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Overtesting for Clostridium difficile may result in increased health care facility–onset C difficile infection LabID events. Our quality improvement project optimized testing through standardization of laboratory processes, electronic health record clinical decision support, and real-time monitoring. Our intervention resulted in a 59% reduction in health care facility–onset C difficile infection LabID events. [ABSTRACT FROM AUTHOR]

Background: Antimicrobial resistance (AMR) is now considered one of the greatest global health threats. This is further compounded by a lack of new antibiotics in development. Antimicrobial stewardship programmes can improve and optimize the use of antibiotics, thereby increasing the cure rates of antibiotic treatment and decreasing the problem of AMR. In addition, diagnostic and antimicrobial stewardships in the pathology laboratories are useful tools to guide clinicians on patient treatment and to stop the inappropriate use of antibiotics in empirical treatment or narrow antibiotics. Medical Laboratory Scientists are at the forefront of performing antibiotics susceptibility testing in pathology laboratories, thereby helping clinicians to select the appropriate antibiotics for patients suffering from bacterial infections. Methods: This cross-sectional study surveyed personal antimicrobial usage, the knowledge and awareness on AMR, and antimicrobial stewardship, as well as barriers to antimicrobial susceptibility testing among medical laboratory scientists in Nigeria using pre-tested and validated questionnaires administered online. The raw data were summarized and exported in Microsoft Excel and further analyzed using IBM SPSS version 26. Results: Most of the respondents were males (72%) and 25-35 years old (60%). In addition, the BMLS degree was the highest education qualification most of the respondents (70%) achieved. Of the 59.2% of the respondents involved in antibiotics susceptibility testing, the disc diffusion method was the most commonly used (67.2%), followed by PCR/Genome-based detection (5.2%). Only a small percentage of respondents used the E-test (3.4%). The high cost of testing, inadequate laboratory infrastructure, and a lack of skilled personnel are the major barriers to performing antibiotics susceptibility testing. A higher proportion of a good AMR knowledge level was observed in male respondents (75%) than females (42.9%). The knowledge level was associated with the respondent's gender ( p = 0.048), while respondents with a master's degree were more likely to possess a good knowledge level of AMR (OR: 1.69; 95% CI: 0.33, 8.61). Conclusion: The findings of this study indicate that Nigerian medical laboratory scientists had moderate awareness of AMR and antibiotic stewardship. It is necessary to increase investments in laboratory infrastructure and manpower training, as well as set up an antimicrobial stewardship programme to ensure widespread antibiotics susceptibility testing in hospitals, thereby decreasing empirical treatment and the misuse of antibiotics.

In 2012, The Spanish Societies of Infectious Diseases and Clinical Microbiology (SEIMC), Hospital Pharmacy (SEFH), and Preventive Medicine, Public Health and Healthcare Management (SEMPSGS) lead a consensus document including recommendations for the implementation of antimicrobial stewardship (AMS) programs (AMSP; PROA in Spanish) in acute care hospitals in Spain. While these recommendations were critical for the development of these programs in many centres, there is a need for guidance in the development of AMS activities for specific patient populations, syndromes or other specific aspects which were not included in the previous document or have developed significantly since then. The objective of this expert recommendation guidance document is to review the available information about these activities in these patient populations or circumstances, and to provide guidance recommendations about them. With this objective the SEIMC, SEFH, SEMPSPGS, the Spanish Society of Intensive Care Medicine (SEMICYUC) and the Spanish Pediatric Infectious Disease Society (SEIP) selected a panel of experts who chose the different aspects to include in the document. Because of the lack of high-level evidence in the implementation of the activities, the panel opted to perform a narrative review of the literature for the different topics for which recommendations were agreed by consensus. The document was open to public consultation for the members of these societies for their comments and suggestions, which were reviewed and considered by the panel., (Copyright © 2022. Published by Elsevier España, S.L.U.)

Introduction: Owing to its accurate diagnosis, rapid turnaround time, cost effectivity, and less rates of error, Matrix-assisted Laser Desorption Ionization Time of Flight (MALDI-TOF) has replaced most of the phenotypic methods of identification. Thus, the objective of this study was to compare and evaluate MALDI-TOF MS to conventional biochemical-to identify bacterial microorganisms., Methods: Different bacterial species isolated from 2010 to 2018 (pre-MALDI-TOF era), using routine bio-chemicals were compared to bacterial species isolated from 2019 to August 2021 (post MALDI-TOF), using MALDI-TOF, in the microbiology laboratory of a tertiary care hospital in North India. Chi-Square test (χ2) was used for the evaluation of bacterial identification between biochemical tests and MALDI-TOF MS association with a 95% confidence interval, considering wrong identification in genera or at a species level., Results: Many different and new genera and species of bacteria could be identified using MALDI-TOF, which was not possible using only routine manual bio-chemicals like Kocuria rhizophilus , Rothia mucilaginosa,   Enterococcus casseliflavus, Enterococcus gallinarum, Leuconostoc, Leclercia adecarboxylata, Raoultella ornithological, Cryseobacterium indologenes. Conclusion: Each of the newly identified bacteria played an important role in deciding treatment. Wide use of the MALDI-TOF system will not only strengthen diagnostic stewardship but also encourage antimicrobial stewardship programs., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Gupta et al.)

Novel diagnostic stewardship in infectious disease consists of interventions that modify ordering, processing, and reporting of diagnostic tests to provide the right test for the right patient, prompting the right action. The interventions work upstream and synergistically with traditional antimicrobial stewardship efforts. As diagnostic stewardship continues to gain public attention, it is critical that antimicrobial stewardship programmes not only learn how to effectively leverage diagnostic testing to improve antimicrobial use but also ensure that they are stakeholders and leaders in developing new diagnostic stewardship interventions within their institutions. This review will discuss the need for diagnostic and antimicrobial stewardship, the interplay of diagnostic and antimicrobial stewardship, evidence of benefit to antimicrobial stewardship programmes, and considerations for successfully engaging in diagnostic stewardship interventions. This article is part of the Antibiotic stewardship Special Issue: https://www.drugsincontext.com/special_issues/antimicrobial-stewardship-a-focus-on-the-need-for-moderation., Competing Interests: Disclosure and potential conflicts of interest: KCC reports speaking and service for bioMérieux, research funding from Centers from Disease Control and Prevention and Merck & Co. KCC has served on advisory boards for bioMérieux, Melinta Therapeutics, La Jolla Pharmaceuticals and AbbVie. MDJ has received consulting fees from Astellas, Cidara, Merck, Entasis, Paratek, Pfizer and Theratechnologies, author royalties from UpToDate, and research grants to her institution from Astellas, Scynexis, Charles River Laboratories and Merck & Co, and has served on the Board of the Society of Infectious Diseases Pharmacists. She also has a patent pending for gene expression–based classifiers of fungal infection. The International Committee of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors is available for download at: https://www.drugsincontext.com/wp-content/uploads/2023/01/dic.2022-9-5-COI.pdf, (Copyright © 2023 Claeys KC, Johnson MD.)

We performed a prospective study to determine if the pretest probability of a positive loop-mediated isothermal amplification test is greater when there are more signs and symptoms of GAS pharyngitis. Patients were enrolled if a clinician obtained a GAS RADT. The McIsaac score was calculated. The prevalence of positive LAMP and RADT results increased as the McIsaac score increased. The calculated sensitivity of LAMP was superior to RADT., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Journal of the Pediatric Infectious Diseases Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Considering the threat of antimicrobial resistance and the difficulties it entails in treating infections, it is necessary to cross borders and approach infection management in an integrated, multidisciplinary manner. We propose the antimicrobial, infection prevention and diagnostic stewardship model comprising three intertwined programs: antimicrobial, infection prevention and diagnostic stewardship, involving all stakeholders. The focus is a so-called 'theragnostics' approach. This leads to a personalized infection management plan, improving patient care and minimizing resistance development. Furthermore, it is important that healthcare regions nationally and internationally work together, ensuring that the patient (and microorganism) transfers will not cause problems in a neighboring institution. This antimicrobial, infection prevention and diagnostic stewardship model can serve as a blue print to implement innovative, integrative infection management. [ABSTRACT FROM AUTHOR]

Introduction: Wound microflora in hard-to-heal wounds is invariably complex and diverse. Determining the interfering organisms(s) is therefore challenging. Tissue sampling, particularly in large wounds, is subjective and, when performed, might involve swabbing or biopsy of several locations. Fluorescence (FL) imaging of bacterial loads is a rapid, non-invasive method to objectively locate microbial hotspots (loads >10 4 CFU/gr). When sampling is deemed clinically necessary, imaging may indicate an optimal site for tissue biopsy. This study aimed to investigate the microbiology of wound tissue incisional biopsies taken from sites identified by FL imaging compared with sites selected by clinical judgment., Methods: A post hoc analysis of the 350-patient FLAAG wound trial was conducted; 78 wounds were included in the present study. All 78 wounds were biopsied at two sites: one at the center of the wound per standard of care (SoC) and one site guided by FL-imaging findings, allowing for comparison of total bacterial load (TBL) and species present., Results: The comparison between the two biopsy sites revealed that clinical uncertainty was higher as wound surface area increased. The sensitivity of a FL-informed biopsy was 98.7% for accurately finding any bacterial loads >10 4 CFU/g, compared to 87.2% for SoC (p=0.0059; McNemar test). Regarding species detected, FL-informed biopsies detected an average of 3 bacterial species per biopsy versus 2.2 species with SoC (p < 0.001; t-test). Microbial hotspots with a higher number of pathogens also included the CDC's pathogens of interest., Conclusions & Perspective: FL imaging provides a more accurate and relevant microbiological profile that guides optimal wound sampling compared to clinical judgment. This is particularly interesting in large, complex wounds, as evidenced in the wounds studied in this post hoc analysis. In addition, fluorescence imaging enables earlier bacterial detection and intervention, guiding early and appropriate wound hygiene and potentially reducing the need for antibiotic use. When indicated, this diagnostic partnership with antibiotic stewardship initiatives is key to ameliorating the continuing threat of antibiotic resistance., Competing Interests: PB is a scientific advisor to MolecuLight Inc. on a consultancy basis. The authors declare that this study received funding from MolecuLight, Inc. The funder had the following involvement in the study: partial involvement in the study design., (Copyright © 2023 Serena, Snyder and Bowler.)

Introduction . Rapid identification (ID) and antimicrobial susceptibility testing (AST) of bloodstream infections (BSI) pathogens are fundamental to switch from empirical to targeted antibiotic therapy improving patients outcome and reducing antimicrobial resistance spreading. Hypothesis . The adoption of a rapid microbiological protocol (RP) based on Matrix-Assisted Laser Desorption Ionization-Time Of Flight Mass Spectrometry (MALDI-TOF MS) and Light Scattering Technology (LST) for rapid diagnosis of BSI could positively impact on patients' antimicrobial management. Aim . The study aim was to evaluate a RP for BSI microbiological diagnosis in terms of accuracy, turnaround time (TAT) and potential therapeutic impact. Methodology . A prospective observational study was conducted: monomicrobial bacterial blood cultures of septic patients were analysed in parallel by RP and standard protocol (SP). In RP the combination of MALDI-TOF MS and LST was used for rapid ID and AST assessments, respectively. To determine the potential impact of RP on antimicrobial therapy management, clinicians were interviewed on therapeutic decisions based on RP and SP results. RP accuracy, TAT and impact were evaluated in comparison to SP results. Results . A total of 97 patients were enrolled. ID and AST concordance between RP and SP were 96.9 and 94.7 %, respectively. RP technical and real-life TAT were lower than SP (6.4 h vs. 18.4 h; 9.5 vs. 27.1 h). The agreement between RP- and SP-based therapeutic decisions was 90.7 (90 % CI 84.4-95.1). RP results could produce 24/97 correct antibiotic changes with 18/97 possible de-escalations and 25/97 prompt applications of infection control precautions. Conclusion . With the application of RP in BSI management, about one-fourth of patients may safely benefit from early targeted antibiotic therapy and infection control policies with one working day in advance in comparison to conventional methods. This protocol is feasible for clinical use in microbiology laboratories and potentially helpful for Antimicrobial Stewardship.

Background: Urinary tract infection (UTI) is a commonly misdiagnosed infectious syndrome. Diagnostic stewardship interventions can reduce rates of asymptomatic bacteriuria treatment but are often labor intensive, and thus an automated means of reducing unnecessary urine testing is preferred. In this systematic review and meta-analysis, we sought to identify studies describing interventions utilizing clinical decision support (CDS) to optimize UTI diagnosis and to characterize the effectiveness of these interventions., Methods: We conducted a comprehensive electronic search and manual reference list review for peer-reviewed articles published before July 2, 2021. Publications describing an intervention intending to enhance UTI diagnosis via CDS were included. The primary outcome was urine culture test rate., Results: The electronic search identified 5013 studies for screening. After screening and full-text review, 9 studies met criteria for inclusion, and a manual reference list review identified 5 additional studies, yielding a total of 14 studies included in the systematic review. The most common CDS intervention was urinalysis with reflex to urine culture based on prespecified urinalysis parameters. All 9 studies that provided statistical comparisons reported a decreased urine culture rate postintervention, 8 of which were statistically significant. A meta-analysis including 4 studies identified a pooled urine culture incidence rate ratio of 0.56 (95% confidence interval, .52-.60) favoring the postintervention versus preintervention group., Conclusions: In this systematic review and meta-analysis, CDS appeared to be effective in decreasing urine culture rates. Prospective trials are needed to confirm these findings and to evaluate their impact on antimicrobial prescribing, patient-relevant outcomes, and potential adverse effects., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Clostridioides difficile is the most prevalent hospital-onset (HO) infection. There are significant financial and safety impacts associated with HO-C. difficile infections (HO-CDIs) for both patients and health care organizations. The incidence of HO-CDIs at our community hospital within an academic acute health care system was continuously above the national benchmark., Methods: In response to the high HO-CDI rates at our facility, an interprofessional team selected evidence-based interventions with the goal of reducing HO-CDI incidence rates. Interventions included: diagnostic stewardship, enhanced environmental cleaning, antimicrobial stewardship and education and accountability., Results: After one year, we achieved a 63% reduction in HO-CDI and have sustained a 77% reduction. The infection rate remained below national benchmark for HO-CDI for over 4 years at a rate of 2.80 per 10,000 patient days and a SIR of 0.43 in 2020., Discussion: Multiple evidence-based interventions were successfully implemented over several service lines over a 4-year period through the collaboration of an interprofessional team. The addition of an accountability processes further improved compliance with standards of practice., Conclusions: Collaboration of an interprofessional team led to substantial and sustained reductions in HO-CDI., (Copyright © 2022 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Febrile neutropenia (FN) is associated with mortality rates as high as 40%, highlighting the importance of appropriate clinical management in this patient population. The morbidity and mortality of FN can be attributed largely to infectious processes, with specific concern for infections caused by pathogens with antimicrobial resistance. Expeditious identification of responsible pathogens and subsequent initiation of empiric antimicrobial therapy is imperative. There are four commonly used guidelines, which have variable recommendations for empiric therapy in these populations. All agree that changes could be made once patients are stable and/or with an absolute neutrophil count (ANC) over 500 cells/mcL. Diagnostic advances have the potential to improve knowledge of pathogens responsible for FN and decrease time to results. In addition, more recent data show that rapid de-escalation or discontinuation of empiric therapy, regardless of ANC, may reduce days of therapy, adverse effects, and cost, without affecting clinical outcomes. Antimicrobial and diagnostic stewardship should be performed to identify, utilize, and respond to appropriate rapid diagnostic tests that will aid in the definitive management of this population., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s), 2022.)

The purpose of this study was to assess the clinical impact of the BioFire FilmArray Meningitis/Encephalitis (ME) panel on antimicrobial use and clinical outcomes. This retrospective, quasi-experiment evaluated adult and pediatric patients with suspected ME, evidenced by cerebrospinal fluid (CSF) culture. Hospital-acquired meningitis patients and patients who received antimicrobials >48 h prior to lumbar puncture were excluded. The primary endpoint was days of antimicrobial therapy pre- and post-implementation of the ME panel. Secondary endpoints included total length of stay, 30-day readmission, and individual days of antimicrobial therapy. Two hundred and sixty-four total adult and pediatric patients were included. Antimicrobial days of therapy had a median of 3 days (IQR 0−5) in the pre vs. post group with a median of 2 days (2−5) (p = 0.099). Days of therapy for acyclovir were significantly decreased in the post group (median 2 days [IQR 1−3] vs. 3 days [IQR 2.5−4.5], p = 0.0002). There were no significant differences in the secondary endpoints. Overall, implementation of the ME panel impacted the duration of antimicrobials, particularly acyclovir; however, opportunities for further education regarding antimicrobial de-escalation and utilization of the panel were identified. Antimicrobial stewardship program intervention is critical to maximize benefit of this rapid diagnostic test.

Objective: To investigate the optimal implementation and clinical and financial impacts of the FilmArray Meningitis Encephalitis Panel (MEP) multiplex polymerase chain reaction testing of cerebrospinal fluid (CSF) in children with suspected central nervous system infection.Study Design: A pre-post quasiexperimental cohort study to investigate the impact of implementing MEP using a rapid CSF diagnostic stewardship program was conducted at Children's Hospital Colorado (CHCO). MEP was implemented with electronic medical record indication selection to guide testing to children meeting approved use criteria: infants <2 months, immunocompromised, encephalitis, and ≥5 white blood cells/μL of CSF. Positive results were communicated with antimicrobial stewardship real-time decision support. All cases with CSF obtained by lumbar puncture sent to the CHCO microbiology laboratory meeting any of the 4 aforementioned criteria were included with preimplementation controls (2015-2016) compared with postimplementation cases (2017-2018). Primary outcome was time-to-optimal antimicrobials compared using log-rank test with Kaplan-Meier analysis.Results: Time-to-optimal antimicrobials decreased from 28 hours among 1124 preimplementation controls to 18 hours (P < .0001) among 1127 postimplementation cases (72% with MEP testing conducted). Postimplementation, time-to-positive CSF results was faster (4.8 vs 9.6 hours, P < .0001), intravenous antimicrobial duration was shorter (24 vs 36 hours, P = .004), with infectious neurologic diagnoses more frequently identified (15% vs 10%, P = .03). There were no differences in time-to-effective antimicrobials, hospital admissions, antimicrobial starts, or length of stay. Costs of microbiologic testing increased, but total hospital costs were unchanged.Conclusions: Implementation of MEP with a rapid central nervous system diagnostic stewardship program improved antimicrobial use with faster results shortening empiric therapy. Routine MEP testing for high-yield indications enables antimicrobial optimization with unchanged overall costs. [ABSTRACT FROM AUTHOR]

The application of clinical diagnostics for gastroenteritis in children has implications for a broad collection of stakeholders, impacting clinical care, communicable disease control, and laboratory utilization. To support diagnostic stewardship as gastroenteritis testing options continue to advance, it is critical to understand which enteropathogens constitute priorities for testing across stakeholder groups. Using a modified Delphi technique, we elicited opinions of subject matter experts to determine clinical and public health testing priorities. There was a high level of overall agreement (≥80%) among stakeholders (final round n  = 15) that testing was important for Campylobacter, Escherichia coli O157 and other Shiga toxin-producing E. coli, Salmonella, Shigella , Vibrio , Yersinia , norovirus, and rotavirus. Immunocompromised children were identified as a special population that warranted the additional testing of three to four bacterial and parasitic targets. To support these clinical and public health testing priorities, diagnostic stewardship strategies can be employed, such as educating clinicians, developing new decision support tools, and using multiplex testing in concert with selective result reporting and annotation. IMPORTANCE Children with diarrhea and vomiting who seek care can be infected with a wide variety of infectious agents. This study reports findings from a survey of clinical, public health, and laboratory subject matter experts on the infectious agents that are most important to test for. The majority agreed on the importance of testing children likely infected with several bacterial agents, as well as two common viruses. Although confirming a child is positive for a viral agent is unlikely to change clinical care, participants noted the importance of monitoring these viruses for public health purposes. To avoid over-testing children, however, these results should be used to support diagnostic stewardship strategies and design new decision support tools.

Background: Limited data exist to guide blood culture ordering in persistent febrile neutropenia (FN), resulting in substantial variation in practice. Unnecessary repeat blood cultures have been associated with patient harm including increased antimicrobial exposure, hospital length of stay, catheter removal, and overall cost., Methods: We conducted a single-center study of adult hematology-oncology patients with ≥3 days of FN. The yield of blood cultures was first evaluated in a 2-year historical cohort. Additionally, a pilot pre-/postintervention study was performed in non-stem cell transplant (SCT) patients following a change in our population clinical practice guideline from a recommendation of daily blood cultures to a clinically guided approach. The primary outcome was cultures collected per days of FN after day 3 of persistent FN., Results: One hundred forty-six episodes of ≥3 days of FN in 108 patients were identified during the historical period. Day 1 blood cultures were positive in 23 of 146 (16%) episodes. Blood cultures were drawn on 374 of 513 (73%) subsequent episode-days (day 2-12) and were negative in 366 of 374 (98%). After the intervention, a 53% decrease was observed in the rate of total blood cultures collected (1.4 preintervention vs 0.7 postintervention; P = .03). Blood cultures obtained after 48 hours rarely yielded clinically significant organisms., Conclusions: Repeat blood cultures are low-yield in persistent FN without new clinical change. A pilot intervention in non-SCT patients successfully reduced the frequency of blood culture collection., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts., (© The Author(s) 2022. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Antimicrobial resistance (AMR) is a major public health challenge with its impact felt disproportionately in Western Sub-Saharan Africa. Routine microbiology investigations serve as a rich source of AMR monitoring and surveillance data. Geographical variations in susceptibility patterns necessitate regional and institutional tracking of resistance patterns to aid in tailored Antimicrobial Stewardship (AMS) interventions to improve antibiotic use in such settings. This study focused on developing a cumulative antibiogram of bacterial isolates from clinical samples at the Cape Coast Teaching Hospital (CCTH). This was ultimately to improve AMS by guiding empiric therapy., Methods: A hospital-based longitudinal study involving standard microbiological procedures was conducted from 1st January to 31st December 2020. Isolates from routine diagnostic aerobic cultures were identified by colony morphology, Gram staining, and conventional biochemical tests. Isolates were subjected to antibiotic susceptibility testing using Kirby-Bauer disc diffusion. Inhibitory zone diameters were interpreted per the Clinical and Laboratory Standards Institute guidelines and were entered and analysed on the WHONET software using the "first isolate only" principle., Results: Overall, low to moderate susceptibility was observed in most pathogen-antibiotic combinations analysed in the study. Amikacin showed the highest susceptibility (86%, n = 537/626) against all Gram-negatives with ampicillin exhibiting the lowest (6%, n = 27/480). Among the Gram-positives, the highest susceptibilities were exhibited by gentamicin (78%, n = 124/159), with clindamycin having the lowest susceptibility (27%, n = 41/154). Among the Gram-negatives, 66% (n = 426/648) of the isolates were identified phenotypically as potential extended-spectrum beta-lactamase producers. Multiple multidrug-resistant isolates were also identified among both Gram-positive and Gram-negative isolates. Low to moderate susceptibility was found against first- and second-line antibiotics recommended in the National standard treatment guidelines (NSTG). Laboratory quality management deficiencies and a turnaround time of 3.4 days were the major AMS barriers identified., Conclusions: Low to moderate susceptibilities coupled with high rates of phenotypic resistance warrant tailoring NSTGs to fit local contexts within CCTH even after considering the biases in these results. The cumulative antibiogram proved a key AMS programme component after its communication to clinicians and subsequent monitoring of its influence on prescribing indicators. This should be adopted to enhance such programmes across the country., (© 2022. The Author(s).)

Background: Several molecular platforms now exist for early detection of infectious pathogens. In this review, we present the currently available literature summarizing clinical outcomes using rapid diagnostic tests (RDTs) in the solid organ transplant (SOT) population. We also present potential benefits and drawbacks of these technologies for SOT patients., Methods: We completed a PubMed search querying for 31 specific RDTs AND ("SOT"). We also queried PubMed for studies on RDT outcomes in the general population. References of the resulting relevant studies were reviewed and incorporated if the study population included at least one SOT patient. All culture specimen types were included. Only full-text peer-reviewed publications in English were examined., Results: Our search yielded eleven studies. Across these studies, integrating RDTs with ASP intervention led to faster species identification and susceptibility results, faster time-to-optimal therapy, decreased hospital length-of-stay and costs, and decreased mortality. Potential drawbacks of RDTs in the SOT population included: overdiagnosis due to increased sensitivity (i.e., Clostridium difficile), decreased yield of tests for respiratory pathogens, and lack of identification of important pathogens in this population such as, Aspergillus species., Conclusions: Although there is a scarcity of studies involving SOT patients, current available data suggests that the use of RDTs helps improve patient outcomes and minimizes inappropriate antimicrobial use when coupled with proactive ASPs. Future studies should focus on clinical outcomes in SOT patients specifically, as well as how to optimize the use of RDTs in conjunction with traditional microbiology methods., (© 2022 Wiley Periodicals LLC.)

Background: Diagnostic stewardship in solid organ transplant (SOT) recipients has the potential to help these vulnerable patients at risk for over-testing and overtreatment., Methods: Herein, we review potential targets for diagnostic stewardship in SOT, such as Clostridioides difficile testing, urine cultures, molecular diagnostics, as well as novel areas of diagnostic stewardship., Results: Bundled interventions focused on appropriate C. difficile testing can result in a significant decrease in testing and clinical diagnosis of C. difficile infection without any harms related to delay in diagnosis. In otherwise stable renal transplant recipients after the first month of transplant, screening urine cultures have not been shown to improve outcomes. Novel targets that require additional study in the SOT population include noninvasive fungal diagnostics and cytomegalovirus testing strategies CONCLUSIONS: Diagnostic stewardship is an innovative approach to improve diagnosis and limit unnecessary antimicrobial use. While there has been little direct exploration of diagnostic stewardship in the SOT population, there is great potential for benefit given frequent testing with diagnostics that have imperfect sensitivity and specificity, and sometimes great cost. Diagnostic stewardship in the SOT population is indeed possible but will require a multidisciplinary effort to ensure that appropriates tests and benefits are realized., (© 2022 Wiley Periodicals LLC.)

Background: Inappropriate Clostridioides difficile testing has adverse consequences for patients, hospitals, and public health. Computerized clinical decision support (CCDS) systems in the electronic health record (EHR) may reduce C. difficile test ordering; however, effectiveness of different approaches, ease of use, and best fit into healthcare providers' (HCP) workflow are not well understood., Methods: Nine academic and 6 community hospitals in the United States participated in this 2-year cohort study. CCDS (hard stop or soft stop) triggered when a duplicate C. difficile test order was attempted or if laxatives were recently received. The primary outcome was the difference in testing rates pre- and post-CCDS interventions, using incidence rate ratios (IRRs) and mixed-effect Poisson regression models. We performed qualitative evaluation (contextual inquiry, interviews, focus groups) based on a human factors model. We identified themes using a codebook with primary nodes and subnodes., Results: In 9 hospitals implementing hard-stop CCDS and 4 hospitals implementing soft-stop CCDS, C. difficile testing incidence rate (IR) reduction was 33% (95% confidence interval [CI]: 30%-36%) and 23% (95% CI: 21%-25%), respectively. Two hospitals implemented a non-EHR-based human intervention with IR reduction of 21% (95% CI: 15%-28%). HCPs reported generally favorable experiences and highlighted time efficiencies such as inclusion of the patient's most recent laxative administration on the CCDS. Organizational factors, including hierarchical cultures and communication between HCPs caring for the same patient, impact CCDS acceptance and integration., Conclusions: CCDS systems reduced unnecessary C. difficile testing and were perceived positively by HCPs when integrated into their workflow and when displaying relevant patient-specific information needed for decision making., Competing Interests: Potential conflicts of interest. D. J. D. reports a grant to his institution for a clinical trial of new susceptibility test systems from bioMérieux, outside of the conduct of the study; payment for consulting on novel diagnostics from OpGen; and payment for consulting on antimicrobial resistance surveillance studies from JMI Laboratories. A. P. G. reports grants or contracts from the Agency for Healthcare Research and Quality (AHRQ), the CDC, and the National Institutes of Health (NIH), outside of the conduct of the study; payment for lecture from the North Carolina Health Association; and Human Factors and Ergonomics Society Executive Council. J. J. reports royalties from UpToDate. D. J. M. reports grant funding to support infection prevention and medical decision making research from the CDC, NIH, AHRQ, and the Veterans Affairs Health Services Research and Development Service, and reimbursement for travel related to meeting planning on speaking at meetings from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. All other authors report no potential conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2022. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Fever is one of the most common causes of medical evaluation of children, and early discrimination between viral and bacterial infection is essential to reduce inappropriate prescriptions. This study aims to systematically review the effects of point-of-care tests (POCTs) and rapid tests for respiratory tract infections on changing antibiotic prescription rate, length of stay, duration of therapy, and healthcare costs. Embase, MEDLINE, and Cochrane Library databases were systematically searched. All randomized control trials and non-randomized observational studies meeting inclusion criteria were evaluated using the NIH assessment tool. A meta-analysis was performed to assess the effects of rapid influenza diagnostic tests and film-array respiratory panel implementation on selected outcomes. From a total of 6440 studies, 57 were eligible for the review. The analysis was stratified by setting and POCT/rapid test type. The most frequent POCTs or rapid tests implemented were the Rapid Influenza Diagnostic Test and film-array and for those types of test a separate meta-analysis assessed a significant reduction in antibiotic prescription and an improvement in oseltamivir prescription. Implementing POCTs and rapid tests to discriminate between viral and bacterial infections for respiratory pathogens is valuable for improving appropriate antimicrobial prescriptions. However, more studies are needed to assess these findings in pediatric settings.

Background: Guidance for blood culture (BC) collection is limited. Inappropriate BC collection may be associated with potentially harmful consequences for the patient such as unnecessary laboratory testing, treatment and additional costs. The aim of the study was to assess the appropriateness of BC collection and related knowledge and attitude of precribers., Materials: We conducted a single-center quality control study to assess the appropriateness of BC collection according to the local guidelines in a Swiss university hospital in 2020 by combining three different approaches: point prevalence, patient-individual longitudinal and diseases-related analysis. Second, we conducted a survey regarding BC collection practices and knowledge among physicians in two non-university and one university hospital using an 18-item electronic questionnaire., Results: We analyzed 1114 BC collected in 344 patients. Approximately 40% of the BCs were collected inappropriately, in particular in diseases with low pretest probability of bacteremia such as non-severe community acquired pneumonia (CAP). Follow-up blood culture (FUBC) collection was inappropriate in 60%. Growth of a relevant pathogen was more frequently observed in appropriately than in inappropriately collected BCs (18% vs. 3%, p < 0.001). In the survey, uncertainty concerning the need of index BC collection was high in non-severe CAP and uncomplicated cellulitis., Conclusions: Almost half of the BCs was not collected according to the guidelines, especially in non-severe CAP and in case of FUBCs. Substantial uncertainty among physicians regarding BC ordering practices was identified. The implementation of diagnostic stewardship programs may improve BC collection practices, increase adherence to local guidelines, and may help reducing unnecessary diagnostics and treatment., (Copyright © 2022. Published by Elsevier B.V.)

Background: Few Japanese hospitals can perform in-house cerebrospinal fluid (CSF) polymerase chain reaction (PCR) to screen for herpes simplex virus, leading to patients being administered acyclovir (ACV) for several days. The FilmArray Meningitis/Encephalitis Panel (ME Panel) is a multiplex PCR test that can identify 14 major pathogens within 1 h. We aimed to investigate the efficacy of the ME Panel in children admitted with central nervous system infections in Japan., Methods: We conducted a single-center, quasi-experimental study. The ME panel was introduced in April 2020. We outsourced the CSF samples to a laboratory during the pre-intervention period (April 2016 to March 2020) and performed the ME panel at our hospital during the post-intervention period (April 2020 to December 2021). Duration and dose of ACV and antibiotic use, length of stay (LOS) in the pediatric intensive care unit (PICU), and total LOS after testing were compared using the Mann-Whitney U test., Results: The number of cases in the pre- and post-intervention periods was 67 and 22 cases, respectively. The median duration of ACV decreased significantly from 6 days to 0 day (p < 0.001), and the median dose of ACV use decreased significantly from 14 vials to 0 vial (p < 0.001). No significant differences were noted in the total duration and dose of antibiotic use, LOS in PICU, and the total LOS after testing., Conclusion: The introduction of ME panel may contribute to appropriate ACV use; however, there was no significant change in the duration and dose of antibiotic use or LOS., (Copyright © 2022 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Background: Urine cultures are nonspecific and often lead to misdiagnosis of urinary tract infection and unnecessary antibiotics. Diagnostic stewardship is a set of procedures that modifies test ordering, processing, and reporting in order to optimize diagnosis and downstream treatment. In this study, we aimed to develop expert guidance on best practices for urine culture diagnostic stewardship., Methods: A RAND-modified Delphi approach with a multidisciplinary expert panel was used to ascertain diagnostic stewardship best practices. Clinical questions to guide recommendations were grouped into three thematic areas (ordering, processing, reporting) in practice settings of emergency department, inpatient, ambulatory, and long-term care. Fifteen experts ranked recommendations on a 9-point Likert scale. Recommendations on which the panel did not reach agreement were discussed during a virtual meeting, then a second round of ranking by email was completed. After secondary review of results and panel discussion, a series of guidance statements was developed., Results: One hundred and sixty-five questions were reviewed. The panel reaching agreement on 104, leading to 18 overarching guidance statements. The following strategies were recommended to optimize ordering urine cultures: requiring documentation of symptoms, sending alerts to discourage ordering in the absence of symptoms, and cancelling repeat cultures. For urine culture processing, conditional urine cultures and urine white blood cell count as criteria were supported. For urine culture reporting, appropriate practices included nudges to discourage treatment under specific conditions and selective reporting of antibiotics to guide therapy decisions., Conclusions: These 18 guidance statements can optimize use of urine cultures for better patient outcomes., Competing Interests: Potential conflicts of interest. All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (Published by Oxford University Press for the Infectious Diseases Society of America 2021.)

Though multiplex respiratory pathogen panels (RPP) have high sensitivity, multiple tests are occasionally performed simultaneously or in rapid succession in an attempt to increase the yield. The purpose of this study was to assess the impact of this practice. "Multiple testing" was defined as >1 RPP performed within 12 hours on the same patient and specimen type. All cases of multiple testing for adults at two hospitals over a 5-year period were included. Chart review was performed to determine whether discordant results led to a clinical diagnosis or change in clinical management. Of 18,779 RPPs, 462 (2.5%) represented cases of multiple testing. Twenty-six of 462 cases (5.6%) produced discordant results. Five discordant results (1.1% of 462 multiple testing episodes) were associated with a clinical diagnosis, and 4 (0.9%) influenced clinical management. Multiple RPP testing facilitates clinical management in <1% of cases. Medical centers may consider de-implementing this practice. [ABSTRACT FROM AUTHOR]

We implemented the BioFire® FilmArray® Meningitis/Encephalitis Panel (MEP) with guidance for use based on patient age, cerebrospinal fluid (CSF) white blood cell (WBC) count and immune system status. MEPs results over 2 years (1/1/2017 to 12/31/18) were reviewed and clinical significance of positive MEP results in patients with CSF WBC ≤ 10 evaluated. Overall, 12% (51/453) of MEPs were positive with 4/184 (2%) positive in nonimmunocompromised (non-IC) with ≤ 10 CSF WBCs. Among positive results in non-IC patient with ≤10 CSF WBCs, none were judged clinically significant. Four of 6 results in immunocompromised patients with ≤10 CSF WBCs were clinically significant. Redundant testing was common and guideline adherence could have safely decreased MEPs use 41% saving >$56,000. Guideline adherence was poor and MEP use can be safely avoided in non-IC adults with <10 CSF WBC, but clinically significant results did occur in IC patients with low CSF WBC. Clinical decision support could reduce unneeded testing and result in significant cost savings. [ABSTRACT FROM AUTHOR]

A urinary tract infection is amongst the most common bacterial infections in the community and hospital setting and accounts for an estimated 1.6 to 2.14 billion in national healthcare expenditure. Despite its financial impact, the diagnosis is challenging with urine cultures and antibiotics often inappropriately ordered for non-specific symptoms or asymptomatic bacteriuria. In an attempt to limit unnecessary laboratory testing and antibiotic overutilization, several diagnostic stewardship initiatives have been described in the literature. We conducted a systematic review with a focus on the application of molecular and microbiological diagnostics, clinical decision support, and implementation of diagnostic stewardship initiatives for urinary tract infections. The most successful strategies utilized a bundled, multidisciplinary, and multimodal approach involving nursing and physician education and feedback, indication requirements for urine culture orders, reflex urine culture programs, cascade reporting, and urinary antibiograms. Implementation of antibiotic stewardship initiatives across the various phases of laboratory testing (i.e., pre-analytic, analytic, post-analytic) can effectively decrease the rate of inappropriate ordering of urine cultures and antibiotic prescribing in patients with clinically ambiguous symptoms that are unlikely to be a urinary tract infection. [ABSTRACT FROM AUTHOR]

Diagnostic stewardship aims to deliver the right test to the right patient at the right time and is optimally combined with antimicrobial stewardship to allow for the right interpretation to translate into the right antimicrobial at the right time. Laboratorians, physicians, pharmacists, and other healthcare providers have an opportunity to improve the effectiveness of diagnostics through collaborative activities around pre-analytical and post-analytical periods of diagnostic testing. Additionally, special considerations should be given to measuring the effectiveness of diagnostics over time. Herein, we perform a narrative review of the literature on these potential optimization opportunities and the temporal factors that can yield changes in diagnostic effectiveness. Our objective is to inform on these considerations to ensure enhanced value through improved implementation and measurement of effectiveness for local stakeholder metrics and/or clinical outcomes research. [ABSTRACT FROM AUTHOR]

Syndromic testing for lower respiratory tract infections with BioFire® FilmArray® Pneumonia Panel Plus (BF) detects 27 pathogens with a turn-around-time of one hour. We compared the performance of BF with culture. Samples from 298 hospitalized patients with suspected pneumonia routinely sent for culture were also analyzed using BF. Retrospectively, patients were clinically categorized as having "pneumonia" or "no pneumonia." BF and culture were compared by analytical performance, which was evaluated by pathogen concordance, and by clinical performance by comparing pathogen detections in patients with and without pneumonia. The BF results for viruses and atypical bacteria were not included in the performance analysis. In 298 patient samples, BF and culture detected 285 and 142 potential pathogens, respectively. Positive percent agreement (PPA) was 88% (125/142). In patients with community-acquired pneumonia (CAP), clinical sensitivity was 70% and 51%, and specificity was 43% and 71% for BF and culture, respectively. In patients with hospital-acquired pneumonia, the corresponding numbers were 55% and 23%, and 47% and 68%. There was no significant improvement of performance, when only high-quality sputum samples were considered. Efficacy of both BF and culture was low. Both tests are best used in CAP patients for whom the diagnosis has already been clinically established. Indiscriminate use may be clinically misleading and a cause of improper use of antibiotics., (© 2022 Scandinavian Societies for Medical Microbiology and Pathology.)

Background : Bloodstream infections increase morbidity and mortality in hospitalized patients and pose a significant burden for health care systems worldwide. Optimal blood culture diagnostics are essential for early detection and specific treatment. After assessing the quality parameters at a surgical intensive care unit for six months, we implemented a diagnostic stewardship bundle (DSB) to optimize blood culture diagnostics and then reevaluated its effects after six months. Material and Methods: All patients ≥18 years old and on the ward were included: pre-DSB 137 and post-DSB 158. The standard quality parameters were defined as the number of blood culture sets per diagnostic episode (≥2), the rate of contamination (2-3%), the rate of positivity (5-15%), the collection site (≥1 venipuncture per episode) and the filling volume of the bottles (8-10 mL, only post-DSB). The DSB included an informational video, a standard operating procedure, and ready-to-use paper crates with three culture sets. Results: From pre- to post-interventional, the number of ≥2 culture sets per episode increased from 63.9% (257/402) to 81.3% (230/283), and venipunctures increased from 42.5% (171/402) to 77.4% (219/283). The positivity rate decreased from 15.1% (108/714) to 12.8% (83/650), as did the contamination rate (3.8% to 3.6%). The majority of the aerobic bottles were filled within the target range (255/471, 54.1%), but in 96.6%, the anaerobic bottles were overfilled (451/467). Conclusions: The implementation of DSB improved the quality parameters at the unit, thus optimizing the blood culture diagnostics. Further measures seem necessary to decrease the contamination rate and optimize bottle filling significantly.