Selective reporting of antibiotic susceptibility test results in European countries: an ESCMID cross-sectional survey
Introduction
Antibiotic use drives bacterial resistance [1], and antibiotic prescriptions are often inappropriate or unnecessary both in outpatient and in inpatient settings [2], [3]. The microbiology laboratory plays a crucial role in antibiotic stewardship programmes [4], in particular through pathogen identification and reporting of antibiotic susceptibility test (AST) results. Huge efforts have been made to reinforce quality control and in the standardisation of testing procedures [5], but the significant impact of reporting on physicians' prescribing behaviour has been overlooked so far. Interpreting AST results might be a challenge for clinicians: they can find it difficult to assess the clinical relevance of the isolate and the practical relevance of minimum inhibitory concentration (MIC) values, and often see AST reports as a menu of possible choices [6], [7].
Selective reporting of AST results is increasingly recognised as one of the key strategies of antibiotic stewardship programmes and has recently been included in the list of interventions recommended by the Infectious Diseases Society of America (IDA) and the Society for Healthcare Epidemiology of America (SHEA) [4], even though the level of evidence supporting this measure is quite low [8], [9], [10]. Selective reporting means that antibiotics are tested as usual (according to national or international recommendations) by the microbiology laboratory, but not all AST results are reported back to the clinician; amoxicillin, trimethoprim/sulfamethoxazole, nitrofurantoin, fosfomycin and pivmecillinam can, for example, be the only antibiotics reported for susceptible strains isolated from urine samples in women [11]. Selective reporting can be performed in several ways: (i) encourage reporting of drugs appropriate for the infection site (e.g. no reporting of nitrofurantoin on blood isolates); (ii) encourage reporting of narrower-spectrum agents over broad-spectrum agents; (iii) discourage reporting of drugs inappropriate for the organism where susceptible results might be misleading (e.g. aminoglycosides for salmonellae); (iv) discourage reporting of drugs that might have negative consequences for patients of a certain age group (e.g. fluoroquinolones for children, nitrofurantoin for elderly); and (v) in certain situations where an antibiotic treatment is not indicated (e.g. asymptomatic bacteriuria, wound swabs or contaminated blood cultures), AST results may not be reported at all [12]. The most likely variables used to determine which antimicrobial agents to include in a selective report are: the identity of the organism; the infection site; patient age and sex; agents tested; and the susceptibility pattern of the isolate in that if mostly susceptible, fewer agents would be reported and vice versa. These can be addressed in software rules to automatically suppress certain results. In all cases, all results are made available to the clinician on request.
It has been shown that reporting results for only a restricted number of drugs tested (‘first-line drugs’ or ‘drugs of choice’) is associated with a decrease in the use of antibiotics for which results are not reported and, conversely, an increased in the use of agents that are reported [8], [9], [10], [13]. Similarly, some studies showed that the absence of AST reporting (e.g. for asymptomatic bacteriuria) was associated with a decrease in the use of antimicrobial agents [12]. Selective reporting could also ultimately have a positive impact on resistance rates owing to the induced changes in antibiotic use [13]. However, data on potential unintended consequences are scarce [7], [12].
Selective reporting of AST results appears to be common practice in some countries, particularly in Northern Europe [14], but to the best of our knowledge no large study has assessed how and to what extent this strategy is implemented. The aim of this cross-sectional survey was to evaluate how and to what extent selective reporting of AST results is implemented in Europe both in inpatient and outpatient settings and to identify the potential barriers to its implementation.
Section snippets
Setting and participants
An ESCMID (European Society of Clinical Microbiology and Infectious Diseases) cross-sectional, self-administered survey was performed. The questionnaire was addressed to all EUCIC (European Committee on Infection Control) or EUCAST (European Committee on Antimicrobial Susceptibility Testing) national representatives in Europe and Israel (38 countries in total). Each national representative was asked to recommend another colleague for the survey if s/he was unable to complete it. All national
Respondents' characteristics and attitudes towards selective reporting of antibiotic susceptibility test results
A total of 38 countries in Europe and Israel were eligible, of which 36 participated in the survey. Of the respondents, 11 were members of EUCIC and 13 of EUCAST, whereas 12 were an alternative contact appointed by the EUCIC/EUCAST national representative. Moreover, 21 national representatives replied also on behalf of 26 national societies (17 CM, 3 ID and 6 IC societies) in 21 countries.
One-half (18/36) of the respondents considered selective reporting to be very useful and another 39%
Discussion
This survey provides an overview of AST selective reporting practice and challenges in 36 countries in Europe and Israel. Although selective reporting has been shown to improve the quality of antibiotic prescriptions [8], [9], [10], [12], [14], [15], it was well implemented in only one-third of the participating countries. Nearly all respondents (34/36; 94%) perceived selective reporting as useful, but they also identified several barriers to implementation, which can explain its incomplete
Acknowledgments
The authors thank the following colleagues who also participated in this survey: Joerg Wuellenweber (Germany); Biljana Kakaraskoska Boceska (Macedonia); Graça Rocha (Portugal); Daniela Pițigoi, Anca Streinu-Cercel, Dragoș Florea and Adrian Streinu-Cercel (Romania); Antonio Oliver (Spain); and Eva Melander and Christian Giske (Sweden).
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The EUCIC-ESGAP-EUCAST Selective Reporting Working Group includes the following investigators who filled in the questionnaire for their country: Austria (Elisabeth Presterl); Azerbaijan (Akif Gurbanov); Belgium (Denis Piérard); Bosnia (Selma Uzunovic); Bulgaria (Rossitza Vatcheva-Dobrevska); Croatia (Arjana Tambic); Czech Republic (Helena Zemlickova); Denmark (Robert L. Skov); Estonia (Paul Naaber); Finland (Antti Hakanen); France (Vincent Jarlier); Germany (Sören Gatermann); Greece (Athanassios Tsakris); Hungary (Endre Ludwig); Iceland (Kristján Orri Helgason); Ireland (Kirsten Schaffer); Israel (Yehuda Carmeli); Italy (Mario Sarti); Kosovo (Lul Raka); Latvia (Arta Balode); Macedonia (Golubinka Bosevska); The Netherlands (Greetje A. Kampinga); Norway (Paul Christoffer Lindemann); Poland (Dorota Żabicka); Portugal (Valquíria Alves); Romania (Oana Săndulescu); Russia (Marina Sukhorukova); Serbia (Snezana Matic); Slovak Republic (Milan Niks); Slovenia (Iztok Štrumbelj); Spain (Luis Martínez-Martínez); Sweden (Annika Wistedt); Switzerland (Hugo Sax); Turkey (Deniz Gür); UK (Kathleen B. Bamford); and Ukraine (Viktor Liashko).