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Antimicrobial Resistance (AMR) is a global threat, and the UK has made significant progress on AMR policies, underlined by national commitments in the UK Government’s 2024-2029 AMR National Action Plan (NAP).1-3 An evaluation of the first UK AMR national action plan published in 2019, found that “environmental health and diagnostics are areas where there are opportunities for big policy wins to address AMR.” Hence, it is not surprising that the updated AMR Action Plan includes the specific commitment focused on the judicious use of diagnostic tests to provide clinical decision support.3
Antimicrobial stewardship (AMS) is crucial in combating the AMR crisis and antimicrobial stewardship programmes (ASPs) provide a framework for responsible antibiotic use, optimising therapy, curbing resistance, and promoting awareness and education.4 ASP’s emerging strategies include diagnostic stewardship, which is vital for effective therapy and limiting AMR development.5
AMR is an ancient and organic subject, as the mechanisms involved are constantly evolving. Consequently, diagnostics need to adapt to continuously support clinical decisions, improve patient outcomes, and prevent development of further resistance.6
Local AMR picture
The latest European Centre for Disease Prevention and Control (ECDC) AMR surveillance shows that high percentages of resistance to third generation cephalosporins and carbapenems in K. pneumoniae and Acinetobacter spp. in several countries is of critical concern.7 The English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) report 2023-24 correlates with the latest ECDC AMR surveillance report. The report found a 3.5% increase in antibiotic-resistant bacteraemia since 2019 with resistant E. coli making up over 65% of the total carbapenemase-producing organisms (CPOs) which have more than doubled between 2021 and 2023. 8
Since the statutory duty to report acquired CPO isolates from human samples began in 2020, NDM has somewhat replaced OXA-48-like as the predominant CPO mechanism detected in England. This slight but steady increase brings treatment concerns; as the reader may relate, NDM-producing organisms are some of the most resistant and challenging organisms to treat. Even more, the overall picture of CPOs in 2023, shows that northern regions and London continued to report higher CPOs incidence, although this is due, in part, to an increase in screening and reporting.8
The increase in Gram-negative resistances to current antibiotic therapy underpins the importance of diagnostics in providing a targeted therapy. Not all organism strains are alike, and tailoring antibiotic therapy based on resistance mechanisms is crucial.
Molecular and phenotypic techniques such as rapid PCR and antibiotic susceptibility testing (AST) can be used to identify the specific resistance mechanisms present in organism, which can then guide the right antibiotic selection and avoid treatment failure in critical populations.
Diagnostic stewardship optimises AMS by ensuring that the right diagnostic tests are used to accurately identify pathogens and their susceptibilities to antibiotics. It ensures that these tests are performed at the right time, especially in clinical conditions like sepsis, when time is of the essence. Results must then be interpreted correctly to guide appropriate clinical decision-making to optimise the antimicrobial therapy.
Many hospitals have introduced rapid molecular and phenotypic testing for these conditions, evaluating its effectiveness in the early administration of appropriate antimicrobial therapy and exploring the associated challenges.
Royal Berkshire Hospital faced challenges in pathogen identification and antimicrobial sensitivity testing due to the absence of an on-site microbiology lab. To address this, the BioFire® system using the BioFire® Blood Culture Identification 2 (BCID2) panel was introduced on-site, offering a 24/7 service for rapid identification of pathogens and resistance markers in just over an hour from positive blood culture samples. The service was run by the blood science rapid response lab with support from the microbiology network team.
A pilot study was conducted with 183 patient samples. Using the BioFire® system, the time to result was around 4 hours, saving an average of 17 hours per patient. The early results impacted 125 out of 183 patients (63%), leading to more appropriate and efficient antimicrobial treatment. Antibiotics could be stopped and de-escalated where appropriate, achieving better antimicrobial stewardship and saving money. Their analysis showed that one day less of antibiotics resulted in a two-day reduction in the length of stay.
The Trust had also optimised the pre-analytical stage of the blood culture collection and processing pathway to further support the analytic stage.
The introduction of the BioFire® system and improvements to the pathway significantly improved the diagnosis and management of bloodstream infections at the Trust. Enhancing patient care and improving infection prevention and control (IPC) strategies. Faster identification of pathogens and their resistance mechanisms facilitated multi-disciplinary teams (MDT) discussions and allowed for:
By integrating advanced diagnostic tools like BIOFIRE® with IPC measures, healthcare institutions can better manage antimicrobial resistance and protect both patients and staff.
To support AMS discussions and initiatives, bioMérieux hosted two events last year. The first event took place in Athlone, Ireland, featuring talks on AMR and the One Health approach. Ireland's first experience with Global Antimicrobial Stewardship Accreditation Scheme (GAMSAS) accreditation was also on the agenda as well as the impactful role of data and lab experiences in tackling AMR.
St. James's Hospital, Dublin, spoke about the use of an automated streaking system (WASP®) and microbiology middleware (MAESTRIA™) to address lab challenges such as increased workflow, staff shortages, and complex processes. As a bioMérieux Centre of Reference for Data and IT, they plan to build on their achievements, interfacing more systems, implementing CLARION® Lab analytics and improving real-time monitoring and data integration.
The second event held in Manchester followed a similar agenda with Gillian Damant, Regional Antimicrobial Stewardship lead - Northwest, speaking about the AMR national action plan and emphasising the importance of a coordinated effort to tackle AMR, focusing on prevention, education, and innovation.
We heard from Edinburgh Royal Infirmary about their clinical study on syndromic molecular testing for pneumonia. Using a combination of PCR assays, they found a significant improvement in pathogen detections (90% vs 40% with standard culture). Results showed that 75% of patients in the molecular arm received appropriate treatment, compared to only 14% in the standard of care group. The BIOFIRE® pneumonia test was effectively assessed for its simplified workflow and rapid turnaround time and is now perceived by clinicians as an effective tool for antimicrobial stewardship.
