Diagnostic challenges in

sepsis

Slides prepared by Dr Parikshit Prayag

 Timeline / when has it
Prior antibiotic therapy
been sent in the course of
the infection

Factors affecting the yield of blood cultures

Causative organisms are Collection methods

known to grow poorly
Ref: Rand KH, Beal SG, Rivera K, Allen B, Payton T, Lipori GP. Hourly Effect of Pretreatment With IV Antibiotics on Blood Culture
Positivity Rate in Emergency Department Patients. Open Forum Infect Dis. 2019 May
Challenges with antimicrobial susceptibility testing for bacteria :

❏ Colistin
❏ Fosfomycin
❏ Other agents

Challenges with antifungal susceptibility testing:

❏ Which method are we using
❏ Availability
❏ Cost
Based on the results of this study, we advise laboratories not to trust gradient tests for colistin
susceptibility testing and to use broth microdilution methods for this purpose.
However BMD is challenging:

❏ No FDA approved commercial AST (cAST) for polymyxin testing.

❏ Heterogenous formulation, binding of polymyxins to the

microtiter plates - variability in susceptibility testing.

❏ Polymyxin binding to plastic surface is saturable, effect is more

apparent at MIC of ≤ 2 μg/mL

❏ Difficult to get an accurate amount of polymyxins into a series of

dilution, which causes skip-well effect in BMD.
Ref: Is it time to move away from polymyxins?: evidence and alternatives, Rajeev Soman, Balaji Veeraraghavan et al, August 2020
Determining fosfomycin MICs
Ref:
Wouter van den Bijllaardt et al. Susceptibility of ESBL Escherichia coli and Klebsiella pneumoniae to fosfomycin and comparison of several
testing methods including Etest, MIC test strip, Vitek 2, Phoenix and disc diffusion, Journal of Antimicrobial Chemotherapy, September
2018
 Blood culture flagged positive

Knowing the bug Knowing the resistance pattern l

How to save time ?

● Molecular diagnostics to detect the bug and resistance patterns

● Syndromic panels

● Genomic Sequencing

● Biomarkers
● Molecular diagnostics to detect the bug and resistance patterns

● Syndromic panels

● Genomic Sequencing

● Biomarkers
MALDI TOF:

❏ Utility

❏ Advantages

❏ Disadvantages
Methods to detect the enzymes:

● Carba R test

● Sepsis flow panel - used in house in Deenanath Mangeshkar Hospital

● Biofire panel

● BD CPO panel
Xpert CARBA R Test
Xpert CARBA R Test
Master Diagnostica Sepsis Flow panel -
Used in Deenanath Mangeshkar
Hospital
BIOFIRE BCID II PANEL
 Xpert Carba R BCID/BCID 2 Sepsis flow

Company Cepheid BioMerieux Vitro Master diagnostica

Test principle Multiplex PCR Multiplex PCR Multiplex PCR with hybridization

Special equipment GeneXpert instrument BioFire Filmarray Hybrid spot platform

Organism ID No Yes Yes – 20 organisms

Resistance markers Oxa-48, KPC, NDM Imp, KPC, Oxa-48, NDM, CTX,SHV,SME,KPC,IMI,GES,IMP,GIM,VIM,SPM,SIM,ND
VIM, Some Imp variants VIM, CTX-M, mcr-1 M, OXA 23,OXA24,OXA-28,OXA-51,OXA-
(IMP-1) 58,mecA,vanA/B

Sample type Bacterial colonies, rectal Positive blood culture Positive blood culture broth
swabs broth

Limitation Does not detect other Does not detected Technically semi complex
common/Carbapenemases common Oxacillinases
Oxa-23, Oxa-51, Oxa-58/ IMI, like Oxa-23, Oxa-51,58
GES
● Molecular diagnostics to detect the bug and resistance patterns

● Syndromic panels

● Genomic Sequencing

● Biomarkers
Syndromic panels:
Syndromic panels:

❏ PCR based assays for simultaneous identification of multiple pathogens

❏ Timely decisions on initiation of antibiotic treatment, admission, isolation, IC measures.

❏ Complex results - Interpretation in light of clinical setting.

❏ Expensive

❏ Positive results may not distinguish between active infection, colonization or persistent

shedders
● Molecular diagnostics to detect the bug and resistance patterns

● Syndromic panels

● Genomic Sequencing

● Biomarkers
● CARBA R
● Sepsis Flow
● BCID Biofire
● Molecular diagnostics to detect the bug and resistance patterns

● Syndromic panels

● Genomic Sequencing

● Biomarkers
Study Design Findings / Remarks

ProHOSP study In the positive PCT patients, serial PCT ● Less antibiotic usage in the
(Patients with measurements made, antibiotic cessation procal group
lower resp tract encouraged when > 80 % decrease in the PCT
infections)

PRORATA trial Initial PCT to guide decisions regarding initiating ● Algorithm overruled in 53% of
(patients in the antibiotics; assessing the trends of PCT to help the cases
ICU) decide when to stop antibiotics ● Slightly higher mortality in the
procal group

SAPS study: Sole intervention: advice to discontinue ● Usage of antibiotic and

Dutch experience antibiotics if PCT has decreased by more than mortality lower in the procal
80% of its peak level or below 0.5 ng/ml group
 PROCAL PEARLS

● Median levels higher in bacterial infections compared with fungal infections

● Gram -ve infections are associated with higher values
● Best evidence for the use of procalcitonin is in respiratory tract infections where it
can be used to guide decisions regarding antimicrobial therapy
● In critically ill patients it is difficult to use the initial procalcitonin values to initiate
antibiotics, as the sensitivity is imperfect
● In critically ill patients, procalcitonin trends can be used to make decisions regarding
limiting the duration of therapy
● Non infectious causes of procalcitonin must be considered
● For PCT - always consider the site of infection
Beta D glucan:
·

What is BDG? Which fungi contain BDG?

❏ Positive results days prior to culture positivity, onset of clinical symptoms or radiologic
signs.
❏ Serial testing useful
❏ High NPV - candida / aspergillus / PCP
❏ Poor specificity, false positive results due to multiple causes common in ICU setting
Summary:

❏ Know the clinical utility of markers

❏ Rapid syndromic panels are fast emerging - the end user is more important

than the panel

❏ Resistance testing has to be amplified

❏ Newer modalities will continue to revolutionize sepsis diagnosis

Thank you