Speed 2014-Antibiogram How to Interpret

ANTIBIOGRAM,

HOW TO INTERPRET

Hendro Wahjono

Department of Microbiology

Dr.Kariadi Hospital

Fac. of Medicine, Diponegoro University

OVERVIEW

Operasionalisasi dan Workflow

Pelayanan Mikrobiologi Klinik

di Rumah Sakit

OLD Indonesian Clin Micr Services ?

- Laboratory-based services- Technical aspect

NEW Indonesian Clin Micr Services ?

(Clin Micro Specialist)Three steps1. Entire Lab-Based Services on Clin Micr2. Consultative-Based Services on Clin Micr3. Team work for Patient Care

Finch et al, 2005


Laboratorium Mikrobiologi Identifikasi dan uji sensitivitas

Hasil pemeriksaan

Konsultasi / Visitasi / Patient care Bersama klinisi ikut terlibat merawat pasien

infeksi.

Turn Around Time report.

Informasi Peta medan kuman Pengelolaan data mikroba

menerbitkan informasi peta medan secara berkala

4

Diagnostic Testing Performed at or near

Site of Patient Care

POCTPoint of Care-Testing

Quality Assurance for POCT

Regulation for POCT

Turn Around Time

Impact on Health Care

NACB- CLSI (NCCLS)

Data Management of POCT

Quality Assessment in the Analytical Phase

Mostly Critical Quality Assurance Pre-Post

Analytical Phase

PATIENT

OPD/WARD

MICROBIOLOGY COUNTERSECTION

STAINING/SAMPLING

CULTURE/SAMPLING

BACTEC 9050/9120,

PHOENIX/VITEK2 / GENE

EXPERT,PCR

SEROLOGI : DENGUE BLOT/NS1,WIDAL/TUBEX, TPHA /VDRL MAT/LAT.FLOW

HOSPITAL INFECTIONCONTROL PROGRAM

CONTINUING

CONSULTATION

ALUR PEMERIKSAAN KULTUR / TES RESISTENSI

TESRESISTENSI

Bactec9050/9120, Bacti Alert

CAIRAN -PLEURA,

PERICARDIUM,SENDI,

ASCITESURIN

PEND.

AGAR DARAH

MC CONKEYAGAR

AGAR SS

AGAR NUTRIEN

LCS

DARAH

PUS

DOKTER PENDERITA

VITEK2

PHOENIX

Critical value

In handl. spec.

Ambil Hasil HasilPermintaan Spec. di lab. Mikro Selesai diambil DibacaT1 T2 T3 T4 T5 T6

1.0 jam 3.0 jam 3.0 hari 1.0 jam 1.0 jam

Point for improvementTelephone / Fax

3.0 hari, 6 jam

Alur pemeriksaan kultur dihubungkan dengan waktu

TURN AROUND TIME

Objectives

Review the Clinical and Laboratory Standards Institute (CLSI) guidelines for cumulative antibiotic susceptibility reporting in term of CLINICAL MANIFESTATION but NOT ANTIBIOGRAM MANIFESTATION !!

Clinical impact of rapid reporting(Turn Around Time, LOS,Mortality Rate andTotal Cost )

10

Objectives

Review the Clinical and Laboratory Standards Institute (CLSI) guidelines for antibiotic susceptibility reporting in the field of ESBL producing Enterobacteriaceae

Discuss how you can utilize this information at your institution

The NCCLS (now known as the CLSI

[Clinical and Laboratory Standards Institute])

defines an antibiogram (ABGM)

as an overall profile of antimicrobial susceptibility results

of a microbial species to a battery of antimicrobial agents

which should reflect patient care needs

along with the institution's formulary

When properly prepared and interpreted,

ABGMs are an important resource for healthcare providers.

(Antibiogram is an in-vitro testing for the sensitivity of an isolated bacteria strain

to different antibiotics.)

In an era of antimicrobial misuse,

increasing anti-infective resistance,

and reduced emphasis on antibiotic development

by pharmaceutical manufacturers,

the need for reliable,

accurate ABGM data

to guide appropriate antibiotic selection is critical

ANTIBIOGRAM REPORT

The antibiogram report

contains the following information

1. Organisms isolated (ESBL)

2. Source (blood, urine, wound)

3. Number of isolates (ISO)

4. List of antibiotics tested*

5. Percent susceptible (100%, 75%, 67%, etc.)

Why prepare an antibiogram?

Fits into several national guidelines

CDC 12-step

IDSA guidelines on antimicrobial stewardship

(2007)

CDC/HICPAC Management of multi-drug resistant

organisms in health care settings (2006)

Part of Joint Commissions standards (IM.4/ IM.8)

The hospital collects and analyzes aggregate data to support

patient care and operations.

16

Core members

Menyusun kebijakan yang terkait dengan

penggunaan antibiotik rasional/ bijak

Membangun kerjasama multidisiplin

Mengendalikan suseptibility hospital pathogen

Implementasi

Surveillan penggunaan antibiotik dan Universal

Precaution

Membangun sistim informasi bersama

Strategic action

Describe the importanceantimicrobial susceptibility testing

in term of handling spec.

Describe the interpretationof susceptibility testing data and clin.manifest.

Describes the post analyticalerrors associated with interpreting

susceptibility testing results

Improving Reporting of AntimicrobialSusceptibility Testing Results: the

Importance of Post Analytical Analysis

Facilitate appropriate antimicrobial usethrough stewardship and infection control

Collateral damage of antibiotic therapy

3rd generationcephalosporins

Fluoroquinolones

C. difficile

MDR Pseudomonas

C. difficile

-lactam-resistantAcinetobacter

VRE

ESBL Klebsiella

Song, Jae-Hoon; The Changing Face of Polymicrobial Infections; presented at 24th ICC, Manila, June 4-, 2005

AM

C

Interpretation

The antibiogram table is very easy to interpret

Biogram Report on Organism Sensitivities

Clients Name

12-01-00 - 12-31-00

Organism ISO1 AM2 CIP GM

Escherichia coli

Urine45 753 88 100

1Isolates

2Antibiotic codes

3 Percent susceptible

There were a total of 40 isolates cultured in urine.

75% of the isolates were susceptible to ampicillin (AM);

88% of the isolates were susceptible to ciprofloxacin (CIP);

100% of the isolates were susceptible to gentamycin (GM);

If you wish to know the number of isolates

that were susceptible to ampicillin,

simply multiply the percent susceptible

(75% = 0.75) x the total number of isolates:

(40): 0.75 x 40(ISO) = 30

This means that out of a total number of 40 isolates of E. coli,

30 were susceptible to ampicillin and 10 were resistant.

Interpretation:

Accumulation of data over a period of months

may indicate resistant patterns developing within your facility.

AM

C

Interpretation: ?

Patient fails to respond to antibiotics

Depressed immune system

Undrained abscess

Foreign bodies

Severe underlying disease

Misdiagnosis

Mixed infection

Superinfection

Interpretation:

Dangers of indiscriminate use of antibiotics

Widespread sensitization of population

Changes in indigenous (normal) flora

Masking serious infections

Drug toxicity

Development of drug resistance

Interpretation:

Factors guiding the choice of an antibiotic

Susceptibility patterns

Safe achievable serum levels

Distribution of antibiotic in tissues

Route of excretion

Toxic side effects

Existing or developing renal or hepatic failure

Absorption characteristics

Existing or developing allergic reactions

Antibiotic interactions with other drugs

Cost

Interpretation:

Ten steps to improve the effective use

of the microbiology laboratory REPORT by physicians

Continuing education programs

Significance of submitting cultures

Obtain specimens before antibiotic therapy

Obtain adequate volumes and numbers

Complete requisition form

Perform Gram stains (i.e., sputum, wounds, internal fluids and tissues)

Transport specimens promptly

Interpret microbiology report in light of clinical conditions

Understand the value and limitation of susceptibility testing

Open lines of communication

Demographics of a requisition form

Patient/resident name

Age/sex

Time specimen taken

Patient/resident location

Type of specimen

(i.e., clean catch urine, right knee drainage, sputum, etc.)

Is patient/resident on forced fluids?

Is patient/resident on antibiotics? If so, which ones? For how long?

Is this specimen an intermittent or foley cath specimen?

Type of test required

Clinical disease of patient/resident if known

(i.e., bacterial endocarditis, fungemia, symptomatic UTI, etc.)

Reasons for not routinely testing

and reporting numerous antibiotics

Selection of drug is influenced by laboratory report

Restricted reporting should help control the following:

1. indiscriminate use of more costly and/

or more toxic drugs

2. inappropriate or unnecessary use of new agents

3. development of resistance through inappropriate use

Many new drugs are very similar to each other,

to older agents or to both,

and testing of one drug from each group is usually sufficient

Some antimicrobial agents are inappropriate for

treatment of infections

even if in vitro results indicate susceptibility.

For example:

-first and second generation cephalosporins and

Salmonella sp.

-beta-lactams and MRSA

-cephalosporins and enterococci

Reasons for not routinely testing

and reporting numerous antibiotics

Laboratory Report #2

Source: Right ankle drainage

Status: Final

Gram Stain: Numerous WBC; many Gram positive cocci in chains

Isolate #1: Heavy growth of: Enterococcus faecalis

Antimicrobial Susceptibility Report

Antibiotic MIC Interpretation

Ampicillin 8 S

Penicillin G 8 S

Tetracycline >16 R

Vancomycin >32 R

S = Susceptible R = Resistant

End of Report


Source: Coccyx

Status: Final

Gram stain: Numerous WBC; many Gram positive cocci seen in clusters

Isolate 1: Heavy growth of: Staphylococccus aureus

S. aureus culture on a blood agar plate showing beta hemolysis



Ampicillin/sublactam >32 R

Cephalothin >32 R

Ciprofloxin >4 R

Clindamycin >8 R

Oxacillin >8 R

Penicillin G >16 R

Tetracycline


Source: Urine (clean catch)

Status: Final

Isolate 1: >100,000 CFU Pseudomonas aeruginosa



Ampicillin >32 R

Carbenicillin >512 R

Ceftriaxone >64 R

Cephalothin >32 R

Ciprofloxacin >4 R

Gentamicin >16 R

Nitrofurantoin >128 R

Norfloxacin >16 R

Tetracycline >16 R

Tobramycin >16 R

Trimeth-sulfa >320 R


End of Report



Status: Final

Result: >100,000 CFU/ml

Multiple organisms isolated. May represent normal flora

from external genitalia rather than urinary bladder.

Please repeat culture if clinically indicated.

End of Report



Status: Final

Isolate 1: >100,000 CFU/ml Klebsiella pneumoniae



Ampicillin >32 R

Carbenicillin >512 R

Ceftriaxone 32 R

Ciprofloxacin >4 R

Gentamicin >16 R

Nitrofurantoin >128 R

Norfloxacin >16 R

Tetracycline >16 R

Tobramycin >16 R

Trimeth/sulfa >320 R


End of Report


Source: Stool

Status: Final

Result: No Salmonella, no Shigella and no Campylobacter isolated.

End of Report

Enterobacteriaceae

Klebsiella

pneumoniae

ESBL +(ICUDr Kariadi

Hospital)

May-June 2011

n=26

Antibiotic name %S

Meropenem 81

Moxifloxacin 79

Cefoperazone/Sulbactam 81

Piperacillin/Tazobactam 80

Amikacin 75

Tigecycline 85

Fosfomicin 80

Dibekacin 67

Cefepime 68

Ampicillin /Sulbactam 70

Cefotaxime 0

Ceftazidime 0

Ciprofloxacin 67

Adapted from Nosocomial Surveillance System Data Dr Kariadi Hospital, 2012

Microbiologic surveillance

Molecular typing

Samestrain?

InvestigateAntibiotics?

Refer

YesNo

YesNo

Organismsidentified

ControlStop

CLSI suggestions for achieving 30 isolates

Combine several years of data

Combine for more than one species in a genus

Combine data from geographically similar institutions

Provide data from published summaries and guides

Modified from 10 30

Optimal number of isolates to report

Primary recommendations:

Analysis and presentation of data

CLSI M39-A2:Vol 25, No. 28, January 2006, p. 1-45.

Data validation:

Include only final verified results

Look for inconsistencies

Imipenem resistant E. coli very rare

Vancomycin resistance in S. pneumoniae

Amikacin resistance in K. pneumoniae

Vancomycin resistant S. aureus

Recent changes in breakpoint may influence vancomycin

intermediate results


Specific locations

By unit of the hospital (ICU vs non ICU)

Inpatient vs. Outpatient

Long term care or nursing home

By culture source (urine vs. non-urine)

Notations regarding specific resistance patterns

Data presentation:


Additional suggestions

Avoid information overload

Organize in an easy to read format

Prepare empiric guidelines at the same time as

antibiogram

# PRESENTASE SENSITIVITAS TERHADAP ANTI BIOTIK DI BANGSAL ICU

RSUP Dr. Kariadi ( BULAN JANUARI - JUNI 2010 )

1. DARAH

Organisma

JML

ISOLAT

AMP

%S

ERY

%S

TCY

%S

CHL

%S

GEN

%S

CIP

%S

FEP

%S

CTX

%S

CAZ

%S

CSL

%S

DKB

%S

FOS

%S

MEM

%S

MFX

%S

FOX

%S

SXT

%S

VAN

%S

AMK

%S

Staphylococcus

epidermidis 26 0 10 50 33 26 13 33 21 50 37 72 57 75 26 60 100 90

Escherichia coli 18 20 50 66 56 50 80 40 33 83 66 82 93 16 33 93

Pseudomonas aeruginosa 16 0 0 50 0 26 33 40 20 14 57 33 60 33 40 0 18 100 53

Staphylococcus aureus

ss. aureus 15 50 60 42 75 100 78 100 100 100 100 86 88 100 93 57 100 100

Acinetobacter baumannii 11 0 25 16 0 10 0 0 80 0 80 20 54 0 57

Enterobacter aerogenes 6 0 50 0 16 40 16 0 0 66 50 50 16 83

Klebsiella pneumoniae ss.

pneumonia 5 0 50 100 0 80 25 40 100 0 100 100 60 0 100

Candida albicans 2

Streptococcus

pneumoniae 1 0 0 100 0 100 100 100 100 100 100 0

NOTE : Staphylococcus epidermidis = MRSE = Positif =Fox

Escherichia coli dan Klebsiella pneumoniae = ESBL =

CTX + CAZ ( Resisten )

Pseudomonas, Acinetobacter baumannii dan

Enterobacter aerogenes = MDRO

* Berhati - hati Pemakaian Terapi Antibiotik Empirik Dengan

Cephalosporin Generasi 3

* Telah Terjadi Infeksi Nosokomial

AMP AmpicillinERY ErythromycinTCY TetracylineCHL ChloramphenicolGEN GentamicinCIP CiprofloxacinFEP CefepimeCTX CefotaximeCAZ CeftazidimeDKB DibekacinFOS FosfomycinMEM MeropenemMFX MoxifloxacinSXT Trimethoprim/SulfatmethoxazoleFOX Ce foxitin VAN VancomycinAMK Amikacin

Reliable answers

Least possible

risk

Rapid diagnosis

Appropriate treatment

Microbiology Lab

Clinician

Communication

Clinical Microbiologist

Understand the importance ofappropriate antimicrobial for patient safety

Policy Deals with

We discuss on the Broad basis

Clinicians / Microbiologists /

Pharmacists and Nurses do take

part.

Policies are framed on demands

of the Clinical areas, depending

on recent Infection surveillance

data contributed from

Microbiology Departments.

GOALS

1.Patient safety

2.Cost reduction

3.Antimicrobial resistance control

Komite Medik

Pelayanan Farmasi Klinik

Tim Pengendalian Infeksi RS


Infectious Diseases Expert Resources

Infectious Diseases Specialists

Optimal Patient Care

Infection Control Professionals

Healthcare Epidemiologists

ClinicalPharmacists

Clinical Pharmacologists

Surgical InfectionExperts

ClinicalMicrobiologists

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Step 4: Access the experts

Conclusion

These findings suggest that antibiograms should be reviewed thoroughly by infectious disease specialists (physicians and pharmacists), clinical microbiologists, and infection control personnel for identification of abnormal findings prior to distribution.

Aggregate antimicrobial resistance data can be used in a number of ways to benefit patient care

Resources

CLSI website

www.clsi.org

IDSA Guidelines on Antimicrobial Stewardship

www.idsociety.org

CDC 12 step program

www.cdc.gov/drugresistance/healthcare/tools.htm

Guidelines for the Management of MDRO

www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf

Sir Alexander Fleming

Documents

Speed 2014-Antibiogram How to Interpret