Implementation of diagnostic stewardship in blood culture laboratory: a large-scale interventional study in a tertiary care hospital, South India

Deepashree Rajashekar; Sarumathi Dhandapani; Apurba Sankar Sastry

doi:10.18203/2349-3933.ijam20231875

Authors

Deepashree Rajashekar Department of Microbiology, JSS Medical College, Mysore, Karnataka, India
Sarumathi Dhandapani Department of Microbiology, JIPMER, Puducherry, India
Apurba Sankar Sastry Department of Microbiology, JIPMER, Puducherry, India

DOI:

https://doi.org/10.18203/2349-3933.ijam20231875

Keywords:

Diagnostic stewardship, TAT, Automated ID and AST system, Sepsis, AST

Abstract

Background: Laboratories with well-established diagnostic stewardship program for culture and antimicrobial susceptibility test (C-AST) play a key role in guiding the clinicians to institute specific targeted therapy.

Methods: The study period was divided into three phases; pre-intervention phase, intervention phase and post- intervention phase. During the pre-intervention phase, the blood culture was performed by conventional methods. During the intervention phase, immense efforts were made for full-fledged implementation of all the components of intervention-educational intervention for microbiology and clinical team and automations for culture, workflow modifications for performing preliminary tests in parallel with reporting, enhanced reporting frequency and stage-wise communication of reports to the clinicians.

Results: There was a significant improvement in the isolation rate in the post-intervention phase (from 10.3% to 15.5%). There has been a steady decrease in mean turnaround time (TAT) of positive culture reports (from 85 to 45 h), which was in turn due to faster blood culture positivity, identification time and AST time. There was also significant improvement in clinical team performance on various parameters such as % of samples sent in pair, % of specimens with appropriate blood volume collected and % culture drawn before the antibiotic start.

Conclusions: Our observation shows significant improvement in the pathogen isolation rate as well as performance of both microbiology and the clinical team. Most patients with sepsis are critically ill, therefore, it is the responsibility of every clinical microbiologist to implement the highest standard of diagnostic stewardship in blood culture laboratory.

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References

ICMR. Available at: http://iamrsn.icmr.org.in/images/pdf/AMSP_Guidelines_final.pdf. Accessed on 12 April, 2023.

Walia K, Ohri VC, Madhumathi J, Ramasubramanian V. Policy document on antimicrobial stewardship practices in India. Indian J Med Res. 2019;149(2):180.

Sahni A, Bahl A, Martolia R, Jain SK, Singh SK. Implementation of antimicrobial stewardship activities in India. Indian J Med Specialities. 2020;11(1):5.

Chandy SJ, Michael JS, Veeraraghavan B, Abraham OC, Bachhav SS et al. ICMR programme on antibiotic stewardship, prevention of infection and control (ASPIC). Indian J Med Res. 2014;139(2):226.

Sharma A, Samaddar A, Maurya A, Hada V, Narula H. Analysis of Blood Culture Data Influences Future Epidemiology of Bloodstream Infections: A 5-year Retrospective Study at a Tertiary Care Hospital in India. Indian J Crit Care Med. 2021;25 (11):1258-62.

Wattal C, Javeri Y, Goel N, Dhar D, Saxena S. Convergence of Minds: For Better Patient Outcome in Intensive Care Unit Infections. Indian J Crit Care Med. 2017;21(3):154-9.

Hasan AS, Uppal P, Arya S, Capoor MR, Nair D. Comparison of BacT/Alert microbial detection system with conventional blood culture method in neonatal sepsis. J Pediatr Infect Dis. 2008;3(1):21-5.

Ahmad A, Iram S, Hussain S, Yusuf NW. Diagnosis of paediatric sepsis by automated blood culture system and conventional blood culture. J Pak Med Assoc. 2017;67(2):192-5.

Chokephaibulkit K, Sitthitrai P, Wanprapa N, Chearskul S, Srifuengfung S. Comparison of BACTEC automated blood culture system and conventional system in hospitalized pediatric patients. J Med Association Thailand. 1999;82(10):1011-6.

Abbas SK, Shah SJ. Comparison Between Manual Blood Culture and Automated Blood Culture System In Cardiology Institute: Comparison of Manual blood culture and automated blood culture. Med J S Punjab. 2020;1(2).

Patel R. MALDI-TOF MS for the diagnosis of infectious diseases. Clin Chem. 2015;61(1):100-11.

Lau SK, Tang BS, Teng JL, Chan TM, Curreem SO et al. Matrix-assisted laser desorption ionisation time-of-flight mass spectrometry for identification of clinically significant bacteria that are difficult to identify in clinical laboratories. Journal of clinical pathology. 2014;67(4):361-6.

Clinical and Laboratory Standards Institute; Performance Standards for Antimicrobial Susceptibility Testing. M100 (31st edition), CLSI, Wayne, PA, USA. 2021.

EUCAST breakpoint tables for interpretation of MICs and zone diameters. 2021;11.

Deepashree R, Chaudhari KV, Bhat P, Prakash SS, Raghvan R. Evaluation of performance of direct disk diffusion test from positively flagged blood culture broth: A large scale study from South India. J Lab Physicians. 2019;11(2):154.

Chandrasekaran S, Abbott A, Campeau S, Zimmer BL, Weinstein M. Direct-from-blood-culture disk diffusion to determine antimicrobial susceptibility of Gram-negative bacteria: preliminary report from the Methods Development and Standardization Working Group. J Clin Microbiol. 2018;56(3).

Thomson RB, McElvania E. Blood culture results reporting: how fast is your laboratory and is faster better? J Clin Microbiol. 2018;56(12).

Jonasson E, Matuschek E, Kahlmeter G. The EUCAST rapid disc diffusion method for antimicrobial susceptibility testing directly from positive blood culture bottles. J Antimicrobial Chemotherapy. 2020;75(4):968-78.

Lyngdoh WV. Comparative evaluation of conventional (manual) blood culture system and BacT/ALERT 3D (automated) blood culture system in a Tertiary care hospital. Researchgate. 2015.

Kuzniewicz MW, Mukhopadhyay S, Li S, Walsh EM, Puopolo KM. Time to positivity of neonatal blood cultures for early-onset sepsis. Pediatr Infect Dis J. 2020;39(7):634-40.

Abdelhamid SM. Time to positivity and antibiotic sensitivity of neonatal blood cultures. J Global Infect Dis. 2017;9(3):102.

Guerti K, Devos H, Ieven MM, Mahieu LM. Time to positivity of neonatal blood cultures: fast and furious? J Med Microbiol. 2011;60(4):446-53.

Cavalieri SJ, Kwon S, Vivekanandan R, Ased S, Carroll C. Effect of antimicrobial stewardship with rapid MALDI-TOF identification and Vitek 2 antimicrobial susceptibility testing on hospitalization outcome. Diagnostic Microbiol Infect Dis. 2019;95(2):208-11.

Beganovic M, Costello M, Wieczorkiewicz SM. Effect of matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) alone versus MALDI-TOF MS combined with real-time antimicrobial stewardship interventions on time to optimal antimicrobial therapy in patients with positive blood cultures. J Clin Microbiol. 2017;55(5):1437-45.

Bouza E, Muñoz P, Burillo A. Role of the clinical microbiology laboratory in antimicrobial stewardship. Med Clin. 2018;102(5):883-98.

Bhavsar SM, Dingle TC, Hamula CL. The impact of blood culture identification by MALDI-TOF MS on the antimicrobial management of pediatric patients. Diagnostic Microbiol Infect Dis. 2018;92(3):220-5.

Dickerson JA, Fletcher AH, Procop G, Keren DF, Singh IR. Transforming laboratory utilization review into laboratory stewardship: guidelines by the PLUGS National Committee for Laboratory Stewardship. J Applied Lab Med. 2017;2(2):259-68.

Nain J, Deepashree R, Tamang P, Bhat P, Prakash S. Comparison of four different methods of smear preparation for Gram staining of positively flagged automated blood culture bottles. J Curr Res Scientific Med. 2018;4(2):98.

Sastry AS. Effect of blood volume in automated blood culture of the BACT/ALERT 3D system on isolation rate and time to positivity of pathogens, in a tertiary care hospital, South India. Int J Med Microbiol Trop Dis. 2019;5(4):176-80.