Criteria for reducing unnecessary testing for herpes simplex virus, varicella-zoster virus, cytomegalovirus, and enterovirus in cerebrospinal fluid samples from adults

Wilen, Craig B.; Monaco, Cynthia L.; Hoppe-Bauer, Joan; Jackups, Ronald; Bucelli, Robert C.; Burnham, Carey-Ann D.

doi:10.1128/jcm.03161-14

Cited by 27Healthcare cost, quality, practicesHerpesvirus Infections and TreatmentsClinical Laboratory Practices and Quality Control

Criteria for reducing unnecessary testing for herpes simplex virus, varicella-zoster virus, cytomegalovirus, and enterovirus in cerebrospinal fluid samples from adults

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Wilen, Craig B., Monaco, Cynthia L., Hoppe-Bauer, Joan, Jackups, Ronald, Bucelli, Robert C., Burnham, Carey-Ann D.·2015·Journal of Clinical Microbiology

DOI 10.1128/jcm.03161-14PMC PMC4390640

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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.

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Previous studies showed a safe reduction in herpes virus testing using a cutoff of 10×10^6 CSF leukocytes per liter in non-immunocompromised patients.
“In these studies, the authors showed a safe reduction in herpes virus testing using a cutoff of 10 × 106 CSF leukocytes pro liter in non-immunocompromised patients (23, 25).”
From Utilization of a Meningitis/Encephalitis PCR panel at the University Hospital Basel – a retrospective study to develop a diagnostic decision rule (2024) · cites this paper as [23]

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Authors: Wilen, C. B., Monaco, C. L., Hoppe-Bauer, J., Jackups, R., Bucelli, R. C., & Burnham, C.-A. D.
Affiliations: Washington University in St. Louis (US)
Department of Laboratories, Barnes-Jewish Hospital, St. Louis, Missouri, USA
ORCID: Wilen, Craig B.
Monaco, Cynthia L.
Jackups, Ronald
Bucelli, Robert C.
Burnham, Carey-Ann D.
Venue: Journal of Clinical Microbiology
Publisher: American Society for Microbiology
Published: 2015-03
Volume: 53
Issue: 3
Pages: 887-895
ISSN: 0095-1137 (ISSN-L)
1098-660X
DOI: 10.1128/jcm.03161-14
PMC: PMC4390640
OpenAlex: W1963762085
Cited by: 27
References: 27
Citations by year: 2026: 2 · 2025: 1 · 2024: 2 · 2023: 5 · 2022: 1 · 2021: 2 · 2020: 3 · 2019: 1 · 2018: 4 · 2017: 1 · 2016: 4 · 2015: 1
FWCI: 6.08
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: journals.asm.org/non-commercial-tdm-license (tdm)
Locations: Journal of Clinical Microbiology (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Digital Commons@Becker (Washington University School of Medicine) (submittedVersion)
Funders: National Institute of Allergy and Infectious Diseases (T32AI007172)
Topics: Health Sciences › Health Professions › General Health Professions › Healthcare cost, quality, practices
Health Sciences › Medicine › Epidemiology › Herpesvirus Infections and Treatments
Health Sciences › Medicine › Physiology › Clinical Laboratory Practices and Quality Control
Keywords: unnecessary laboratory testing, cerebrospinal fluid, herpes simplex virus, varicella-zoster virus, cytomegalovirus, enterovirus, nucleic acid amplification tests, CSF cell count, immunocompetent adult, computerized physician order entry, health care costs
MeSH terms: Adult, Aged, Cerebrospinal Fluid, Costs and Cost Analysis, Cytomegalovirus, Enterovirus, Humans, Leukocyte Count, Leukocytes, Mononuclear, Meningitis, Aseptic, Middle Aged, Retrospective Studies, Sensitivity and Specificity, Herpesvirus 3, Human, Cohort Studies, Simplexvirus, Nucleic Acid Amplification Techniques, Molecular Diagnostic Techniques

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Criteria for reducing unnecessary testing for herpes simplex virus, varicella-zoster virus, cytomegalovirus, and enterovirus in cerebrospinal fluid samples from adults

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