diagnostic stewardship a tool for antimicrobial ... - strama

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Diagnostic stewardship A tool for antimicrobial stewardship (ASP)

Swedish perspective

Tinna (Christina) ÅhrénInfectious disease physician

Clin. microbiologist/SU Head of Strama VG

www.vgregion.se/strama

www.menti.comcode: 52 26 33

Code will be shown an all slides

Aim of microbiology diagnostics?

• Aid for diagnosis

• Identify treatment alternatives

• Base for empiric treatment alternatives• Predominating bacteria/diagnosis

• Aggregated levels of resistance

A chain of factors influence the final results of culture and treatment

• Before the sample arrive in the lab• Sampling techniques• Requested analyses• Information given to lab.

• Bed side diagnostics

• Transportations to lab• Service 24/7, incl. loading of blood cultures

Preanalytisk fas

Analytisk fas Postanalytisk fas

A chain of factors influence the final results of culture and treatment

• What we do in the lab influence the final report• Methods for species identification

• AST- determination methods

• AST- algorithms

• The one answered: Recommended by RAF

• The one tested: minimum …

• Individualized for selected patient(s)

• Interpretation and clinical relevance of findings

Preanalytisk fas

Analytisk fas Postanalytisk fas

Preanalyticfas

Postanalyticfas

Analytic fas

What happens when the report

arrives!

A chain of factors influence the final results of culture and treatment

Room for improvement??

Today:It is not about:

• test chosen

• strain identification methods

• AST – methods, algorithms etc.

It is about how we forward our answers irrespective what has been done

First: Do what you must (might be a lot) not to delay proper treatment

Second: make a judgement what to report

www.menti.comcode: 52 26 33

English here – Swedish in the ”phone”

Where do you work: 1. In the laboratory2. In Strama committee3. Clinician, usually not working with Strama

In what type of “landsting”/county: 1. Large county with University hospital2. Medium size county with

one larger + minor hospitals3. Small size county, with only minor hospitals

52 26 33

1.

2.

Background data

Resultat från mentometer

Resultat från mentometer

Diagnostic ASP1. Lab 2. Strama + Clinicians

LAB: The design of the answer from lab may influence AB usage, e.g. by adding comments, give an AST-report etc?

0 % 100 %

52 26 33

Resultat från mentometersvar från Lab.

Resultat från mentometersvar från Strama.

Hospital care

Primary care

Strama i VGR educational workshops- responses från clinicians

Clinicians have trust in lab.

Typical case

•67 year old man

•now fever, no other anamnestic information is available for lab.

• arrives at ER and a blood culture is drawn, cefotaxime is given

Would you continue treatment?

• Coagulas-negative staphylococci (CNS) –contamination?

• Coagulas-negative staphylococci (CNS) – with AST

• S. haemolyticus with AST

0 % 100 %

0 % 100 %

+

0 % 100 %

• KNS ¼ bottles,• Malditof:

S. haemolyticus

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alwaysnever

Doctors working in hospital care: Would you continue to give antibiotics ….?

+ KNS ¼ bottles

Refrain from details if the findings most likely are not clinically relevant??

Another case

• Elderly lady

• Chronic ulcer on left ankle

• Now symptoms of possible infection

• No fever

• Wound-culture has been taken

• Two alternative culture results but the same anamnesis

First type of ulcer/culture

Pseudomonas + mixed Gram-negative flora!

Blood plate Gram-negative plate

• P. aeruginosa, with AST, and skin flora

• As above, but add a comment ”relevant finding?”

• Skin flora, including P. aeruginosa (no AST)

0 % 100 %

0 % 100 %

0 % 100 %

Which response would youuse/prefer?

1. lab. 2. Strama

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Resultat från mentometersvar från Lab.

Resultat från mentometersvar från Strama.

Would you treat with antibiotics….

Hospital care

Primary care

Strama i VGR educational workshops- responses från clinicians

Would you treat with antibiotics….Hospital care

Primary careThis wound should not have been

treated with antibioticsMisled??

Strama i VGR educational workshops- responses från clinicians

Another ulcer, same patient S. aureus and skin flora

Blood plate Staph plate

Hospital care

Primary care

Would you treat this patient with antibiotics?

Again, treatment increaseswhen AST-results are given!

Strama i VGR educational workshops- responses från clinicians

Should lab avoid to give these AST-results (PHC)- what is your opinion?

1. Lab. 2. Strama

• Not ciprofloxacin, E coli urinary culturenonfebril UTI?

• Not cefalosporin, Gram-negative rods in wound culture?

• Not ciprofloxacin, pseuodomonas in woundculture

0 % 100 %

0 % 10 %

0 % 10 % 52 26 33

Resultat från mentometersvar från Lab.

Resultat från mentometersvar från Strama.

Hospital care

Primary careThey seem to agree to selective reporting

Strama i VGR educational workshops- responses från clinicians

Should only AST for the primaryrecommended AB be answered ?

How did the clinicians interprete this report?

• This was the only treatment alternative?

• Other commonly used alternatives also work?

0 % 100 %

0 % 10 %

Exempel: if sensitive only reportS. aureus -isoxa.pc

Pneumococci - penicillin

Should only AST for the primaryrecommended AB be answered?

Primary care

An accompanying comment is needed!

• How often do you react on a comment given?

• How often have you wished for a comment to aid you

• Do you know what Pantoea agglomerans is?

0 % 100 %

0 % 100 %

0 % 100 %

alwaysnever

Comments on the reportWhat did they answered?

Hospital care

Primary care

Comments are really wanted

Strama i VGR – educational workshops - responses

NPH-culture from a 2 year old child How do you react on this answer:

”H. influenzae sensitive to beta-lactam antibiotics”

• give me an AST-profile, instead …. please!

• OK, I can treat with pcV

• OK, I can treat with amoxicillin

0 % 100 %

0 % 100 %

0 % 100 %

alwaysnever

Strama i VGR – educational workshops

Primary care

The lab. must help the clinicians

”H. influenzae sensitive to beta-lactam antibiotics”

amoxicillin

Strama i VGR – educational workshops - responses

Lab: Would you consider to send out this comment – urinary culture:

”Remissuppgifter saknas. Om patienten har tydliga tecken på UVI vänligen meddela lab. så odlar vi provet”

(there will be now delay in the report, if wanted)

52 26 33

No culture results in case of ABU?

Leis JA, Rebick GW, Daneman N et al. Reducing antimicrobial therapy for asymptomatic bacteriuria amongnoncatheterized inpatients: a proof-of-concept study. Clin Infect Dis. 2014 Apr;58(7):980-3. doi:

10.1093/cid/ciu010.

–Proportion ABU treated decreased from 48 to 12 %!

Urinary culture day 1, hospital care (USA)(ca 41 000 patients with and without culture)

six additional bed-days36 607 additional days with antibiotics

In those cultured

Resultat från mentometersvar från Lab.

50 %

How would you react on the following report:

”Remissuppgifter saknas. Om patienten har tydliga tecken på UVI vänligen meddela lab. så odlar vi

provet”

1. Big deal, it was probably an ABU, she is better

now..

2. Did we miss to add patient information (again) –

call lab

3. Call lab – what are they doing – everything must

be cultured ….

Strama i VGR – educational workshops

Primary care

No culture results for urin sample, incomming report”empty” …..

Hospital care

Strama i VGR – educational workshops - responses

Take home message

• There is a trust in the laboratories judgment

• The lab must aid the clinicians in the evaluation of clinical relevance of results

- Refrain from reporting clinically nonrelevant details

• Consider selective reporting in selected cases- An AST-report may signal that AB-treatment is needed

• Comments are really wanted and needed

Take home message

• There is a trust in the laboratories judgment

• The lab must aid the clinicians in the evaluation of clinical relevance of results

- Refrain from reporting clinically nonrelevant details

• Consider selective reporting in selected cases- An AST-report may signal that AB-treatment is needed

• Comments are really wanted and needed

Need to increase the collaboration between the laboratory and the clinicians ??

Thank you!

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