Real Life Clinical Impact of Antimicrobial Stewardship Actions on the Blood Culture Workflow from a Microbiology Laboratory

Abstract

Background: Accelerating the diagnosis of bacteremia is one of the biggest challenges in clinical microbiology departments. The fast establishment of a correct treatment is determinant on bacteremic patients’ outcomes. Our objective was to evaluate the impact of antimicrobial therapy and clinical outcomes of a rapid blood culture workflow protocol in positive blood cultures with Gram-negative bacilli (GNB). Methods: A quasi-experimental before–after study was performed with two groups: (i) control group (conventional work-protocol) and (ii) intervention group (rapid workflow-protocol: rapid identification by Matrix-Assisted Laser Desorption/Ionization-Time-Of-Flight (MALDI-TOF) and antimicrobial susceptibility testing (AST) from bacterial pellet without overnight incubation). Patients were divided into different categories according to the type of intervention over treatment. Outcomes were compared between both groups. Results: A total of 313 patients with GNB-bacteremia were included: 125 patients in the control group and 188 in the intervention. The time from positive blood culture to intervention on antibiotic treatment decreased from 2.0 days in the control group to 1.0 in the intervention group (p < 0.001). On the maintenance of correct empirical treatment, the control group reported 2.0 median days until the clinical decision, while in the intervention group was 1.0 (p < 0.001). In the case of treatment de-escalation, a significant difference between both groups (4.0 vs. 2.0, p < 0.001) was found. A decreasing trend on the change from inappropriate treatments to appropriate ones was observed: 3.5 vs. 1.5; p = 0.12. No significant differences were found between both groups on 7-days mortality or on readmissions in the first 30-days. Conclusions: Routine implementation of a rapid workflow protocol anticipates the report of antimicrobial susceptibility testing results in patients with GNB-bacteremia, decreasing the time to effective and optimal antibiotic therapy.

MALDI‐TOF mass spectrometry rapid pathogen identification and outcomes of patients with bloodstream infection: A systematic review and meta‐analysis

“…Of the included studies, nine studies received six points on the quality assessment tool, due to compromising generalizability and a limited sample size (Carreno et al, 2016 ; Clerc et al, 2013 ; Mok et al, 2019 ; Nagel et al, 2014 ; Osthoff et al, 2017 ; Puckett et al, 2021 ; Shimamoto et al, 2021 ; Vlek et al, 2012 ; Wenzler et al, 2016 ). Ten studies received seven points (Delport et al, 2016 ; Huang et al, 2013 ; Jeon et al, 2018 ; Lo et al, 2020 ; Lockwood et al, 2016 ; López‐Pintor et al, 2021 ; Niwa et al, 2019 ; Perez et al, 2013 , 2014 ; Zadka et al, 2019 ), two studies received eight points (Dixon et al, 2021 ; MacGowan et al, 2020 ), indicating high quality of study (Table S1 ). Overall, 14,515 patients were included for analysis.…”

“…Studies were conducted in nine countries between 2012 and 2021. The countries most represented were the USA (eight studies) (Carreno et al, 2016 ; Huang et al, 2013 ; Lockwood et al, 2016 ; Nagel et al, 2014 ; Perez et al, 2013 , 2014 ; Puckett et al, 2021 ; Wenzler et al, 2016 ), Switzerland, Canada, Korea, Japan and the UK (two studies each) (Clerc et al, 2013 ; Osthoff et al, 2017 ); and the Netherlands, Israel and Spain (one study each) (López‐Pintor et al, 2021 ; Vlek et al, 2012 ; Zadka et al, 2019 ). Except three cohort studies and two RCT studies, the remaining 16 studies were one group pre–post studies.…”

“…Three studies (Delport et al, 2016 ; Vlek et al, 2012 ; Wenzler et al, 2016 ) were performed in children, while the other 18 studies were on adults (Carreno et al, 2016 ; Clerc et al, 2013 ; Dixon et al, 2021 ; Huang et al, 2013 ; Jeon et al, 2018 ; Lo et al, 2020 ; Lockwood et al, 2016 ; López‐Pintor et al, 2021 ; MacGowan et al, 2020 ; Mok et al, 2019 ; Nagel et al, 2014 ; Niwa et al, 2019 ; Osthoff et al, 2017 ; Perez et al, 2013 , 2014 ; Puckett et al, 2021 ; Shimamoto et al, 2021 ; Zadka et al, 2019 ). In six studies, MALDI‐TOF MS bacterial identification was implemented with antibiotic stewardship (Carreno et al, 2016 ; Huang et al, 2013 ; Lockwood et al, 2016 ; Nagel et al, 2014 ; Puckett et al, 2021 ; Zadka et al, 2019 ).…”

“…Although most of the included studies were high‐quality pre–post design (Carreno et al, 2016 ; Delport et al, 2016 ; Huang et al, 2013 ; Jeon et al, 2018 ; Lockwood et al, 2016 ; López‐Pintor et al, 2021 ; Mok et al, 2019 ; Nagel et al, 2014 ; Niwa et al, 2019 ; Osthoff et al, 2017 ; Perez et al, 2013 , 2014 ; Puckett et al, 2021 ; Vlek et al, 2012 ; Wenzler et al, 2016 ; Zadka et al, 2019 ), MacGowan et al conducted the sole multicentre randomized controlled trial. According to the trial results, the introduction of MALDI‐TOF MS service reduced the time to pathogen identification by almost half (38.5 vs. 55.2 h, p < 0.0001); however, it did not reduce the time to effective antibiotics (24 vs. 13 h, p = 0.056) or 28‐day mortality by nearly half (18.5% vs. 17.7%, p = 0.42).…”