Tag Archives: focused antibiotic reporting

“Too soft, too generous, too nice, and too slow…”

Antimicrobial Resistance, Confessions of a Microbiologist, The Art of Microbiology, , ,

Guidelines for antimicrobial stewardship often include only a cursory mention of the role of the clinical microbiology laboratory, which is a shame, because in my opinion it is one of the key areas where real change to anti-microbial stewardship can be effected. (The other key area is in the writing of sensible narrow spectrum empiric antibiotic policies.)

But we don’t help ourselves…. Speaking generally, I think clinical microbiology laboratories are notoriously bad at antimicrobial stewardship.

Why?

Several reasons actually.

Because we are too soft: We often release antimicrobial susceptibilities from the laboratory even when we have no idea what is going on with the patient. I.e. no clinical details have been provided. Therefore we think nothing of releasing a range of antibiotics to the clinician when we don’t actually know what is wrong with the patient, whether they have an infection, and how severe it is.

Antibiotic susceptibilities should not be released unless the laboratory has reasonable evidence that they are required.

Because we are too generous: We are happy to test a whole range of antibiotics (often up to 20 for the one isolate!), “just in case” one of them might need to be used. This range often includes both narrow spectrum and broad spectrum agents. Probably over 95% of all the susceptibilities that we test and report are never utilised.

We need to dramatically reduce the range of antibiotics that we test for and we need to focus our reporting to the narrowest spectrum antibiotics that we can get away with.

Because we are too nice: We have a low threshold for releasing antibiotic susceptibilities on “putative pathogens“. By doing this, we have just given the green light for the clinician to classify a putative pathogen as an actual pathogen, and therefore start/continue antibiotics.

If we have isolated a putative pathogen, let’s keep it putative. Report the organism, and ask the clinician to make a clinical assessment, and then to get back to the laboratory if susceptibilities are required.

Because we are too slow: We are certainly quicker than we used to be, thanks to MALDI-TOF, smart incubators, and increasingly rapid PCR platforms, but we need to be quicker still… We need to get rid of self-congratulatory, retrospective infectious serology testing and channel our test budgets into real-time diagnosis with PCR or similar, and on patients who fulfil well defined clinical criteria for testing. We need to get rapid molecular platforms for STDs into Sexual Health clinics so they are not required to prescribe an antibiotic for everybody who walks through the door. We need to increase Influenza and RSV testing during the winter season to try and reduce unnecessary antibiotic prescribing for viral infections.

Not only do we need to be quicker, we also need to be smarter…

The clinical microbiology laboratory doesn’t score very well in the antimicrobial stewardship report card. We need to be bold and innovative to change things for the better.

But it is entirely up to us…

Michael

“The Narrow Minded Microbiologist”

Confessions of a Microbiologist, ,

Let’s take the following scenario…

You isolate an E. coli from a blood culture, and it turns out to be susceptible to all the antibiotics that you have tested it against (everything from amoxycillin to meropenem).

So how many antibiotics do you (the lab) report to the clinicians for the above case?

i) One, amoxycillin (with a comment saying other susceptibilities available on request)

ii) Two or three relatively narrow spectrum agents.

iii) Several choices, including broad spectrum ones like ceftriaxone, piperacillin/tazobactam or meropenem.

iv) “The works”! i.e. everything you test against.

I suspect a good proportion of laboratories would fall into category iii !

But really I think we should all be in category i or ii…

Meropenem & co. should never get near a microbiology result report unless it is clear it is really needed.

Out of sight, out of mind…

Traditionally clinical microbiology laboratories would give as much information as possible to the clinicians (we are far too nice…), but with little regard to the potential collateral damage such a policy could cause.

Remember that clinicians may have different agendas when treating an individual patient. (Check this article out)

Things are changing. People are beginning to realise just how important a role the laboratory can play in good anti-microbial stewardship. As the discipline grows, this will become a core focus for microbiologists.

It is not just antibiotic reporting of course. The laboratory has many other important roles in the field of anti-microbial stewardship such as :

  • Creating an “antibiogram” to guide empiric antibiotic choices for guidelines.
  • Use of rapid diagnostics to expedite identification of causative organisms.
  • Use of rapid diagnostics to expedite identification of MDROs.
  • Use of suitable report comments to discourage antibiotic use when the result suggests it may not be necessary.

The microbiology result report is key in communicating the laboratory information to clinicians in such a manner that the result is interpreted the way we want it to be.

Stay narrow, stay focused…

Michael

 

 

 

“The Antibiotic Free Period”

Confessions of a Microbiologist, ,

The patients who get the most courses of antibiotics are as expected, the ones who get the most infections, and these infections are often recurrent at the one site. A few examples are the elderly person who gets recurrent urinary tract infections, the toddler who gets recurrent otitis media, or the patient with chronic obstructive pulmonary disease (COPD), who gets recurrent bouts of bronchitis.

The antibiotic selection pressure on such patients is often intense, and one can often see by observing their microbiology results over time, that the infecting organisms become increasingly resistant, until multi-drug resistant organisms (MDROs) appear, and the clinician is forced to resort to less routine and more exotic antibiotics to treat the infection.

Whilst some of these “infections” will absolutely require antibiotics, many don’t, and many more were probably not bacterial infections in the first place.

What these patients really need is “An Antibiotic Free Period” . A period where the playing field is level. When MDROs have to compete against their susceptible counterparts in the absence of selection pressure, the increased fitness of the susceptible bacteria will win in the end. (This may take a while, and varies from patient to patient, and from organism to organism, but it will happen eventually.)

MDROs really don’t like level playing fields, they much prefer the odds slanted in their favour…

How can the microbiology laboratory assist in creating antibiotic free periods for patients?

Well we can add a comment to the result, for example “Uncomplicated otitis media does not routinely require antibiotic therapy” or “The isolation of pseudomonas from a patient with COPD does not imply acute infection.”, etc., etc.

or we can simply withold susceptibilities. For example an E. coli in a urine from an elderly Rest Home patient could have a comment along the lines of: “No clinical details have been provided with this sample. Asymptomatic bacteruria occurs in a significant proportion of elderly patients. If this patient has urinary symptoms, and they are continuing, please contact the laboratory for antimicrobial susceptibilities.”

It is my experience that the presence of an MDRO on a microbiology result report causes a reflex reaction from the requestor and increases the chance that the patient will be treated with antibiotics.

However the exact opposite should really apply. The threshold for treating an infection caused by an MDRO, as opposed to a susceptible one, should go up, not down.

One of the roles of microbiology laboratories, and clinical microbiologists, should be to facilitate antibiotic free periods where the opportunity arises…

Michael

There were seven new subscribers last week during the “Purple Cow Giveaway”. Rather than draw 5 from 7, I will ensure all seven new subscribers get a copy of my book. 🙂