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Case 1: Use to improve AMS (Pneumonia)

In this video, Professor Bassetti presents a patient case study in which syndromic testing was used to add value to diagnosis, treatment and outcome.
So I’ll try to discuss with you about how to use syndromic testing to improve antimicrobial stewardship. So I think we can start with a very simple case. We have a patient that is admitted with an hospital-acquired pneumonia because the patient was already hospitalised, a week before, in the hospital for pancreatitis – so is now again admitted to the hospital for pneumonia. And obviously, this pneumonia is considered a hospital-acquired pneumonia even if it was present in the community, because the patient was already admitted to the hospital for a week. So we have the classical sign of pneumonia. And we have, obviously, to start an antibiotic, because the patient is septic. So how do we stratify the risk for this patient?
So the patient was hospitalised for a week, so there is a risk for gram negatives - Pseudomonas, Klebsiella, and other Enterobacterales. But also there is a role for Staphylococcus aureus. But at the same time, the patient was also in the community. So we cannot rule out, significantly, virus or even typical bugs of community-acquired pneumonia, like Streptococcus pneumonia, like Chlamydia, Legionella, or Mycoplasma. So we decided to prescribe, especially because this was considered a hospital-acquired pneumonia, piperacillin/tazobactam alone. And we decided to perform a syndromic test, a BioFire test – and we performed the BioFire test on the bronchoalveolar lavage, because of the patient – we decided to perform a bronchoscopy. So we started the treatment with piperacillin/tazobactam.
And after a few hours, the results showed that the patient has Streptococcus pneumonia, community-acquired pneumonia. So obviously, piperacillin-tazobactam is not the best drug for treating Streptococcus pneumonia. And we de-escalated, or we changed, the treatment from piperacillin/tazobactam to ceftriaxone, 2 grams a day. And this is a classical example of a syndromic test applied to a patient with pneumonia in order to optimise the antimicrobial stewardship approach. You know, this is a patient that, without this kind of test, was treated previously with piperacillin/tazobactam. Obviously, it’s not the best antibiotic treatment for Streptococcus pneumonia. But the patient presents several characteristics paradigmatic of an hospital-acquired pneumonia. So I think this is a good example in how to optimise antibiotic treatment, how to escalate or de-escalate.
So I think that – this is obviously the example for hospital-acquired pneumonia – but the same type of approach should be used even in community-acquired pneumonia, or even with a panel that we can use in bloodstream infections, even in bloodstream infections. So I really believe this is a nice approach in order to optimise antibiotic treatment.

In this video, Professor Bassetti presents a patient case study in which syndromic testing was used to add value to diagnosis, treatment and outcome.

Case summary

  • Patient admitted with hospital-acquired pneumonia (HAP) from the previous hospital stay for pancreatitis the week before
  • Patient showing classical signs of pneumonia
  • Patient septic so antibiotic therapy required immediately. Key risks/considerations included:
    • Risk of gram-negative (Pseudomonas, Klebsiella, and other Enterobacterales) infection, as well as Staphylococcus aureus, due to previous hospitalisation
    • Risk of viral origin, or even typical microbes of community-acquired pneumonia (CAP) as the patient also spent time out of hospital
  • Patient prescribed piperacillin/tazobactam (pip/taz) alone
  • Syndromic test performed on bronchoalveolar lavage (BAL)

Case resolution

A few hours after the syndromic test was performed on the patient’s BAL sample, results showed that the causative agent was Streptococcus pneumoniae (seen in CAP). Pip/taz was therefore de-escalated, and the patient’s antibiotic therapy was changed to ceftriaxone (2 g/day).

This is a classic example of how syndromic testing can be used safely to optimise antimicrobial stewardship.

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Syndromic Testing and Antimicrobial Stewardship

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