = 0.010). Ketersediaan hasil uji sebelum pemulangan pasien
berkaitan dengan peningkatan kesesuaian pengobatan (rasio odds, 22.65 [interval
kepercayaan 95%, 2.86179.68]). RDT akan menghemat sekitar $37,000 pertahun.
Hasil ini mendukung penggunaan RDT NG/CT untuk memperluas upaya pengelolaan
antimikroba pada ED
Pendahuluan

N. gonorrhoeae (NG) dan C. trachomatis (CT) merupakan 2 infeksi menular

seksual atau sexually transmitted infections (STI) paling umum, dimana hal ini akan
mengakibatkan komplikasi serius jika dibiarkan dan tidak diobati. (Centers for Disease
Control and Prevention; Centers for Disease Control and Prevention, 2015a) Pada
tahun 2014, telah dilaporkan lebih 350,000 kasus NG dan 1.4 juta kasus CT di Amerika
Serikat (Centers for Disease Control and Prevention). Metode non-kultur, termasuk uji
amplifikasi asam nukleat atau nucleic acid amplification tests (NAAT), tersedia secara
luas untuk mendeteksi NG/CT genital dan merupakan uji diagnostik yang dipilih dan
direkomendasi oleh Centers for Disease Control and Prevention (CDC) (Centers for
Disease Control and Prevention, 2014). Dengan NAAT tradisional, banyak fasilitas
kesehatan dapat melakukan hasil uji NG/CT dengan waktu penyelesaian antara 1 dan 4
hari. Perpanjangan waktu untuk hasil uji coba ini berdampak pada pemberitahuan
pasien dan pasangannya, sebagaimana juga dengan pengobatan untuk hasil pasien tes-
positif yang tidak mendapatkan terapi empiris. Sementara itu, penggunaan terapi
antimikroba empiris berlebihan pada pasien tes-negatif dapat menyebabkan peningkatan
resistensi antimikroba (U.S. Department of Health and Human Services Centers for
Disease Control and Prevention, 2014).
Timbulnya penyebaran resistensi antimikroba merupakan ancaman bagi
kesehatan masyarakat. CDC mempertimbangkan NG resisten obat sebagai ancaman
kesehatan masyarakat yang memerlukan tindakan segera dan agresif (U.S. Department
of Health and Human Services Centers for Disease Control and Prevention, 2014).
Sejak tahun 1986, Proyek Pengawasan Isolasi Gonococcal CDC telah mengawasi
kerentanan NG terhadap terapi antimikroba yang berbeda. Ceftriaxone dan
azithromycin, 2 dari antimikroba terkahir yang tersisa dengan cakupan yang dapat
diandalkan melawan NG dan sekarang menunjukkan peningkatan MIC (Centers for
Disease Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, STD,
and TB Prevention). Sementara persentase isolasi NG dengan penurunan kerentanan
terhadap ceftriaxone mencapai puncaknya pada 0,4% pada tahun 2011 dan stabil pada
tahun 2013 sebesar 0,05%, pengawasan lanjutan masih diperlukan (Centers for Disease
Control and Prevention National Center for HIV/AIDS, Viral Hepatitis, STD, and TB
Prevention; Centers for Disease Control and Prevention, 2015b). Pedoman pengobatan
Penyakit Menular Seksual CDC merekomendasikan terapi kombinasi pada pengobatan
NG untuk mencegah tekanan selektif dan resistensi terhadap pilihan pengobatan yang
tersisa (Centers for Disease Control and Prevention, 2015b).
Program pengelolaan antimikroba telah dikembangkan di dalam rumah sakit
untuk mempromosikan resep agen antimikroba yang optimal dalam upaya
meningkatkan khasiat, memperbaiki keamanan pasien, dan mengurangi resistensi
antimikroba (Dellit et al., 2007; Society for Healthcare Epidemiology of America et al.,
2012). Pengembangan rapid diagnostic tests (RDTs) dapat membantu mencapai tujuan
ini dengan menyediakan deteksi organisme infeksi yang tepat waktu dan
memungkinkan terapi antibiotik sesuai terget. The Infectious Diseases Society of
America (IDSA) dan Society for Healthcare Epidemiology of America (SHEA)
menganjurkan penggunaan RDT untuk meningkatkan kemampuan deteksi dan untuk
memandu pengobatan yang tepat sebagai bagian dari program penatagunaan
antimikroba. SHEA dan IDSA juga sepakat bahwa penyelidikan yang mengevaluasi
pengembangan dan efektivitas biaya RDT adalah prioritas. RDT NAAT untuk deteksi
genital NG / CT disetujui pada tahun 2012. Analisis independen terhadap RDT telah
melaporkan sensitivitas dan spesifisitas yang setara dibandingkan dengan NAAT
tradisional (Gaydos et al., 2013; Goldenberg et al., 2012; Tabrizi et al., 2013). Uji coba
baru-baru ini open-label, acak, controlled pada pasien departemen gawat darurat (ED)
menemukan bahwa penggunaan RDT untuk NG / CT mengakibatkan penurunan
paparan antibiotik yang tidak perlu pada pasien tes-negatif (May et al., 2016). Subjek
yang diacak pada RDT diminta untuk menunggu di ED selama 90 menit setelah
pengumpulan sampel, meningkatkan kemungkinan pasien yang hadir pada saat hasil tes
tersedia (May et al., 2016). Hal ini mungkin tidak layak dilakukan dilapangan. Selain
itu, dampak RDT pada waktu untuk pemberitahuan pasien terhadap hasil tes atau waktu
untuk pengobatan yang tepat tidak dievaluasi.
Tujuan dari penelitian ini adalah untuk mengetahui apakah penerapan RDT NG /
CT sebagai standar perawatan di ED akan memperbaiki kesesuaian pengobatan dengan
mengurangi paparan antimikroba pada pasien tes-negatif sambil meningkatkan tingkat
pengobatan pada pasien dengan tes-positif. Kami berhipotesis bahwa pelaksanaan RDT
akan menghasilkan peningkatan kesesuaian pengobatan untuk NG / CT serta perbaikan
waktu untuk pemberitahuan pasien dan penurunan biaya perawatan.

Bahan dan Metode

1. Desain studi dan pengaturan
Penelitian kuasi-eksperimental, single-center ini dilakukan di sebuah
rumah sakit pendidikan di perkotaan dengan sekitar 70.000 kunjungan ED per
tahun dan lebih dari 1500 tes NG / CT dilakukan setiap tahun di ED. Pasien
berusia 15 tahun yang diuji untuk NG / CT melalui RDT (Desember 2014-
Januari 2015) dibandingkan dengan historis kelompok kontrol yang diuji
menggunakan NAAT tradisional (Desember 2013-Januari 2014). Pasien
dieksklusikan jika mereka diuji di fasilitas satelit atau dirawat di rumah sakit dan
mengikuti test. Pasien yang meninggalkan ED sebelum pemeriksaan
dieksklusikan, karena penyedia layanan tidak dapat mengevaluasi pasien untuk
terapi empiris. Pasien yang didiagnosis dengan pelvic inflammatory disease
(PID) juga dieksklusikan, karena pengobatan PID mungkin tumpang tindih
dengan pengobatan NG / CT meskipun hasil tes negatif. Persetujuan dewan
pengawas kelembagaan dengan pengabaian informed consent diperoleh sebelum
inisiasi studi.

2. Proses pengujian pre-intervensi

Pengujian tradisional dilakukan dengan menggunakan Gen-Probe
Aptima Combo 2 untuk NG / CT Assay (Hologic, Bedford, MA). Sampel yang
digunakan oleh ED termasuk urin laki-laki atau sampel uretra dan sampel
endoserviks wanita. Setelah diterima oleh laboratorium mikrobiologi, sampel
ditempatkan di media transportasi dan kemudian dikirim ke laboratorium di luar
lokasi untuk pengujian. Waktu penyelesaian yang diharapkan dari pengumpulan
sampai hasil adalah 24-72 jam. Hasil diumumkan oleh laboratorium off-site 24
jam per hari jika tersedia. Laporan dari semua hasil ditinjau sekali sehari oleh
staf ED.
3. Validasi RDT dan proses penngujian intervensi
RDT dilakukan dengan menggunakan uji GeneXpert CT / NG (Cepheid,
Sunnyvale, CA). RDT divalidasi dibandingkan dengan metode pengujian
tradisional dengan sensitivitas dan spesifisitas yang konsisten dengan yang
dilaporkan oleh pabrik (Cepheid, 2015). Sebanyak 53 spesimen pasien
dikumpulkan dan diuji termasuk sampel urin tangkapan pertama pria dan wanita,
swab vagina yang dikumpulkan oleh pasien, dan swab endoserviks yang
dikumpulkan oleh penyedia. Selain itu, panel verifikasi NG / CT diuji dengan 17
sampel: 4 strain C. trachomatis, 2 strain N. gonorrhoeae, 1 strain N. cinerea, dan
1 strain N. flavenscens. Sensitivitas CT adalah 100% dan spesifisitas 100%.
Sensitivitas GC adalah 94% dan spesifisitas 100%.
Sampel yang digunakan oleh ED termasuk spesimen urin untuk pria dan
wanita, swab vagina yang dikumpulkan sendiri, dan swab endoserviks yang
dikumpulkan oleh penyedia. Setelah diterima laboratorium mikrobiologi, sampel
diuji segera dengan menggunakan RDT. Waktu yang diharapkan dari
pengumpulan spesimen sampai hasil kira-kira 120-180 menit. Penyedia
bertanggung jawab untuk menilai apakah hasilnya tersedia sebelum pasien
dipulangkan dan keputusan untuk diobati. Selain itu, laporan elektronik dibuat
untuk dikaji ulang setiap hari oleh staf ED yang menampilkan semua hasil dari
24 jam sebelumnya.

4. Seleksi peserta
Laporan yang dihasilkan komputer dari rekam medis elektronik
digunakan secara retrospektif mengidentifikasi semua pasien yang diuji NG / CT
selama masa studi. Data yang dikumpulkan meliputi karakteristik pasien,
karakteristik pengujian, terapi antimikroba yang diberikan, kesesuaian
pengobatan awal, waktu untuk menguji hasil, pemberitahuan waktu terhadap
pasien hasil test-positif, waktu untuk pengobatan yang sesuai, dan lama rawatan
ED.
Kelompok uji tradisional terdiri dari 200 pasien berturut-turut yang hadir
ke ED antara 1 Desember 2013 dan 31 Januari 2014. Pasien yang diujicobakan
untuk NG / CT dipertimbangkan untuk perawatan empiris sebelum
diberhentikan berdasarkan pertimbangan penyedia (Centers for Disease Control
and Prevention, 2015b). Setelah hasil tes didapat, petugas ED memberi tahu
pasien yang dinyatakan hasil test positif NG / CT dan memberikan konseling
dan edukasi melalui telepon. Pasien yang tidak menerima pengobatan empiris
diberikan perawatan dengan resep dengan telepon atau dengan permintaan untuk
kembali ke ED untuk pemberian antimikroba parenteral. Jika pasien tidak dapat
dihubungi setelah melakukan 3 upaya telepon, sebuah surat bersertifikat
dikirimkan ke pasien dan informasi pasien diteruskan ke departemen kesehatan
kabupaten untuk ditindaklanjuti.
RDT dilaksanakan dan digunakan di ED pada bulan Oktober 2014.
Kelompok RDT terdiri dari 200 pasien berturut-turut yang hadir ke ED antara 1
Desember 2014 dan 31 Januari 2015. Jika hasilnya tersedia sebelum pasien
pulang, pasien dengan hasil positif diberi pemberitahuan, konseling, dan
pengobatan untuk NG / CT saat berada di ED. Pasien test-negatif diberi tahu dan
melarang pemberian antimikroba yang tidak perlu. Jika pasien sudah siap untuk
dipulangkan sebelum penyelesaian hasil RDT, penyedia memiliki pilihan untuk
memberi perawatan empiris kepada pasien dan memungkinkan tindak lanjut
hasilnya setelah dikeluarkan. Penyedia tidak dianjurkan untuk menunda
 pemulangan pasien agar dapat menunggu hasil RDT. Staf ED akan
menghubungi pasien dengan hasil positif untuk pemberitahuan, konseling, dan
mengikuti perawatan proses yang sama dengan tes tradisional. Pada kedua
kelompok, pasien juga diskrining dan diobati untuk IMS tambahan (mis.,
Trikomonas) jika ada indikasi

5. Hasil
Poin utama penelitian ini adalah untuk membandingkan persentase
pasien yang mendapat pengobatan yang tepat selama indeks kunjungan ke ED
dengan menggunakan tes tradisional dibandingkan RDT untuk NG / CT.
Pengobatan yang tepat didefinisikan sebagai titik akhir gabungan pasien positif
tes yang menerima terapi antimikroba sesuai dengan pedoman CDC 176 K.R.
Rivard et al. / Diagnostic Microbiology and Infectious Disease 87 (2017) dan
pasien tes negatif tidak mendapatkan pengobatan antimikroba.
Poin sekunder termasuk waktu untuk menguji hasil, waktu sampai
pemberitahuan pasien tentang hasil tes positif, dan waktu untuk pengobatan
yang tepat. Waktu untuk menguji hasilnya dihitung saat laboratorium menerima
sampel sampai saat hasil tes diunggah ke rekam medis. Waktu untuk
pemberitahuan pasien tentang hasil tes positif dihitung saat hasil NG / CT
tersedia pada saat pemberitahuan pasien didokumentasikan dalam catatan medis.
Waktu untuk pengobatan yang tepat untuk pasien dengan tes positif dihitung
saat hasil NG / CT tersedia pada saat terapi antimikroba yang tepat diberikan.
Pemberian terapi antimikroba yang tepat termasuk pemberian obat awal di ED,
masuk kembali ke ED untuk perawatan, atau resep telepon. Analisis biaya
dilakukan dengan menggunakan data keuangan institusional untuk menentukan
biaya rata-rata perlakuan yang tepat dan tidak tepat pada kedua kelompok. Biaya
diperoleh dengan menggunakan biaya langsung ke institusi tes, biaya kunjungan
ED dan ditinjau kembali berdasarkan kode diagnosis, dan biaya antimikroba
.
6. Analisis
Penelitian ini didukung untuk mendeteksi perbedaan mutlak 15% pada
pengobatan antimikroba awal yang tepat dengan menggunakan uji 2 sisi dengan
= 0,05 dan = 0,2. Ukuran efek 15% dipilih berdasarkan literatur sebelumnya
yang mengevaluasi integrasi RDT menjadi program pengelolaan antimikroba
(Clerc et al., 2013; Parta et al., 2010). Dipastikan bahwa 167 pasien di masing-
masing kelompok perlu disertakan dalam penelitian ini. Data percontohan dari
lokasi penelitian menemukan bahwa sekitar 125 pasien per bulan diujicobakan,
oleh karena itu, 2 bulan dimasukkan ke dalam masing-masing kelompok dengan
jumlah pendaftaran maksimal 200 pasien per kelompok (n = 400).
Untuk semua karakteristik dasar dan poin akhir studi, data kategoris
dibandingkan dengan uji chi square atau uji Fisher exact; Data kontinyu
dibandingkan dengan uji t Student atau uji Mann-Whitney U. Analisis regresi
logistik multivariat dilakukan untuk menentukan variabel yang relevan secara
klinis yang terkait secara independen dengan kelayakan pengobatan. Semua
variabel yang terkait dengan terapi yang sesuai dalam analisis bivariat (P b 0,2)
dipertimbangkan untuk dimasukkan ke dalam model multivariat. Data yang
masuk diteruskan dan digunakan untuk mendapatkan model akhir untuk terapi
yang tepat. Variabel signifikan pada model akhir adalah P b 0,05. Uji statistik
dilakukan dengan menggunakan SPSS 21.0 (SPSS, Chicago, IL)
Hasil

1. Karakteristik dari subjek studi

Sebanyak 400 pasien (200 per kelompok) termasuk dalam analisis.
Karakteristik dasar serupa di antara kelompok (Table 1). Ada lebih banyak
wanita (80% berbanding 71,5%, P = 0,047) dan lebih banyak pasien hamil (21%
berbanding 12%, P = 0,022) pada kelompok tradisional dibandingkan dengan
kelompok RDT. Sembilan belas pasien (9,5%) dinyatakan positif NG / CT pada
kelompok tradisional dan 20 pasien (10%) dinyatakan positif pada kelompok
RDT. Prevalensi keseluruhan infeksi CT, infeksi NG, dan koinfeksi dengan NG
/ CT adalah 6,0% (n = 12), 2,0% (n = 4), dan 1,5% (n = 3) pada kelompok
tradisional dan 7,0% (n = 14), 1.5% (n = 3), dan 1.5% (n = 3) pada kelompok
RDT

2. Hasil utama
Pengobatan awal dianggap tepat pada 60% pasien pada kelompok
tradisional dibandingkan dengan 72,5% pada kelompok RDT (P = 0.008, Table
1). Perbedaan ini didorong oleh pasien tes-negatif yang tidak diberi terapi
antimikroba. Untuk pasien tes-positif, pengobatan empiris diberikan secara tepat
pada indeks kunjungan ED pada 15 pasien (78,9%) pada kelompok tradisional
dan 18 pasien (90%) pada kelompok RDT (P = 0,407). Waktu rata-rata untuk
menguji hasil secara signifikan menurun pada kelompok RDT dibandingkan
dengan kelompok tradisional (2,4 [1,4-12,0] dibanding 31,7 [9,7-105,9] jam, P b
0,001), seperti juga waktu untuk pemberitahuan pasien tentang hasil positif (17,4
[0,0-93,0] dibanding 53,7 [26,9-79,9] jam, P = 0,010). Dari catatan, ada 2 pasien
dalam kelompok tradisional (semua diobati secara empiris) dan 7 di kelompok
RDT (5 diobati secara empiris) yang tidak dapat diberi tahu tentang hasil tes
positif mereka melalui telepon (P = 0,092). Tidak ada perbedaan waktu yang
signifikan secara statistik untuk menguji sampel pasien atau lamanya berada di
ED (Table 1).
 Rata-rata waktu untuk pengobatan yang tepat untuk pasien uji
positif pada kelompok tradisional adalah 23,0 56,3 jam. Lima belas
pasien (78,9%) diobati secara empiris pada kunjungan ED awal dan 4
(21,1%) memerlukan tindak lanjut untuk pemberian pengobatan. Dari
mereka yang memerlukan perawatan setelah pemulangan, 2 (10,5%)
pasien diminta untuk kembali ke DE untuk pengobatan NG. Waktu rata-
rata untuk pengobatan yang tepat pada kelompok RDT adalah 4,9 21,3
jam. Semua pasien di kelompok RDT dirawat sebelum pemulangan di
ED atau hilang saat di follow-up; 5 pasien (25%) secara definitif diobati
pada kunjungan ED awal (hasil positif tersedia sebelum dikeluarkan dan
digunakan untuk terapi langsung), 13 (65%) diobati secara empiris pada
kunjungan ED awal, dan 2 (10%) tidak dapat dihubungi melalui telepon
dan memerlukan follow-up Departemen kesehatan kabupaten. Tidak ada
pasien di kelompok RDT yang meminta pendaftaran kembali untuk
perawatan. Pengujian melalui RDT dikaitkan dengan penghematan biaya
$ 4891 ($ 24,46 per pasien) dibandingkan dengan pengujian tradisional
selama studi ($ 343.566 dibanding $ 348.457).
Sepuluh variabel dipilih untuk regresi logistik multivariat untuk
menguji faktor-faktor yang terkait secara independen dengan perlakuan
yang tepat (Table 2). Satu-satunya faktor yang terkait secara positif
dengan kelayakan pengobatan adalah tersedianya hasil tes NG / CT
sebelum dipulangkan (Rasio odds [OR], 22,65 [interval kepercayaan
 95% {CI}, 2,86-179,68, P = 0,003]). Secara total, 40 pasien di kelompok
RDT dapat diberitahu tentang hasil tes mereka sebelum dipulangkan.
Dari pasien ini, ada 5 tes-positf dan 100% pasien ini mendapat
pengobatan yang tepat. Dari 35 pasien tes-negatif, 34 tidak diberi
antimikroba yang tidak perlu. Satu pasien dirawat meski mendapat hasil
negatif karena pasien tersebut adalah pekerja seks komersial yang
melaporkan dirinya. Pasien yang melaporkan gejala genital discharge
lebih mungkin untuk menerima pengobatan yang tidak tepat (OR, 0.42
[95% CI, 0.260.68, P b 0.001]).

Diskusi

ED menyajikan area penting untuk implementasi RDT untuk mempromosikan

penggunaan antibiotik yang tepat karena antibiotik sering diresepkan dan efek turunnya
dapat lebih jauh. Studi ini menemukan bahwa penerapan RDT sebagai standar
perawatan untuk pengujian NG / CT dikaitkan dengan peningkatan yang signifikan
dalam kesesuaian pengobatan antimikroba. Selama masa studi, jumlah pasien yang
perlu di tes dengan RDT untuk mencegah 1 pasien menerima terapi yang tidak tepat
adalah 8 pasien. Mengingat meningkatnya resistensi antimikroba NG, hasil ini penting
karena literatur sebelumnya telah menunjukkan kesesuaian pengobatan awal NG / CT
menjadi rendah. Sebuah tinjauan literatur yang membandingkan 13 penelitian yang
mengevaluasi pengujian NG / CT dan pengobatan empiris di beberapa ED menemukan
bahwa 43-84% pasien uji positif tidak diberi pengobatan empiris awal sementara 7,9-
31,9% pasien tes-negatif diobati secara empiris (Jenkins et al., 2013). Sebuah kohort
retrospektif yang mengevaluasi 1260 wanita untuk NG / CT di sebuah kota, ED
menemukan bahwa 88,3% pasien tes-negatif mendapat pengobatan empiris sementara
38,3% yang dinyatakan positif tidak diobati pada kunjungan awal mereka (Levitt et al.,
2003).
Ada sedikit literatur yang mengevaluasi penggunaan RDT untuk meningkatkan
pemanfaatan antimikroba pada pasien yang diuji untuk NG / CT dalam situasi apapun,
termasuk ED. Tiga penelitian telah dipublikasikan untuk mengevaluasi model hipotesa
NG / CT RDT di klinik rawat jalan dan pengaruhnya terhadap hasil pasien dan biaya
perawatan. Studi ini menunjukkan bahwa pelaksanaan RDT cenderung dapat
menurunkan prevalensi penyakit, mengurangi komplikasi, dan memberikan
penghematan biaya yang signifikan (Huang et al., 2013; Hui et al., 2013; Turner et al.,
2014). Baru-baru ini, sebuah percobaan terkontrol acak diterbitkan dengan
membandingkan penggunaan RDT dengan standar perawatan NAAT pada 70 pasien
ED dan menunjukkan peningkatan penggunaan antimikroba (May et al., 2016). Studi
kami menunjukkan tidak hanya peningkatan pemanfaatan antimikroba yang tepat,
namun juga memperbaiki waktu untuk pemberitahuan pasien untuk hasil positif dan
penurunan biaya perawatan. Penting untuk dicatat bahwa lama ED tetap sama antara
kelompok tradisional dan RDT; Oleh karena itu, pemanfaatan RDT tidak mempengaruhi
kinerja ED. Selain itu, RDT menghasilkan penghematan biaya. Hal ini didorong oleh
perbedaan dalam pengujian tradisional dan biaya RDT ($ 26 dibanding $ 19, masing-
masing), penurunan penggunaan antimikroba, dan penurunan kebutuhan untuk kembali
ke ED. Diperkirakan selama 12 bulan, RDT akan menghemat sekitar $ 37.000 per
tahun. Penghematan biaya ini tidak memperhitungkan iklan PID atau komplikasi
lainnya. Catatan, ini adalah studi retrospektif, yang bergantung pada keakuratan
dokumentasi.
Hasil penelitian ini juga menunjukkan bahwa perbaikan proses harus dilakukan
untuk mengoptimalkan pemanfaatan RDT di dalam ED. Dari 200 pasien yang diuji
dalam kelompok RDT, hanya 40 (20%) yang hadir di kelompok ED pada saat hasilnya
tersedia. Dalam regresi logistik multivariat, satu-satunya faktor yang menemukan
dampak positif pada kesesuaian pengobatan adalah memiliki hasil tes yang tersedia
sebelum dikeluarkan dari ED. Dari catatan, penggunaan RDT saja tidak terlepas terkait
dengan kelayakan pengobatan. Sering terjadi keterlambatan dalam follow-up pasien
setelah dipulangkan dari ED. Hal ini berpotensi mengakibatkan keterlambatan
pengobatan jika pasien tidak diobati secara empiris, serta penundaan pemberitahuan dan
perlakuan terhadap pasangan yang terkena dampak. Implikasi dari hal ini
menggarisbawahi perlunya hasil tes cepat sebagai masalah kesehatan masyarakat.
Berdasarkan hasil analisis ini, penulis telah menyarankan intervensi yang ditargetkan
untuk meningkatkan proporsi hasil tes yang tersedia sebelum dikeluarkan, termasuk
peningkatan penggunaan urutan triase keperawatan untuk pengujian NG / CT untuk
meningkatkan jumlah tes yang dilakukan sebelum pemeriksaan dengan penyedia.
Pemanfaatan RDT ini untuk pasien yang memenuhi kriteria tertentu selama proses triase
memungkinkan waktu lebih cepat untuk menguji pesanan dan pemrosesan yang akan
meningkatkan kemungkinan hasil tes tersedia selama kunjungan ED. Kami berhipotesis
bahwa pemanfaatan RDT yang lebih baik akan menghasilkan lebih banyak pasien yang
menerima hasil sebelum dipulangkan, yang akan diterjemahkan ke dalam lebih banyak
pasien yang dirawat dengan tepat dan pasangan diberitahu lebih awal.
Satu-satunya faktor yang terbukti berdampak negatif pada kesesuaian
pengobatan adalah pasien yang hadir ke ED dengan gejala genital discharge,
kemungkinan karena sejumlah besar pasien test-negatif menerima terapi antimikroba
empiris. Meskipun kami menyadari bahwa standar perawatan adalah untuk memberikan
pasien bergejala dengan pengobatan untuk NG / CT, pasien-pasien ini diklasifikasikan
sebagai "perlakuan yang tidak tepat" untuk tujuan evaluasi kami untuk menunjukkan
jumlah pasien yang mungkin telah terhindar penggunaan antimikroba yang tidak perlu
jika hasil RDT tersedia sebelum dipulangkan dari ED. Selain itu, ada potensi bias kapan
saja proses baru diimplementasikan. Karena ada banyak pembaruan edukasi mengenai
proses pengujian NG / CT, penyedia layanan mungkin telah meningkatkan
kewaspadaan di fase RDT untuk memberikan perawatan empiris. Dampak perbedaan
temporal antara periode studi diminimalkan karena intervensi studi adalah satu-satunya
perubahan yang dilakukan pada standar perawatan selama periode ini. Selanjutnya,
membandingkan periode waktu yang sama selama 2 tahun berturut-turut meminimalkan
variasi musiman pada jumlah pasien yang diuji untuk NG / CT.
 Kesimpulannya, penerapan RDT untuk NG / CT di ED secara signifikan
meningkatkan kesesuaian pengobatan awal dengan mengurangi penggunaan
antimikroba yang tidak perlu, mengurangi waktu untuk pemberitahuan pasien, dan
menghasilkan penghematan biaya. Setelah hasil tes sebelum keluarnya pasien dari ED
secara independen dikaitkan dengan penanganan yang tepat. Intervensi untuk
meningkatkan proporsi tes yang dihasilkan sebelum dikeluarkan diperlukan untuk
memperbaiki pemanfaatan RDT. Temuan evaluasi ini mendukung penggunaan NG / CT
RDT sebagai komponen penatalayanan antimikroba di ED

Ucapan Terima Kasih

Penulis ingin mengucapkan terima kasih pada G. Robert DeYoung, PharmD,

BCPS, Untuk dukungan pengelolaan administrasi dan data serta Cora Manby,
Microbiology Technical Specialist untuk dukungannya dengan validasi dan penerapan
pengujian.

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