Activity Transcript

Kenneth Alexander, MD, PhD: Hello. I'm Dr Kenneth Alexander. I'm chief of the Division of Infectious Diseases and vice chair for research at Nemours Children's Hospital in Orlando, Florida. Welcome to this Medscape program entitled, "To Know Is Better With Rapid Diagnostic Tests: Optimizing Respiratory Infection Management in Urgent Care." I'm very pleased to be joined today by Dr Timothy Hendrix, who is medical director of AdventHealth Centra Care, also here in Orlando, and Dr Janette Nesheiwat, who is a family and emergency medicine physician and medical director at CityMD in New York City. Tim, Janette, welcome.

Today, we'll be discussing the use of rapid diagnostic testing for upper respiratory infections in the urgent care setting, but first, we've seen some dramatic shifts in the epidemiology of upper respiratory infections since the COVID-19 pandemic. This is a study published this year in Nature Reviews Microbiology. What you can see on this slide are some really interesting things. On the left-hand side of the slide, you see the usual seasonal variation with the different viral diseases that we diagnose in our laboratories. As you'll remember, in March and April of 2020, we saw that big decrease in viral diseases as we all went into hiding with COVID-19, and then later in the year as things reopened, we saw a gradual resurgence of viral infections. But there's some interesting things I want you to note.

First of all, we didn't see the usual viruses. We didn't see a lot of influenza, and in the beginning, we saw almost no respiratory syncytial virus. Then, the other thing that happened is that we lost our usual seasonality. It wasn't flu season from November to March. It wasn't RSV season from October to May. Instead, it all seemed to roll along in a steady state, and so this has really changed how we've had to think about respiratory viruses and respiratory virus diagnosis. So, Tim, that's the microbiology. What's been your experience in your clinics here in Orlando? Have you seen the unusual patterns of upper respiratory tract infections following the pandemic?

Timothy W. Hendrix, MD, FAAFP: Well, Ken, you're right. That's exactly what we've seen in our urgent care centers in Florida and particularly in Orlando, is this unpredictable pattern where, in this aftermath of the pandemic, we've just seen respiratory virus is taking over with a vengeance and not following any seasonal pattern. Our flu season this last year started early in the fall, peaked with record numbers of flu patients in the winter, and then it lingered on into the summer. During that time, we had an overlapping COVID season. During flu season in November and December, we had to start testing for both flu and COVID to differentiate those patients that had those influenza-like symptoms.

As you mentioned, the RSV infections were high, especially in the fall, earlier than we typically see RSV. And you remember the news reports and the hospital reports of pediatric wards -- I'm sure, Ken, you're very familiar with this, being overwhelmed with those RSV patients, and we saw them in urgent care also. And strep. I don't know if any of you remember the shortage of amoxicillin this last year because of the number of patients being diagnosed with strep, and that lingered at our urgent cares until almost the summertime. And most recently in the summertime now, we have seen a doubling in COVID-19. So we've seen this small wave start, which it followed a typical pattern. We saw throughout COVID that after a holiday, we'd see more COVID because of traveling and people interacting, so we're feeling that right now.

Dr Alexander: Thanks, Tim. So, Janette, I think you'd agree that more people are using urgent care clinics now than ever before. What do you think accounts for this shift, and are there particular demographics that seem to be more drawn to care at an urgent care center?

Janette Nesheiwat, MD: Hey, Ken. Yes, absolutely, and I think the answer is multifactorial. We definitely saw a change because of the pandemic. You remember everything was shut down. Even primary care doctors' offices were shut down. The only thing really that was left open were the emergency departments and urgent care centers. Even the specialist offices were shut down, and in a sense, urgent care centers, we were offloading the burden and trying to minimize the burden on the emergency departments. So one of the greatest things is that urgent care offers convenience. You don't have to have an appointment. You can walk in. Our hours are quite long and flexible.

A lot of people, they don't have a primary care doctor. Or maybe they do have a primary care doctor, and they just can't get an appointment. And that makes it difficult. Sometimes they want to go in and see a doctor before they go to work or maybe after work. Their primary care doctor's office is closed. Or especially on the weekends, it's really hard to get an appointment and see a doctor on the weekend. You don't want to go to the emergency room (ER) for something [like] maybe strep throat or a broken wrist or something that can be covered in an urgent care center where we can do so much that you don't have to go to the ER.

The other thing is insurance. Will insurance cover your urgent care visit vs maybe an ED visit that was not necessary? So it's going to probably be less expensive as well going into a urgent care center vs an emergency department. And the last thing that I want to point out is that we serve all ages, so from newborns up until senior citizens. And, of course, if somebody comes in and they have something that is not something we can take care of, like a heart attack, we'll stabilize them and send them off to the emergency room.

If they do come in to see an urgent care doctor, we want to still make sure that they have a primary care doctor, that they have appropriate follow-up because, for example, in urgent care we can't do mammograms and Pap smears and colonoscopies, so that's really important. We are seeing an increase in the number of visits to the urgent care center. The greatest increase, about 56%, are among the Gen Z'ers, age 20 to 24. And interestingly, if you go to the opposite end of the spectrum, we are still seeing increase in the number of visits among the elderly population, those who are 75 and older, but it's not as big a jump as we're seeing in the younger population. So the older population, over the age of 75, they're still sticking to their primary care doctors, to their geriatricians, which I think is fantastic. But if there's ever an event where they need us, especially on a weekend or maybe they can't get in to see their primary care, we are there for them to help support them in any way that we can.

Dr Alexander: So first of all, Janette, I have to express my respect and admiration for what our urgent care docs did during the COVID pandemic. You're right. A lot of things were shut down, and these folks were brave front-liners in the whole process. So if I understand, then, that what's happening is urgent care center and retail health clinic utilization have decreased with increasing age for men and women and yet in other groups it's increasing -- what's going on here?

Dr Nesheiwat: I think that's because, for example, in the elder population, they have a pattern. They have a routine, and they're happy with sticking to that routine. But when it comes to the younger generation that have gone to college and they're so busy, they're always on the go, they have hectic lifestyles, but they're well-educated, they just don't have time to get in to see their primary care doctor.

Or again, there's just a lack of access. We have a shortage of primary care doctors in this country, so we definitely need more residencies in primary care. But that, I think, plays a role, is the lack of access. But remember, prevention is the key. That's why as a primary care doctor we're always huge proponents of getting your routine physicals, having a primary care doctor, so that if we find something, we can take care of it because early detection is the key to better prognosis.

Dr Alexander: Yeah. I think that's a real important point, Janette. Thank you. So, Tim, we know that urgent care clinicians see all types of patients of all ages from, again, the very young, as Janette mentioned, up through the elderly. So as an urgent care doc, what do you see as your role as an urgent care physician when a patient comes in with symptoms of an acute upper respiratory infection?

Dr Hendrix: Well, our primary role in urgent care is managing that patient's expectations for antibiotics. I think many of us that have dealt with patients with that acute virus. Trying to convince them that it is viral, there is no need for an antibiotics, that's a big part of our job. But 1 example of that is the Choosing Wisely campaign that issued recommendations that say, for example, for sinusitis, don't routinely prescribe antibiotics for acute mild to moderate sinusitis unless the symptoms are more than 10 days. Now, that seems like a lot, and most of our patients come in convinced they've had a sinus infection for the last 24 hours. We're trying to manage those expectations, educate our public to the necessity of that. Also, you can prescribe earlier if their symptoms are worsening after an initial improvement, and the symptoms must include a discolored nasal discharge and facial or dental tenderness on percussion. So that's where all the specialties have come together and issued these recommendations.

Now, my role in urgent care also is in that rapid detection of flu and COVID, and I see my responsibility to help reduce the transmission in the community by helping people identify what infection they're dealing with and how to quarantine. And also, if it's viral, they don't need an antibiotic. And then another key element of my evaluation is reducing hospitalizations by identifying those high-risk individuals diagnosed with flu or COVID and treating them with the appropriate antiviral to reduce their chance of ending up in the hospital. So, a lot of things going on with these upper respiratories, more than just the coughs and colds.

Dr Alexander: Janette, let's get into some specifics of the available upper respiratory tract diagnostic tests. Can you review for us quickly the different types of rapid diagnostic tests for upper respiratory infections that are available and then some of the commercially available broad syndromic panels?

Dr Nesheiwat: Yes, Ken. And that's the beauty of medicine, is having these tools, these tests, these rapid tests to help us better care for our patients, to give them a definitive diagnosis. So we've got the multiplex polymerase chain reaction (PCR) panels. We have what's called the narrow panels and the broad spectrum. Now, where I work, we usually have the 2-in-1 or the 3-in-1, what's most common that we see in our practice. For example, we have the 2-in-1 COVID and flu test, which is really nice and convenient because it's uncomfortable to have a swab up your nose 2 or 3 times when you can do a 2-in-1 or a 3-in-1, like the COVID, flu, and RSV. So the narrow panels usually do a 2-in-1 or a 3-in-1, which is, again, what we use in our practice, but then we've got the broad panels, which can test for both viral and bacterial pathogens, up to about 22 of them, which is really nice.

So we've got the FilmArray, the Respiratory Panel 2, the Respiratory Panel 1. It can check for both bacterial and viral pathogens. For example, pertussis, that's a big one, especially since a lot of children are not up-to-date with their vaccinations with their Tdap [tetanus, diphtheria, acellular pertussis], which protects them against pertussis. So you can get that pertussis testing, also, for example, mycoplasma, pneumonia, and then the basic viruses, the most common viruses that we see, adenovirus, rhinovirus, COVID, RSV. Those are important.

And then we've got the ePlex, or Respiratory Panel 2. It does check for chlamydial pneumonia, mycoplasmal pneumonia, similar to the NxTAG. It doesn't check against RSV, so that's something that maybe we won't see in a pediatric panel. The Verigene Respiratory Panel doesn't check against COVID, so some of these panels are similar. There's some overlap. It's all about what is covered by your insurance and what's most comfortable. For example, it's not easy to get these swabs on little children, and they're not the most comfortable. So that's where the antibiotic stewardship comes into place and testing stewardship comes into place as well to try to hone down on what's best for your patient.

Dr Alexander: So one of the things that I think we should also discuss here, too, is that a challenge we have is COVID doesn't look that different from flu. That doesn't look that different from RSV, and yet each of these has different management and care implications. So, I think one of the beautiful things about these panels is that somebody has thought about the differential diagnosis of what we're seeing here.

There's also, Tim, a new blood assay, a blood-based assay, that was just approved by the FDA in early July. This particular test measures 2 different immune biomarkers for the purpose of quickly differentiating between viral and bacterial infection in a point-of-care setting. Can you talk briefly about this assay?

Dr Hendrix: Yeah, sure Ken. This rapid point-of-care test called FebriDx is an immunoassay, as you indicated, to differentiate between bacterial and viral infections by measuring these immune response biomarkers. Now, these immune response biomarkers may be familiar to us, the myxovirus resistance protein A and the C-reactive protein (CRP), each having its own strengths, [with] myxovirus being good at detecting viral infections, CRP better for inflammation and bacterial infections. But combined together, it increases the power of detection of, whether it's a bacteria or virus. Very simple. The answer you're getting is, is it bacterial/viral?

So this is a finger stick, whole blood. Here, we have the diagnostic accuracy of these tests for the FebriDx. And on the left, you have bacterial; on the right, we have viral. I will point out the key takeaway here is that the specificity for detecting . . . I'm sorry, the sensitivity for detecting a bacterial infection with the FebriDx was estimated [at] 93%, and the negative predictive value is 98.7%. So what that can help a clinician as they're trying to decide do they need an antibiotic, this can add a fair amount of confidence that if it's negative, it's not going to be a bacterial infection.

Dr Alexander: So that's exciting, right? A test with a strong negative predictive value when it comes to testing for bacterial infections, that can give us some real useful information.

Now, we've reviewed the different types of upper respiratory tract infection rapid diagnostic tests that are available, but let's talk about how they should be used in the urgent care setting. Janette, what are you seeing in your CityMD clinics? Are the rapid diagnostic tests for upper respiratory infections being used? Are they well established? Do you have protocols for using these things? What's going on?

Dr Nesheiwat: Yeah. They are absolutely just a staple in our practice because not only is it a useful tool in providing good patient experience and helping guide us in our plan of care, but it helps to give us a definitive diagnosis. For example, if you provide a positive flu test or a COVID test, then we could say, "Look, this is what you're suffering from. You tested positive for influenza." And then we could talk about a plan of care, whether they need an antiviral -- there's so many of them that are available that we can choose from. You talk about what the best plan of care is for them, and then that usually will lead to more compliance and more patient satisfaction.

Also, your patients will come in and they say, "Hey, I was exposed to strep," or "I was exposed to flu" or COVID; "My child has it," or "a classmate has it." And we're able to conduct that test that they need based on their history, based on their exposure, based on their symptoms. And especially if they have any underlying medical problems, any comorbidities, it would be in their advantage so that we can really home in on a definitive diagnosis for them. So, it's a standing protocol if a patient comes in and if they meet all the criteria, for example, after taking their vitals and their history and they've got a fever, yes, to save time and to maximize efficiency, we will swab them for flu or swab them for COVID. But if they're not having any other symptoms, like a severe sore throat, then we wouldn't swab them for strep throat, for example. It's really based on what they're presenting with, what's their exposure, and then taking it from there.

Dr Alexander: Good. Now, Tim, what about in the Centra Care system? What are you guys doing?

Dr Hendrix: Well, we have standard standing orders that we've put in place, especially during flu and COVID seasons, to automatically test people with a rapid flu, rapid COVID, for specific symptoms that they're presenting with so that when I see the patient, I've already got the test results ready. It can help assist in making that diagnosis. But we also want to be careful because if we just generalize test everybody, these rapid tests do have a false-positive rate if somebody doesn't have any symptoms, and you might get a positive in diagnosis inappropriately. So we want to combine that, as Janette indicated, based on your symptom characteristics and be very careful about those standing orders that you have. They have to have those symptoms to run the test. We do the strep test. Do a quick strep test. Somebody has a sore throat. You get a quick answer, especially if there's been an exposure.

Dr Nesheiwat: Yeah.

Dr Alexander: That's important. So, Tim, let's take this a little bit further. There was a study published recently in the Journal of Clinical Infectious Diseases that asked the question, how does rapid influenza diagnostic testing influence clinical decision-making for patients with acute upper respiratory infections in an urgent care? Restated, does testing for flu make a difference?

Dr Hendrix: Well, sure. This study compared patients with acute respiratory infection symptoms who received a rapid influenza diagnostic test called a RIDT, basically your flu test, and patients who did not receive a flu test in 2 urgent care clinics. And what they found was that compared to the population who weren't tested for the flu, patients who were tested for the flu were more likely to be prescribed the antiviral, and less likely to be prescribed the antibiotic. On the secondary analysis of that same data, compared to participants only in the flu-tested population to determine differences between their positive and negative results, there was a significant decrease in antibiotic prescribing and a significant increase of antiviral prescribing, even within those people that were testing positive or negative, regardless of the results. We also found a significant decrease, or they found a significant decrease, in rapid strep testing for people that were flu tested. And the key takeaway on this one is that clinicians were less likely to prescribe antibiotics in those flu-tested patients regardless of the result, whether positive or negative, suggesting that the presence of a test influenced the clinician's behavior.

Dr Alexander: I think this is an important point because what this is showing is both good diagnostic stewardship and good antimicrobial stewardship, so I think this is really a big deal because it's helping us do the right things, which is good for patients. It's good for healthcare providers, and it's good for the people that are paying the bills here.

Janette, I'd like to circle back with you for a second to the concept of diagnostic stewardship. In your urgent care setting, what kinds of processes do you have in place to ensure that the right patients are getting the right rapid diagnostic tests? Obviously, there's seasonality to consider, things like that. Or who's not getting them? Do you have strategies in place, be they standing orders, stop orders, reflexive testing, best practice alerts? Tell me what you guys are doing.

Dr Nesheiwat: Yes, Ken. Just like Dr Tim mentioned, we have standing orders, as well, but what we do is we really try to home in on the patient's history and their symptoms. How many days have you been having a headache, body aches, sore throat, fever, malaise, fatigue? Were you exposed? What kind of work do you do that maybe puts you at a higher risk of exposure? And then we try to take all that information and try to stick to a specific test based on that feedback that the patient gives us and also based on their physical examination, as well, looking in their throat, looking in their ears. Maybe they have an otitis media and it's not a virus, or maybe it is viral based on what you hear on their lung exam, for example. So we do use the standing orders. We try to gather all the information we can from the patient. Again, we want to maximize the clinical efficiency. That's important.

And then as far as reflex testing, yes, if they're high risk, high risk of exposure, if they're a candidate for treatment. For example, if someone tests positive for influenza but they're on day 4, we know that we're not going to be able to treat them with certain medications at that point because some antivirals are best if they're started within a certain time frame, for example, within 48 hours. Otherwise, they won't really do much, and then you might have unwanted side effects from those medicines. But if you are a senior citizen with heart disease or lung disease and diabetes, then we want to make sure that we cover all of our bases to make sure that we get you the proper testing and the proper treatment, especially if you're an eligible candidate for that treatment, like an antiviral for coronavirus, for example.

Dr Alexander: So, Janette, I think you've raised an important point here, and that is that these rapid panels are an adjunct to our history and physical, not a replacement. And if we're going to do right, we still got to get that history and examine the patient. So in the urgent care setting, do you see a role for the broad syndromic panels, where we're looking for 20, 22 different viruses in bacteria? Or do you think that the more limited panels, 2, 3, 4 viral pathogens, are more appropriate? What do you see as the barriers as well for the uptake of these things in urgent care?

Dr Nesheiwat: It's a luxury to be able to perform the broad-spectrum panels, but realistically and practically, I think this is something more that would be beneficial in a hospital setting or especially among pediatrics or someone who has a weakened or immune-compromised system. But, for example, where we work, we're limited to the narrow spectrum where we just do a 2-in-1 or 3-in-1. I would like to have the broad spectrum because, again, I want to give my patient a definitive diagnosis. I think, again, that helps with compliance and satisfaction -- a lot of patients coming in thinking they have a bacterial infection, not realizing that most infections are viral and that antibiotics don't treat viruses. So I think some of the barriers, though, when it comes to these testing are, is insurance going to cover it? We don't want to run a test on a patient and then they get a surprise bill for $300 or $400, so we want to stick to what's most common and also consider if it's treatable. I think those are some important points to look at.

Dr Alexander: Okay. And, Tim, what about in the Centra Care system?

Dr Hendrix: Yeah. We haven't really found these useful because of the barriers. I'd love to run a lot of tests in urgent care, but in terms of lab licensing, complexity of testing, the time it takes to process, that's going to lengthen the time they're in the clinic. Do I need a panel to tell them that they've got a rhinovirus, that they have a cold. But also, the barrier is the reimbursement and cost, etc. So we haven't migrated this way to using these panels, although I think they're really cool. But how useful and how is it going to change the management of your patient? You have to look at that. Now, a more complex patient, of course, if you're trying to sort out what's making this person ill. . . . You mentioned pertussis being detected on these panels. I'd love to be able to detect pertussis if somebody has been coughing for a few weeks and get a rapid diagnosis, but the practicality is minimal in urgent care.

Dr Alexander: Yeah. And I think you guys have brought up a couple of interesting points, and you're right. There's what we can do and what we can treat. I've always wondered, though, with a lot of these families if you can name the demon, if you can say to a family, "This is parainfluenza 3," as Janette talks about, will they be more compliant? Will they be more accepting?

So, to round things out, let me ask the 2 of you about the role of other providers in urgent care. Here, I'm talking about advanced practice clinicians, and what part should they be playing in ensuring that patients with acute upper respiratory infections get tested, their results get interpreted properly, reported, and patients get the care that they need. Tim, let's start with you on this one.

Dr Hendrix: Well, I think all of us in urgent care have seen that transition over the last few years to nurse practitioner, physician assistants (PAs) playing a greater role in our urgent cares. One of the things that I see as important is make sure that as you're supervising our advanced practice professionals (APPs) that they're in alignment as far as managing the use of antibiotics, identifying that patient, and not overprescribing antibiotics, or steroids -- we're seeing more of that. So you've really got to make sure that you have your providers in alignment, all of your provider physicians included, on what your goals are for your urgent care. But definitely, with the addition of APPs, we're able to expand our access for our patients, whereas there aren't as many physicians to fill these roles. So, this is a future of medicine and multiple specialties.

Dr Alexander: Okay. Janette, what are your thoughts?

Dr Nesheiwat: Yeah. I agree with Tim. It's all about alignment and teamwork, being on the same page that we can provide the best care for our patients. And I also think the most important thing is good communication with your patient. Good communication will lead to good outcomes, regardless of what test that you have available, and if you are conducting a test, making sure that we inform and educate the patient what this test will give us, what information it will give us, and how it will help us in our plan of care so that ultimately we do provide the best plan of care and guidance for our patients so that they can continue with their home care remedies and that sort of thing, and follow up as well, which I think is an important facet when it comes to overall health of our children, our adults, all age groups.

Dr Alexander: So, Tim, Janette, this has been a lot of fun and a great discussion. Let's wrap things up with a few concluding remarks. First of all, I think we have to keep in mind that there have been dramatic swings in the epidemiology of respiratory viruses since the COVID pandemic. We've seen large and out-of-time, out-of-sequence outbreaks of influenza, RSV, human metapneumovirus. And, of course, COVID is still lurking out there, and we're seeing a surge. Urgent care clinics have been and really done an admirable job being the front line for a lot of these problems, certainly with COVID and really with all acute upper respiratory infections. The exciting thing about urgent care is with the science, with the way care is delivered, it looks like the cost is lower than going to an emergency room for nonemergent illnesses, and that's a really important thing.

Rapid diagnostic testing in the urgent care setting for upper respiratory infections has an important role to play, and the roles are a couple. First of all, it's avoiding unnecessary antibiotic prescribing and can be used as a guide to appropriate use of antivirals. It can limit the use of other unnecessary testing. We don't want to test little tiny babies for strep. There's other things that we can look for that will give us better answers. And ultimately, as we communicate with families and share with them the information we get, it may ease that demand and the effort we have to spend talking about the need or non-need for antibiotics. And as we've talked about, these rapid diagnostic tests are not a substitute for clinical judgment. In fact, they should add to our clinical judgment. They don't replace that careful physical exam and history and aren't always appropriate to use, but in the right patient, they really are wonderful things diagnostically and in the help of our care.

Janette, Tim, thank you both very much for joining me today. This has been a lot of fun and a great discussion that I think our audience will benefit from listening to. Thank you all for watching and participating in this Medscape activity. Please, continue on to answer the questions that follow and complete the evaluation.

This transcript has not been copyedited.