1/ #SHEASpring2023 @samdominguez309 talking to us about the nuts and bolts of building a diagnostic stewardship program!
@COpedsID
2/ Things are complex and we are getting a lot of sensitive tests coming to market. Interpreting results can be challenging ImageImage
3/ The goal of diagnostic stewardship isn’t just about stopping testing! It’s ensuring that tests are being used in a thoughtful way. Dr. Dominguez has been working in this space for years, but calls for more outcomes and economics research in this space Image
4/ Right test:
📌 is the test appropriate for the clinical setting?
📌 performance (sensitivity, specificity, ppv, npv)
📌 testing volumes
📌 additional test or replacement?
📌 we should do more theoretical clinical impact simulations!
📌 cost vs. value
5/ right patient:
Will the patient be affected by this result? If not, may not be the right test! Image
6/ How do we making change and impact?
Consider hierarchy of effectiveness Image
7/ Example: implementing the meningitis/encephalitis panel in a pediatric setting Image
8/ Right time:
Will the test result be available in time to impact care?
📌 consider setting, lab workflow

Right interpretation:
Will the clinician understand the result? Image
9/ The Banerjee study is a great example of this — most impact of rapid diagnostic test seen when combined with active stewardship Image
10/ there are potential harms of dx stewardship and we should acknowledge them.
📌 risk of missed diagnosis
📌 clinician perceived loss of autonomy

Possible solutions for this: Image
11/ Teamwork and stakeholder engagement is key! Image
12/ Ending with a big THANKS to a wonderful team! Image
13/ Next up, Dr Handel talking to us about new diagnostics pitfalls and promise Image
14/ what about novel/less common diagnostic tests?

mNGS is a great example. One test to rule them all?
📌 while the 2014 study in NEJM sparked a lot of excitement, things aren’t always so clear or accurate in this space. Image
14/ Use of these tests is variable with lots of (sometimes passionate) feelings about how/why/when to use them.

So what to do?!
Hint: it’s complex Image
15/ Right test:
📌 what question is being asked?
📌 are there alternatives to answering that question?
📌 do data for using mNGS in the given scenario exist?

Example of where this seemed to work well: Image
16/ Right person:
Should we use something like this in immunosuppressed vs immunocompetent patients? Image
17/ interpretation can be really challenging!

Will this test prompt the right action? Image
18/ The recommendations for this type of testing include:
📌 oversight is needed! ID and/or lab personnel should approve testing
📌 carefully consider the question you’re trying to answer (review the literature)
📌 pause to consider utility
📌 considering drawing and holding
19/ Finally, ways we can fill the gaps are listed. Im a huge fan of a collaborative for sharing diagnostic stewardship strategies!
@AndrewHandel Image
20/ Now updates from @CWoodsHillMD on future of brightSTAR collaborative Image
21/ what’s next?!
📌 assessing the sustainability of BrightStar 1, seeing what really happened to CLABSI
📌some D&I work (LIBRA)
📌 BrightStar respiratory (yay!!) Image
22/
36% reduction in CLABSI. The reasoning for this is unclear, but the team is going to dig deeper into this to work to understand it. More to come!
23/ Application of implementation science coupled with behavioral science to understand why clinicians choose to order tests.
📌 picu clinicians like to act
📌 picu clinicians like to provide usual/customary care
📌 outcome bias
23/ Loss aversion may drive how we approach diagnostic testing in the PICU Image
24/ LIBRA will be a hybrid pilot trial that will explore implementation strategies to implement optimal use of blood cultures safely
24/ BrightStar respiratory
@asicksamuels is a leader on this one! Can’t wait to see if/how this program safely reduces unnecessary respiratory testing!

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More from @andreaprinzi

Dec 30, 2021
1/ Hey #IDTwitter #LabTwitter @ASCLS @ASMicrobiology , I want to take a moment to break down our new study: Endotracheal Aspirate Culture Variability and Antibiotic Use in Mechanically Ventilated Pediatric Patients ja.ma/31f9Zv8 via @JAMANetworkOpen @JAMANetwork
2/ This work was a multidisciplinary effort, & I am REALLY proud of that! I think this is a great example of the cool work we can do when we put our clinical laboratory and infectious disease minds together to answer questions about diagnostic tests and #stewardship #IDtwitter
3/ Dr. Sarah parker (@HandshakeASP @COpedsID ), Dr. Anna Sick-Samuels (@asicksamuels ) and myself all had a similar question: Do hospitals that use more endotracheal aspirate cultures have more days of therapy in their mechanically ventilated patients?
Read 27 tweets
Sep 3, 2021
1/ Happy Friday!
Today I am celebrating #scicomm! As of this week, I have contributed 21 articles to the @ASMicrobiology Bugs & Drugs blog! Here's a recap of some of these articles for those who love clinical #microbiology
#IDTwitter @ASCLS @CUAnschutz #MedEd @JClinMicro
2/ First, just a quick note on writing for @ASMicrobiology. Volunteering my time to write has been one of the highlights of the last 2 yrs for me! So grateful for the amazing Bugs & Drugs team, especially @JulieMarieWolf @JClinMicro @ScienceInTheDMV who took a chance on me.
3/
YELLOW FEVER AND FRACTIONAL DOSES
#Publichealth piece discussing the yellow fever outbreak of 2015/16 in Africa & highlighting the amazing work of researchers working on fractional #vaccine dosing. It's an amazing story, full of impressive characters.
asm.org/Articles/2021/…
Read 19 tweets
Sep 1, 2021
1/ I loved writing this new @ASMicrobiology article. I talked to Dr. Derick Kimathi (@Toinoti, medical researcher in Kenya), about using fractional doses of yellow fever #vaccine. I hope you find this as interesting as I did #IDtwitter #epitwitter
asm.org/Articles/2021/…
2 / This is a follow up article to the one I wrote back in May that briefly detailed the history of #YellowFever in the United States, and how the development of #diagnostics for the disease as well as modern research stemmed from that #history.
asm.org/Articles/2021/…
3/ The #YellowFever #outbreak that started in Angola in 2015 ravaged major cities like Luanda & Kinshasa, and resulted in 11 imported cases in China - a country that harbors the mosquito that spreads the yellow fever virus and has a population immunologically naïve to YF.
Read 8 tweets
Aug 19, 2021
1/ Proud to be a part of this hot-off-the-press #stewardship study examining time to blood culture positivity by pathogen and primary service. A joint effort by scientists at @ChildrensColo @CUMedicalSchool @CUAnschutz. Check it out #IDTwitter ! Summary 🧵
pubmed.ncbi.nlm.nih.gov/34407980/#:~:t…
2/ Some background:
* Historically, infants and children are given antibiotics until blood cultures are negative at 48-72 hours.
*Empirically treating is essential for children with bacteremia, but waiting for this negative BC period may be unnecessary. pubmed.ncbi.nlm.nih.gov/25567785/
3/ Why we did this study:
* Understanding the time it takes for blood cultures to become positive (with respect to certain organisms and subspecialties) can help shorten overall antimicrobial duration.

*Shortening duration= fewer adverse events, less resistance, shorter stays
Read 23 tweets
Apr 7, 2021
1/I want to take some time to share findings from our semi-recent PETACS study. This was a wonderful collaboration between @COpedsID faculty, survey designers, and #microbiologists across the US.
@JClinMicro @ASMicrobiology #ASMClinMicro
jcm.asm.org/content/59/3/e…
2/ First, I want to emphasize that this project highlights many of the reasons I chose to pursue a #PhD in clinical & translational science. As a long-time microbiologist, I can say that the clinical lab doesn't often have a seat at the clinical effectiveness / research table.
3/ This project focuses on the tracheal aspirate culture- a diagnostic process that is greatly limited by contamination with normal respiratory flora, and which lacks consensus or standardization across labs and hospitals. @ASCLS @ASMicrobiology @ASCP_Chicago
Read 26 tweets
Mar 30, 2021
1/Dr. Lewis Roberts is giving a really interesting talk at @ACTScience #TS21 that walks us through the art of reviewing and questioning a scientific talk.

We are all pretty familiar with reviewing manuscripts, but I think this is a fresh take!
@EdgeforScholars #phdlife #PhD
2/
This is like a dynamic (real-time) manuscript review. The corollary:
* One key for presenters: strategically repeat yourself
*Tell them what you're going to say (abstract)
*Tell them (introduction, methods, results)
*Tell them what you told them (discussion)
#TS21 @ACTScience
3/
The 40,000 ft view:
*What is the main aim of the study? Should be in the first few minutes of a presentation
*When you are listening, pick out:
-What is the problem they are trying to solve?
-What is the overall hypothesis?
#TS21
Read 7 tweets

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