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
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
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
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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 %
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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)
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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!