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Linking Syndromic testing and AMS

In this video, Professor Manaf Alqahtani discusses AMS and the value of syndromic testing in AMS programmes.
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What’s the role of syndromic testing in the AMS programme? Well first of all, let me define. I’m pretty sure many of you guys understand what we mean by antimicrobial stewardship. It just basically means it’s a multidisciplinary team where you have a group of infectious disease specialists sitting on the table with the pharmacists – hopefully they have a good training in infectious diseases – clinical microbiologists, an infection control professional (ICP) and a hospital epidemiologist. Their function is to have an integrated programme and to provide and monitor all the antimicrobial prescriptions to patients. So basically in this slide, you can see here the ID specialists, like myself, what’s going to be my role?
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My role is to assess the clinical signs and symptoms of the patient, hopefully to bring up some diagnostic advice with some antimicrobial treatment and duration. The hospital pharmacist here has a big role in the antimicrobial drug dosing, in following the patient and drug interaction and toxicity. And of course, we should never forget about the clinical microbiologists where they have the rapid diagnostic tools, give us the interpretation and the results. And of course, we have other colleagues like intensivists. Again, they look at the risk stratification, assessing clinical signs of the infectious disease. This is the whole collaboration with the whole team. This is what you mean by the antimicrobial stewardship programme.
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The goal is to improve the management of infection in a timely manner. This is a complex slide, but in any hospital when we talk about antimicrobial stewardship, there are actually three important elements that our patients lie in between. So you will see here different colours – the green and the orange and the red. This goes to the complexity of the patient. Green is no complexity of the case. Red indicates high complexity. Overall, the antimicrobial stewardship, the diagnostics stewardship and the infection control prevention stewardship, they have a role. What’s their role? Their role is to provide the best care, unifying care, for our patient and to minimise the adverse events from the drug.
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To minimise the adverse events from the antibiotic such as the resistance, reduce hospital-acquired infections, and reduce the hospital stay. And finally, reduce or manage the hospital resources for something else rather than use the money for treating hospital-acquired infections, or complications from antimicrobial abuse. I think that’s more than enough to kind of give you an overview of the role of AMS and syndromic testing. Some of you maybe are not very familiar with diagnostic stewardship. It means syndromic testing, so one point-of-care single testing that can lead to multiple reports, and antimicrobial stewardship programme – a combination of those means diagnostic stewardship. So you provide the best diagnosis in the principle of antimicrobial stewardship.
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For those who are working within a lab community, those steps are referred to as a pre-analytic, analytic and post-analytic. This is an example of the steps where diagnostic stewardship actually may improve in testing common infectious diseases. I’m not going to go through the whole list just for the sake of time, but this is meant to just give you some general principles. When you order a test – this is the pre-analytic part – so test only a clinical presentation that is consistent with the clinical diagnosis. If the patient comes in with dysuria then you think about the diagnosis – you’re going to put your money here in collecting urine specimen, some blood culture depending on the case scenario.
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So ordering here meaning using your test based on the clinical. So you’re aligning the test with the clinical presentation. Now for collection, which is again pre-analytical, you really have to make sure that you’re providing to the microbiology lab appropriate specimens. There’s really no point, for example, in taking superficial swab and you’re thinking of a deep infection. Processing here is the analytical part, which is using the adjunctive lab test to distinguish between colonisation and infection. And this is sometimes very difficult for the clinician to know the difference between colonisation and infection. But processing here will be very important in any microbiology lab because we are dealing with so many germs so the risk of contamination is very high.
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So here’s where you want to have a test that would minimise this. Reporting, again this is post-analytic, you really want to report something of value. You want to report not junk of bacteria that doesn’t cause the problem or common cell flora. And here again where you can see that the beauty of syndromic testing or the rapid diagnosis testing. Again to summarise what I have said previously, what’s your goal here when you have a sick patient with infection? Your goal is you want to apply the right test on the right patient. So your question’s going to be, will the clinic care that I’m going to provide the patient, would it be affected by the test result.
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Because at the end, whatever test you’re going to order, you don’t want that result to lead to harm of the patient. So your question’s going to be am I using the right test to make right diagnosis for the patient? And here where we talk about linking the diagnostic to the stewardship. This is new terminology maybe for some of you. But this is where I see the upcoming years in infectious diseases and microbiology, is actually linking your diagnostic tool to the stewardship. You want to reduce the cause, minimise the side effect, and use the right test. And provide the optimum care. So is the test appropriate for the clinical setting? Am I using the right test or not?
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Will the clinical care of the patient be affected by this? Will it give some value? And finally, will the result be available in a timely manner? There’s really no point to have a test that’s going to take days or weeks to have a diagnosis, especially when it comes to a viral infection where we used to have some viral cultures which takes weeks to have the results. Can we have the results in a few hours or in a few minutes? This is where the key thing about the rapid diagnostic test with stewardship. I think we talked about this is slide, let’s just move to the next.
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Do we have some international guidelines that really endorse the importance of stewardship and rapid diagnostic tests? And the answer is yes. Go to the clinical infectious disease in 2016 – you have that represented at the bottom – and they have a clear statement that antimicrobial stewardship should be advocated for the use of the rapid viral test for respiratory pathogen. And we are living in a pandemic situation during a winter season where a patient might come in either with a COVID pneumonia, or maybe with influenza pneumonia. You would love to have a test where it can tell you, this has an influenza pneumonia versus SARS-CoV-2, for example, pneumonia. So this is where you need rapid viral testing.
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However, the most important thing would be to use the rapid diagnostic testing on the blood specimen to optimise the antibiotic therapy and improve the clinical outcome, which is the bacteremia. We are all aware of the high mortality of bacteremia when you give the wrong antibiotic. For those who have been in the lab for decades, the blood culture technique it is the gold standard. But it has its own pitfalls, disadvantages, time, contamination et cetera. Would you really be able to have some rapid diagnostic bloodstream infection that can give you the results, and the resistance hopefully, in a timely manner? Here where we have rapid diagnostic test, if you are a clinician, you’re aware of some biomarkers – that we use them.
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So white blood cell is a biomarker for an inflammation, which could result from an infection. You all know about the ESR, the CRP, those are acute phase proteins. Lactate as well and procalcitonin. Procalcitonin – we could spend the whole day talking about procalcitonin and its role in stewardship. It has a beautiful role, and I have seven years experience in using procalcitonin in guiding me in initiating antibiotic versus discontinuation of antibiotic. Gram stain of course. And the ultimate – and I think in the upcoming years we’re going to really focus on molecular, which is the rapid diagnostic testing. So just to give you an example – let’s go to the traditional method.
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If you don’t have those rapid diagnostic tools, like the syndromic testing, you have a patient, you take the blood for whatever infection they have, let’s say bacteremia. So you put them on an empiric antibiotic and you’re going to use the protein antibiotic, day zero. Go by day one until day 3 because this is where you’re going to wait for the blood culture report. And the blood culture report comes and unfortunately, it was different organisms that has different coverage for the antibiotic. So you have lost three to four days by giving the wrong choice of antibiotic. And this can lead to maybe transferring the patient to an ICU, or unfortunately, that might cause death. How about if I do something different?
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If I apply the rapid molecular test. So you take the blood, you start the empiric choice from day zero. And on the same day, because it’s going to just take a couple of minutes, you apply the rapid molecular diagnosis. You have your result, then you target your antibiotic within the same day or the next day. Beautifully done. Patient has less length-of-stay and good outcome.

Professor Manaf Alqahtani elaborates on AMS in this video, discussing the value syndromic testing — and diagnostic stewardship using syndromic testing — adds to existing AMS programs.

As Professor Alqahtani explains in the video, rapid molecular identification methods — such as syndromic testing — shorten the time taken to identify offending microorganisms. This can result in targeted antimicrobial therapy being given sooner for the appropriate duration, and can subsequently aid antimicrobial stewardship by encouraging efficient use of antimicrobials.

Patient pathway with traditional vs rapid molecular identification and testing methods: using traditional methods means that the patient would be on empiric, broad-spectrum antimicrobials from Day 0 of the sample being taken into Day 3, before standard identification and susceptibility methods would allow target antimicrobial therapy to be given; using rapid molecular techniques results in the patient being able to receive targeted antimicrobial therapy from around Day 2 Organism Identification and Initiation of Targeted Antimicrobial Therapy: Traditional versus Rapid Molecular diagnostics for bloodstream infection – click here for a closer look

For more information and further reading on this topic, please see the see also section below.

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Syndromic Testing and Antimicrobial Stewardship

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