Diagnostic Stewardship: Ushering in a New Era of Stewardship

Column Authors: Elizabeth Monsees, PhD, RN, CIC, FAPIC | Infection Control Practitioner, Teaching Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine
Yolanda Ballam, BS, CIC | Senior, Certified Infection Preventionist

Column Editor: Rana El Feghaly, MD, MSCI | Director, Clinical Services | Director, Outpatient Antibiotic Stewardship Program | Associate Professor of Pediatrics, UMKC School of Medicine

Over the past several years, stewardship has become a popular term. Scientific journals have associated antibiotic stewardship programs (ASPs) with pandemic stewardship, personal protection equipment stewardship, vaccine stewardship and diagnostic stewardship, to name a few. Visualizing “stewardship” has become tantamount to Oprah Winfrey’s declaring 276 audience members “winners” of brand-new sedans: “You get a car! And you get a car!” Almost 20 years later, people still talk about that memorable, still-functional reference, because it was immensely generous, but more so because it defined an era. Given the successful track record of how stewards have partnered with clinical teams to lend their highly specialized clinical and operational expertise to improve care, the idea of stewardship has evolved with new meaning and is now applied to many practices.

In line with the shared goals of antibiotic stewardship, diagnostic stewardship aims to improve outcomes, avoid patient harm, optimize antibiotic use, improve care efficiencies and minimize institutional costs.¹ Six years ago, Dr. Dan Morgan outlined three primary stages of diagnostic stewardship: 1) preanalytic processes that refine ordering and collection, 2) analytic processes that use laboratory expertise to distinguish colonization from infection, and 3) postanalytic processes in which laboratory teams and stewards provide results that guide appropriate practice.² Modifying the diagnostic pathway for common infectious diseases and testing processes from ordering through reporting help position clinicians to target therapy and minimize potential scenarios for overtreatment.

National Activity

Nationally, diagnostic stewardship strategies are unfolding. The Society for Healthcare Epidemiology of America formed an interdisciplinary diagnostic stewardship task force, where we have had the privilege of serving. In February, the first in a series of publications was released highlighting strategies germane to ASPs: reducing cognitive biases, risk assessment tools, nudges to guide decision-making, framing language, and human factors considerations such as order sets and reflex testing.¹ Potential proposed interventions include refining ordering for common pediatric tests such as blood culture collection processes, respiratory cultures, urine cultures and fungal diagnostics. We can expect upcoming publications to address diagnostic stewardship and notable topics such as ASPs, health care-associated infections and COVID-19.

Pediatric Activity

One exemplar of pediatric diagnostic stewardship activity is from Johns Hopkins in partnership with the Agency for Healthcare Research and Quality. The BrighT STAR (Testing Stewardship to reduce Antibiotic Resistance) Collaborative (>20 participating hospitals) initiated a clinical practice strategy to guide providers and nurses in selecting blood cultures when evaluating children with signs and symptoms of sepsis. Data published last year from 14 participating sites indicated a 33% relative reduction in the blood culture rate. The BrighT STAR project reduced not only the rate of broad-spectrum antibiotic use overall but also the rate of broad-spectrum antibiotics initiated as empiric treatment. The rate of central line-associated bloodstream infections declined as well.³ Balancing measures of mortality, length of stay, readmission, sepsis, and severe sepsis/septic shock remained static in the pre- and post-implementation periods. Pediatricians at Johns Hopkins have expanded collaborative work to include a respiratory culture project using a similar framework. To accompany this work, Chiotos et al. published results from a mixed-methods study that evaluated indications for ordering respiratory cultures and perceived barriers to implementing this form of diagnostic stewardship intervention. The authors note significant variation in respiratory culture use and barriers such as fear of missing a diagnosis, removal of autonomy, and anchoring to default practices learned during training.⁴ The central themes of both projects include the systematic use of effective practices thereby influencing the adoption and sustainability of implementation strategies.^5,6

What can I do to support this work?

1. Be aware of current activity. Leaders in our pediatric intensive care unit (PICU) have partnered with Infectious Diseases, Infection Prevention, Laboratory Medicine and Clinical Informatics to explore work processes, begin data analysis and secure stakeholder support for a blood culture improvement project, like the BrighT STAR Collaborative. Last year, the team developed a blood culture algorithm to pilot. Recently, an initial survey of blood culture practices has been deployed to nurses in the PICU with a survey to prescribing colleagues (physicians, advanced practice providers) expected to be sent in the next several weeks. This project follows quality improvement methodology as an iterative process to ensure acceptability, adaption, appropriateness and sustainability.⁷
2. Recognize opportunities in outpatient settings. Asymptomatic children are often carriers of group A Streptococcus (GAS). Those under 3 years of age are more likely to have viral pharyngitis compared to GAS.⁸ Refining the selection or use of rapid antigen tests (RADTs) for GAS pharyngitis or children presenting with viral features has been an important target for ASPs and demonstrates “the right test, for the right patient, to prompt the right action.”^9,10 Additional outpatient examples include avoiding the use of bagged urine specimens in a non-potty-trained child for urinary tract infections due to very high contamination rates (85%-99%).¹¹ As many clinicians know, Clostridioides difficile is often a measure of stewardship performance and judicious antibiotic use. However, infants are often asymptomatic carriers until intestinal microbiota is established around 2 years of age.¹² Until then, C. difficile testing should be avoided unless the child has strong risk factors. As summer approaches, a common question is whether to test for Lyme disease following a tick bite. Knowing a patient’s history is essential for informing appropriate testing. Thus, if a child has not traveled to an endemic area, primarily the Northeast or Upper Midwest regions of the United States, and does not have clear signs and symptoms consistent with Lyme disease, testing is not warranted.¹³
3. Know what is circulating in the community. Understand the specificity and positivity of rapid molecular testing. Molecular testing is very specific and offers fast results, but be aware that false positives increase as incidence of disease decreases. Consider whether it is prudent to test for respiratory syncytial virus (RSV) or influenza if the rates of RSV in the community are very low (<10%) or declining. Partner with local laboratories and colleagues at Children’s Mercy to know what respiratory viruses are the “bug du jour.” Clinicians should generally avoid pathogen panel (GI, RPP, etc.) testing in the outpatient setting as it includes detecting multiple pathogens simultaneously. Pathogen panels can save time and help direct therapy, but are costly and may detect pathogens that are not clinically actionable. Testing should benefit patient management and optimize clinical yields.¹⁴
4. Include non-prescribers in diagnostic stewardship efforts. As ASPs have expanded their reach from inpatient to outpatient settings, the need to build stewardship capacity among nursing and other clinical partners continues to gain attention. Within the Centers for Disease Control and Prevention’s Core Elements for ASPs, nursing and other key partners have been highlighted because nurses often initiate microbiology cultures, are well-positioned to reduce contamination, and have knowledge of indications for use.¹⁵ Our PICU blood culture improvement project was initiated due to advanced practice registered nurses’ interest and recognition that practices could be streamlined. With thanks to Tiffany Mullen, MSN, RN, ACCNS-P, CCRN, and Kathy Baharaeen, MSN, RN, CCRN, and in partnership with their medical colleague, Sarah Brunner, MD, we have been able to engage a diverse group of clinicians as we begin our diagnostic stewardship journey on collection practices.

Join us as we enter a new era of stewardship – it’s bound to be exciting!

References

1. Fabre V, Davis A, Diekema DJ, et al. Principles of diagnostic stewardship: a practical guide from the Society for Healthcare Epidemiology of America Diagnostic Stewardship Task Force. Infect Control Hosp Epidemiol. 2023;44(2):178-185. doi:10.1017/ice.2023.5
2. Morgan DJ, Malani P, Diekema DJ. Diagnostic stewardship-leveraging the laboratory to improve antimicrobial use. JAMA. 2017;318(7):607-608. doi:10.1001/jama.2017.8531
3. Woods-Hill CZ, Colantuoni EA, Koontz DW, et al. Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. JAMA Pediatr. 2022; 176(7):690-698. doi:10.1001/jamapediatrics.2022.1024
4. Chiotos K, Marshall D, Kellom K, et al. Mixed-methods process evaluation of a respiratory-culture diagnostic stewardship intervention. Infect Control Hosp Epidemiol. 2023;44(2):191-199. doi:10.1017/ice.2022.299
5. Nilsen P, Thor J, Bender M, Leeman J, Andersson-Gäre B, Sevdalis N. Bridging the silos: a comparative analysis of implementation science and improvement science. Front Health Serv. 2022;1:817750. doi:10.3389/frhs.2021.817750
6. Boehm LM, Stolldorf DP, Jeffery AD. Implementation science training and resources for nurses and nurse scientists. J Nurs Scholarsh. 2020;52(1):47-54. doi:10.1111/jnu.12510.
7. Livorsi DJ, Drainoni ML, Reisinger HS, et al. Leveraging implementation science to advance antibiotic stewardship practice and research. Infect Control Hosp Epidemiol. 2022;43(2):139-146. doi:10.1017/ice.2021.480
8. Monsees EA, Burns AN, Lee BR, Wirtz A, El Feghaly RE. Considerations for implementation: pediatric outpatient antimicrobial stewardship program. Am J Infect Control. 2021;49(12):1543-1546. doi:10.1016/j.ajic.2021.07.017
9. Shapiro DJ, Lindgren CE, Neuman MI, Fine AM. Viral features and testing for streptococcal pharyngitis. Pediatrics. 2017;139(5):e20163403. doi:10.1542/peds.2016-3403
10. Norton LE, Lee BR, Harte L, et al. Improving guideline-based streptococcal pharyngitis testing: a quality improvement initiative. Pediatrics. 2018;142(1):e20172033. doi:10.1542/peds.2017-2033
11. American Academy of Pediatrics Section on Urology. Do not perform a bagged urine specimen for urine culture to confirm urinary tract infection in a non-potty-trained child. Choosing Wisely. January 4, 2022. https://www.choosingwisely.org/clinician-lists/do-not-perform-a-bagged-urine-specimen-for-urine-culture-to-confirm-urinary-tract-infection-in-a-non-potty-trained-child/
12. Sammons JS, Toltzis P, Zaoutis TE. Clostridium difficile infection in children. JAMA Pediatr. 2013;167(6):567-573. doi:10.1001/jamapediatrics.2013.441
13. Moore A, Nelson C, Molins C, Mead P, Schriefer M. Current guidelines, common clinical pitfalls, and future directions for laboratory diagnosis of Lyme disease, United States. Emerg Infect Dis. 2016;22(7):1169-1177. doi:10.3201/eid2207.151694
14. Qavi AJ, McMullen A, Burnham CD, Anderson NW. Repeat molecular testing for respiratory pathogens: diagnostic gain or diminishing returns? J Appl Lab Med. 2020;5(5):897-907. doi:10.1093/jalm/jfaa029
15. Centers for Disease Control and Prevention. The core elements of hospital antibiotic stewardship programs. Published 2019. https://www.cdc.gov/antibiotic-use/healthcare/pdfs/hospital-core-elements-H.pdf