Tuesday, February 6, 2018

Diagnostic Test Stewardship! (Cautiously) En Vogue!

Diagnostic test stewardship is en vogue at the moment.  

This excellent article, co-authored by my 60 miles-west-of-Richmond, University of Virginia academic- hospital-neighbor, Dr. Costi Sifri, is a nice summary of opportunities and challenges to safely reduce unnecessary diagnostic infectious diseases testing. 

I mentioned this topic in a previous blog. Dr. Dan Diekema just published a nice commentary on the HAI Controversies Blog.

Many of our new diagnostic tests (PCR based) are very sensitive and cannot discern between active disease vs colonization.  Coupled with pragmatic surveillance definitions set forth by the CDC, we over diagnose catheter associated urinary tract infections and bloodstream infections, hospital onset C. difficile and ventilator associated pneumonia anywhere from 15%-68% (as referenced in the article above).

I enthusiastically agree, we need to critically assess how tests are ordered so as to minimize overdiagnosis and minimize potential harms. If we do this thoughtfully, with appropriate oversight and ongoing critical assessment, this could have a huge impact (on cost and safety).

However, we want to avoid prior missteps from over enthusiasm, like MRSA active detection and isolation, which was all the rage (for some) about 10 years ago. Now we are learning that contact precautions for the control of endemic MRSA may not be infection prevention salvation, as explored here.

Times and perspectives change.

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