By Chris Cook, PharmD, Ph.D.
Battling a serious infection is a race against the clock. When a patient enters the ED with symptoms that suggest a bloodstream infection, the biggest concern is sepsis and septic shock. Septic shock is an immune response to a blood-stream infection that quickly spirals out of control, leading to widespread blood clotting, organ failure and restricted blood supply to tissues. A patient may walk into the ED and seem relatively fine and be dangerously septic just a few hours later if not treated quickly. In order to treat those patients quickly, they must be diagnosed quickly.
And while the doctor may diagnose the patient with pneumonia within the hour; unfortunately, it will take 24 hours or more before the doctor knows what bug is causing the pneumonia. That is the underlying problem of antibiotic usage and antimicrobial resistance. Since it can take a day or more to accurately identify the pathogens, patients are treated empirically with broad-spectrum antibiotics, because without treatment against the pathogen, they could die before the traditional laboratory identifies the bug.
That is why condensing the diagnostic timeline from sample collection to pathogen identification and generating antibiotic susceptibility testing (AST) results is the anchor of an effective antibiotic stewardship program. The speed of diagnostics has increased dramatically in the last decade and will continue to do so. These new tools are phenomenal. They provide us with information in just hours that used to take days.
That information allows us to treat patients very precisely, but technology alone will not solve the problem of antibiotic resistance. Technology must be coupled with a robust antibiotic stewardship and process improvements to provide rapid results that are then acted upon in real-time. Stewardship is not something that the clinical lab or clinicians alone can do. Stewardship is a team sport!
No matter how cutting-edge a new microbiology detection technology is, healthcare institutions will fail to curtail resistance if that technology is not used as a part of a larger antibiotic stewardship effort. A complete antibiotic stewardship plan should be implemented according to the Joint Commission’s guidelines and include a committed team with members from the lab, pharmacy, prescribers and administration support. No piece of equipment can generate real antibiotic stewardship in any lasting way. The keys to any effective antimicrobial stewardship efforts must include the people, the processes and the technology.
New Technology and Robust Stewardship are Both Required to Curtail Resistance
Johns Hopkins University acquired peptide nucleic acid fluorescence in situ hybridization (PNA-FISH), a diagnostic tool for the rapid assessment of Gram positive organisms.1
While that new technology provided very fast results, the lab process made no accommodations to share the actionable information in a timely manner with clinicians. As a result, no clinical benefit was seen after the acquisition of the technology.
Another study assessed the value of PNA-FISH for the rapid identification of coagulase-negative staphylococci in the absence of antimicrobial stewardship intervention.2
The authors concluded, “PNA FISH was instituted at Boston Medical Center for the rapid identification of coagulase-negative staphylococci (CoNS). Without active notification or antimicrobial stewardship intervention, a pre- and post-impact analysis showed no benefit of this assay with respect to the length of hospital stay or vancomycin use.”
New Antimicrobial Stewardship Standard from The Joint Commission
As of the beginning of 2018, roughly half of all U.S. hospitals were compliant with the Joint Commission stewardship mandate, “New Antimicrobial Stewardship Standard by The Joint Commission,” outlined below. The remainder are in various stages of completion—some very close, while others are lagging far behind. The (critical access) hospital’s antimicrobial stewardship program includes the following core elements:
- Leadership Commitment: Dedicating necessary human, financial and information technology resources
- Accountability: Appointing a single leader responsible for program outcomes. Experience with successful programs shows that a physician leader is effective
- Drug expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use
- Action: Implementing recommended actions, such as systemic evaluation of ongoing treatment need, after a set period of initial treatment (for example, antibiotic time out after 48 hours)
- Tracking: Monitoring the antimicrobial stewardship program, which may include information on antibiotic prescribing and resistance patterns
- Cosgrove SE; Use of PNA FISH for blood cultures growing Gram-positive cocci in chains without a concomitant antibiotic stewardship intervention does not improve time to appropriate antibiotic therapy. Diagn Microbiol Infect Dis. 2016 Sep;86(1):86-92.
- Holtzman C; Assessment of impact of peptide nucleic acid fluorescence in situ hybridization for rapid identification of coagulase-negative staphylococci in the absence of antimicrobial stewardship intervention; J Clin Microbiol. 2011 Apr;49(4):1581-2. doi: 10.1128/JCM.02461-10. Epub 2011 Jan
Opinions expressed in this article are not necessarily those of bioMérieux, Inc.
Christopher Cook, PharmD, Ph.D.
Christopher Cook has over 20 years’ experience in pharmacy practice ranging from academia to clinical practitioner and outcomes researcher. Dr. Cook is currently the Senior Director, Antimicrobial Stewardship Customer Support at bioMérieux, Inc.. He also serves on the National Quality Forum Patient Safety Committee. Prior to joining bioMerieux, Dr. Cook served as a Clinical Professor at the University Of Georgia College Of Pharmacy.