w w w . e l s e v i e r . c o m / l o c a t e / b j i d
The
Brazilian
Journal
of
INFECTIOUS
DISEASES
Original
article
Top
10
evidence-based
recommendations
from
the
Brazilian
Society
of
Infectious
Diseases
for
the
Choosing
Wisely
Project
Alessandro
C.
Pasqualotto
a,b,∗,
Camila
S.
Almeida
c,
Dimas
A.
Kliemann
d,
Guilherme
B.
Barcellos
e,f,
Flávio
Queiroz-Telles
g,
Edson
Abdala
h,
Mariangela
Resende
i,
Filipe
P.
Batista
j,
José
E.
Vidal
k,
Jaime
Rocha
l,
Sonia
M.
Raboni
g,
Sergio
Cimerman
k,
Ana
C.
Gales
maUniversidadeFederaldeCiênciasdaSaudedePortoAlegre,PortoAlegre,RS,Brazil bSantaCasadeMisericórdiadePortoAlegre,PortoAlegre,RS,Brazil
cUniversidadedeCaxiasdeSul,CaxiasdoSul,RS,Brazil dHospitalNossaSenhoradaConceic¸ão,PortoAlegre,RS,Brazil eHospitaldeClinicasdePortoAlegre,PortoAlegre,RS,Brazil fChoosingWisely,Brazil
gUniversidadeFederaldoParaná,PR,Curitiba,Brazil hUniversidadedeSãoPaulo,SãoPaulo,SP,Brazil
iUniversidadeEstadualdeCampinas,Campinas,SP,Brazil
jHospitalUniversitárioOswaldoCruz,UniversidadedePernambuco,Recife,PE,Brazil kInstitutodeInfectologiaEmilioRibas,SãoPaulo,SP,Brazil
lPontifíciaUniversidadeCatólicadoParaná,PR,Curitiba,Brazil mUniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazil
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t
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Articlehistory:
Received26July2019 Accepted16August2019
Availableonline25September2019
Keywords: Choosingwisely Quality Safety Infectiousdiseases Microbiology Diagnostictests Healthcareadministration
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TheChoosingWiselyInitiativeaimstocollectstatementsfrommedicalsocietiesallover theworldonmedicalinterventionsthatresultinnobenefittopatients,withthepotential tocauseharm.InthisarticlewepresenttheviewsoftheDiagnosticLaboratoryGroupat theBrazilianSocietyofInfectiousDiseases(SBI).TenexpertsfromSBIwereaskedtolist 10diagnosticteststhatwereperceivedasunnecessaryinthefieldofinfectiousdiseases. Aftervotingforthemorerelevanttopics,a questionnairewassenttoall SBImembers, inordertoselectforthemostimportantitems.Atotalof482voteswereobtained,and thetop10resultsareshowninthismanuscript.TheChoosingWiselystatementsofSBI shouldfacilitateclinicalpracticebyoptimizingtheuseofdiagnosticresourcesinthefield ofinfectiousdiseases.
©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
∗ Correspondingauthorat:MolecularBiologyLaboratory,heliponto,HospitalDomVicenteScherer,SantaCasadeMisericordiadePorto
Alegre.AvIndependencia,155,PortoAlegre,90020-090,Brazil. E-mailaddress:Pasqualotto@santacasa.org.br(A.C.Pasqualotto). https://doi.org/10.1016/j.bjid.2019.08.004
1413-8670/©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Overuseoflow-valueorunnecessaryhealthcareresourcesisa globalproblem,andagrowingbodyofevidencedemonstrates its prevalence and harms.1 Choosing Wisely Initiative is a front-line healthcareprofessional-led campaign to address overuse2,3 associatedwithnegativeimpactonpatientsafety and increased health care costs without proven benefits. The campaign first started in the United States in 2012 and was led by the American Board of Internal Medicine (ABIM) Foundation. With partnersincluding national med-ical societies, hospitals and universities, the campaign is now active in more than 20 countries (https://www. commonwealthfund.org/series/choosing-wisely). Differ-ent groups have joined the campaign byreleasing lists of evidence-based recommendations of tests, treatments, and procedures that are overused, clinically unnec-essary, and/or with the potencial for causing harm. After the lists are created, a debate is usually started involving healthcare professional and the lay commu-nity.
ChoosingWiselyBrazilemergedin2015andhasnow10 nationalmedicalsocietiesrecognizedbytheBrazilianMedical Association (AMB)that released recommendations,besides five hospitals and the Bahia School ofMedicine and Pub-lic Health. This article aims to summarize the list of the top 10 recommendations developed by the Brazilian Soci-ety of Infectious Diseases (SBI) for the Choosing Wisely project.
Methods
Agroupof10 infectiousdiseases physicians,leaded bythe chairoftheDiagnosticLaboratoryGroupatSBI(Pasqualotto AC),were invitedtoparticipateinthisproject. Inaddition, the group also consisted of the SBI president (Cimerman S),arepresentativeofChoosingWiselyBrazil(BarcellosGB), and an undergraduate medical student (Almeida CS). The group was informed about the principles of the Choos-ing Wisely projectand invited tosubmit 10 topics each of laboratory-relatedtopicsthatcouldfitintheChoosingWisely project.Thenextstepinvolvedadiscussionwiththesteering group,fortheselectionofthe10mostrelevant recommen-dations based on current strength of evidence from each item. Afterwards, this list wassubmitted topublic consul-tation. Based on a 95% confidence interval and an alpha levelof5%,asampleof292participantswouldbenecessary. Members ofSBIreceivedalinkfrom anonline surveytool “SurveyMonkey” website through e-mail and “WhatsApp”. Theywere asked toselect,amongthese10 topics,the five mostrelevantones.Thesurveylinkwasalsopublishedon the“SBIFacebook’spage”.Thetop-5recommendationswere publishedinPortugueseintheChoosingWiselyBrazil web-site.
TheChoosing Wisely manuscript list ofthe top-10 rec-ommendationsbySBIwereorganizedbasedonthenumber ofvotesreceived,from the mostrelevanttotheless voted items.
Results
A total of 106 recommendations were received from the steering committeegroup.Amongthesequestions,32 were selectedafterexcludingredundantandnon-appropriate top-ics. The group voted for the 10 most relevant questions. These questions were sent forvoting toaround 1600 indi-viduals via Facebook, WhatsApp and e-mail. These people includedSBImembersandthegeneralmedicalcommunity. Thetotalnumberofrespondersreached482physicians,and thelistoftopicsorderedbythenumberofvotesispresented below. Asummary of theserecommendations isshown in Table1.
1 Donotuseswabculturesformicrobiologicaldiagnosisof ulcers.
(67.8%ofvotes;n=327)
Theuseofmicrobiologyswabsforculturingulceratedskin diseasescommonlyreflectscontaminationwithskin micro-biota.Furthermore,the superficialswabsdonotreflectthe microbiologyofthedeepertissue,andsotheseculturesthat donotcorrelatewiththepathogenicbacteriainvolvedwith thedisease.4,5Swabsamplingmayprovidemisleadingresults; therefore,werecommendusingtissuebiopsytoconfirmthe diagnosis of infected ulcers since it is unlike to represent superficialcontamination.4,6,7
2 Do not order urine cultures for asymptomatic patients, exceptforpregnantwomenandpatientsundergoing uro-logicalsurgery.
(65.1%ofvotes;n=314)
Urinarygrowthofbacteriaiscommonlyseenin asymp-tomatic patients and its prevalence varies with age, sex, and the presence of genitourinary abnormalities. Asymp-tomatic bacteriuria is generally present in 3–5% of young women and diabetic patients, and its frequency may increase up to 18% inthe elderly population.8,9 Due to its high frequency ofoccurrence, screening for asymptomatic bacteriuria is not recommended, except in cases when adverse outcomes can beprevented by antimicrobial ther-apy – e.g., in pregnancy and before urological surgery. In pregnancy, screening and treatment reduce the incidence of pyelonephritis, preterm delivery, and low birth weight whereas inpre-operativeurological context,screening and treatment decreases the rates of postoperative fever and sepsis.10–12
3 Donotusetreponemaltestsinthefollow-upofpatients treatedforsyphilis.
(64.7%ofvotes;n=312)
Therearetwotypesofserologicaltesttodiagnosesyphilis: non-treponemal (NNT) and treponemal tests (TT).13 Both typesoftestarerequiredtoconfirmadiagnosisofsyphilis.14 TT,suchastheFTA-Abs,aremorespecific,sincetheydetect
T.pallidumantigens.Therefore,theyareusedtoconfirmthe diagnosis ofsyphilisinpatients withpositiveNTT, as well
Table1–SummaryoftheBrazilianSocietyofInfectiousDiseasesrecommendationsfortheChoosingWiselyInitiative.
Condition Recommendation Reason
Ulceratedskin
infection
Swabsamplingshouldnotbeusedfordetermine
microbiologicaletiology
Swabsamplingusuallyrepresentcontamination
fromskinmicrobiota
Urinarytract
infection
Donotordinarilyorderurineculturesfor
asymptomaticpatients
Urinarygrowthofbacteriaiscommonlyseenin
asymptomaticpatients
Syphilis Donotusetreponemaltestsinthefollow-upof
patientstreatedforsyphilis
Treponemaltestsmayremainpositiveduring
lifetimeaftersyphilisistreated
Toxoplasmosis Donotrepeatanti-ToxoplasmaIgGantibodytestsin
patientsknowntobeIgGpositive
IgGantibodiesagainstToxoplasmaremainpositive
duringlifeinpatientswithpreviousIgGtests
Herpessimplex
infection
Donotuseantibodydetectiontodiagnoseorscreen
forherpessimplexinfection
Thedetectionofanti-herpessimplexantibodiesis
oflimitedclinicaluse,mainlyduetothehigh
seroprevalenceofsuchinfections
Clostridiumdifficile
infection
DonottestforClostridiumdifficileinpatientswithout diarrhea
ManypatientsaresimplycolonizedbyC.difficile
HIVinfection DonotroutinelyrepeatCD4measurementsin
patientswithprolongedviralloadsuppression
CD4monitoringoffersnoclinicalbenefitinpatients
whohavesuppressesviralloadsandCD4counts
>300cells/mm3after48weeks
HepatitisCvirus
(HCV)infection
DonotmeasureHCVviralloadformonitoring
patientswhohavereachedsustainedvirologic
responsefollowingtreatment
HCVviralmonitoringhasreducedimportance
nowadayssincenoveltherapiesoffersimilar
antiviralpotency,regardlessofbaselineviralload
Leishmaniasis Donotuseserologicaltestsasthesolebasisto
diagnoseleishmaniasis
Asymptomaticindividualscanpresentwithpositive
serologyforLeishmaniaspecieswithnoassociation
withdiseaseinendemicareas
Invasive aspergillosis
DonottestforAspergillusgalactomannaninserum
samplesinnon-neutropenicpatients
Sensitivityofserumgalactomannantestingis
markedlyreducedinnon-neutropenicindividuals
asincases whereNNT haverecognizedlow sensitivity, as inlatesyphilis.However,treponemalantibodytiterscorrelate poorlywiththediseaseactivityasitmayremainpositivefor thepatient´slifetime.13,15,16Asaresult,TTshouldnotbeused formonitoringserologicalactivityandtreatmentoutcomesin patientspreviouslytreatedforsyphilis.
4 DonotuseToxoplasmaIgGtestforthefollow-upin immuno-competentpatientsanddonotrepeatanti-T.gondiiIgGin patientswithapreviouspositiveIgGtest.
(51.7%ofvotes;n=249)
Due to the high seroprevalence ofT. gondiiinfection in theoverallpopulationisnotrecommendedtorepeatIgGin immunocompetentpatientsthatalreadyhaveapositivetest neithertorepeat testsforserologicalfollow-up.The preva-lenceofToxoplasmainfection variesbetween countriesand oftenwithinagivencountry orbetweendifferent commu-nitiesinthe same regiondependingon the environmental andthesocioeconomiclevelsofthepopulation.17,18Insome areasinBrazil,theserologicalprevalenceofT.gondiiinfection rangesfrom50to80%,19includingareaswhereIndiantribes liveinrelativeisolatedlocations.20ApositiveIgGtestconfers longlifeprotectionagainsttoxoplasmosis.Onceaformed Tox-oplasmainfectionisconfirmedisnotrecommendedtorepeat IgGserologicaltestssincetitersofIgGremainpositive life-long.
5 Donotuseserologicaltestingtodiagnoseorscreenfor HSV-1andHSV-2ingeneralpopulation.
(50.07%ofvotes;n=239)
Duetothehighprevalenceofherpessimplexinfectionin thegeneralpopulationdetectionofantibodiesagainstherpes
simplex1(HSV-1)andherpessimplex2(HSV-2)hasverylittle useinclinicalpractice.In2012,onestudyestimatedthat67% ofworldpopulationundertheageof50wasalreadyinfected byHSV-1.TheestimatedglobalprevalenceforHSV-2,forthe sameagepopulation,was11%.21Brazilianstudieshavealso shownelevatedseroprevalenceofherpessimplexinfectionin adults.22
6 DonottestforClostridiumdifficileinpatientswithout diar-rhea.
(48.3%ofvotes;n=233)
Asymptomatic Clostridium difficile carriage frequently occurs in patients on antimicrobial therapy and in hospi-talized patients, especially the elderly. Colonization occurs in 5–15% of healthy adults whereas the rates increase up to 57% in residents in long-term care facilities.23 For this reason,itisnotclinicallyusefultotestforC.difficilein asymp-tomaticpatientswithoutdiarrheasincethepresenceofthe pathogen instoolsindicatecarriageonly,whichshouldnot betreated.23–25 Thediagnosis ofC.difficile infection should combineclinicalsymptomswithlaboratorytests.26
7 DonotroutinelyrepeatCD4measurementsinHIVpatients withprolonged(>2years)viralloadsuppressionandhigh (≥500cell/mL)CD4counts,unlessvirologicalfailureoccurs oranopportunisticinfectiondevelops.27–30
(43.1%ofvotes;n=208)
CD4cellsmonitoringcanbeceasedinpeoplelivingwith HIV/Aids (PLHIV) who are stable on antiretroviral therapy and virologically suppressed, in settings where viral load monitoringisavailable.Inthesepatients, frequentCD4cell counting is unnecessary sinceit rarely leadsto change in
clinicalmanagement.Inaddition,CD4cellsremainstableover timeinmostpatients27,28–meaningfulCD4declineis uncom-mon. Furthermore,CD4 countmay naturally vary between measurements(<30%),inasensethatfrequentsamplingmay onlycauseunnecessaryanxietytopatients.Prospective stud-ies have confirmed that CD4 monitoring offers no clinical benefitinpatientswhohavesuppressedviralloadandCD4 counts>300 cells/mm3 after 48 weeksoffollow up.29 This strategyhasbeenrecommendedforvirologicallysuppressed patientswithCD4countsbetween300–500cells/mm3,forat least2years.30
8 DonotmeasureHCVviralloadformonitoringpatientswho havereachedsustainedvirologicresponsepost-treatment, unlessthereisanongoingriskofreinfectionoran unex-plainedhepaticdysfunction.
(29.2%ofvotes;n=141)
Giventheefficacyofdirect-actingantiviraltherapyforthe treatmentofchronicHCVinfection,patientswhoachievean undetectableHCV-RNA inserum orplasma at12weeksor 24 weeks after treatment are considered as having a sus-tainedvirologicresponse(SVR).Amongpatientswhoachieved SVRwithpeginterferon/ribavirin treatment,morethan99% haveremainedfreeofHCVinfectionwhenfollowedforfive years aftertreatment completion.31 Therefore, it is unnec-essarytoassessHCV recurrenceorreinfectiononceSVR is achieved,sinceitisconsideredtobevirologicalcureofthe infection.Viralmonitoringhasreducedimportancenowadays sincenoveltherapiesoffersimilarantiviralpotency,regardless ofbaselineviralload.32 Furthermore,itoffersnoprognostic value.Itismostlyrecommendedtodocumentthepresenceof HCVviremia.Annualviralmonitoringisonlyrecommendedin patientswhohaveongoingriskexposureforHCV(e.g.people whoinjectdrugs).33,34
9 Donotuseserologicaltestsasthesolebasistodiagnose leishmaniasisinendemicareas.
(28.2%ofvotes;n=136)
Theprevalence ofantibodies against Leishmania species rangesfrom<10%to30%inendemicareas.Therefore, anti-bodydetection againstLeishmania speciesisoflittle use in thediagnosisofleishmaniasis.35,36 Asymptomatic individu-als,whohavenohistoryofvisceralleishmaniasis(VL),can presentwithpositiveserologyforLeishmaniaspecieswithno association with disease.Furthermore,antibodies may not bedetectedormaybepresentatlowlevelsin immunocom-promisedpatients withVL.35–37 Finally, eventhoughserum antibodylevelsdecreaseafterleishmaniasistreatment,these mayremaindetectableuptoseveralyearsafterdiseasecontrol and cannotdistinguishbetween activeand previous infec-tion.Therefore, testsfor antileishmanialantibodiesshould notbeperformedasthesolediagnostictoolinpatientswith leishmaniasis.38
10 DonottestforAspergillusgalactomannaninserum sam-plesinnon-neutropenicpatients.
(14.3%ofvotes;n=69)
Invasiveaspergillosis(IA)isoneofthemostserious fun-galinfectionsaffectingimmunocompromisedpatients.This condition is associatedwith high mortality, especially due toitschallengingdiagnosis.39,40Serumgalactomannan(GM) has been extensively used to screen neutropenic patients at risk to develop IA, in association with chest computed tomography (CT).However,sensitivityofserum GMtesting is muchreduced innon-neutropenicindividuals, including solid-organ transplant patients, patients with graft versus hostdisease,and other patientstakingsteroids. Therefore, non-neutropenicpatientsatriskforIAshouldbetestedwith GMinbronchoalveolarlavagesamples,insteadofserum sam-ples.
Conclusions
Thetop-10ChoosingWiselystatementsoftheDiagnostic Lab-oratory Group atSBI were presented inthis article. These recommendationsaimtoreduceunnecessaryandoverused tests performed on patients with different sorts of infec-tions.Asaresult,weexpecttoprovidepatientswithabetter standardofcare,potentiallyreducingthenegativeimpactof unnecessarytestsinpatients.
Conflicts
of
Interest
Theauthorsdeclarenoconflictsofinterest.
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