In this article four experts from bioMérieux discuss microbiology strategies to advance antimicrobial stewardship, reflecting on a recent Xchat (Twitter Chat) on the topic.
Authored By: Katarzyna Wojcik, PMP, PhD, Andrea Prinzi, PhD, MPH, CPH, SM(ASCP), Amanda Suchanek, Ph.D., Jessica Blavignac
There is no question that antimicrobial resistance (AMR) has created new challenges for all stakeholders, requiring active and continued collaboration between healthcare professionals and various disciplines to overcome.
In October 2023, Chat host #ASPchat partnered with bioMérieux and its experts; Katarzyna Wojcik, Andrea Prinzi, Amanda Suchanek, and Jessica Blavignac, to share expertise on various strategies that microbiology laboratories can apply to help advance diagnostic and antimicrobial stewardship programs (ASP).
Laboratory directors, medical laboratory scientists, pharmacists, nurses, and physicians are key leaders in ASP efforts to combat AMR. The success of AMS programs and initiatives relies on the collaboration between these medical teams, and the involvement of the medical microbiology laboratory is imperative. The incorporation of effective laboratory processes supports the systematic application of best practices needed to be good stewards of antibiotics.
Data are more than just numbers
AMR is now recognized as a leading cause of global mortality. In 2019, The Lancet shared a systemic analysis that reported an estimation of 1.27 million deaths attributed to and 4.95 million deaths associated with AMR globally. One of the best tools stakeholders have to act against AMR is data, of which laboratories are a primary generator. Access to rapid data allows hospitals to act quickly, reduce time to appropriate antimicrobial therapy, reduce costs, and provide a more accurate diagnosis for the patient, which ultimately develops medical excellence and helps fight AMR.
During the October #ASPChat, bioMérieux and participants agreed on the value of local data to help understand and communicate the true impact of AMR. While the global AMR statistics are powerful, having local data makes information more relatable and actionable. Resource hubs like the Centers for Disease Control (CDC) and the Public Health Agency of Canada (PHAC) provide information that helps to relay the science and severity of AMR burden and the value of ASP.
“I really love the resources the @CDC_AR has come out with. Easy-to-understand communication of the science around #AMR is super important, and I think @CDCgov coming out with a dedicated resource hub is pretty fantastic.”
–Amanda Suchanek, Ph.D. Medical Advisor, bioMérieux
Chat participants also shared that institution-specific data resonate best with providers when it comes to prescribing and direct patient care. Institution-specific data can be leveraged to provide feedback to clinicians and help encourage ASP best practices. For example, the data can be used to evaluate provider antibiotic use versus approved criteria for use and then relay these data back to clinicians like a report card. These data, including antibiotic utilization, hospitalization rates, length of stay, and AMS interventions with associated outcomes serve as impactful benchmarking metrics and may support the prevention and reduction of AMR by encouraging improved stewardship.
Antibiograms: Local Data Super Tool
Access to AMR data on a local level is critical to fully understanding local resistance patterns and implementing effective ASP initiatives. Enter super tool, antibiogram.
“Antibiograms inform appropriate antimicrobial prescribing. Antibiograms help get the right drug to the right patient at the right dose.”
–Katarzyna Wojcik, PMP, PhD, Senior Medical Science Liaison, bioMérieux
While this super tool can be the best opportunity to determine local susceptibility rates, track resistance trends, and inform empiric antibiotic therapy, antibiograms can be complex, vary in development amongst institutions, and may be poorly understood.
So how can antibiograms be more user-friendly and impactful? Stewardship teams can collaborate with prescribers and the microbiology laboratory to ensure proper education that provides guidance and confidence in antibiogram use and appropriate interpretation and application to clinical decision-making.
Amanda Suchanek, Ph.D. Medical Advisor, bioMérieux, discussed resources like the CLSI M39 guideline which provides specific recommendations to help ensure that antibiograms are accurate, reliable, and valid. Recent updates introduced to the CLSI M39 guideline in the 5th edition, like color coding, address current trends in microbiology laboratories, informatics systems, and ASPs to enhance the value of cumulative antimicrobial susceptibility test (AST) data generated.
“The point of an antibiogram is to offer clinicians data on local trends so that they may take that into account when selecting appropriate empiric therapy. A lot of data is produced by the micro lab each year, and consolidating this information can be daunting.”
–Andrea Prinzi, PhD, MPH, SM (ASCP) Field Medical Director, bioMérieux
The optional use of the color-coded system on routine or enhanced antibiograms was discussed during the #ASPchat, as a way to further support the prescriber for optimal empirical treatment. Another participant offered advice that including antibiograms directly in treatment guidelines can allow the provider guidance, to see recommended therapies and local resistance rates to better understand why specific therapies were selected.
The Role of Diagnostic and Antimicrobial Stewardship
If antibiograms are the engine to help identify local AMR trends, the microbiology laboratory is the fuel for that engine. With antibiotic overuse being a key driver for AMR, #ASPchat experts suggested that we must urgently reconsider how we use antimicrobials to preserve for future generations. Reducing inappropriate antibiotic use is possible with the help of innovative and rapid diagnostics and the support of various disciplines partnering together.
Think of it as a team sport. Diagnostic stewardship encompasses considerations across the diagnostic process from pre-analytic to post-analytic, with inputs from laboratory medicine, pharmacy, nursing, and treating clinicians to ensure appropriate tests are ordered and resulting data are actionable and timely.
“Diagnostic stewardship is complementary to ASP: implying ordering the right tests, for the right patient, at the right time; judicious use of rapid diagnostics for proper antibiotic therapy initiation & avoiding excessive use of broad-spectrum antibiotics.”
–Jessica Blavignac, Director of Scientific and Medical Affairs, bioMérieux
While diagnostic stewardship is needed to ensure appropriate testing, ASPs are needed to ensure that clinician prescribing is appropriate in the context of diagnostic test results. As technology continues to evolve, rapid diagnostics in the laboratory can support ASP initiatives by providing real-time decision support at the time of result reporting to secure the right interpretation, supporting optimal antibiotic therapy.
This act of stewardship remains needed to help new diagnostic advancement conserve additional healthcare resources and enhance patient care. A strong and consistent cadence of communication between treating physicians, ASPs and the lab can make the difference between a small number of necessary tests and many unnecessary ones. As Katarzyna Wojcik, PMP, PhD, Senior Medical Science Liaison, bioMérieux said, “ASPs + Lab = best test choice = best use of results!”
“Pre-analytic: help provide education about appropriate test collection practices, support the lab in rejection of tests that don’t meet criteria. For expensive/complex tests targeted for intervention, consider requiring ASP or ID team approval prior to ordering. Post-analytic: Communication is key! Serve as a translator between the lab & clinicians, explaining test results and/or any relevant interventions. Provide education around lab reporting practices.”
–Andrea Prinzi, PhD, MPH, CPH, SM(ASCP), Field Medical Director, bioMérieux
Another helpful strategy #ASPchat experts suggested to influence patterns of antimicrobial prescribing is the intervention known as nudging. Nudging retains prescriber autonomy while guiding their decision-making with strategic data. With many complexities around the emergence of AMR, implementing effective ASP interventions requires a coordinated multidisciplinary effort. Open communication and openness to communication are warranted to help change these behavioral aspects of prescribing in various settings.
Antimicrobial Susceptibility Results – Context Is Key
A major component of reporting antimicrobial susceptibility results is the inclusion of minimum inhibitory concentration (MIC) in reporting. MICs provide useful insights that can lead to more effective antibiotic decision-making. Among the bioMérieux experts and other participants in the #ASPchat, there was agreement that reporting MICs is valuable data, especially if updated breakpoints are not being used. However, this information is important only when understanding what to do with it.
“In my practice, we always reported the MIC. There are multiple reasons for this, but mostly clinicians wanted to see it. The MIC is useful information for dosing and is essential information if a lab is not using up-to-date breakpoints. That said, the nuances of MICs are not always fully understood, and labs may choose to not to report them. Even if not reported, making MICs accessible for clinicians as needed is helpful.”
– Andrea Prinzi, PhD, MPH, CPH, SM(ASCP), Field Medical Director, bioMérieux
Amanda Suchanek, Ph.D. Medical Advisor, bioMérieux concurred with this by saying, “I tend to like to err on the side of more data is better so I would rather see the MICs, or at least have access to them. I understand that having *too* much data can present a whole new set of problems. Context is everything.”
Collaboration between the lab and ASPs is warranted to help clinicians interpret the MIC values in the context of infection sites, test methods, dosing, and more. Data generated from automated antimicrobial susceptibility testing may be limited in what can be tested in terms of antibiotics and MIC dilutions.
One method is to use clinical pharmacokinetic-pharmacodynamic (PK-PD) target attainment analyses to determine efficacy. While the use of MICs can present challenges to those with limited exposure, continuing to seek a better combination of tools will allow for a more intentional approach to reporting and data, and facilitate empiric therapy.
In conclusion, the #ASPchat stimulated thoughtful discussion among laboratory professionals, clinicians, and pharmacists which yielded valuable insights about how the microbiology laboratory can help improve stewardship initiatives and combat the serious and growing public health concern of AMR.
Please share your thoughts in the comments below. We would love to keep this conversation going!
ABOUT THE AUTHORS
Katarzyna Wojcik, PMP, PhD is a Senior Medical Science Liaison at bioMérieux
Andrea Prinzi, PhD, MPH, CPH, SM(ASCP) is a Field Medical Director of US Medical Affairs at bioMérieux
Amanda Suchanek, Ph.D. is a Medical Advisor at bioMérieux
Jessica Blavignac is a Director of Scientific and Medical Affairs at bioMérieux
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