INFECTION CONTROL
to allow up to three hours. “This will allow us to make more sensible prescribing choices and exercise more discretion and effort in looking for alternative diagnoses. In less-sick patients, it is probably safe to wait a little longer, so we can use antimicrobials a little more judiciously. If we can safely implement this, then we should absolutely be doing it,” he commented. “Across England, from 2016, there was a commissioning incentive (CQUIN) for hospitals to screen for sepsis in people who had a high NEWS (now NEWS 2) score and to deliver antimicrobials within one hour to those people identified with a red flag. We saw huge progress. It is very rare that you see such significant process improvements. The delivery of antimicrobials within one hour went from 32% at baseline in 2016 to 80% in just three years, which suggests that we may have been impacting on saving lives, but we are not always doing this, and it is naïve to think that we are.” He pointed out that a recent national emergency laparotomy audit7
showed
that there is significant room for improvement. “You would think that if a patient came into hospital with an acute abdomen with peritonitis, requiring urgent surgical intervention, we would be on top of our game. The reality is that we are not.”
The audit found that one-third of patients needing immediate surgery did not get to theatre in the recommended time frame, while 78% of patients with suspected sepsis did not receive antibiotics within one hour. “We are attending these patients with senior clinicians, in the vast majority of cases, yet we are still only delivering the recommendations in around 21% of these patients. We still have problems and must consider how we can improve,” he explained.
Culture improvement He added that data from intensive care shows that antimicrobial de-escalation is “not a given” or routinely accepted. Some of the academic literature has associated early de-escalation with prolongation of antibiotic therapy, which had led to reticence.8 “We need to consider the culture within healthcare; how we encourage de-escalation and how we ensure we do it safely, because people aren’t fully sold on this concept, at present,” Dr Daniels continued.
He highlighted a study by Lui et
al., which looked at the frequency of antibiotic de-escalation in an acute care hospital.9
Of the 240 patients studied, 151 (63%) had their antibiotic regimens
de-escalated by 72 hours. The proportion of patients de-escalated by 96 hours with positive versus negative cultures was similar: 71% and 72%, respectively. “The important point, here, is the
results of the cultures did not impact on the reliability of de-escalation of antibiotics. Therefore, we need to improve the culture around this. We need to understand how we can better integrate diagnostics into our healthcare systems, and use them to impact prescribing behaviour,” he commented. Dr Daniels also highlighted the fact that patients admitted to intensive care units with COVID-19 are routinely started on antimicrobials, as well as other immunomodulatory therapies. Yet National Institute for Health and Care Excellence (NICE) guidelines10
state that
bacterial infection occurs in fewer than 8% of people with COVID-19. “NICE does not suggest giving antibiotics ‘just in case someone has a secondary bacterial infection’; they say you should look for a secondary bacterial infection, and then start antimicrobials rapidly, which is sensible medicine.” Nevertheless, a study by Abu-Rub
et al.11
found that more than half of ICU patients with SARS-CoV-2 infection received antibiotics. They concluded that prescribing is “significantly higher than the estimated frequency of identified bacterial co-infection”. “We know there are rapid diagnostic tests available, but don’t get them and we don’t access them,” he commented. He pointed out that a hospital may process tests in batches on a Tuesday
WWW.PATHOLOGYINPRACTICE.COM SEPTEMBER 2022
and a Friday, which means that patients receive antimicrobials needlessly for three days. This is because it is convenient for the hospital and makes for a more efficient laboratory, but it does not have to be this way. “We are prescribing antibiotics, pending the availability of a test, because we don’t have these at the point of care in a timely fashion. So why can’t we better integrate them into our healthcare system?” Dr Daniels continued. He added that antibiotic prescribing for patients with community-acquired pneumonia is often inappropriate, with many patients being given combination therapies “just in case it is Legionnaires” (although the actual incidence of this is low).
“This is because we cannot access the diagnostic tests. Although these are available and should be able to provide a diagnosis the same day, they are still being sent off in batches, so there are unnecessary delays. We need to get the information to the point of care more rapidly,” he asserted, adding that he did not want to see sepsis being perceived as “a low-hanging fruit” and a driver of antimicrobial resistance, when we are not integrating diagnostic tests at the point of care.
Dr Daniels went on to point out that “we have a problem with the culture around cultures”. Many junior doctors do not take blood cultures well or understand that if they perform them properly and in a timely fashion that they can get results that will have an impact on their prescribing. In some hospitals, blood
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Optimising the use of existing antibiotics is essential in the battle against sepsis and AMR.
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