Intensivists’ beliefs about rapid multiplex molecular diagnostic testing and its potential role in improving prescribing decisions and antimicrobial stewardship: a qualitative study

Abstract

Background Rapid molecular diagnostic tests to investigate the microbial aetiology of pneumonias may improve treatment and antimicrobial stewardship in intensive care units (ICUs). Clinicians’ endorsement and uptake of these tests is crucial to maximise engagement; however, adoption may be impeded if users harbour unaddressed concerns or if device usage is incompatible with local practice. Accordingly, we strove to identify ICU clinicians’ beliefs about molecular diagnostic tests for pneumonias before implementation at the point-of-care. Methods We conducted semi-structured interviews with 35 critical care doctors working in four ICUs in the United Kingdom. A clinical vignette depicting a fictitious patient with signs of pneumonia was used to explore clinicians’ beliefs about the importance of molecular diagnostics and their concerns. Data were analysed thematically. Results Clinicians’ beliefs about molecular tests could be grouped into two categories: perceived potential of molecular diagnostics to improve antibiotic prescribing (Molecular Diagnostic Necessity) and concerns about how the test results could be implemented into practice (Molecular Diagnostic Concerns). Molecular Diagnostic Necessity stemmed from beliefs that positive results would facilitate targeted antimicrobial therapy; that negative results would signal the absence of a pathogen, and consequently that having the molecular diagnostic results would bolster clinicians’ prescribing confidence. Molecular Diagnostic Concerns included unfamiliarity with the device’s capabilities, worry that it would detect non-pathogenic bacteria, uncertainty whether it would fail to detect pathogens, and discomfort with withholding antibiotics until receiving molecular test results. Conclusions Clinicians believed rapid molecular diagnostics for pneumonias were potentially important and were open to using them; however, they harboured concerns about the tests’ capabilities and integration into clinical practice. Implementation strategies should bolster users’ necessity beliefs while reducing their concerns; this can be accomplished by publicising the tests’ purpose and benefits, identifying and addressing clinicians’ misconceptions, establishing a trial period for first-hand familiarisation, and emphasising that, with a swift (e.g., 60–90 min) test, antibiotics can be started and refined after molecular diagnostic results become available.

Development and implementation of a customised rapid syndromic diagnostic test for severe pneumonia

“…Commercial multiple-pathogen arrays that include respiratory bacteria have recently become available, however most reports of their use in ventilated patients remain limited to describing diagnostic performance, and reporting 'potential' to change antimicrobial therapy rather than impact on clinical practice 3,37,38 . Concerns have been raised about the risks of over-treatment from molecular diagnostics 16,17,39,40 , whilst conversely promising tests with the potential to change therapy have not always proven this in clinical practice 15,19 . These commercially available assays lack the broad coverage and customisability of the TAC, with consistent concerns raised around limited organism coverage adversely impacting treatment decisions 3,17,19,37,38 .…”

“…Concerns have been raised about the risks of over-treatment from molecular diagnostics 16,17,39,40 , whilst conversely promising tests with the potential to change therapy have not always proven this in clinical practice 15,19 . These commercially available assays lack the broad coverage and customisability of the TAC, with consistent concerns raised around limited organism coverage adversely impacting treatment decisions 3,17,19,37,38 .…”

“…There is now widespread acceptance of the presence of a respiratory microbiome 41,42 and the lungs of ventilated patients present a challenge to highly sensitive molecular diagnostics 16,17 .…”

“…There is, therefore, a pressing need for rapid, sensitive, multipathogen-focussed diagnostic tests for pneumonia 16 . However, although intensive care physicians appreciate the potential advantages of such diagnostics, they are also wary of potential downsides 17 , emphasising the need for evaluation of these tests in real-life clinical practice.…”

Evaluation of Molecular Point-of-Care Testing for Respiratory Pathogens in Children With Respiratory Infections: A Retrospective Case-Control Study

“…The absence of early, rapid, and accurate laboratory testing for infectious pathogens is the major reason for overuse or misuse of antibiotics. The development of accurate and cost-effective rapid molecular diagnostic tests for respiratory infectious pathogens can therefore help to improve antimicrobial stewardship (AMS) (Pandolfo et al, 2021).…”