MOLECULAR DIAGNOSTICS
Introducing near-patient testing Having already successfully used rapid PCR testing for TB, Clostridioides difficile and SARS-CoV-2, UHCW recognised the potential benefit of rapid molecular CPE testing for the stroke admissions pathway. The service therefore chose to trial near-patient PCR testing, with the aim of improving triage speed and freeing up isolation rooms by using them more efficiently. The trust selected the Xpert Carba-R assay (Cepheid), as this PCR-based diagnostic assay is capable of detecting five major carbapenemase genes – blaKPC, blaNDM, blaVIM, blaIMP and blaOXA-48-like – in approximately 50 minutes. This decision was supported by a recent meta-analysis of diagnostic studies, which had concluded that the test offered excellent diagnostic accuracy from rectal swabs and clinical isolates, especially for high-risk populations.9 Implementation of the rapid PCR
pathway for CPE screening at UHCW required a highly collaborative and pragmatic approach. While the idea originated in the microbiology team, buy- in from the wider hospital was essential. Initial implementation was carried out in the stroke admissions unit during winter 2021/2022, where pressures were high and the benefits of faster triage could be most clearly measured. The laboratory team led the initial training and set up the testing protocols in consultation with the IPC and stroke teams. A major focus was placed on staff education, ensuring that results were interpreted correctly and acted upon quickly. Clinicians quickly recognised the value of this approach for avoiding unnecessary isolation, and IPC teams
appreciated the ability to act on results immediately and ensure contacts were appropriately followed up.
Improving patient experience and clinical outcomes The introduction of molecular CPE testing has dramatically improved side-room allocation within the stroke admissions unit. Although the precautionary isolation of high-risk patients remains in place, the ability to rule out colonisation within hours, rather than days, has significantly reduced unnecessary isolation times, easing pressure on side room availability and reducing the resource burden associated with enhanced infection control measures. Decisions about patient triage and isolation can now be made more efficiently, allowing safe de-escalation for patients who have tested CPE negative, and improving the availability of side rooms for those who genuinely require isolation. This approach has also improved
antimicrobial stewardship by preventing transmission, in turn avoiding colonisation and therefore eliminating the risk of infection caused by CPE. Patients presenting through the stroke pathway are often acutely unwell, and so may be empirically started on broad-spectrum antimicrobials while infection status is clarified. This is especially important in those with a history of recurrent UTIs, long-term catheter use, or recent overseas healthcare exposure. Confirmation of colonisation and the specific carbapenemase gene(s) present enable escalation of appropriate antibiotics where required, improving treatment
choices for specific patients infected with CPE.10
This approach aligns with the goals
of the UK’s Antimicrobial Resistance (AMR) Strategy 2019–2024, which encourages the optimal use of antimicrobials in human health, and reinforces good national antibiotic stewardship priorities.11 Beyond antibiotics, faster integration of patients into appropriate wards and clinical care pathways can help to improve outcomes. Stroke patients benefit from early mobilisation and structured rehabilitation, and any delays in moving from assessment to treatment impairs these objectives. Rapid PCR enables clearer decisions on infection risk within an hour so that patients can be safely placed in the correct care area sooner. The fast turnaround of results also helps to reduce the psychological burden on patients, ensuring they spend as litle time as possible in isolation. Many patients arriving on the stroke pathway are elderly or cognitively impaired, and unnecessary isolation can heighten confusion and anxiety. By minimising the time spent in single rooms, UHCW has improved both bed management and the patient experience. There is also anecdotal feedback from clinical teams that the shift to faster diagnostics has improved workflows and reduced uncertainty. Nursing staff reported greater clarity on barrier precautions, and pharmacy colleagues were beter able to support the antibiotic review process.
Enhancing infection control The implementation of rapid PCR testing at UHCW has allowed a more efficient, targeted approach to IPC, particularly
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