Medical laboratories to become antimicrobial stewards in the fight against antibiotic resistance

At the start of 2017, new requirements for antimicrobial stewardship programs became effective for hospitals and other providers that must accredit to the standards of Medicare Conditions of Participation (COP) and The Joint Commission. Clinical laboratories serving hospitals are already engaged in efforts to improve the use of antibiotics in ways that slow the growth of antibiotic-resistant strains of infectious agents.

Even as the nation’s hospitals embark on efforts to implement effective antimicrobial stewardship programs, researchers continue to seek solutions to the same problem. They are following several paths to combat the growing resistance certain pathogens have to antibiotics. In particular, two approaches are interesting for pathologists and medical laboratory personnel. One involves understanding the processes that lead to antibiotic resistance. The other is to identify useful biomarkers associated with specific strains of pathogens.

Two Avenues of Promising Research

In the first area of research, along with developing newer, more powerful antibiotics to combat antibiotic resistant bacteria, scientists are working toward a greater understanding of the processes at the molecular level that underlie that resistance.

One of the current targets of investigation is plasmids. A group of scientists at the University of Oxford used an experimental model to show how plasmids can speed up the natural process of antibiotic resistance. Dr. Craig MacLean, PhD, Associate Professor and Royal Society University Research Fellow in Zoology at Oxford, was the senior author of their study, which was published in Nature Ecology and Evolution.

MacLean says, “Many of the most important resistance genes are found on plasmids, which are small, circular DNA molecules that live inside bacteria. Plasmids are capable of moving between bacteria and are usually thought of as being important ‘vehicles’ that transfer resistance genes between bacteria.” He goes on to explain that his team’s study shows that plasmids can speed the evolution of new types of resistance, because bacteria typically carry more than one copy of a plasmid.

“These findings demonstrate a new role for plasmids in antibiotic resistance and evolutionary innovation, and they highlight the threat posed by plasmids to public health,” said MacLean.

The second avenue of research to address the growing threat posed by antibiotic resistance is the work being done to identify biomarkers, which are associated with specific bacteria. For example, a study published in The Lancet Global Health, describes a trial that compared an antibiotic strategy based on biomarkers and common best practices used at the primary-care level. The trial had more than 2,000 participants and found that point-of-care testing for specific biomarkers reduced the use of antibiotics.

Dr. Craig MacLean (above), University of Oxford, is Associate Professor, Royal Society University Research Fellow; and Hugh Price Fellow in Evolutionary Biology, Jesus College. The MacLean Lab at Oxford studies “evolutionary processes that drive the spread and maintenance of resistance in populations of pathogenic bacteria.” (Photo copyright: University of Oxford.)

Dr. Craig MacLean (above), University of Oxford, is Associate Professor, Royal Society University Research Fellow; and Hugh Price Fellow in Evolutionary Biology, Jesus College. The MacLean Lab at Oxford studies “evolutionary processes that drive the spread and maintenance of resistance in populations of pathogenic bacteria.” (Photo copyright: University of Oxford.)

The study focused on C-reactive protein (CRP), which the researchers described as “a biomarker for the presence of an inflammatory process.” Their investigation compared outcomes for patients with non-acute respiratory tract infections when a CRP test was performed at the point of care to when usual best practices were followed. The researchers conclude, “Antibiotic use for acute respiratory infections was significantly reduced by C-reactive protein guidance at the point of care.” They also found, “no differences regarding recovery, serious adverse events, and patients’ satisfaction.”

Governmental Efforts

The government is joining researchers and public health organizations in the effort to stem the dangerous trend of antibiotic resistance. The Joint Commission issued a new antimicrobial stewardship standard, which became effective on January 1, 2017. In an article published by the American Society of Health-System Pharmacists (ASHP), Margaret Van Amringe, Vice President for Public Policy and Government Relations at The Joint Commission, said that the new standard will ensure healthcare organizations have an antimicrobial stewardship program in place.

The Centers for Medicare and Medicaid Services (CMS) also is pushing for stewardship programs. In a June, 2016, press release, CMS issued a proposed rule changing the conditions of participation to include having an antibiotic stewardship program with specific leaders. Because CMS accounts for such a large portion of overall healthcare spending, there is little doubt that hospitals will implement antibiotic stewardship programs in the immediate future.

Pathologist, Clinical Laboratories, Key to Slowing Spread of Antibiotic Resistance

Regardless of what government agencies, public health organizations, or even individuals choose to do, antibiotic resistance will continue to grow. Medical pathologists will play a critical role in slowing the spread of antibiotic resistance. Tests to identify biomarkers, tests to learn whether a specific bacterium is susceptible to a specific agent, as well as diagnosing the cause of infections, are all within the realm of the clinical pathology laboratory.

Antibiotic resistance is increasing throughout the world. The World Health Organization (WHO) website states that, “Antibiotic resistance is one of the biggest threats to global health, food security, and development today,” and that, “Without urgent action, we are heading for a post-antibiotic era, in which common infections and minor injuries can once again kill.”

However, pathologists and clinical laboratories will soon play a critical role in fighting the growing threat of antibiotic resistance. As research scientists attack the problem on different fronts, pathologists will likely find themselves on the frontline of the battle, with the expertise to diagnose the cause of infection, to identify biomarkers associated with inflammation, and to provide data on whether specific bacteria will be vulnerable to specific antibiotics.

Public Health Organizations Stress the Danger

The Centers for Disease Control and Prevention (CDC) also stresses the grave threat posed by the specter of a post-antibiotic world. The CDC groups antibiotics with several other drugs and classifies them as antimicrobial agents. Their website states, “Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics and at least 23,000 people die each year as a direct result of these infections.”

The CDC lists four critical steps to fighting antibacterial resistance:

• Prevent infections before they begin;

• Track resistant infections;

• Improve how antibiotics are prescribed; and

• Develop new tests.

Antibacterial resistance is part of a natural process, and both the WHO and the CDC stress that the process can be slowed, but not stopped. The role of the clinical pathology laboratory is crucial. The CDC says, “We will always need new antibiotics to keep up with resistant bacterial as well as new diagnostic tests to track the development of resistance.”

—Dava Stewart

Related Information:

World Health Organization Fact Sheet on Antibiotic Resistance

Centers for Disease Control and Prevention Antibiotic/Antimicrobial Resistance

CDC, About Antimicrobial Resistance

Point-Of-Care C-Reactive Protein Testing to Reduce Inappropriate Use of Antibiotics for Non-Severe Acute Respiratory Infections in Vietnamese Primary Health Care: A Randomised Controlled Trial

Approved: New Antimicrobial Stewardship Standard

New Antimicrobial Stewardship Standard Issued by Joint Commission

CMS Issues Proposed Rule that Prohibits Discrimination, reduces Hospital-Acquired Conditions, and Promotes Antibiotic Stewardship in Hospitals