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What is antimicrobial stewardship?

In this video Professor Manaf Alqahtani discusses antimicrobial resistance, antimicrobial stewardship and diagnostic stewardship.
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We’re all aware about antimicrobial resistance. It’s a global public health concern. In Europe, each year, you have more than 670,000 infections due to multidrug-resistant bacteria. Across Europe, almost 33,000 people die as direct consequences from their infection. Now, why do people make a big deal about resistance? Is this worth the time for you to learn about AMS and syndromic testing? Well, you all aware, when you have a MRSA bacteremia, the increased risk of mortality goes up by 1.9. Additional length of stay goes up by 2.2 days. And there’s no need to mention about the additional costs for that. And that goes, again, for MRSA surgical site infection, VRE infection, resistant Pseudomonas, and resistant Enterobacter.
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All of them would increase your risk mortality. And you’re going to increase the length-of-stay in a hospital, as I said. And the ultimate outcome of this is going to be additional costs. So the role of rapid diagnostics in tackling AMR. The first question people are going to ask me, what would be the most singularly important of these 10 points to tackle resistance? I’m going to choose rapid diagnostics. Of course, public awareness, antibiotic in agriculture, surveillance, human capital, global innovation, et cetera – all of these are very important. But, being a clinician, rapid diagnostics would be the most important in tackling antimicrobial resistance.
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A lot of people, especially physicians, non- infectious disease and microbiologists, they are always going to ask, what’s the evidence from the literature about rapid diagnostic testing, and antimicrobial stewardship? So let’s just go to the WHO priority list of resistance organisms. Just to remind you, there are three categories. They are divided into category 1, or priority 1 (critical), and priority 2, which is high, and priority 3, which is medium. And, of course, I’m not going to go through the list of the organisms. Those are the common organisms, where they, in fact, are considered as the top resistant organism.
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So category number 1, critical, you’re all aware, or maybe you heard of, or you have seen in your patients, Acinetobacter baumannii when it is resistant to carbapenem. It’s an awful pathogen. It can lead to a severe infection. And, unfortunately, we have a very limited choice of antibiotic. Now, do I have to remind you about Pseudomonas aeruginosa? And especially, when it becomes resistant to carbapenem, it’s a nightmare for any intensivist. Enterobacteriaceae, it’s another gram negative, where it can be an ESBL producer or carbapenem resistant. So those are really the critical bugs that can lead to problems for our patients.
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So the impact of rapid diagnostic testing on antimicrobial stewardship – the utility and the benefit of RDT (which stands for Rapid Diagnostic Testing), are clearly embedded in the definition of AMS. So AMS a “coordinated intervention designed to improve and measure the appropriate use of antibiotics”. How? By promoting the selection of optimum antibiotics during regimen, including dosing, duration, and the route. So the goal of antimicrobial stewardship is really to improve the patient outcome – and that’s the ultimate goal – and to reduce the drug-adverse event, such as C. difficile, and emergence of antimicrobial resistance. Of course, there’s so much published literature. And I have the references at the bottom.
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It has been shown, a clear association between the RDT and the improvement at the time to optimum antimicrobial therapy, that the rate of return infection, mortality, length-of-stay at the hospital, of course, that has been really laid out nicely in several literature. The most significant impact of optimisation of antimicrobial therapy really occurs with the integration of the RDT with the AMS intervention, especially in the realm of positive blood culture. Do we have more evidence about the early pathogen identification, how it can we reduce time to appropriate therapy, and improving the outcome and reducing the hospital cost? Yes, there are retrospective analyses.
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Around 56,000 patients that came in with a gram bacterial infection, and you can name them, from UTI, to hospital-acquired infections, and bloodstream infections. And they have been stratified by the antibiotic sensibility to the index pathogen. So resistance we had around 6,000. Susceptible, were around 50,000. And we examined the clinical and the economic burden that was associated with the delayed recipient of antimicrobial therapy. So you know that delayed antimicrobial therapy received by around 46% in patient with resistant and around 33% in patient with susceptible infection. And, of course, that is going to lead to increased exposure to antibiotics by 4.5 days, at least. Increased length-of-stay by 5 days. And, of course, induce, or increase, additional costs by $11,000 US dollars.
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And then, of course, 31% lower chance in being discharged. And 60% increased risk of hospital mortality. So you can imagine the negative impact of using the wrong antibiotic or the wrong type for the patient. And that can lead to poor outcome, unfortunately. So how about implementation of those rapid molecular diagnostics, such as syndromic testing, and its role in the antimicrobial stewardship? And I think we talked about this, on a slide, where actually, we talked about two major principles here. That you should have diagnostic testing – we call it diagnostic stewardship – and that you use the right test, for the right patient, on the right time. What’s your goal?
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Your goal is, actually, to give the right interpretation, to give the right antimicrobial therapy, at the right time. This is exactly what we mean by diagnostic stewardship and antimicrobial stewardship. And it is essential to have those combinations of essential elements in the stewardship to have a good outcome. So a functioning, collaborative partnership between the lab and the clinical side is essential. And that’s what we are missing, unfortunately, in some hospitals, where you can see clearly there is a gap between the personnel in the lab and between a clinician. The aim of this tutorial is actually to give you a hint in how you combine both diagnostics and stewardship at the same.

In this video Professor Manaf Alqahtani discusses antimicrobial resistance (AMR) and antimicrobial stewardship (AMS), linking it to broader discussions on diagnostic stewardship and the support it provides for AMS programmes.

Antimicrobial stewardship encourages appropriate and responsible use of antimicrobials, and is crucial in the ongoing fight against antimicrobial resistance. Diagnostic stewardship makes use of laboratory testing to guide, and optimise, treatment choices and patient outcomes, slowing AMR spread.

The link between AMS and diagnostic stewardship is discussed briefly in this video and is expanded on in the following step, with syndromic testing as the laboratory method of choice.

References cited in the video have been provided as links in the see also section below.

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Syndromic Testing and Antimicrobial Stewardship

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