under the microscope
By Rodney E . Rohde , PhD , MS , SM ( ASCP ) CM SVCM , MBCM , FACSc
Antibiotic Resistance and the Medical Laboratory
In the 2019 Antibiotic Resistance ( AR )
Threats Report , former Centers for Disease Control and Prevention ( CDC ) director , Robert R . Redfield , MD , discusses the radical change that has occurred over the history of antibiotic use from the 1940 ’ s until today . In the foreword , he states to stop antibiotic resistance , the U . S . must :
● Stop referring to a coming post-antibiotic era — it is here . We are living in a time where miracle drugs no longer perform miracles and a microscopic enemy is ripping families apart . The time for action is now and we can be part of the solution .
● Stop playing the blame game . Each person , industry , and country can affect the development of antibiotic resistance . We each have a role to play and should be accountable to make meaningful progress against AR .
● Stop relying only on new antibiotics that are slow getting to market and that , sadly , these germs will one day render ineffective . We need to adopt aggressive strategies to keep germs away and infections from occurring in the first place .
● Stop believing that antibiotic resistance is a problem “ over there ” in someone else ’ s hospital , state , or country — and not in our own backyard . AR is in every U . S . state and in every country globally . There is no safe place from antibiotic resistance , but everyone can take action against it , from handwashing to improving antibiotic use .
Whether one is discussing AR or more generally antimicrobial resistance ( AMR ), together they represent a slow-burning global emergency . The World Health Organization ( WHO ), Centers for Disease Control and Prevention ( CDC ), and other agencies have predicted that AMR could lead to an economic impact of $ 100 trillion dollars causing 10 million deaths annually by 2050 without action . AMR can become a slow-burning pandemic leading the world in mortality over longtime leaders like cancer and other health conditions .
How can we help ? What can those of us who work in public health , the medical laboratory and healthcare do to help curb this global emergency ?
In an April 2021 research study , Langford , et al . conclude that laboratory reporting of antibiotic susceptibility results for urine cultures is associated with empirical and directed prescribing of the reported antibiotics . Laboratories can play an important role in guiding appropriate antibiotic selection for urinary indications . Briefly , after a patient specimen is identified as a bacterial pathogen , the medical laboratory / clinical microbiology professional will perform an antibiotic susceptibility test ( AST ) on the pathogen . Testing determines the potential effectiveness of specific antibiotics on the bacteria and / or determines if the
bacteria show resistance to certain antibiotics . Used properly , AST results help select the drug ( s ) that will likely be most effective in treating an infection .
This research study has important and practical findings for antibiotic stewardship programs ( ASP ). “ Nudging ” is a term used to describe the concept of modifying “ choice architecture ” to augment decision-making , without introducing incentives or inhibiting personal decisions by physicians ( or other decision maker ). Research shows that nudging is a promising intervention in the microbiology and medical laboratory . Selective reporting via nudging is a process whereby only certain culture and antibiotic susceptibility results are reported back to the clinician ; the strategy aims to help guide appropriate antimicrobial prescribing . Selective reporting can take multiple forms , ranging from not reporting any susceptibility results at all to reporting only first-line antibiotics or agents with lower adverse risks . While national and international guidelines recommend the use of selective reporting , specific reporting policies are discretionary for individual laboratories , resulting in a high degree of variability .
Ultimately , the goal of nudging can influence how a physician does or does not select and / or utilize a particular antibiotic . Langford ’ s findings confirm their hypothesis that laboratory variability exists in selective reporting which influences antibiotic prescribing decisions . Approximately three-fold odds of directed antibiotic prescribing occurred when an antibiotic agent was listed on the susceptibility report and an association between laboratory antibiotic susceptibility reporting and prescribing in the empirical window . This suggests that the microbiology / medical laboratory can be highly influential in antibiotic prescribing choices , even when the prescriber is making decisions in the absence of a urine culture result ( empirical or syndromic decisions ).
Lastly , ongoing and growing development of rapid diagnostics ( MALDI-TOF , PNA-FISH , qPCR , NGS , etc .) will continue to offer powerful discriminatory methods for pathogen identification and genes that may confer resistance to antimicrobial drugs . It is critical the experts on laboratory testing ( medical laboratory professionals ) are at the table for test selection and proper interpretation to aid physicians , pharmacists , and other healthcare professionals . Another important tool for hospitals to utilize will be the newly created doctorate of clinical laboratory science ( DCLS ). The DCLS will be the future of diagnostic management teams and laboratory test utilization at the intersection of open communication with the entire healthcare team , including physicians .
Rodney E . Rohde , PhD , MS , SM ( ASCP ) CM SVCM , MBCM , FACSc , serves as chair and professor of the Clinical Laboratory Science Program at Texas State University . Follow him on Twitter @ RodneyRohde / @ TXST _ CLS , or on his website : http :// rodneyerohde . wp . txstate . edu /