The Critical Role of Rapid Diagnostics in Antibiotic Stewardship

A book on antimicrobial resistance with plastic models of molecules.

(Adobe Stock 709965990 by Vitalii Vodolazskyi)

Rapid diagnostics are revolutionizing the approach to patient care in health care settings, which is essential in improving outcomes and combating the rise of antimicrobial resistance (AMR). Unlike traditional diagnostic methods, which may take days to yield results, rapid diagnostics provide actionable information within minutes. This quick turnaround enables health care providers to promptly identify the cause of infections, initiating targeted treatments sooner and improving recovery times. Timely, accurate diagnostics are particularly critical in severe cases like sepsis, where early intervention can be lifesaving.

Moreover, rapid diagnostics support antibiotic stewardship efforts by distinguishing between bacterial and viral infections. This precision allows clinicians to avoid unnecessary antibiotic use, which is crucial in preventing AMR and protecting the efficacy of existing antibiotics. However, the adoption of rapid diagnostics faces challenges such as resource limitations and high upfront costs. Addressing these barriers can optimize their use, fostering a proactive approach to better patient care and AMR prevention.

To learn more, Infection Control Today^® (ICT^®) interviewed Alesia McKeown, PhD, the scientific partner in infectious Diseases at Roche Diagnostics, and Jeanie Bach, MSN, RN, CCRN, the Disease Area Partner in Infectious Diseases at Roche Diagnostics.

ICT: What role do rapid diagnostics play in improving patient outcomes and reducing the misuse of antibiotics in health care settings?

Jeanie Bach, MSN, RN, CCRN: Rapid diagnostics provide results in minutes, compared to traditional methods that often take days to deliver results. This allows health care providers to quickly identify the cause of an infection, enabling them to initiate appropriate treatment sooner. This rapid intervention can be lifesaving in critical situations, such as sepsis, reducing complications and improving recovery times. Rapid diagnostics help tailor a more targeted treatment by providing immediate, actionable results, ensuring that patients receive the right therapy faster, thereby improving outcomes and preventing disease progression. Additionally, this timely intervention reduces the need for broad-spectrum antibiotics, helping to mitigate unnecessary antibiotic use.

One of the significant contributors to antibiotic resistance is the misuse or overuse of antibiotics, often prescribed when the cause of an infection is unclear. Relying solely on clinical acumen for diagnoses, especially in conditions like respiratory illnesses and sepsis where symptoms frequently overlap with other infectious processes, makes it difficult to accurately identify a specific bacterial agent or distinguish between bacterial, viral, or fungal infections. This uncertainty frequently leads to the prescription of inappropriate or broad-spectrum antibiotics, contributing to AMR and suboptimal patient outcomes.

Rapid diagnostics help distinguish between bacterial and viral infections, enabling providers to prescribe antibiotics only when necessary. This precision reduces unnecessary antibiotic exposure, preserving their effectiveness for future use and lowering the risk of harmful side effects, such as Clostridioides difficile infections, which can occur when antibiotics disrupt the gut's healthy bacteria.

ICT: What are the current challenges in implementing widespread use of diagnostics for AMR, and how can health care systems address these barriers?

JB: Many health care settings encounter challenges such as limited access to lab resources, a need for more trained personnel to ensure quality standards, and concerns about proper specimen handling, especially for diagnostic solutions implemented outside of traditional laboratory environments. The perception of high upfront costs often deters investment, as health care systems may overlook the long-term benefits of solutions like rapid diagnostics in AMR management. Customizable and flexible diagnostic panels further enhance these benefits by enabling precise pathogen identification and facilitating targeted treatments tailored to specific clinical needs. These solutions not only have the potential to reduce hospital stays and improve outcomes but also play a critical role in supporting antimicrobial stewardship.

In addition to these logistical and operational challenges, a cultural barrier exists to overcome. Many health care providers are accustomed to relying on empirical treatments, particularly when diagnostics are perceived as too complex, costly, or slow. However, as the need for faster, more accurate diagnostics grows, the widespread adoption of rapid testing, especially outside traditional laboratory settings, requires a shift in clinical practice as providers adapt to using these tools in decentralized environments where they are not typically implemented.

Investing in education and training, optimizing lab instruments and workflows, and ensuring resource access can help address challenges. Clear implementation strategies and communicating long-term cost benefits can ease concerns about complexity and upfront costs. Leadership must also foster a cultural shift toward adopting diagnostics over empirical treatments to improve outcomes and combat AMR.

Q3. What actionable strategies would you recommend for healthcare providers to further improve diagnostic-driven antibiotic stewardship and combat AMR more effectively?

JB: Developing antibiotic and diagnostic stewardship programs is essential for improving patient outcomes and combating AMR. These programs can be tailored to fit the available resources, whether implemented by a small, focused team in smaller health care settings or as part of a more significant, more comprehensive effort in hospitals with greater resources. Both approaches ensure that providers utilize diagnostics to guide more targeted antibiotic use, supporting effective stewardship regardless of the institution's size or capacity.

By incorporating appropriate and targeted diagnostic solutions, health care teams can enable timely, precise identification of infections, further improving the accuracy and effectiveness of antibiotic treatments. Additionally, by incorporating clinical decision support systems (CDSS), health care providers can ensure that diagnostics directly inform evidence-based prescribing decisions. Continuous education and training on AMR trends and best practices are also critical components of a successful stewardship program, keeping health care teams informed and adaptable.

Fostering collaboration between pharmacists, microbiologists, and infectious disease specialists strengthens decision-making and enhances the overall effectiveness of the stewardship efforts. Partnering with public health entities to track AMR patterns and adjust local prescribing guidelines ensures that stewardship initiatives are aligned with current resistance data. Finally, collaborating with industry partners to find tailored, optimal solutions for specific health care settings and patient populations further enhances the success of these programs. Through these comprehensive strategies, health care providers can promote more precise antibiotic use and reduce the spread of resistance.

ICT: Can you explain the importance of accurate diagnostics, such as the cobas liat 4-plex respiratory test, in enabling health care providers to differentiate between viral and bacterial infections, and why this distinction is vital for combating AMR and contributing to antibiotic stewardship?

Alesia McKeown, PhD: The cobas liat 4-plex respiratory test harnesses the power of polymerase chain reaction (PCR) to detect and differentiate between SARS-CoV-2, influenza A, influenza B, and respiratory syncytial virus (RSV), all within the same patient sample. These viruses present with symptoms similar to bacterial and other viral infections, such as fever, cough, and congestion, making it difficult to diagnose the causative agent based on clinical presentation alone. Without clear diagnostic information, antibiotics are often prescribed empirically and without confirmation of a bacterial infection.

One study by Deb et al (2022) observed inappropriate antibiotic prescribing in 42.2% of patients presenting with upper respiratory symptoms in primary care settings. This study highlights the overwhelming contribution of upper respiratory tract infections to inappropriate antibiotic use and the growing concern about antimicrobial resistance.

By providing rapid, definitive PCR results at the point of contact (POC), the test enables clinicians to confirm a viral infection during the patient’s visit and initiate the appropriate treatment. This distinction is essential for antibiotic stewardship because it helps prevent unnecessary antibiotics, which are ineffective against viral infections. Furthermore, the test results provide an opportunity for patient education. When consulting with the patient on their test results, the clinician now has a platform to educate on the difference between viral and bacterial etiologies and explain why antibiotics are inappropriate for viral infections. These discussions may foster better adherence to treatment recommendations and improve patient and provider satisfaction.

ICT: Can you share any data or case studies that highlight the effectiveness of the cobas liat 4-plex test in promoting more responsible antibiotic use?

Alesia McKeown: The cobas liat 4-plex test received emergency use authorization (EUA) in June of this year. We have not yet had sufficient time to collect and publish any clinical study data outside of what is presented in the product insert. However, multiple studies are using our legacy respiratory assays that demonstrate the effectiveness of the cobas liat system in supporting antimicrobial stewardship initiatives.

The coba liat system has proven effective in promoting responsible antibiotic use across various health care settings. Hansen et al (2018) found that using the system for influenza testing in the emergency department led to changes in prescribing in 58% of cases, including a 24.5% reduction in inappropriate antibiotic use. Similarly, May et al (2023) reported a 20.2% reduction in antibiotic prescriptions for SARS-CoV-2 positive patients when using the cobas liat assay in the emergency department. In primary care, May et al (2022) showed that implementation of the cobas liat Strep A assay reduced antibiotic prescribing by 44% for patients who tested negative. This study also found that 99% of antibiotics were prescribed within the initial patient visit, further underscoring the value of rapid molecular testing at the POC to make informed treatment decisions when needed most.

Another strength of the cobas liat system is its ability to be utilized in “non-traditional” patient care settings, like community pharmacies. Klepser et al. (2019) evaluated the effect of the cobas® liat assays for influenza and Group A streptococcal (GAS) pharyngitis in a community pharmacy. One of the standout findings was that no patients who tested positive for influenza received antibiotics. This is especially significant compared to a national estimate that up to 38% of influenza-positive patients may be prescribed antibiotics inappropriately. This finding illustrates the potential of the cobas liat system to greatly reduce antibiotic misuse in cases of viral infections, which do not require antibiotic treatment.

These studies collectively show that the cobas liat system can profoundly reduce unnecessary antibiotic use by providing rapid, point-of-care diagnostic results in the initial patient visit. However, the adoption of a new technology does not guarantee immediate results. Collaboration within and between clinicians, laboratorians, and antimicrobial stewardship committees is key to maximizing the benefits of such technology, ensuring cross-team support and action for driving responsible antibiotic use.

References

1. Hansen GL, Moore JC, Herding E, et al. Clinical Decision Making in the Emergency Department Setting Using Rapid PCR: Results of the CLADE Study Group. J Clin Virol. 2018;102:42-49. doi:https://doi.org/10.1016/j.jcv.2018.02.013
   
2. Chandra Deb L, McGrath BM, Schlosser L, et al. Antibiotic prescribing practices for upper respiratory tract infections among primary care providers: A descriptive study. Open Forum Infect Dis. 2022;9(7). doi:https://doi.org/10.1093/ofid/ofac302
   
3. May L, Robbins EM, Canchola JA, Chugh K, Tran NK. A study to assess the impact of the cobas point-of-care RT-PCR assay (SARS-CoV-2 and Influenza A/B) on patient clinical management in the emergency department of the University of California at Davis Medical Center. J Clin Virol. 2023;168:105597. doi:https://doi.org/10.1016/j.jcv.2023.105597
   
4. May L, Sickler J, Robbins EM, Tang S, Chugh K, Tran N. The Impact of Point-of-Care Polymerase Chain Reaction Testing on Prescribing Practices in Primary Care for Management of Strep A: A Retrospective Before–After Study. Open Forum Infect Dis. 2022;9(5). doi:https://doi.org/10.1093/ofid/ofac147
   
5. Klepser DG, Klepser ME, Murry JS, Borden H, Olsen KM. Evaluation of a community pharmacy–based influenza and group A streptococcal pharyngitis disease management program using polymerase chain reaction point-of-care testing. J Am Pharm Assoc. 2019;59(6):872-879. doi:https://doi.org/10.1016/j.japh.2019.07.011
   
6. Ciesla G, Leader S, Stoddard J. Antibiotic prescribing rates in the US ambulatory care setting for patients diagnosed with influenza, 1997–2001. Respiratory Medicine. 2004;98(11):1093-1101. doi:https://doi.org/10.1016/j.rmed.2004.03.021