A prospective study evaluating the effect of a "Diagnostic Stewardship Care-Bundle" for automated blood culture diagnostics.

OBJECTIVES: We prospectively implemented a diagnostic stewardship care-bundle checklist, 'Sepsis-48 DSB', with the aim of reducing intervening duration of key steps of automated blood culture diagnostics (aBCD). METHODS: Sepsis-48 DSB was implemented for automated blood culture bottles (BCBs) received from adult intensive care units (AICUs) during the intervention period (P2; July 2020-June 2021) and intervening durations were compared with those during the retrospective, pre-intervention period (P1; March-June 2020). During both periods, provisional blood culture reports (pBCR) were issued wherein direct microbial identification (dID) was performed in BCBs with Gram-negatives by directly inoculating conventional biochemical tests and direct antimicrobial susceptibility testing (dAST) using EUCAST RAST method. The results were compared with the standard of care (SoC) method (i.e. full incubation followed by identification and AST by VITEKⓇ-2 Compact). RESULTS: During P2, significant reductions in loading time (LT; median: 63.5 vs. 32 minutes, P < 0.001), time to dID+dAST performance (TTD; 186 vs. 115 minutes, P = 0.0018) and an increase in compliance to bundle targets (LT ≤45: 44% vs. 66%, P = 0.006 and TTD ≤120: 34% vs. 51.7%, P = 0.03) were observed. Using dID+dAST method, results were read 694 minutes earlier than SoC method. Of 176 pBCR, 165 (94%) were concordant with SoC in microbial identification of species. Categorical agreement for any drug-bug combination was 92.7% (1079/1164) and corresponding major, very major, and minor error rates were 8.8% (19/216), 4.9% (45/921), and 1.8% (21/1164), respectively. CONCLUSION: The 'diagnostic stewardship care-bundle' strategy was successfully implemented with considerable diagnostic accuracy leading to significant reductions in duration of targeted steps of aBCD.

A prospective study evaluating the effect of a 'Diagnostic Stewardship Care-Bundle' for automated blood culture diagnostics.

OBJECTIVES: We prospectively implemented a diagnostic stewardship care-bundle checklist, 'Sepsis-48 DSB', with the aim of reducing intervening duration of key steps of automated blood culture diagnostics (aBCD). METHODS: Sepsis-48 DSB was implemented for automated blood culture bottles (BCBs) received from adult intensive care units (AICUs) during the intervention period (P2; July 2020-June 2021) and intervening durations were compared with those during the retrospective, pre-intervention period (P1; March-June 2020). During both periods, provisional blood culture reports (pBCR) were issued wherein direct microbial identification (dID) was performed in BCBs with Gram-negatives by directly inoculating conventional biochemical tests and direct antimicrobial susceptibility testing (dAST) using EUCAST RAST method. The results were compared with the standard of care (SoC) method (i.e. full incubation followed by identification and AST by VITEKⓇ-2 Compact). RESULTS: During P2, significant reductions in loading time (LT) [median: 63.5 vs. 32 minutes, P < 0.001], time to dID+dAST performance (TTD) [186 vs. 115 minutes, P = 0.0018] and an increase in compliance to bundle targets [LT ≤45: 44% vs. 66%, P = 0.006 and TTD ≤120: 34% vs. 51.7%, P = 0.03] were observed. Using dID+dAST method, results were read 694 minutes earlier than SoC method. Of 176 pBCR, 165 (94%) were concordant with SoC in microbial identification of species. Categorical agreement for any drug-bug combination was 92.7% (1079/1164) and corresponding major, very major, and minor error rates were 8.8% (19/216), 4.9% (45/921), and 1.8% (21/1164), respectively. CONCLUSION: The 'diagnostic stewardship care-bundle' strategy was successfully implemented with considerable diagnostic accuracy leading to significant reductions in duration of targeted steps of aBCD.

A prospective study to reduce turnaround time of microbiologically positive blood cultures in patients with sepsis in intensive care unit.

PURPOSE: To determine the accuracy of direct microbial identification (dID) and antimicrobial susceptibility testing by EUCAST rapid antimicrobial susceptibility testing (rAST) methodology from positively flagged blood culture bottles (BCBs) as well as reduction in turnaround time (TAT) compared to standard methodology. METHODS: It was a hospital based, prospective cohort study conducted over a period of 21 months from March 2020 to November 2021 in which positively flagged blood culture bottles were simultaneously processed by dID â€‹+ â€‹rAST and by VITEK®-2 Compact system or Kirby-Bauer disk diffusion method. TAT was calculated as the time (hours) taken from receipt of sample in bacteriology laboratory to release of clinical reports with complete identification and susceptibility testing results in both methods. RESULTS: Of 301 dID â€‹+ â€‹rAST performed in study, 125 (41.5%) BCBs were identified as having one of the 8 reportable micro-organisms by EUCAST rAST standard. Amongst VITEK concordant BCBs with gram-negatives, mean reduction in TAT by dID â€‹+ â€‹rAST methodology was 23 â€‹± â€‹1.4 â€‹h. Amongst VITEK concordant gram-negatives, Categorical Agreement (CA) rates for any drug-bug combination were 94.4%, 94.5% and 93.6% and Very Major Error (VME) rates were 3.1%, 3.4% and 3.9% at 4-, 6- and 8-h reading time, respectively. CONCLUSIONS: EUCAST rAST methodology can generate susceptibility testing reports a day earlier if incorporated into the laboratory workflow. For resource-limited settings, implementing EUCAST rAST approach can be used effectively in early reporting, which can reduce antimicrobial use and improve patient outcomes by promoting timely escalation or de-escalation of empirical antibiotic therapy.

Implementing EUCAST rapid antimicrobial susceptibility testing method for sepsis: lessons learned in a tertiary care center.

INTRODUCTION: We prospectively evaluated EUCAST rapid antimicrobial susceptibility testing methodology for susceptibility testing directly from blood culture bottles in comparison to CLSI disk-diffusion method. METHODOLOGY: During May-November 2019, positively flagged blood culture bottles showing Gram-negative micro-organisms were simultaneously processed by rapid antimicrobial susceptibility testing and CLSI methodology. Antibiotics tested were cefotaxime, ceftazidime, piperacillin-tazobactam, imipenem, meropenem, gentamicin, tobramycin and trimethoprim-sulphamethoxazole. RESULTS: Overall, 80 isolates identified as Escherichia coli (n = 24, 30%), Klebsiella pneumoniae (n = 15, 18.7%), Pseudomonas aeruginosa (n = 16, 20%) and Acinetobacter baumannii (n = 25, 31.2%) were included. Categorical agreements  of rapid antimicrobial susceptibility testing at 4-, 6- and 8-hour reading times were 88.1% (304/345), 90.8% (425/468) and 92.3% (467/506), respectively. Major Error rates were 14% (21/150), 4.9% (10/206) and 4/236 (1.7%), whereas Very Major Error rates were 1.1% (2/177), 1.3% (3/232) and 3.3% (8/243), respectively. Results categorized as "Area of Technical Uncertainty" were significantly lower at 8-hour {10.2% (39/384) vs 5.2% (28/534), 4- vs 8-hour, p = 0.003, Fischer's exact test}. CONCLUSIONS: Except for a slightly higher Very major error rate, rapid antimicrobial susceptibility testing at 8-hour is equivalent to Disk-diffusion method (CLSI-M100) using CLSI-M52 criteria for equivalence: (Categorical agreement ≥ 90%, Very major error ≤ 1.5% and Major error ≤ 3%). Poor Categorical agreements at all reading times were noted for piperacillin-tazobactam, ciprofloxacin and E. coli. Performance of rapid antimicrobial susceptibility testing methodology in resource limited settings brings unique challenge of identifying micro-organisms within 8 hours. We suggest reading and reporting of results at a single time point using rapid antimicrobial susceptibility testing method i.e. at 8-hour.

Corticosteroids in Covid-19 pandemic have the potential to unearth hidden burden of strongyloidiasis.

COVID-19 pandemic has posed formidable public health and clinical challenges to the entire humanity. A significant proportion of the COVID-19 patients have been provided immunosuppressive agents, particularly corticosteroids, as a part of management of moderate to severe COVID-19 disease. This has the drawback of development of strongyloides hyperinfection to disseminated infection in latent strongyloides infection patients. We are reporting the case of strongyloidiasis hyperinfection in a COVID-19 patient from a developing country, who initially received corticosteroid therapy for management of COVID-19, but later presented to hospital with non-specific, strongyloides related symptoms.