title: Criteria for reducing unnecessary testing for herpes simplex virus, varicella-zoster virus, cytomegalovirus, and enterovirus in cerebrospinal fluid samples from adults.
abstract: Excessive utilization of laboratory diagnostic testing leads to increased health care costs. We evaluated criteria to reduce unnecessary nucleic acid amplification testing (NAAT) for viral pathogens in cerebrospinal fluid (CSF) samples from adults. This is a single-center split retrospective observational study with a screening cohort from 2008 to 2012 and a validation cohort from 2013. Adults with available results for herpes simplex virus 1/2 (HSV-1/2), varicella-zoster virus (VZV), cytomegalovirus (CMV), or enterovirus (EV) NAAT with CSF samples between 2008 and 2013 were included (n = 10,917). During this study, 1.3% (n = 140) of viral NAAT studies yielded positive results. The acceptance criteria of >10 nucleated cells/μl in the CSF of immunocompetent subjects would have reduced HSV-1/2, VZV, CMV, and EV testing by 63%, 50%, 44%, and 51%, respectively, from 2008 to 2012. When these criteria were applied to the 2013 validation data set, 54% of HSV-1/2, 57% of VZV, 35% of CMV, and 56% of EV tests would have been cancelled. No clinically significant positive tests would have been cancelled in 2013 with this approach. The introduction of a computerized order entry set was associated with increased test requests, suggesting that computerized order sets may contribute to unnecessary testing. Acceptance criteria of >10 nucleated cells/μl in the CSF of immunocompetent adults for viral CSF NAAT assays would increase clinical specificity and preserve sensitivity, resulting in significant cost savings. Implementation of these acceptance criteria led to a 46% reduction in testing during a limited follow-up period.
authors.affiliation: Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
authors.forename: Craig B
authors.initials: CB
authors.lastname: Wilen
authors.affiliation: Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
authors.forename: Cynthia L
authors.initials: CL
authors.lastname: Monaco
authors.affiliation: Department of Laboratories, Barnes-Jewish Hospital, St. Louis, Missouri, USA.
authors.forename: Joan
authors.initials: J
authors.lastname: Hoppe-Bauer
authors.affiliation: Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
authors.forename: Ronald
authors.initials: R
authors.lastname: Jackups
authors.affiliation: Department of Neurology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
authors.forename: Robert C
authors.initials: RC
authors.lastname: Bucelli
authors.affiliation: Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA cburnham@path.wustl.edu.
authors.forename: Carey-Ann D
authors.identifier: http://orcid.org/0000-0002-1137-840X
authors.initials: CA
authors.lastname: Burnham
mesh_terms: D000328:Adult; D000368:Aged; D002555:Cerebrospinal Fluid / Q000166:cytology* / Q000821:virology*; D015331:Cohort Studies; D003365:Costs and Cost Analysis; D003587:Cytomegalovirus / Q000302:isolation & purification; D004770:Enterovirus / Q000302:isolation & purification; D014645:Herpesvirus 3, Human / Q000302:isolation & purification; D006801:Humans; D007958:Leukocyte Count; D007963:Leukocytes, Mononuclear / Q000166:cytology*; D008582:Meningitis, Aseptic / Q000175:diagnosis*; D008875:Middle Aged; D025202:Molecular Diagnostic Techniques / Q000191:economics / Q000379:methods*; D021141:Nucleic Acid Amplification Techniques / Q000191:economics / Q000379:methods*; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D018139:Simplexvirus / Q000302:isolation & purification