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Training package on institutional AMR strategy development

Building an institutional AMR strategy based on rapid diagnostic tests

A guide from the perspective of the hospital microbiology laboratory – serving hospital departments

Table of contents

I. Preparatory phase

I.1. Building up a knowledge pool on AMR and multiresistant bacteria

WHO competency framework for health workers’ education and training on antimicrobial resistance:

https://apps.who.int/iris/bitstream/handle/10665/272766/WHO-HIS-HWF-AMR-2018.1-eng.pdf

This competency framework is intended to serve as a reference (for academic institutions, educators, accreditation bodies, regulatory agencies and other users) to help ensure that pre-service education and in-service training equip health workers with the requisite competencies to address AMR. It complements other relevant existing WHO guidance on AMR and lays the foundation for the development of more in-depth educational resources and AMR curricula.

Freely available courses about AMR:

https://www.ecdc.europa.eu/en/all-topics-z/antimicrobial-resistance/directory-guidance-prevention-and-control/training-courses – collection page with courses from

  • several agencies: WHO, ECDC, USAID
  • training institutes of some countries: Denmark, Sweden, UK

Antimicrobial resistance and stewardship e-Learning Repository of British Society from Antimicrobial Chemotherapy
https://bsac-jac-amr.com/jac-amr-resources/

I.2. Assessing the local AMR situation in the hospital

I.2.1. Identification of hospital departments with a high risk of infection/colonization with multiresistant bacteria

Start with existing information:

  • Check the laboratory register for departments’ requests for microbiological testing.
  • Identify the departments with a high rate of multidrug-resistant bacteria detected.

Suggested literature on risk assessment:
https://www.who.int/publications/i/item/9789241550178

The following hospital departments have a high risk of infection with multiresistant bacteria:

    • Emergency Department
    • Surgery Department
    • Combustion Surgery Department
    • Intensive Care Unit
    • Oncology

 

I.2.2. Identification of patients with a high risk of infection/colonization with multiresistant bacteria

Individual-level risk assessment focuses on these factors

  • health status of the patient,
  • patient’s underlying diseases (internal risk factors)
  • factors related to the care itself (external risk factors, e.g. device usage)

Suggested literature:
https://apps.who.int/iris/handle/10665/259462
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6055232/
https://pubmed.ncbi.nlm.nih.gov/34117191/
https://www.sciencedirect.com/science/article/pii/S1876034119302928
https://ccforum.biomedcentral.com/articles/10.1186/cc8877

I.2.3. Monitoring antibiotic susceptibility rates for key bacteria and sharing reports with prescribers

Antimicrobial susceptibility testing with phenotypic methods is based on the measurement of the MIC (mg/L) and breakpoints to categorize bacteria and fungi as susceptible, intermediate or resistant.

The European Committee on Antimicrobial Susceptibility Testing (EUCAST) has harmonized antibiotic interpretive breakpoints throughout Europe. They have been or are now being implemented in most countries in Europe and beyond.

Please consult the EUCAST website for information on performing and interpreting antimicrobial susceptibility testing
https://www.eucast.org/
https://pubmed.ncbi.nlm.nih.gov/26089441/

Knowledge of the likely pathogens and the likely susceptibility of these pathogens to antibiotics is essential to clinical decisions regarding empiric antibiotic therapy.

 

An example of a template for monitoring antibiotic  susceptibility

I.3. Planning the laboratory process with rapid AMR diagnostic test

I.3.1. Possibilities and advantages of the AMR DetecTool against the currently used diagnostic methods

The AMR DetecTool device can detect bacteria’s most common resistance mechanisms directly from the patient’s sample (blood culture, urine, rectal swab, bronchoalveolar lavage / tracheal aspirate), shortening the workflow for the detection of multidrug-resistant bacteria to 30 minutes. Rapid detection is essential to prevent further spread and fight efficiently against MDR bacteria.

The main advantages of the AMR DetecTool include:

  • quick and accurate treatments
  • higher recovery rate of the patients
  • decrease in mortality
  • shorter hospital stays
  • decreasing operational expenses, like treatment costs, treatment time and length of hospital stay

Resistance mechanisms detected:

  • ESBL: CTX-M MULTI
  • Carbapenemases: KPC, OXA, VIM, IMP, NDM
  • VAN A/B: vancomycin-resistant Enterococci
  • OXA-Ab: OXA-type carbapenemases in Acinetobacter sp.
  • 3GC: third-generation cephalosporin resistance

The Carba5 test detects OXA, KPC, VIM, IMP and NDM enzyme types; thus, specific antibiotics can be prescribed. OXA & KPC can be treated with meropenem + beta-lactamase inhibitor.

I.3.2. Specimen selection and collection

The AMR DetecTool rapid tests need the same specimen as the currently used laboratory tests: blood culture, urine, rectal swab, and no required extra sampling.

I.3.3. Using the device

  • Detailed user guide with a video here
  • User manual is downloadable here

I.3.4. Integrating the device into the workflow

Integrate the AMRDetecTool after the gram stain, from the positive blood culture and after screening and microscopic test from the urine, before identification at the species level.

 

The workflow sections where the AMR DetecTool is to be integrated

I.4. Preparing a plan for health economic calculations

 

I.5. Preparation of a meeting with the key stakeholders of the hospital

Suggested stakeholders for cooperation:

  • hospital management
  • finance unit
  • microbiology department
  • clinical prescribers, e.g. ID specialists, intensivists
  • medical heads of departments, especially of departments with a high risk of infection/colonisation with multiresistant bacteria
  • infection prevention and control practitioners
  • quality-of-care/patient-safety teams

Suggested topics for discussions:

  • advantages and possibilities of rapid AMR  testing with the AMRDetecTool (see: I.3.1.)
  • types of rapid tests (see: I.3.1.)
  • rapid, accurate treatment based on rapid testing results (see: I.3.1.)
  • cost-effectiveness (see: I.4.)
  • selecting patients for rapid testing (based on risk assessment at the institutional and personal level) – the issue of infection/colonisation (see: I.2.1.)
  • reporting the results of the AMR DetecTool device
  • feedback from the clinicians to the lab concerning the prescribed antibiotics (the issue of empirical treatment)

Additional background information to prepare for the meeting

1. The issue of empirical treatment

“Because microbiological results do not become available for 24 to 72 hours (with the currently used standard methods), initial therapy for infection is often empiric and guided by the clinical presentation. It has been shown that inadequate therapy for infections in critically ill, hospitalized patients is associated with poor outcomes, including greater morbidity and mortality as well as increased length of stay.

Therefore, a common approach is to use broad-spectrum antimicrobial agents as initial empiric therapy.

Hospital-acquired infections are frequently related to the presence of invasive devices and procedures that result in loss of the normal barriers to infection, as is the case with intravascular catheter-associated bacteremia, ventilator-associated pneumonia, and catheter-associated urinary tract infections (UTIs). They are commonly caused by drug-resistant organisms, which are often endemic in hospitals because of the selection pressure from antimicrobial use. In selecting empiric antimicrobial therapy for such infections, clinicians should consider the following:

  • the site of infection and the organisms most likely to be colonizing that site (e.g., intravascular catheter-associated bacteremia is frequently a result of colonization and infection caused by staphylococci present on the skin)
  • prior knowledge of bacteria known to colonize a given patient (e.g., a nasal screening swab [currently conducted routinely by many hospitals before admitting patients to the intensive care unit] may indicate that the patient is colonized with MRSA)
  • the local bacterial resistance patterns or antibiograms available for important pathogens at most hospitals.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/
General Principles of Antimicrobial Therapy

What is the evidence base of used aggregated antibiotic resistance percentages to change empirical antibiotic treatment? A scoping review:
https://www.clinicalmicrobiologyandinfection.com/article/S1198-743X(21)00700-X/pdf

2. Communication between the laboratory and the hospital departments

During a microbiological diagnostic process, some preliminary results are generated; the relevant ones that base a therapeutic decision need to be communicated to the clinicians to facilitate patient care.
***
Microbiological labs need to ensure expertise in interpreting results.
As laboratory testing becomes more specialized and faster, the need to accurately interpret test results is ever more important.
When is critical information communicated to hospital clinical staff for decision-making, such as selection or modification of an antibiotic regimen, who must be involved? In most cases, the decision is easily made by the primary service. However, late at night, especially when coverage physicians not familiar with the case are involved or the decision rests on incomplete pathogen identification or antibiotic susceptibility results, who does the work? Current approaches include programs to educate healthcare providers about new diagnostic tests, antibiotic options, and when to contact a specialist not currently involved in the case.

Communication Between Clinicians and the Hospital-Based Microbiology Laboratory: Strategies for 2018 and Beyond
https://ir.library.louisville.edu/cgi/viewcontent.cgi?article=1041&context=jri

 

I.6. Meeting the key stakeholders

  • discuss the previously prepared topics
  • listen to each other’s needs
  • discuss the whole process
  • discuss the collaboration and communication
  • discuss the follow-up issues
  • prepare a reminder of what was discussed

 

II. Implementation phase

Integrating the device into the laboratory process – collaborate with the laboratory team

Adding the new workflow to the laboratory quality manual

Continuous communication and workflow improvement with the clinicians 

Monitoring the results and the antibiotic usage in the hospital wards

III. Continuous operational and monitoring phase

Operating the laboratory workflow with the AMR DetecTool device
Continuous communication with the stakeholders
Keep up to date the awareness about AMR

Reporting on resistance of bacteria and prescribed antibiotics
Presenting data

Making cost savings calculations at hospital level
Presenting the cost savings

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