SCCM Resource Library-12-Utility of Testing for Respiratory Viral Co-Infections With SARS-CoV-2 at Time of Initial Diagnosis

Video Transcription

Hello, my name is Matthew Norris and I am a PGY3 resident at Overlook Medical Center in Summit, New Jersey.  Today I'm privileged with the opportunity to present my work on the utility of testing for viral respiratory co-infections with SARS-CoV-2 at the point of initial diagnosis.  I have no disclosures to report. At the beginning of the pandemic, there was only uncertainty in how to best manage and treat patients with COVID-19.  Much of what we did was understandably based on anecdotal evidence from the wards and social networking with other doctors from around the world.  As in the Northeast, we had just begun to come out of a bad winter influenza season, there was a question of whether we should be checking these patients for additional  respiratory viruses. Policy guidance at the time endorsed testing for respiratory pathogens other than SARS-CoV-2,  albeit with the acknowledgement that there was little evidence to support the utility of or recommend against additional viral testing.  The question of whether respiratory viral co-infection testing at the point of initial care is of any utility is crucial to consider in the setting of over 100,000 new COVID-19  diagnoses per day in the United States since November. This study was a retrospective chart review.  It utilized only a single site being a 500-bed community teaching hospital in Northern New Jersey.  It included all adult patients with first-time nasal swab positivity for SARS-CoV-2 by PCR who received additional viral testing during the same visit between March 16th and April  20th. The decision to either test with a low-target PCR, high-target PCR, or not perform secondary viral PCR testing was based on individual provider judgment.  1,676 patients without a prior COVID-19 diagnosis were identified as having the SARS-CoV-2 virus over a six-week period.  The mean age of these patients was 54 with a standard deviation of 17.5 years, 53% being male.  767 of these patients, approximately 46%, were evaluated for a secondary viral co-infection. The mean age was 53 with a standard deviation of 17 years, approximately 56% being male.  Patients received either low-target PCR or high-target PCR. There were no patients that received both.  None of the low-target PCRs were positive, whereas seven of the high-target PCRs were positive. Only one patient's initial secondary viral testing appeared to change management upon  chart review, which was the one patient who tested positive for influenza B as that patient received oseltamivir.  The data supports emerging literature that respiratory viral co-infections at the point of initial care were rare during the first outbreak.  Being unable to directly measure the cost of viral testing, 22 Medicare clinical laboratory fees schedules were used.  This allowed us to come up with an estimated cost to insurances and patients of approximately $326,425.45. Unfortunately, this had minimal impact on patient care.  A large retrospective study of New York City hospitals during the same time period yielded very similar results.  Approximately 35% of patients, or 1,996 of 5,700, underwent high-target PCR testing, whereas only one was found to have influenza A. From this, we can estimate using the same  numbers for each test that approximately $1 million was spent, which was very unlikely to have had an impact on patient management.  Although the influenza rates were low in all the studies evaluated from the first wave, an argument could be made to screen patients during a traditional flu or RSV season.  Using data from two California studies released during the first wave, a low-target viral testing strategy showed how more patients, more than three times as many patients, could  be screened for either the flu or RSV compared to utilization of high-viral-target testing. In conclusion, viral co-infection during the first wave appears to have been rare.  Positive secondary viral testing appears to rarely change management in patients with COVID-19. Minimizing use of high-target respiratory PCR in patients with COVID-19 will serve to  free up laboratories to perform higher-impact testing and allow better allocation of healthcare financial resources during this pandemic.  Thank you very much, and I hope you all have a great day.

Video Summary

Matthew Norris, a PGY3 resident at Overlook Medical Center, conducted a study on the utility of testing for viral respiratory co-infections with SARS-CoV-2 at the point of initial diagnosis. The study found that viral co-infections during the first wave of the pandemic were rare and positive secondary viral testing rarely changed patient management. The study suggests that minimizing the use of high-target respiratory PCR in COVID-19 patients would free up laboratories and allocate healthcare resources more effectively. The estimated cost of viral testing during the study period was approximately $326,425.45. Norris concludes that prioritizing higher-impact testing is crucial during the ongoing pandemic.

Asset Subtitle

Infection, Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Matthew Norris, MD

Introduction/Hypothesis: Over 4.8 million cases of COVID-19 have been diagnosed in the United States as of 8/2/2020, with >50,000 new cases diagnosed per day since 6/24/2020. The question arises at the point of care of whether to test patients initially diagnosed with SARS-CoV-2 for a secondary respiratory co-infection. The CDC has endorsed testing for respiratory pathogens other than SARS-CoV-2 to date. However, there is little evidence to support, or recommend against, additional respiratory pathogen testing.

Methods: The following is a retrospective cohort study of all adult patients with nasal swabs positive for SARS-CoV-2 by PCR from 3/16/2020 to 4/20/2020 at a 500-bed community teaching hospital in Northern New Jersey. Decisions regarding test selection for secondary respiratory pathogens were performed by emergency department providers per individual clinical judgement. Both a 12-25 target respiratory PCR panel and 3-target PCR were available at our institution. Being unable to measure direct costs, 2020 Medicare clinical laboratory fee schedules were used to estimate cost. Approval to perform this study (IRB #1597737, decision 4/29/2020) was obtained through the Atlantic Health System Institutional Review Board.

Results: 1,676 adult patients without a prior SARS-CoV-2 diagnosis were identified as having the virus at time of emergency department presentation. 572 patients were tested with a 12-25 target respiratory PCR while 195 patients were tested with a 3-target viral PCR. Seven 12-25 target PCRs were positive for a co-infection (1 Influenza B, 1 Human Metapneumovirus, 2 Rhinovirus/enterovirus, 3 non-COVID coronaviruses) while all 3-target PCRs were negative. Positive viral testing changed management in one case (patient who tested positive for Influenza B received oseltamivir).

Conclusions: Data supports emerging literature showing respiratory viral co-infection during the initial outbreak was rare. Testing at our hospital cost an estimated $326,425.45 but had minimal impact on patient care. As most respiratory viral co-infections are unlikely to change management in patients with SARS-CoV-2 infection, minimizing use of high-target respiratory viral PCRs will free up laboratories to perform more targeted viral testing and allow better resource allocation during our current pandemic.

Meta Tag

Content Type Presentation

Knowledge Area Crisis Management

Knowledge Area Infection

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag COVID-19

Tag Resource Allocation

Year 2021

Keywords

viral respiratory co-infections

SARS-CoV-2

patient management

high-target respiratory PCR

healthcare resources

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