Is diagnostic stewardship possible in solid organ transplantation?

Abstract

Background: Diagnostic stewardship in solid organ transplant (SOT) recipients has the potential to help these vulnerable patients at risk for over-testing and overtreatment.Methods: Herein, we review potential targets for diagnostic stewardship in SOT, such as Clostridioides difficile testing, urine cultures, molecular diagnostics, as well as novel areas of diagnostic stewardship. Results: Bundled interventions focused on appropriate C. difficile testing can result in a significant decrease in testing and clinical diagnosis of C. difficile infection without any harms related to delay in diagnosis. In otherwise stable renal transplant recipients after the first month of transplant, screening urine cultures have not been shown to improve outcomes. Novel targets that require additional study in the SOT population include noninvasive fungal diagnostics and cytomegalovirus testing strategiesConclusions: Diagnostic stewardship is an innovative approach to improve diagnosis and limit unnecessary antimicrobial use. While there has been little direct exploration of diagnostic stewardship in the SOT population, there is great potential for benefit given frequent testing with diagnostics that have imperfect sensitivity and specificity, and sometimes great cost. Diagnostic stewardship in the SOT population is indeed possible but will require a multidisciplinary effort to ensure that appropriates tests and benefits are realized.

Diagnostic stewardship: what impacts antibiotics use?

“…But recent literature demonstrates that diagnostic stewardship process interventions can be implemented within a healthcare system and tailored to infectious syndromes. Diagnostic stewardship is well described in urinary tract, gastrointestinal, respiratory and bloodstream infections, but there is also emerging evidence of diagnostic stewardship in the ICU, among transplant [40] and immunocompromised populations, paediatric patients and in prosthetic joint infections, osteomyelitis and central nervous system infections, which were not included in this review. Future considerations for diagnostic stewardship should include the integration and institutionalization of systems-based interventions in patient care.…”

Changing the culture of blood cultures: Opportunities for diagnostic stewardship in febrile neutropenia

“…Though there are limited studies evaluating the impact of diagnostic stewardship in immunocompromised patients -including those with hematologic malignancies and recipients of solid organ transplants, hematopoietic cell transplants (HCT), or other cellular therapies -there is a growing body of literature suggesting that diagnostic stewardship can be feasible, safe, and effective even in this population who is at high risk for serious infections. [4][5][6] Several diagnostic stewardship opportunities that have been proposed for transplant recipients include appropriate stool testing for Clostridioides difficile infections, judicious use of urine cultures to reduce treatment of asymptomatic bacteriuria, targeted diagnostic testing of respiratory samples and limiting the use of surveillance blood cultures. 5,6 Febrile neutropenia, a common complication in patients with hematologic malignancies and HCT recipients, involves high utilization of diagnostic tests and presents unique diagnostic stewardship opportunities.…”

“…[4][5][6] Several diagnostic stewardship opportunities that have been proposed for transplant recipients include appropriate stool testing for Clostridioides difficile infections, judicious use of urine cultures to reduce treatment of asymptomatic bacteriuria, targeted diagnostic testing of respiratory samples and limiting the use of surveillance blood cultures. 5,6 Febrile neutropenia, a common complication in patients with hematologic malignancies and HCT recipients, involves high utilization of diagnostic tests and presents unique diagnostic stewardship opportunities. Blood cultures are an important part of any febrile neutropenia work-up, as approximately 25% of patients evaluated for febrile neutropenia have bacteremia, 7 but the utility of repeat blood cultures following appropriate therapy is uncertain.…”

“…7 Reaching for high-cost molecular tests on blood or plasma samples is tempting in this setting, but optimal use of such tests is not well defined. 6 The following Brief Communication by Sheu et al provides an important contribution to the limited literature describing blood culture yield in febrile neutropenia and has significant implications for the future of blood culture stewardship. Sheu et al performed a retrospective analysis to assess the positivity rate of repeat blood cultures in early post-HCT recipients with bacteremia diagnosed within 24 h of the onset of febrile neutropenia.…”