THE ROLE OF DIAGNOSTICS IN THE

ANTIMICROBIAL RESISTANCE RESPONSE

LONDON SCHOOL OF
HYGIENE & TROPICAL MEDICINE

WEEK 1 INTRODUCTION TO THE ROLE OF DIAGNOSTICS IN THE RESPONSE TO

AMR
STEP 1.12 ROLE OF DIAGNOSTICS IN THE AMR RESPONSE - SCREENING

ANDREW WHITELAW: Probably one of the first questions people have is what,
is a screening test, and how does it differ from other diagnostic tests we use?
If we think of when you're using a laboratory test, the typical scenario is a
patient arrives in your practice or whether you're working, and they have
certain a constellation of symptoms and signs. The doctor makes a provisional
diagnosis based on their symptoms and signs. And they will usually send a
laboratory test to either confirm or exclude the likely diagnoses. So this is
based on an individual patient and trying to support or refute a particular
diagnosis.

The laboratory test results may also be used to decide on patient appropriate
management, to give information about prognosis-- how sick the patient is, the
chance of recovery and so on. When we're talking about a screening test, the
screening test is a test that's applied very often to patients who don't have
obvious signs of disease. And it can be used either to pick up early disease, as
you do for screening for certain cancers or for diabetes, for example. In the
context of anti-microbial resistance, we typically talk about screening tests
being used to detect the presence of particular resistant organisms in patients
who may not actually have infection.

So one of the big differences is that a diagnostic microbiological test will be

sent looking for a range of pathogens. A patient arrives with a cough and a
fever, for example. And you send a sputum to find out which organism is
causing that cough and fever. A screening test would be a patient arriving at a
hospital where they are at risk of having a particular resistant organism. You'll
send a specimen looking for one specific organism and one specific resistance
or a limited number of resistant mechanisms. So you're screening otherwise
healthy patients. And for antimicrobial resistance, the screening is normally
done to change infection control practises rather than to manage that
individual patient.

How do we do screening? What methods can be used for screening tests?

Broadly speaking, microbiological screening can be done using other culture or

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molecular tests. For culture, we would take the specimen that sent, inoculate it
onto media, and see if we can grow the particular organism or the resistant
organism. For molecular testing, we'd look using DNA based techniques, such
as polymerase chain reaction, PCR, to see if we can pick up the particular
resistance gene of interest. And that is in a nutshell molecular or culture based
screening.

When do we use screening cultures? This is a very difficult question to answer,

because there's no one size fits all approach. And I will touch on this in later
sections of this course. But in principle, you would use screening cultures for
AMR in patients who are at risk of carrying a resistant organism. So if they've
been exposed to the hospital environment where you know a particular
resistant organism is common and they're coming to a new hospital, you may
want to screen them to see if they are carrying that particular organism.

A very important point to remember about the screening test is if you are
doing a screening test on a patient, you need to have some justification for
why you are doing a screening test. Random screening on every second patient
coming in is meaningless. So you need to identify the population you want to
screen. And you need to identify what you're going to do with that screening
result. We've been in a situation before we screened patients and staff
members for carriage of a particular resistant organism, we got a positive
result, and we thought, now what? Think about the 'now what' before you start
the screening.

So if you're able to isolate the patient or put them in some sort of protective
area where they're unlikely to transmit the organism, that's great. If you want
to do the screening just to find out the burden of resistance in your settings so
that you can inform policy, that's great. But know why you're doing a screening
and what you're going to do with results before you embark on a screening
programme.

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