Poor antimicrobial prescribing decisions often are triggered by laboratory results that create red herrings or worse. Inappropriate/ poor specimen collection and/or a request form that provides no context to the investigation often sets the ball rolling. Inappropriate workup and reporting of contaminant or colonising isolates may then follow (it may be impossible for the lab to judge in the absence of clinical notes or context). Reports that publish susceptibility results on contaminant bacterial or fungal isolates or unneeded results for broad spectrum agents often then prompt treatment and potentially prolong hospital stays (see this recent reference for a great example of why ‘cascade’ reporting is warranted- it can reduce usage and resistance!).
And so, we recognise that some sort of pathology stewardship is an essential element of antimicrobial stewardship programs.
We previously highlighted an article that examined inappropriate pathology ordering in Australia and New Zealand. The article was written in response to significant increases in workload and evidence from the UK that 25% of all pathology requests were unnecessary or inappropriate. Spelman surveyed 140 Australian and New Zealand infectious diseases physicians and medical microbiologists as to what they considered the most useless of microbiology tests. Pet peeves included (see also Box 1 below):
- Tests ordered with results that are never reviewed by the clinician.
- Single samples taken for serological diagnosis without subsequent convalescent sera submission.
- Serological fishing expeditions – requests for tests where there is no supporting clinical illness or epidemiological link.
- Dry swabs submitted for bacterial culture. Swabs instead of pus or tissue submitted from surgical procedures.
- Environmental swabs collected in the absence of epidemiological evidence of a local healthcare infection issue.
- Tests for ‘clearance’, such as repeat throat and nose swabs for respiratory viruses or repeat stool tests for Clostridium difficile.
Spelman gives a great introduction into pathology stewardship – definitely worth a read! Box 2 below summarises some of his suggestions for improvement.
- National Coalition of Public Pathology. Encouraging quality pathology ordering in Australia’s public hospitals. Final report. Sydney: NCOPP, 2012. http://www.ncopp.org.au/UserFiles/file/NCOPP%20QUPP%20Project%20Final%20Report%20(web).pdf
- Spelman, Denis. “Inappropriate pathology ordering and pathology stewardship.” The Medical journal of Australia 202.1 (2015): 13-15.
- United Kingdom Department of Health. Report of the second phase of the review of NHS pathology services in England. Chaired by Lord Carter of Coles. 2008.