We need more than just new antibiotics to fight superbugs

By 2050, drug resistant diseases could be killing more people than cancer, an extra 10m deaths per year. They could also cause a loss to the global output of US$100 trillion dollars – equivalent to a sum greater than the size of the current global economy.

A potential future catastrophe in healthcare, where even routine surgical procedures and easily treated infections become significantly more hazardous, is commonly attributed to the appearance of new strains of antibiotic-resistant bacteria. It is often argued that the answer is more funding for the development of new antibiotics.

What is less commonly recognised is the possibility of a future catastrophe in food production. Modern practice means the extensive use of antibiotics in the farming of fish, poultry and meat. In the US, 70% of all antibiotics enter the food chain.

An arms race against natural selection

Antibiotics are effective against bacteria, just one class of microbe, while the term antimicrobial resistance (AMR) covers the development of resistance in a wider group of bacteria, fungi, viruses and protozoa (such as malaria) to the various measures used to combat them.

The development of new antimicrobial drugs is an arms race against natural selection that cannot be won: when antimicrobials (not just antibiotics) are applied, microbes of all types (not just bacteria) have proven to be adept at developing resistant strains from the survivors. If the drug kills 99.99% of a population of microbes, it is the genetic makeup of the survivors that goes forward to the next generation. To mitigate against potential catastrophes in healthcare and food production, measures over and above the development of new antibiotics have to be undertaken.

These include two key elements. One is infection prevention. If a dangerous microbe never enters the body, no antimicrobial is required. The development of new microbe-resistant materials and products, as well as the development of minimally invasive procedures in hospitals and clinics, improvements in waste disposal and a revolution in cleaning, are some of the measures already being researched.

However, this does not just involve scientists and clinicians. To take just one example, despite all efforts, many in the UK and the US persist in washing their hands lamentably short of the 20 seconds in warm soapy water that experts recommend. We need better leadership to rectify this by implementing advice from those who understand behaviours in workplaces and homes, and we need to invest in science and engineering that makes proper handwashing easy for the public to adopt.

The second element to reducing the use of antimicrobials is the removal of environments that encourage resistant strains to develop, for example in the body of the patient or farm animal, with simple measures such as ensuring a full prescription is taken rather than stopping early when symptoms disappear – a practice that encourages the survival of resistant microbes. Other measures include the invention of sensors to detect infection early and identify the specific microbe present, so that targeted antimicrobials can be used in place of broad-spectrum agents, one example of responsible antimicrobial stewardship.

We must understand how society, climate, land and water resources interact to alter the risk of microbes moving from one host to another. It is a realistic scenario that a resistant strain in a UK hospital might have emerged because of livestock practices half way across the world, where increased flooding, cultural practices, conflict, the movement of money and populations, and the accepted patterns of behaviour, create an environment very different to our own. Conversely, we could find that resistant strains in far-off countries might have their roots in the use of antibiotics in intensive farming in the UK.

The way to do it

The figure below illustrates how the problem extends geographically, and across the workforce and society. The patient in the hospital bed has a reduced risk of infection if the surgeons use a minimally invasive procedure illuminated with lights that deter microbes, and if the surgical instruments, the trays, the rooms, and the tubes that enter the patient (the catheters, nasal drips, endoscopes and so on) are made of materials on which microbes do not readily adhere, and are properly and promptly cleaned (weekend closure of sterile services departments might appear to save costs in the short term but must avoid allowing Friday’s contamination to dry on before washing on Monday).

The anti-resistance movement. University of Southampton., Author provided

For the patient shown in the figure, wounds can be cleaned and dressed with materials that deter microbes. If infection does occur, it can be promptly targeted with a specific (as opposed to broadspectrum) antimicrobial if it is detected early and rapidly identified (with instruments that feed into a communications hub that alerts the doctor’s phone, which is already becoming equipped with apps containing guidance informed by local susceptibility data).

Treatment of the waste from this patient (solid, fluids and materials contaminated with them) alters the possibility of AMR spreading. Achieving the right hospital environment requires far more than the development of new drugs, and their use by healthcare workers. It goes into the management and maintenance of the hospital, and in to the practices of the people who implement these. New technologies and practices must be designed to ensure that their use will be adopted, which requires understanding design and understanding people.

Indeed, the world outside of the hospital (in the lower half of the figure above) provides an enormous reservoir in which AMR can develop. Analysis and, if necessary, change of our processes and technologies are required in water and waste treatment, and in the production, transport, packaging and retail practices in the food industry.

In many parts of the world, climate change and flooding, war, corruption, politics, received wisdom, traditions and religious practices, and the supply of fuel and money, play a far greater role in food, water, waste treatment, healthcare and the transport of microbes from one host to another, than do the outputs of the drug companies.

The twin potential catastrophes are global, and so are the causes. The solutions lie with scientists and engineers to develop new technologies and embed new practices in the public and workforce; they lie with farmers, plumbers, office workers, water and sewage workers, medical practitioners, food retailers, innovators in business … indeed most of us. And they lie with those who are responsible for shaping behaviour across the world – not just the pharmaceutical companies.

Tim Leighton is Professor of Ultrasonics and Underwater Acoustics at University of Southampton.

This article was originally published on The Conversation.
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Getting doctors to reduce diagnostic testing is hard, but we should keep trying

Health-care resources are wasted when doctors overuse diagnostic tests. The tests may be redundant or inappropriate in the first place, and may also generate false-positive results, which prompt further needless investigation, or cause adverse effects.

Over the past decade, the use of pathology laboratory tests is thought to have increased by 5% to 10% each year. At the same time, requests for diagnostic imaging (radiology) investigations have increased by approximately 9% per year. These services now account for approximately 15% of all Medicare outlays.

It’s difficult to ascertain the proportion of diagnostic investigations that represents genuine overuse because of the problem of defining “appropriate” testing. But in hospital settings, as many as two-thirds of requests for some common pathology tests may be avoidable, because they’ve been shown to have no impact on diagnosis or management.

Still, the reasons for uncritical overuse of investigations are complex. They include inexperience, lack of awareness of the evidence base for using tests, lack of awareness of tests’ costs, patient requests, the practice of “defensive medicine” (investigating for unlikely alternative possibilities, primarily to minimise risk of later litigation), as well as various non-clinical factors such as geographical location.

In hospital settings, most test requests are submitted by junior medical officers. So there’s been support for strategies targeted at doctors in the early years of postgraduate training, which is recognised as a critical period. These have included restricting the range of tests junior doctors may request, an approach found to be effective in emergency departments.

More broadly, management systems with budgetary controls as well as online systems with decision support have also been promoted.

Education may have a valuable role to play. Several studies indicate that education, audit and feedback can be useful in limiting demand for diagnostic investigations.

In collaboration with the Royal College of Pathologists of Australasia, my colleagues and I have developed an open-access website to educate junior medical officers about the rational use of diagnostic investigations. Users interact with simulated cases and can request investigations as they attempt to establish a diagnosis.

As they progress through each case, they’re presented with a running tally of the costs of the tests sought. At the end, they receive feedback via comparison with what an expert senior doctor would have done.

In a trial at a large Sydney hospital, we demonstrated significant hospital-wide cost savings in the period immediately following active engagement of the cohort of junior doctors with this website. There was also an encouraging reduction in the number of blood samples collected from patients.

Unfortunately, in agreement with other studies of educational interventions, these changes in test-requesting behaviour were not sustained over the following months.

But there’s additional evidence that routine requests for diagnostic investigations can be reduced if junior doctors are provided with cost data at the time of submitting requests. Clearly, there’s a strong case for integrating this information into online systems used in hospitals, to provide reinforcement.

We have developed a version of this website for UNSW medical students. Together with other teaching activities and resources, this aims to influence the mindset of young doctors before they graduate. As others have pointed out, one of the goals of medical school education should be to encourage young doctors away from a shotgun approach and towards the critical use of investigations in diagnosis.

Another strategy to influence demand for imaging or laboratory tests is to educate patients to ask their doctors about whether particular tests are necessary or appropriate. The widely supported “Choosing Wisely” campaign, which was launched in Australia in late April, promotes such conversations between patients and providers.

Doctors may soon find themselves being asked five questions about the next test – or treatment, or procedure – they recommend to their patients!

Rakesh Kumar is Professor of Pathology at UNSW Australia.

This article was originally published on The Conversation.
Read the original article.

Detention whistleblowers with ‘legitimate’ concerns have nothing to fear – Dutton

Immigration Minister Peter Dutton has tried to hose down concerns doctors could face two years imprisonment for speaking out about shortcomings in the health care of detained asylum seekers under controversial new laws that came into effect on 1 July.

In a statement issued earlier today, Mr Dutton said the new Australian Border Force 2015 Act would “not restrict anyone’s ability to raise genuine concerns about conditions in detention, should they wish to do so through appropriate channels”.

Critics, including leading medical practitioners and barristers, have complained the laws, which threaten all detention centre staff – including health workers – with imprisonment for any unauthorised disclosure of information, target whistleblowers and will further deepen the secrecy surrounding the operation of immigration detention centres.

The AMA and other medical groups have called for an amendment to the law to explicitly protect health workers and allow them to advocate on behalf of their patients.

AMA President Professor Brian Owler said an Australian Human Rights Commission documenting cases of child sexual abuse at Australian-run detention centres demonstrated the need for greater transparency in their operation.

“One of the problems that we’ve got here is an issue of transparency. I think there are a lot of people, particularly doctors, that have been very concerned about the provision of health care.

“The standard of health care, particularly in offshore centres such as Nauru and Manus Island, is well below that we would expect on the mainland, and I think having some sort of independent health group as there used to be, indeed, to actually oversee that and provide some sort of transparency, that gives the Australian people the reassurance that we’re actually fulfilling at least the obligations of providing good health care to people that are in detention, is something that we really want to carry through.”

Dr Ai-Lene Chan, a GP who worked at the Nauru detention centre, together with colleagues Dr Peter Young and Dr David Isaacs, has warned that the new laws place doctors working in detention centres in an increasingly invidious position.

“The restrictions placed on doctors working in immigration detention results in health care that cannot be consistent with Australian codes and clinical standards,” the doctors said, noting that pathology tests frequently go missing, IT communications are regularly disrupted and the supply of medicines is underdeveloped.

The doctors warned that the Australian Border Force 2015 Act would only serve to compromise care even further.

It said the restrictions it put in place would fundamentally compromise vital aspects practice like sharing clinical information and research, and engaging in professional discussion.

“The Australian Border Force Act directly challenges professional codes of ethical conduct, including the safeguard of clinical independence and professional integrity from demands of third parties and governments,” they wrote. “The legislation aims to silence health professionals and others who advocate for their patients.”

But Mr Dutton said claims the Government wanted to gag whistleblowers with “legitimate” concerns were wrong.

“Any person who makes a public interest disclosure, as defined within the Public Interest Disclosure Act 2013, will not be subject to any criminal prosecution under the ABF Act,” the Minister said. “While the Government will take action to protect operationally sensitive information, such as personal information or information which compromises the operational effectiveness or response of our officers, the airing of general claims about conditions in immigration facilities will not breach the ABF Act.”

Mr Dutton said the Australian Border Force would investigate leaks of “operationally sensitive” information, but added “the public can be assured that it will not prevent people from speaking out about conditions in immigration detention facilities”.

Adrian Rollins

Whistleblower doctors face jail threat from today

Controversial laws under which doctors could face two years imprisonment for speaking out about shortcomings in the health care of detained asylum seekers come into effect today.

In a measure critics complain targets whistleblowers and will further deepen the secrecy surrounding the operation of immigration detention centres, the new Australian Border Force 2015 Act legislation, passed by Parliament in May, demands that all detention centre staff – including health workers – take an oath, and threatens two years imprisonment for any unauthorised disclosure of information.

Introducing the legislation, Immigration Minister Peter Dutton told Parliament the measure was necessary to “provide assurance to industry and our domestic and international law enforcement and intelligence partners that sensitive information provided to the Australian order Force and my department…will be appropriately protected”.

But the new legislation has fuelled concerns about a lack of scrutiny and accountability in the operation of immigration detention centres, particularly given the disbandment of the independent Immigration Health Advisory Group in late 2013.

Calls by the AMA and other medical groups for an amendment to the law to protect health workers and allow them to advocate on behalf of their patients have so far fallen on deaf ears.

The Government has also ignored suggestions that responsibility for the administration of asylum seeker health services be transferred to the Health Department, and that a body to provide independent oversight of care be reinstated.

Doctors warn the legislation contravenes clinical independence, which is a fundamental tenet of medical practice, by seeking to make medical practitioners and other health workers subject to the demands of the Government.

Dr Ai-Lene Chan, Dr Peter Young and Dr David Isaacs said the new laws placed doctors working in detention centres in an increasingly invidious position.

“The restrictions placed on doctors working in immigration detention results in health care that cannot be consistent with Australian codes and clinical standards,” they said, noting that pathology test frequently go missing, IT communications are regularly disrupted and the supply of medicines is underdeveloped.

The doctors warned that the Australian Border Force 2015 Act would only serve to compromise care even further.

It said the restrictions it put in place would fundamentally compromise vital aspects practice like sharing clinical information and research, and engaging in professional discussion.

The focus on the treatment of detained asylum seekers is intensifying amid allegations that some detainees, including children, have been sexually assaulted and physically abused.

AMA President Professor Brian Olwer earlier this year highlighted an Australian Human Rights Commission report documenting disturbing cases of sexually and physical assault on children in detention.

Professor Owler said the findings underlined the need to get children out of detention.

“Detention is not a safe place for children and this report clearly defines that by the number of assaults, including sexual assaults, unfortunately, that have happened to children, but also the effects on children’s health, particularly mental health,” he said at the time.

Professor Owler said the issue demonstrated the need for greater transparency in the operation of detention centres, rather than deeper secrecy.

“One of the problems that we’ve got here is an issue of transparency. I think there are a lot of people, particularly doctors, that have been very concerned about the provision of health care.

Adrian Rollins

[Case Report] Hypoplastic left heart in the 6500-year-old Detmold Child

Palaeopathology, the scientific study of ancient diseases, has evolved in recent decades into a modern scientific area and become part of medical research. Virtual autopsies, like those undertaken in modern forensic institutes, can be done on ancient mummies to examine injuries, genetic defects, acquired diseases, and determine sex.1

Inappropriate pathology ordering and pathology stewardship

To the Editor: We commend Spelman’s insightful discussion of the need for pathology stewardship.1

The Royal College of Pathologists of Australasia (RCPA) advocates a structured approach underpinned by national standards, aimed at minimising harm to patients as well as reducing laboratory and hospital costs. The College recommends hospital pathology stewardship programs with multidisciplinary input; harmonisation of testing and reporting; electronic decision support systems; educational strategies; and collection and analysis of national and state data.

Within this advocacy framework, the RCPA has led or collaborated on many projects relating to harmonisation, standardisation and structuring of reports, consumer benefits and risks, effective communication of results, point-of-care testing, quality of genetic testing (http://www.health.gov.au/internet/main/publishing.nsf/Content/pathology-qupp-index), and a free online educational tool for doctors (http://investigate.med.unsw.edu.au/home.jsf). The College advocates and advises on pathology rotations for junior doctors.

The RCPA Manual (http://www.rcpa.edu.au/Library/Practising-Pathology/RCPA-Manual/Home) provides decision support tools and comprehensive guidance on use and interpretation of pathology investigations.

While these initiatives will promote quality use of pathology, we stress that coordinated support from major national institutions is needed to effect real change.

[Comment] Spondyloarthropathy: interleukin 23 and disease modification

Prevention of progressive loss of normal articular structure and preservation of functional capability are central goals of therapeutic discovery in rheumatology. Despite the remarkably effective inhibition of structural damage in rheumatoid arthritis that was achieved with biological agents targeting tumour necrosis factor, and the ability to reduce signs and symptoms of disease in spondyloarthropathy with the same treatments, prevention of disease progression and bone pathology in seronegative spondyloarthropathies has been immensely challenging.

Statin-associated myotoxicity in an incarcerated Indigenous youth — the perfect storm

Clinical record

A previously healthy 18-year-old dark-skinned Indigenous man was incarcerated in a juvenile detention centre in New South Wales for 3.5 years from 2010 to 2013. Juvenile detention limits outdoor activity and, consequently, exposure to sunlight. Young people are confined indoors for schooling and other programs, with additional periods of cell lockdowns to accommodate detainee movements and staff handovers. Periods outdoors involve bursts of strenuous physical activity, mostly team sports or swimming. Further, detention centre policy requires young people to wear T-shirts and hats, and to use sun protection factor 30+ sunscreen when outdoors.

On entering custody, the patient’s weight was 65 kg, with a healthy body mass index (BMI) of 21 kg/m2 (reference interval [RI], 18.5–24.9 kg/m2). Full blood count, urea, electrolyte and creatinine levels and liver function test results were normal, and a blood-borne virus screen returned a negative result. He had a strong family history of type 2 diabetes in his mother and maternal grandmother, and, reportedly, of hypercholesterolaemia and early cardiovascular death in his father and paternal grandfather.

Seven months after incarceration, the man developed auditory and visual hallucinations and was noted to be withdrawn and depressed, with long periods spent resting in his cell owing to fatigue. He was commenced on the antipsychotic quetiapine 150 mg at night and the antidepressant fluoxetine 20 mg in the morning. At commencement of these medications, his weight was 89 kg (BMI, 29 kg/m2). Baseline pathology tests were not repeated at this time.

Six months after commencement of psychotropic medications, his weight had increased a further 25 kg to 114 kg and he was morbidly obese (BMI, 36 kg/m2), with phenotypes of metabolic syndrome including central obesity (waist circumference, 108 cm [RI, < 94 cm]), hyperlipidaemia (total cholesterol, 7.8 mmol/L [RI, < 5.5 mmol/L]; low-density lipoprotein cholesterol, 4.9 mmol/L [RI, < 4.0 mmol/L]; high-density lipoprotein cholesterol, 0.8 mmol/L [RI, > 1.0 mmol/L]), elevated triglyceride level (2.28 mmol/L [RI, < 2.0 mmol/L]), and fatty liver disease (γ-glutamyl transferase, 83 U/L [RI, 0–60 U/L]; alkaline phosphatase, 208 U/L [RI, 30–110 U/L]; alanine transaminase, 72 U/L [RI, 0–55 U/L]; aspartate transaminase, 46 U/L [RI, 0–45 U/L]) (Figure). Blood pressure and thyroid-stimulating hormone levels were within normal limits. With concerns about his obesity and metabolic derangements, quetiapine was ceased. He received counselling for dietary restriction (portion control, low saturated fat diet, reduction of energy-dense snacks) and, in particular, was encouraged to avoid the additional bread, butter and sugary drinks that are available to supplement meals. Increased physical activity was encouraged. An off-label trial of metformin was commenced, given the evidence for weight benefits in antipsychotic recipients,1 and increased to 1 g twice daily over the following 4 weeks.

Three months later, the patient’s fasting lipid levels remained similarly elevated despite lifestyle changes, and he agreed to trial atorvastatin 10 mg daily. He was also permitted to take recreational leave from the centre and commenced thrice-weekly training with the local football club.

Three weeks after commencing atorvastatin, the patient complained of worsening fatigue but denied having muscle tenderness, myalgia or cramping. Creatine kinase (CK) levels were normal at atorvastatin commencement, but had risen to 350 U/L (RI, < 170 U/L). Atorvastatin dosage was reduced to 5 mg in the morning, metformin was continued and fluoxetine was ceased.

Serial changes in the patient’s CK levels are shown in the Figure. Five weeks after atorvastatin commencement, lipid levels had improved but CK levels continued to rise and all medications were ceased. There were concerns regarding rhabdomyolysis, but urinalysis results, estimated glomerular filtration rate and renal function remained normal. His physical symptoms remained unchanged. The patient was encouraged to rest and drink plenty of water. He continued to play competition football. CK levels continued to rise, peaking at 3042 U/L.

Serum 25-hydroxyvitamin D levels were found to be low, and he was treated with cholecalciferol (vitamin D3) 1000 IU daily, increasing temporarily to 4000 IU daily after endocrinologist consultation. Serial CK and 25-hydroxyvitamin D levels showed slow improvement initially, with substantial improvements contemporaneous with aggressive vitamin D supplementation (Figure). The patient continued with lifestyle strategies and (in concert with cessation of psychotropic medications) lost 10 kg in weight, but lipid levels remained elevated. Fluoxetine was recommenced by the treating psychiatrist at 20 months because of concerns regarding the patient’s mood.

At the conclusion of his sentence, the patient was released from custody and referred to the local Aboriginal Medical Service for continuing management of his hypercholesterolaemia, myositis, and metabolic and mental health problems.

Indigenous Australians have a reduced life expectancy of up to 20 years compared with non-Indigenous Australians and, by 40 years of age, are 10 times more likely to suffer premature cardiac-related death.2 In recognition of this, the Indigenous Chronic Disease Package (through Closing the Gap initiatives) encourages the use of statins, recommending treatment at lower lipid thresholds.3

There is evidence that Indigenous populations may be at higher risk of statin-related myopathy owing to a higher risk of vitamin D deficiency,4 higher rates of human T-cell lymphotropic virus type 1 infections causing polymyositis5 and, possibly, genetic susceptibility to statin-associated myotoxic effects (the SLCO1B1 gene prevalent in other indigenous populations6). Other risk factors predisposing our patient to statin-related myopathy were his age, strenuous exercise, mild hepatic dysfunction and concomitant use of fluoxetine (a CYP3A4 inhibitor).4,7,8 As CK elevation persisted after atorvastatin cessation, the differential diagnosis was necrotising autoimmune myopathy, previously described in indigenous patients with persistent myopathy.9 The recommencement of fluoxetine at 20 months may also have perpetuated the elevated CK level.

Almost 12 000 people are incarcerated in NSW, with a quarter being Indigenous Australians and at greatest risk of vitamin D deficiency.10 This is the first report of statin-related myopathy in an Indigenous adolescent or an incarcerated person. It is worth noting by other clinicians who work with Indigenous and incarcerated groups that the risk factors for this patient’s “perfect storm” were not unusual — metabolic syndrome, vitamin D deficiency, and use of statins in the context of mental illness and concomitant psychotropic medication use.1,2

This report highlights the need for monitoring of vitamin D levels and supplementation (with an argument for easier access to injectable vitamin D in this group), with pre-statin counselling, particularly for those at high risk of statin-related myopathy — Indigenous Australians, youths, females, and those serving lengthy custodial sentences.

This case also highlights the detrimental effects of antipsychotics on weight and metabolic risk. An international declaration supporting young people with psychosis11 has delineated the obligations of health care providers to prevent weight gain and metabolic complications that contribute to the 25-year shortfall in life expectancy in people with severe mental illness.

In addition to these learning points, there are the obvious problems of the unmet health needs and human tragedy in this vulnerable patient group: a baseline high metabolic risk associated with Aboriginality and family medical history, the constraints of incarceration exacerbating the risk of vitamin D deficiency, and a doubling of weight resulting in rapid-onset obesity secondary to antipsychotic use. Co-prescription of lifestyle interventions at the time of commencing antipsychotic therapy is essential. In addition, metformin has proven efficacy in abrogating weight gain following antipsychotic commencement, with its use encouraged in patients who make clinically significant weight gains.1

Lessons from practice

Indigenous Australians, young people and those serving lengthy custodial sentences are at risk of low vitamin D levels and statin-associated myopathy.
Aggressive vitamin D supplementation may be required to normalise levels before commencing statin therapy.
For all people receiving antipsychotics, lifestyle intervention should be co-prescribed, and weight gain should be monitored and actively prevented.
Metformin has proven benefit for weight loss in patients who significantly gain weight on antipsychotic treatment.

Creatine kinase (CK) and other markers according to time and medications.

An incidentaloma not to be missed

A frail 92-year-old woman presented with pelvic and femoral fragility fractures after a fall. She had synchronous gross abdominal distension which was diagnosed as ascites. Computed tomography was requested to exclude malignancy before performing paracentesis.

Formal imaging showed a large intraperitoneal structure. The 4-Hounsfield unit attenuation was consistent with simple fluid. However, identification of septations, together with rim enhancement, led to a revised diagnosis of a cystic mass. The lesion measured 24 cm × 28 cm × 33 cm and, at an estimated volume of 16 L, displaced most of the abdominal and pelvic viscera. Fortunately, this was recognised before paracentesis.

Inappropriate pathology ordering and pathology stewardship

An effective system of stewardship is needed to optimise the use of pathology tests

Many hospital clinical pathology laboratories presently experience annual increases in workload of 5%–10%.1 Such increases in demand are often not accompanied by concomitant increases in laboratory resources. This environment presents a significant challenge to laboratories that have no control over test-ordering patterns. Compounding this situation is the fact that many pathology tests are inappropriate or unnecessary, as they have no impact on patient care. The extent of inappropriate pathology test ordering in Australia is unknown, but a United Kingdom report on National Health Service pathology services estimated that 25% of all requests were unnecessary or inappropriate.2 Such tests are ordered for a variety of reasons, often in the belief that more testing equates to better patient care. Unfortunately, this is not always the case, and in some circumstances the opposite may be true.

Ozbug3 is a well established closed and moderated email list largely but not solely restricted to members of the Australasian Society for Infectious Diseases, predominantly comprising Australian and New Zealand infectious diseases physicians but also including registrars, medical microbiologists and infection prevention practitioners. There are about 800 subscribers, who discuss a broad range of topics. I asked the following question on Ozbug: “What microbiology laboratory investigation would you consider to be the one, although requested, results in least patient benefit? or What do you consider to be the most useless of microbiology tests?” The unexpectedly large number of responses (140) to this question and the ensuing rich discussion are the stimuli for this article.

My aim here is to discuss and attempt to understand inappropriate or unnecessary pathology testing, to define the drivers for and impact of such testing, and to suggest interventions to improve the use of pathology services. I will focus on hospital pathology services and provide specific examples from my discipline of microbiology.

Inappropriate pathology test ordering

Tests that are ordered but the results of which are never viewed by the clinician are of no use to the management of the specific patient. Duplicate tests or tests performed before initial testing results are available are unnecessary. Similarly useless tests include those that, no matter what the result, will not impact on patient care. Some serological diagnoses require collection of initial and convalescent sera. In many such circumstances, only a single sample is obtained and this is of no use. Many of the serological tests undertaken for the investigation of fatigue have a low likelihood of a useful result and may give the patient false hope of a result that will lead to a definitive diagnosis and effective therapeutic intervention. A serology test should only be performed when the clinical illness and epidemiology support that diagnosis. Otherwise a false-positive result may complicate patient management. These last two points are exemplified by Lyme disease serology, which is often performed in a setting of vague, non-specific symptoms in a patient who has never visited a known endemic region or country.

For bacterial culture, a dry swab in a specimen jar is unlikely to be useful. A midstream urine specimen that has a normal urinalysis result is most unlikely to identify a pathogen. A recent trend is to swab environmental services or inanimate objects for resistant organisms. This often occurs in the absence of epidemiological evidence to support such a link, and such swabbing should be resisted.

Generally, microbiology tests for clearance, such as repeat throat and nose swabs for respiratory viruses and repeat stool tests for Clostridium difficile, are unnecessary or not recommended.

Other common individual tests suggested by Ozbug correspondents as inappropriate or unnecessary are included in Box 1. Ozbug correspondents acknowledge that for many of the tests mentioned, it is not the test itself that is under scrutiny but the use of that test, and also that these tests may be useful in specific circumstances or jurisdictions. Laboratories also have the responsibility to offer tests that have been validated for the purpose for which they are offered.

Factors contributing to inappropriate pathology ordering

The prime reason for ordering pathology testing is to optimise patient diagnosis and management. Most practitioners agree on the importance of prudent use of pathology services. However, there may be other less apparent drivers for suboptimal pathology test ordering. Such testing may be tied to the patient’s or the family’s expectations rather than to an actual need for such testing. The physician’s anxiety or fear of missing a diagnosis may generate the feeling that something needs to be done, leading to overinvestigation without a clear rationale for that testing. Junior doctors may order according to peer perception or because they are concerned that their consultant may criticise them if the test has not been requested. In some circumstances when a doctor is time pressured, ordering pathology tests may be an easier course than the timely consideration of management options.

Other less than ideal reasons to order pathology tests include: “wouldn’t it be nice to know”, “I cannot find (or have not looked for) the previous result”, “I may want to publish the case in the future” and “I do not believe the result from the first laboratory and I want to send it to a second laboratory”. Some individual factors contributing to suboptimal testing, suggested by Ozbug correspondents, are summarised in Box 2.

Pathology laboratories may also contribute to the number of inappropriate tests. New technology with new testing menus may be introduced before there is evidence that such developments have a favourable impact on patient outcomes.4

Risks of inappropriate pathology ordering

Some tests are not only unnecessary but may be misleading or even harmful. The receipt and subsequent processing of saliva when sputum is ordered may identify transient oral colonising bacteria such as Streptococcus pneumoniae or methicillin-resistant Staphylococcus aureus. This may do a patient harm if the organism is then assumed to be the aetiological cause of the pneumonia, targeted treatment is given and the real cause of pneumonia is overlooked.

When inappropriate or unnecessary tests are ordered, there is a risk of a false-positive result, leading to further unnecessary testing, other investigations and even unnecessary treatments with attendant adverse effects. Ober has described this cascade effect, highlighting that a “normal range” typically includes 95% of all normal subjects, with up to 5% of normal subjects given an abnormal result.5 With modern multichannel analysers, more often used in other pathology disciplines, the chance of a false-positive result is further increased.

Inappropriate pathology testing consumes laboratory resources, both budgetary and labour. This may, especially in more manual disciplines such as microbiology, lead to delays in processing and increase the turnaround time for specimens from the patients in greatest need.

Strategies to improve pathology test ordering

There has been much discussion among the Ozbug group concerning possible strategies to improve microbiology test ordering. Individual strategies suggested by Ozbug correspondents are shown in Box 3. There are a limited number of studies documenting the impact of a strategy targeting a specific test with a decrease in the ordering of that test during the period of observation.6 However, such interventions generally do not tackle the breadth of pathology testing, and the long-term sustainability of such interventions is questionable.

Overall, the Ozbug discussions emphasise the need for an ongoing system of stewardship to ensure the optimal use of pathology resources. To be effective, a system needs to be developed together with all the major stakeholders, have a strong and iterative educational component, be evidence-based, include a system of regular audit with feedback, and especially target those tests that are high cost, resource expensive and frequently used inappropriately. Orders from clinicians should be considered requests for testing as well as for specialist pathologist input. Within my own discipline, the clinical microbiologist should take an active lead in decisions about testing menus and indications, specimen acceptability and acceptance, testing quality, and test interpretation.

Just as antimicrobial stewardship has now become a national standard for hospital accreditation, a system of pathology stewardship would optimise the use of pathology resources. This is not a new concept. In 1922, Peabody wrote:

Good medicine does not consist in the indiscriminate application of laboratory examinations to a patient, but rather in having so clear a comprehension of the probabilities and possibilities of a case as to know what tests may be expected to give information of value.7

1 Ozbug correspondents’ examples of inappropriate microbiology test ordering*

Most extra tests performed on cerebrospinal fluid when no abnormalities were found on microscopy
Routine cultures of vascular catheters
Vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus surveillance cultures in unquarantined patients
Parasites in stools in hospitalised patients
Surveillance blood cultures in asymptomatic patients
Streptococcal, herpes, typhoid fever (eg, Widal test) and Lyme disease serology
Legionella and pneumococcal urinary antigens in patients with normal chest x-ray results
Repeated bacterial surveillance cultures of endoscopy equipment

* Note: In some specific circumstances these tests may be appropriate.

2 Ozbug correspondents’ reports of potential factors contributing to inappropriate test ordering

Suboptimal teaching of undergraduates and graduates
Pressure of work for both clinicians and pathologists
Lack of pathologist input for test menu development and specimen suitability information
Clinicians’ poor understanding of test reliability and validity
Clinicians’ lack of knowledge and concern about pathology costs
Ease of ordering tests electronically or using prestamped request slips
Income generation of some pathology testing
Acceptance of public pathology as a learning environment that encourages more pathology
Fear of litigation

3 Strategies suggested by Ozbug correspondents to improve microbiology test ordering

Enhanced education of medical students and graduates
Pathology ordering audit and feedback
Increased collaboration and engagement with clinicians
Development of rejection rules such as minimum retest intervals
Display of costs of pathology tests with pathology results
Standardisation of investigations for specific clinical syndromes
Development and promulgation of golden rules regarding pathology testing
Pathology rotations for junior medical staff
Prevention of duplicate testing