Antimicrobial Stewardship from Policy to Practice: Experiences from UK Antimicrobial Pharmacists
the introduction of national stewardship guidelines, and an increased focus on stewardship as part of the UK five-year antimicrobial resistance strategy, have accelerated and embedded developments.
the introduction of national stewardship guidelines, and an increased focus on stewardship as part of the UK five-year antimicrobial resistance strategy, have accelerated and embedded developments.
EVIDENCE OF SHORTCOMINGS
National mycology laboratory diagnostic capacity for invasive fungal diseases in 2017: Evidence of sub-optimal practice
In recent years there have been increasing reports of invasive fungal disease and the emergence of more intrinsically resistant species of pathogenic fungi, such as Candida auris. ESPAUR initiated an analysis of current practices in diagnosis and treatment of mycological infections. Key findings published the 2019 report ‘National mycology laboratory diagnostic capacity for invasive fungal diseases in 2017;
A report commented under ‘Highlights’
In recent years there have been increasing reports of invasive fungal disease and the emergence of more intrinsically resistant species of pathogenic fungi, such as Candida auris. ESPAUR initiated an analysis of current practices in diagnosis and treatment of mycological infections. Key findings published the 2019 report ‘National mycology laboratory diagnostic capacity for invasive fungal diseases in 2017;
A report commented under ‘Highlights’
- There is a need to improve the UK diagnostic capacity for invasive fungal diseases.
- A minority of laboratories have local access to β-D-Glucan and galactomannan testing
- Susceptibility testing of Aspergillus is currently conducted by few laboratories
British Society for Medical Mycology best practice recommendations
* The recommendations emphasise .. and the need for susceptibility testing of all Aspergillus spp,
* All aspergillus isolates from patients who have allergic bronchopulmonary aspergillosis, aspergilloma, or acute or chronic aspergillosis should be susceptibility tested...itraconazole) in case additional susceptibility testing is needed at a later date.
* BAL fluid is recommended for diagnosis of invasive fungal disease in patients with haematological disease
* β-D-glucan screening of serum from patients at high risk of invasive fungal disease should be considered as a negative result has a high negative predictive value, enabling invasive fungal disease to be excluded.
* The recommendations emphasise .. and the need for susceptibility testing of all Aspergillus spp,
* All aspergillus isolates from patients who have allergic bronchopulmonary aspergillosis, aspergilloma, or acute or chronic aspergillosis should be susceptibility tested...itraconazole) in case additional susceptibility testing is needed at a later date.
* BAL fluid is recommended for diagnosis of invasive fungal disease in patients with haematological disease
* β-D-glucan screening of serum from patients at high risk of invasive fungal disease should be considered as a negative result has a high negative predictive value, enabling invasive fungal disease to be excluded.
An investigation of antifungal stewardship programmes in England
A second report, 'An investigation of antifungal stewardship programmes in England' included the following comments;
'There is an urgent need to improve across many diagnostic areas including the timely accessibility of/to fungal biomarkers and susceptibility testing.'
'Clinicians say: lack of diagnostic tests or long TAT’s of tests is a main issue when managing patients with suspected invasive fungal infections.'
A second report, 'An investigation of antifungal stewardship programmes in England' included the following comments;
'There is an urgent need to improve across many diagnostic areas including the timely accessibility of/to fungal biomarkers and susceptibility testing.'
'Clinicians say: lack of diagnostic tests or long TAT’s of tests is a main issue when managing patients with suspected invasive fungal infections.'
| an_investigation.pdf |
An antifungal stewardship programme (AFS) is designed to reduce empirically prescribed antifungal treatments and improve patient care.
- The availability of rapid diagnostics and in-house EUCAST broth microdilution will help create an AFS programme.
- The automation of β-D-Glucan testing by the FACIS system has made daily testing with a TAT of 1 hour feasible for all laboratories. β-D-Glucan is a key biomarker that has a significant impact on the empiric prescription of antifungals.
- MICRONAUT -AM is based on Broth microdilution susceptibility testing as used by EUCAST and uses EUCAST breakpoints for interpretation of results.
NHS Antifungal Stewardship Implementation Pack - Version: 0.7 June 2019
This pack provides information and guidance to support the local implementation of this Improving Value initiative. A local implementation project can use the guidance contained within this pack to guide successful implementation.
This pack provides information and guidance to support the local implementation of this Improving Value initiative. A local implementation project can use the guidance contained within this pack to guide successful implementation.
| pss1-meds-optimisation-trigger-5-antifungal-stewardship-implementation-pack-v7.pdf |
Impact of a diagnostics-driven antifungal stewardship programme in a UK tertiary referral teaching hospital.
'The AFS programme was successful in reducing the number of inappropriate initiations of antifungals by 90%. Concurrently, mortality due to invasive candidosis was reduced by 58%. BDG testing can guide safe cessation of antifungals in ICU patients at risk of invasive candidosis.'
'The AFS programme was successful in reducing the number of inappropriate initiations of antifungals by 90%. Concurrently, mortality due to invasive candidosis was reduced by 58%. BDG testing can guide safe cessation of antifungals in ICU patients at risk of invasive candidosis.'
Effectiveness of an antifungal stewardship programme at a London teaching hospital 2010–16
'Empirical treatment was often unnecessary, with 82% having no evidence of IFI. Advice was given in 64% of reviews (most commonly de-escalating or stopping treatment) and was followed in 84%.'
Antifungal stewardship in critical care: Implementing a diagnostics-driven care pathway in the management of invasive candidiasis
'Although adopting a diagnostics-driven approach was found to be useful in the cohort of patients with BDG results available, the use of once-weekly BDG testing did not result in an observed reduction in the consumption of anidulafungin, highlighting an important limitation of this approach.'
'Although adopting a diagnostics-driven approach was found to be useful in the cohort of patients with BDG results available, the use of once-weekly BDG testing did not result in an observed reduction in the consumption of anidulafungin, highlighting an important limitation of this approach.'
How Long is Too Long? Fungal biomarker turn-around-time (TAT) and antifungal stewardship.
A median turn-around time of 1-2 weeks significantly devalues the use of fungal biomarkers
| fungal_biomarker_turn-around-time__tat__and_antifungal_stewardship__how_long_is_too_long____aspergillus___aspergillosis_website.pdf |
Recent Advances and Novel Approaches in Laboratory-Based Diagnostic Mycology
'The application of digital readers—which provide a quantitative output are a major improvement when using LFD, removing subjectivity and providing a value for clinical interpretation and have been
identified as critical to clinical use, can be applied to both serum and BAL fluid, and are available for'
FungiXpert now added
Fungal Disease Diagnostics from BioConnections
|
ERA Biology A pioneer in products for invasive fungal disease diagnosis. Products include Aspergillus galactomannan, Beta-D-Glucan,and Cryptococcal capsular polysaccharide in LFA, EIA & PCR formats.
MICRONAUT Broth microdilution is the technique that should be used for antifungal susceptibility according to EUCAST. This product has been evaluated and is in use in leading UK hospitals.
LDBIO The National Aspergillosis Centre in Manchester, UK has tested their LFA device for Aspergillus antibody and found it to be accurate, identifying 91% of cases of Chronic Pulmonary Aspergillosis in 30min.
|
Invasive Aspergillosis KEY PUBLICATIONS
|
COVID-19 associated invasive aspergillosis: data from the UK National Mycology Reference Laboratory. From the discussion 'In addition to radiological imaging, serial screening for CAPA (CoVID Associated Pulmonary Aspergillosis) in ICU patients with deteriorating respiratory function should include: (i) regular (at least weekly) Aspergillus antigen testing of serum samples, (ii) regular (at least weekly) BDG testing of serum samples , (iii) Aspergillus antigen testing of BAL fluids (where available) or non -directed lavages/tracheal aspirates and (iv) Aspergillus PCR in conjunction with conventional mycological examination (microscopy and culture) of respiratory secretions if available. '
Invasive fungal disease occurs often in critically ill patients with COVID-19 on mechanical ventilation, according to a study published in Clinical Infectious Diseases.
A national strategy to diagnose COVID-19 associated invasive fungal disease in the ICU
Confronting and mitigating the risk of COVID-19 Associated Pulmonary Aspergillosis (CAPA)
|
| ||||||||
Pulmonary Aspergillosis KEY PUBLICATIONS
|
Chronic Pulmonary Aspergillosis—Where Are We? and Where Are We Going?
'The use of Aspergillus IgG antibody as a diagnostic tool is far superior to the use of Aspergillus precipitins and should always be used as the gold standard ..to confirm infection.' J. Fungi 2016, 2(2), 18; https://doi.org/10.3390/jof2020018 Evaluation of LDBio Aspergillus ICT Lateral Flow Assay for IgG and IgM Antibody Detection in Chronic Pulmonary Aspergillosis
Precis; The LDBIO Aspergillus ICT IgG-IgM immunochromatographic technology (ICT) test was compared with Aspergillus IgG titers in CPA patients, measured by ImmunoCAP-specific IgG assays (cutoff value, 40 mg of antigen-specific antibodies [mgA]/liter For proven CPA patients versus controls, sensitivity and specificity for the LDBio Aspergillus ICT were 91.6% and 98.0%, respectively. In contrast, the routinely used ImmunoCAP assay exhibited 80.5% sensitivity for the same cohort Of the 154 patients in our CPA case group, 108 had precipitins testing (for Aspergillus antibody) performed as part of routine diagnostics, with 57.4% sensitivity. |
CLICK FOR LDBIO PAGE
| ||||
|
Evaluation of the LDBio Aspergillus ICT lateral flow assay for serodiagnosis of allergic bronchopulmonary aspergillosis.
Precis; Early recognition and diagnosis of allergic bronchopulmonary aspergillosis (ABPA) is critical to improve patient symptoms, and antifungal therapy may prevent or delay progression of bronchiectasis and development of chronic pulmonary aspergillosis. ABPA and control sera collected at the National Aspergillosis Centre (Manchester, UK) and/or from the Manchester Allergy, Respiratory and Thoracic Surgery research biobank were evaluated using the Aspergillus ICT assay. Results were read both visually and digitally (using a lateral flow reader). Serological Aspergillus-specific IgG and IgE, and total IgE titres were measured by ImmunoCAP. . The test effectively distinguished between Aspergillus-sensitization complicating asthma and/or bronchiectasis, and underlying conditions. It is rapid (result in <30 minutes) and easy to perform, with simple result interpretation by visible inspection. Overall, the LDBio Aspergillus ICT exhibits excellent performance as a screening tool in the ABPA diagnostic pathway Published: September 25, 2020 https://doi.org/10.1371/journal.pone.0238855 |
CLICK FOR LDBIO PAGE
| ||
RECOMMENDED FOR UPDATES
|
|
