Editor's Note
March 4, 2024
Judicious Use of Rapid Viral Tests in Emergency Departments
Lona Mody
JAMA Intern Med. Published online March 4, 2024. doi:10.1001/jamainternmed.2024.0044
Acute viral illnesses are common, pervasive, and burdensome to patients, families, and health care systems.1Patients often present to emergency departments (EDs), which is followed by extensive diagnostic investigations, such as blood tests, cultures, chest radiography, and computed tomography scans to rule out bacterial illnesses. These tests and evaluations can increase ED time and, when inconclusive, be followed by high antibiotic use.
The easy availability of rapid viral tests has been associated with their widespread use in hopes of reducing more expensive diagnostic tests and empirical antibiotic use. Rapid molecular viral tests include monoplex polymerase chain reaction tests that are specific to the pathogen, multiplex polymerase chain reaction tests that test for multiple pathogens simultaneously, and antigen tests that detect proteins called antigens from the viruses. The question is, are these tests associated with clinical treatment of patients with acute viral illnesses in EDs?2
In this issue of JAMA Internal Medicine, the systematic review and meta-analysis of 11 randomized clinical trials by Schober et al3 shows that these rapid viral tests were not associated with reduced (1) overall antibiotic use or (2) a composite measure of hospitalization, influenza antiviral use, ED length of stay, or ED return. Rapid positive viral test results were associated with a reduced need for subsequent chest radiography and blood tests and informed subsequent influenza antiviral use. The study showed a reduction in antibiotic use in those with rapid positive test results for influenza that was counterbalanced with increased antibiotic use in those with a negative test result. However, this study did not find similar benefit for the now emerging multiplex testing.
It should be noted that all of the studies included in this systematic review and meta-analysis were conducted before the start of COVID-19 pandemic, and only 16% of the population were adults. This study shows that while there is some utility in using rapid monoplex tests to detect influenza virus, evidence to use rapid multiplex tests to detect multiple viruses remains underdeveloped. Thus, rapid viral tests should be used judiciously. Further, there is a need to build high-quality evidence to identify at-risk populations for whom these tests are most informative, efficient, and cost effective.
