This editorial refers to "Corynebacterium striatum and the deceptive diagnosis in a dialysis-dependent chronic liver disease patient: A case report" by Kataria et al, 2026; https://dx.doi.org/10.12998/wjcc.v14.i11.119674.
INTRODUCTION
Modern clinical practice increasingly encounters diagnostic ambiguity at the interface between commensalism, colonization, contamination, and true pathogens, particularly in complex, device-dependent, and immunocompromised patients[1]. Organisms traditionally labeled as commensals, such as Corynebacterium striatum, are now emerging as clinically significant pathogens in high-risk hospital environments, as described by Kataria et al[2] on the recent issue of World Journal of Clinical Cases. This shift challenges conventional microbiological interpretation and exposes gaps in clinical decision-making. This case exemplifies a critical reality: Optimal outcomes are not determined solely by antimicrobial choice, but by the timely integration of diagnostic, therapeutic, and system-level decisions. The transition from an apparently stable clinical state with negative initial investigations to fulminant infective endocarditis and septic shock reflects a failure to dynamically reassess evolving risk in a vulnerable host.
In opposite ways too, without proper clinical contextualization, microbial identification runs the danger of misclassifying colonization, contamination, or latent infection as active disease, which could result in needless antimicrobial therapy and disturb the microbial ecosystems in humans and the environment[3]. For instance, Candida albicans frequently colonizes the gastrointestinal tract before translocating and causing invasive candidiasis in susceptible hosts[4]. Many bacteria survive as commensals or colonizers and only become pathogenic under particular host or environmental conditions. Similarly, the identification of latent viruses such as human cytomegalovirus requires cautious interpretation, as the host’s immunological state, rather than the organism’s mere presence, determines viral survival and reactivation[5]. Therefore, before starting or increasing antimicrobial therapy, integrated antimicrobial stewardship (IAS) is required, including interpretation of microbiological data within the clinical, host, and ecological context.
IAS, as operationalized through the Society of Antimicrobial Stewardship PractIces (SASPI)’s 42-point framework, aligned with international practice guidelines, a multidomain stewardship model across clinical, microbiological, procedural, and administrative domains, provides one such systems-based approach for managing complex healthcare-associated infections[6]. Within this approach, stewardship is conceptualized as a continuous and multidisciplinary process rather than an isolated antimicrobial decision. IAS extends beyond antimicrobial prescription to include: (1) Diagnostic stewardship (timely cultures, interpretation in context); (2) Infection prevention (asepsis, catheter care); (3) Device stewardship (early recognition and removal of infection sources); (4) Therapeutic stewardship (appropriate empiric therapy, de-escalation, and optimization); and (5) Administrative and behavioral accountability (audit, documentation, multidisciplinary coordination)
In a case by Kataria et al[2], characterized by dialysis dependence, advanced cirrhosis, recent prolonged hospitalization, and intravascular device exposure, each SASPI element becomes interdependent. Failure or delay in any single domain can propagate across the system, converting a manageable infection into a catastrophic outcome.
Thus, IAS must be conceptualized not as a static protocol but as a dynamic, case-centered continuum, in which every clinical encounter, particularly complex cases, offers an opportunity to apply, audit, and refine stewardship practices. The present case illustrates how the absence of such an integrated application can lead to delayed recognition, suboptimal timing of interventions, and ultimately, mortality, despite microbiologically appropriate therapy.
KEY STEWARDSHIP THEMES EMERGING FROM THIS CASE
This case does not represent a failure of antimicrobial selection alone; rather, it highlights multidimensional stewardship gaps across the continuum of care.
Diagnostic stewardship: Context over convention
The central challenge was distinguishing contamination from true infection/pathogen[1]. Repeated isolation of Corynebacterium striatum in a high-risk host with an indwelling catheter should have triggered earlier escalation of suspicion. IAS emphasizes that microbiological results must be interpreted in a clinical context, not solely on the basis of the organism’s reputation. Delayed repeat cultures and echocardiographic reassessment contributed to diagnostic lag. And wrong diagnosis plays a vicious cycle towards creation of antimicrobial resistance[7]. In the context of blood culture isolates, each clinician must follow certain checkpoints/steps to decide pathogenicity before the conventional decision to treat[8].
Microbiological stewardship: Organism-host interplay
This case reinforces that pathogenicity is host-dependent. In immunocompromised and device-bearing patients, low-virulence organisms can behave aggressively[9]. IAS requires close clinician–microbiologist collaboration, with attention to: (1) Repeated isolation patterns; (2) Concordance across samples; and (3) Clinical correlation.
Microbiologists must go beyond microbial identification to determine actual pathogenicity to practice diagnostic stewardship[10]. Rational antimicrobial therapy depends on the ability to distinguish between pathogens and non-pathogens. To ensure repeatability and clinical reliability, ethical diagnostic practice also requires transparent reporting of sample techniques, quality controls, sequencing operations, and analytical pipelines[11]. Artificial intelligence and emerging molecular diagnostics should complement expert interpretation rather than replace it, thereby promoting accuracy, transparency, and moderation while avoiding overdiagnosis and unnecessary antibiotic exposure[12]. Most importantly, when a microbiologist identifies a microorganism, it must undergo an eight-step checklist before reporting[13].
Device stewardship: The missed source
The indwelling dialysis catheter represented a probable nidus of infection, yet early removal and complete microbiological evaluation (e.g., catheter-tip culture) were delayed. IAS highlights that device management is as critical as drug therapy, particularly in the management of bloodstream infections[14].
Therapeutic stewardship: Timing over choice
Empiric therapy during septic shock and subsequent de-escalation to vancomycin were appropriate. However, the timing of initiation relative to disease evolution limited effectiveness. This case highlights a key IAS principle: Appropriate antimicrobials cannot compensate for delayed diagnosis and source control[15]. Persistent bacteremia despite therapeutic levels further emphasizes the need for integrated management rather than escalation alone.
Surgical stewardship: When optimal care is not feasible
Multivalvular infective endocarditis with large vegetations warranted surgical evaluation, yet intervention was not feasible due to advanced cirrhosis and instability. IAS must incorporate real-world constraints and adapt strategies for patients in whom definitive source control is not possible.
Infection prevention and control: Upstream determinants
The patient’s trajectory was shaped by recent prolonged hospitalization, invasive procedures, and catheter exposure. This reflects upstream gaps in: (1) Catheter care practices; (2) Infection prevention bundles; and (3) Early discharge stewardship and follow-up IAS, therefore, extends beyond acute care to continuity of care and the prevention of healthcare-associated infections[6].
Educational stewardship: Bridging perception gaps
A persistent cognitive bias that views certain organisms as contaminants remains a major barrier. This case describes the need for training clinicians to interpret ‘unusual pathogens’ in high-risk hosts and reinforcing that repetition equals relevance in microbiology.
Administrative stewardship: Systems and accountability
The absence of structured triggers such as: (1) Alerts for repeated blood culture positivity; (2) Protocols for catheter-associated infections; and (3) Mandatory reassessment checkpoints reflects gaps in institutional stewardship systems. IAS requires embedding these into routine workflows through audit, feedback, and accountability mechanisms.
Moving forward, every department involved in patient management must align its practices under a unified stewardship model. A structured multidisciplinary stewardship approach may further support implementation across departments involved in complex infection management. There are different approaches to medicinal departments such as geriatrics, critical care, gastroenterology, neurology, community/public health as OLD AGE AMSP, INTENS AMSP, GUT CARE ASP, NEURON AMSP, and COMMUNITY Steward models respectively[16-20]. For surgical and other departments, there exist HEAD-NECK AmSp, KIDNEY AMSP, INSAAF, GUARDIAN, and DISPENSER Amsp models respectively[21-25]. One such operational model is summarized through the PRESCRIBES framework[26]. The PRESCRIBES framework offers a structured checkpoint system to ensure: (1) Policy-driven accountability; (2) Resource integration across departments; (3) Education and behavioral change; (4) Surveillance and microbiological accuracy; (5) Culture; (6) Rational antimicrobial use; (7) Information transparency and audit systems; (8) Behavioural modifications; (9) Engagement; and (10) Sustainibility.
CORE ELEMENTS OF IAS
Rather than operating in isolated silos, a fully integrated program brings together hospital leadership, prescribers, microbiologists, and pharmacists. Key strategies by SASPI and other international health societies include a ‘DIA model’ (Figure 1A): (1) Diagnostic stewardship: Ensuring accurate, rapid microbiological cultures are obtained prior to initiating therapy, reducing the risk of treating asymptomatic bacteriuria or viral infections with broad-spectrum antibiotics[27]; (2) Infections prevention and control (IPC) Stewardship: A mandatory 100% compliance is required for implementing standard and transmitted precautions in IPC practices, especially in low- and middle-income countries; and (3) Antimicrobial Stewardship: The 4Ds are to be strictly practiced for optimizing the drug, dosage, delivery (route), and duration of therapy to treat the infection without fostering resistant organisms (Figure 1B)[28]. This step also requires multidisciplinary accountability, requiring peer-to-peer review, prospective audits, and feedback to continually refine local antibiograms and reduce inappropriate usage rates, which account for up to 50% of antibiotic prescriptions[6]. There is an increasing need for Clinical Decision Support System, embedding institutional prescribing guidelines directly into electronic health records to prompt prescribers for clinical indications and appropriate durations[29]. Rather than introducing a new stewardship paradigm of the DIA model, the SASPI framework is intended to operationalize and integrate internationally accepted stewardship principles, including diagnostic stewardship, antimicrobial optimization, infection prevention, multidisciplinary collaboration, and continuous quality improvement, into a structured, case-based implementation model. In this regard, it complements existing global stewardship recommendations, including World Health Organization established stewardship guidance and guidance from international professional societies such as Infectious Diseases Society of America, while adapting these principles to complex real-world clinical practice, especially with consideration to one-health dimensions[30-32].
Figure 1 DIA model of integrated antimicrobial stewardship practices as proposed by.
A: Society of Antimicrobial Stewardship PractIces; B: 4Ds of antimicrobial stewardship practices.
Corynebacterium striatum in humans
Corynebacterium striatum is an underappreciated human pathogen associated with serious infections in both immunocompetent and immunocompromised hosts. Corynebacterium striatum infections tend to be more frequent in males, and major sites of infection have included the bloodstream, lungs, and central nervous system. Most are nosocomially acquired, and there is a significant association with medical devices ranging from intravascular catheters to central nervous system drainage devices. Empiric therapy with vancomycin is advisable, as susceptibility to other agents varies. Treatment may also include removal of foreign material, such as an intravascular catheter. The present editorial, with respect to the case in question, describes the wide spectrum of infections associated with Corynebacterium striatum[2].
CONCLUSION
This case illustrates a fundamental truth in modern infectious diseases practice: Catastrophic outcomes often arise not from resistant organisms alone, but from fragmented or delayed integration of stewardship. The progression from presumed contamination to fatal multivalvular endocarditis highlights how diagnostic delay, device-related risks, and system-level gaps can converge despite appropriate antimicrobial therapy.
IAS must therefore be implemented as a continuous, multidisciplinary process, particularly in complex cases involving high-risk hosts and invasive devices. The SASPI 42-point framework with inbuild ‘DIA model’ provides the operational backbone for such integration, but its effectiveness depends on real-time application across all domains of care, especially the PRESCRIBES framework for each clinical department. Most importantly, while international frameworks provide evidence-based stewardship principles, SASPI seeks to translate these principles into a coordinated clinical practice, using a single operational model applicable across diverse clinical scenarios.
In complex, evolving cases such as this, IAS is not optional; it is the determinant of outcome. Embedding these principles into routine clinical workflows will not only improve individual patient outcomes but also mitigate the broader threat of antimicrobial resistance within healthcare systems.
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Infectious diseases
Country of origin: India
Peer-review report’s classification
Scientific quality: Grade B, Grade C
Novelty: Grade C, Grade C
Creativity or innovation: Grade C, Grade C
Scientific significance: Grade B, Grade C
P-Reviewer: Kosuta I, Chief Physician, MD, PhD, Research Fellow, Croatia; Sergi CM, Emeritus Professor, MD, PhD, Professor, Canada S-Editor: Liu JH L-Editor: A P-Editor: Wang WB
