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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.
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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?
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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.
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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.
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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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