Role of the Clinical Microbiology Laboratory in Antimicrobial Stewardship

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Key points

  • The microbiology department should be able to systematically select patients who will benefit from microbiological information and assigned proactively to a fast track protocol.

  • The microbiology department should develop diagnostic routines for same-day reporting and implement rapid identification and antimicrobial susceptibility testing procedures for special patients and samples.

  • The microbiology red phone is made up of a medical microbiologist and all the information the laboratory must make

Systematic selection of patients who will especially benefit from microbiological information and will be proactively assigned by the microbiologist to a fast track protocol

All clinical samples submitted to the laboratory cannot be given the same priority or diagnostic preference. This means that the laboratory itself needs to have the capacity to identify patients who will benefit from rapid proactive action. In our department, we have discussed what the best warning criteria might be for selecting patients who are likely to benefit from a fast track approach. Some of these criteria are listed in Box 1.

These patients should be assigned to a microbiologist guide,

Rapid reporting of positive and negative test results: Microbiology red phone

Communication with clinicians is essential1 and a particular section of the laboratory should be responsible for providing such preferential information. We call this section the microbiology red phone. The section is made up of a medical microbiologist who coordinates all requests for rapid information from clinicians and all the information the laboratory must make sure is reported to clinicians during the critical period of management. Ideally, the section is functionally equipped with a

Speeding up the laboratory workup of samples of particular significance

Clinical samples on which a rapid diagnosis must be made are variable, and so are the ways to speed up the diagnosis. Here are just a few examples of how diagnostic routines within a context of antimicrobial stewardship can be expedited. A recent advance is the possibility of confirming or excluding a diagnosis of influenza virus or respiratory syncytial virus (RSV) in less than 1 hour.3, 4, 5 In our opinion, these results can influence antimicrobial stewardship by adding a laboratory message.

Rapidly searching for certain pathogens

Rather than providing an exhaustive description of all potential laboratory tests that could have an impact on antimicrobial stewardship, we only give a few examples targeting each group of microorganisms. We have already mentioned the great usefulness in the field of virology of an immediate influenza and RSV test during the seasonal incidence of these agents. Another example is the cerebrospinal fluid screening test for herpes simplex virus, which is often performed in patients with suspected

Rapid antimicrobial susceptibility testing

We have discussed the usefulness of antibiotic tests carried out directly on the clinical specimen received, without waiting for bacterial isolation and the standard performance of these tests. In our laboratory, these rapid tests are used routinely in patients with suspected pneumonia associated with mechanical ventilation. When added to the use of chromogenic agars, these tests are extraordinarily practical for providing a reliable antibiogram within 18 hours of incubation. The rapid

Systematic search for conflictive pathogens

Microorganisms that need to be routinely searched for in different samples and patient groups have not yet been precisely defined and each hospital and service has its own preferences. As an example, we comment on some of the circumstances that we believe may have the greatest impact on antimicrobial policy.

The detection of carrier status of S aureus has been discussed elsewhere in this article. Nasal sample detection is considered sufficiently representative of body colonization status,

Rapid detection of resistance

We have discussed the possibility of quickly determining the sensitivity or resistance of different bacteria or fungi to antimicrobial agents, both using tests based on microcultures and microscopy and tests carried out directly on clinical samples. As particularly promising, we would like to highlight the possibility of immediate sensitivity results through mass spectrometry and other techniques (MALDI-TOF-MS).100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114 As far as

Alliance with clinical pharmacy and the stewardship committee to influence prescription: checklists

As mentioned elsewhere in this article, it is essential to carry out programs based on hospital pharmacy and microbiology department databases to detect errors in clinical practice and implement alerts.115 In the context of antibacterial stewardship, combining information on antibiotic prescription versus isolation sensitivity in microbiology is a continuous source of intervention programs.115, 116, 117, 118, 119, 120, 121, 122, 123, 124, 125, 126, 127

Many programs are based on alerting

Statistics for clinicians and epidemiologists: the stewardship committee

One of the obligations of microbiology is to keep statistical information based on its databases to guide stewardship programs. Tables of the microorganisms most frequently isolated in the different samples and their antimicrobial sensitivity should be provided at intervals of no longer than 6 months and subdivided particularly for some units, such as critical care, according to their particular data.129

Microbiology can also provide trend indices of different processes based exclusively on

Periodic meetings with groups of physicians and nurses

Microbiology must leave the laboratory and become physically visible to the doctors and nurses of the institution. That is why we believe that the department should, at least once a year, visit the units, both in the hospital and beyond that submit more samples to the laboratory. This visit should consist of sharing available microbiology data on available tests from microbiology in relation to the visited department, exploring opportunities for improvement, and discussing problems that the

Acknowledgments

The authors thank Ana Burton for her help in the preparation of the article.

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      The laboratory can prioritize processing samples from patients who benefit most from rapid microbiologic data (eg, intensive care and transplant/immunocompromised patients).5 In addition to implementing protocols that allow for more rapid antibiotic optimization, they can also institute protocols that improve AU: restricting the antibiotic susceptibility results that are reported (eg, susceptibility test result cascading), and implementation of rejection criteria for clinical specimens with high likelihood of false positivity (eg, poorly collected wound swabs, sputum samples with high levels of epithelial cell contamination, and urine samples with negative urinalyses).5,42 The laboratory is also essential in development of facility-specific antibiograms.

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    Disclosure statement: The authors have no conflict of interest to declare.

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