Blood cultures
treatment, which may be inappropriately broad or inadequate. Broad spectrum therapy is often seen as the ‘safe’ option but this view is now increasingly being challenged for two main reasons: growing evidence of antimicrobial- associated harm to individual patients and Antimicrobial Resistance (AMR). First, let’s acknowledge that despite the
use of broad-spectrum antibiotic therapy, a significant number of patients with severe infections, do in fact receive inappropriate empirical antibiotic therapy.3
Thus, broad-
spectrum therapy certainly does not guarantee effective treatment against the pathogen causing infection. To that end, a recent US study of over 20,000 patients with bloodstream infection revealed that approximately one in five patients received ineffective empirical antibiotic therapy.4
obviously problematic as it may lead to further deterioration, development of complications, and reduced survival.4,5 AMR is clearly a risk factor for inadequate empiric therapy in bloodstream infections.3,6,7
Inadequate empiric antibiotic therapy is
The
rise in AMR will make empiric antibiotic selection more challenging and, in a catch 22 situation, prescribing broad-spectrum regimen to all patients may favour further development of resistance. There is therefore no time to waste. Prescribing broad-spectrum regimens
may not only increase resistance but is also associated with C. difficile infection, and antimicrobials may worsen outcomes to individual patients in several ways including direct drug toxicity, adverse reaction, immune cell dysfunction, and disruption of the microbiome.8
While it is well acknowledged
and accepted that undertreatment (failure to treat the causal organism) can be associated with higher mortality, awareness on the risk of unnecessarily broad-spectrum treatment is lower, despite recent evidence that, in septic patients, it is also associated with higher odds of death.7
All in all, broad-spectrum therapy is
not ideal but has to be balanced with the need for a rapid initiation of antimicrobials in patients diagnosed with sepsis.
Are delays justifiable? Delays in obtaining blood culture results can lead to delayed initiation of appropriate
antibiotic therapy, which can result in prolonged hospitalisation, increased healthcare costs, and higher mortality rates. Microbiological techniques have undergone advancements in recent decades, but the identification of the causative pathogen and its susceptibility profile can still take several days. New rapid molecular techniques that can identify pathogens and resistance genes, as well as fast automated antimicrobial susceptibility testing methods, are swiftly closing this gap. Furthermore, cutting- edge technologies such as Next-Generation Sequencing (NGS) and metagenomics are expected to emerge in the near future, further advancing the field of clinical microbiology. A fast and accurate diagnosis of the causing
microorganism and a correct susceptibility testing improves the care and outcome of patients with BSI/sepsis. Indeed several studies have shown that reducing turnaround time for blood culture is associated with a reduction in antibiotic duration, as well as patient length of stay in ICU and hospital, and may also reduce mortality when associated with antimicrobial stewardship.9 Importantly, in order to have an optimum impact on patient care, these new methods must be embedded in a multi-faceted approach
Delays in obtaining blood culture results can lead to delayed initiation of appropriate antibiotic therapy, which can result in prolonged hospitalisation, increased healthcare costs, and higher mortality rates.
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that addresses pre-analytics steps such as transportation, particularly important today given the consolidation of pathology services and centralised laboratories. The puzzle will then be completed once results are quickly made available to the treating physicians. The term ‘microbiologistics’ has been introduced to refer to all these logistics aspects in microbiology.10 It can therefore be tempting to delay implementation of new technologies that offer faster results by insisting that the rest of the pathway be optimised first, creating a chicken and egg situation. Unfortunately, patients are the ones suffering the cost of delays and whose voices are rarely included in this forum.
Role of AMS team The AMS team plays an important role in assisting with the optimisation of antimicrobial use in acute care settings. Numerous studies have shown that integration of rapid diagnostic testing for BSIs with an antimicrobial stewardship programme is key to achieving a significant clinical impact and, importantly mortality was reduced only when rapid methods were accompanied with antimicrobial stewardship.9,13
To note, antimicrobial
stewardship recommendations are more likely to be accepted if they expand antibiotic spectrum compared with reducing spectrum, and if they increase rather than decrease antibiotic exposure.11 Strong collaboration and communication
is therefore essential too. There may be an opportunity, here, to leverage insights from behavioural science to enhance the effectiveness of antibiotic stewardship
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