Fighting Antibiotic Resistance: laboratory requirements and supporting solutions
Last May, the BD® Academy Centre in Milan hosted the first of a series of conferences named “Innovation Lab – Solutions for supporting laboratories in the fight against AMR”. The occasion was a fruitful time of debate and discussion, with the exchange of experiences between different health professionals who are active participants in the fight against antimicrobial resistance (AMR). Along with the daily challenges and needs of practitioners, the importance of the role of the Microbiology Laboratory emerged.
Now, in World AMR Awareness Week, we would like to take this opportunity to reiterate the important points emerging from the conference and issue a reminder that a second edition of “Innovation Lab – Solutions for supporting laboratories in the fight against AMR” is being held this week, with a third edition planned before summer 2025. In addition, a new section dedicated to combatting AMR is now available here in BD® Academy, to find out more about the best solutions available and BD's commitment to this matter.
Today in Italy, approximately 11,000 deaths are caused by infections from antibiotic-resistant microorganisms.1 This already alarming situation has worsened as a result of the incorrect use of antibiotics during the 2020 pandemic, as revealed by the analysis of new data provided by the WHO Global Clinical Platform for Covid-19.2
The alarm concerns the whole of Europe, and it is estimated that from 2050 the situation could become even worse. The European Centre for Disease Prevention and Control (ECDC) promotes a high level of health security within the Union. Specifically, in the field of microbiology, the ECDC has a mandate to “encourage cooperation between experts and reference laboratories in order to accelerate the development of sufficient capacity in the community for the diagnosis, detection, identification, and characterisation of infectious agents that may threaten public health. “4 The ECDC emphasises that the microbiology laboratory is the first line of public health defence against communicable diseases and AMR.4
In Italy, much work is being done to reduce mortality due to infections by resistant microorganisms, however much remains to be done. The recent National Plan to Combat Antibiotic Resistance (PNCAR 2022-2025) includes many interventions that have yet to be fully implemented. The disparity between different regions of Italy in terms of action taken works against a centrally coordinated approach, an approach with three main pillars: supervision, monitoring and prevention. In the fight against AMR, networking is indeed crucial. In fact, some virtuous realities have developed regional supervision platforms that collect data from different laboratories in the country and produce reports on a regular basis, in order to monitor and support decision-making on the strength of epidemiological data.
The main requirements of the AMR laboratory in the hospital setting
Several requirements emerged from the discussion among participants. If met, these could optimise the work of monitoring, diagnosis, and optimal, timely therapeutic choice(Diagnostic and Antimicrobial Stewardship).
In particular, there emerged a requirement for:
– training of health care workers involved in monitoring and searching for resistant pathogens, but also workers working in departments at greater risk of infection;
– encouraging greater dialogue between practitioners and microbiologists who report to the analytical laboratory, particularly in the sharing of data, which must be rapid, accurate and comprehensive;
– improvement and enhancement of hospital computer systems (not just laboratories), which often fails to enable continuous, automated tracking from sampling to analysis to the final alert to the department involved and, therefore, to the patient to be treated;
– the final report must be readable, complete, interpretable, reliable, reproducible, and useful to the practitioner who must decide on the treatment;
– monitoring of the hospital environment (environmental microbiology), aimed at the detection of resistant pathogens not only from biological samples taken from patients, but also from environmental sampling. This approach is yet to be understood and studied in detail.
Some participants shared their direct experience of successful collaboration between microbiologists and practitioners, underlining the central role of the laboratory in managing a complex patient and the importance of the antibiogram in clinical practice. The advent of new technologies for identification and susceptibility testing has led to a remodelling of the analysis laboratory and a new management of workflows. In fact, it is important to recognise and exploit all the limitations and advantages of the analytical tools available. New technologies such as molecular should not replace translational ones, but should be used synergistically, bearing in mind that they provide complementary information. Traditional techniques are somewhat time-consuming and involve manual dexterity; however, they still provide fundamental information, such as MIC.
Another key point that emerged is the importance of available up-to-date shared local epidemiological reports. In collaboration with infectious disease specialists, virtuous pathways have already been implemented in some settings with regard to the supervision and management of blood cultures with the integration of available methods. The usefulness of identifying resistance markers was also emphasised. For example, active, specific monitoring of the NDM gene has highlighted a dramatic increase in its expression since April 2023, as against a rate of infection and colonisation of Klebsiella pneumoniae strains that did not reflect the same trend.
The role of the Microbiology Laboratory3
Diagnostics
The role of the microbiology laboratory is central to supporting professionals and performing a service that meets current challenges efficiently and ensures the best patient care.
The laboratory brings with it a chain of activities, primarily critical in diagnostics, which have a great impact on AMR. To make a correct diagnosis, the pre-analytical phase is crucial and must be followed by rapid, accurate testing. The implementation of rapid diagnostics (such as molecular tests) increases the complexity of the laboratory flow, but can speed up the availability of results. The communication of results is a key factor. The microbiology laboratory must have a decision-making role as to which path to take (conventional or rapid), based on the type of sample and the patient's medical history. It is, in fact, essential to perform the correct test, on the correct patient and, above all, at the right time. This approach, which is a reflection of Antimicrobial Stewardship, should be implemented in every hospital setting.
Antibiogram
The antibiogram plays an important role in deciding on the most appropriate therapy. In particular, the MIC still makes the difference in the therapeutic choice based on the patient's clinical condition, the site of infection or the type of antibiotic and microbial species identified. MIC allows us to create a phenotypic profile of the microbial species, determine its susceptibility and provide information on the dosage of antibiotics required.
Reports
Culture test reports must be reliable, accurate and lead to susceptibility testing to determine the best therapy. These steps can open up a supervision process and the issuing of an Alert both in the hospital facility affected by the infection and nationwide when necessary. Reporting is also important in order to obtain shareable, accessible epidemiological data . Cumulative antibiograms, still a subject of debate today, are important and must be managed by advanced computer systems compatible with the LIS system.
ROLE OF THE MICROBIOLOGY LABORATORY IN THE FIGHT AGAINST AMR3
- Guidance in the pre-analytical phase
- Availability of rapid and accurate diagnostic tests
- Reliability of culture reports and AST
- Surveillance and alert systems
- Production of epidemiological reports and cumulative antibiograms
- Training and updating
- Continuous dialogue with physicians for therapeutic choice
BD solutions
The systems and services offered by BD are based on an awareness of the challenges facing our National Health System, for example staff shortages, rising costs, spread of resistant pathogens, lack of accurate, timely results, and rapid communication of data. Healthcare responses to these limitations include the use of automated processes to shorten times, building a structure that enables cost savings, the implementation of programmes to combat the spread of resistant pathogens, and finally the use of high-level computer systems.
As BD Italy, we felt it was important to create opportunities for discussion among health care practitioners such as the Innovation Labs on the topic of AMR, at the BD head office in Milan. In fact, for more than 50 years we have worked alongside health care practitioners in the fight against AMR, providing not only solutions to support laboratories in obtaining accurate results quickly enough for successful management of the patient, but also services and training for the continuous improvement of diagnostic work and the delivery of care in health facilities.
Find out more about our commitment to fighting AMR through our dedicated page, or download BD’s 5 pillars against AMR.
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Bibliography
- Antimicrobicoresistenza. In Italia circa 11.000 morti l’anno. Priorità a interventi per la ricerca e per la sostenibilità degli antibiotici Reserve – Quotidiano Sanità https://www.quotidianosanita.it/studi-e-analisi/articolo.php?articolo_id=118376
- Uso eccessivo di antibiotici in ospedale nei pazienti con Covid-19 potrebbe aver esacerbato la resistenza antimicrobica – Quotidiano Sanità. https://www.quotidianosanita.it/studi-e-analisi/articolo.php?articolo_id=121814 e
- Morency-Potvin P, et al Antimicrobial Stewardship: How the Microbiology Laboratory Can Right the Ship Clin Microbiol Rev 30:381– 407. https:// doi.org/10.1128/CMR.00066-16.
- ECDC public health microbiology strategy 2018–2022 https://www.ecdc.europa.eu/sites/default/files/documents/ECDC-public-health-microbiology-strategy-2018-2022.pdf
