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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
Pelayanan Mikrobiologi Klinik
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
Laboratory Report #3
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
Antimicrobial Susceptibility Report
Antibiotic MIC Interpretation
Ampicillin/sublactam >32 R
Cephalothin >32 R
Ciprofloxin >4 R
Clindamycin >8 R
Oxacillin >8 R
Penicillin G >16 R
Tetracycline
Laboratory Report #4
Source: Urine (clean catch)
Status: Final
Isolate 1: >100,000 CFU Pseudomonas aeruginosa
Antimicrobial Susceptibility Report
Antibiotic MIC Interpretation
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
S = Susceptible R = Resistant
End of Report
Laboratory Report #6
Source: Urine (clean catch)
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
Laboratory Report #8
Source: Urine (clean catch)
Status: Final
Isolate 1: >100,000 CFU/ml Klebsiella pneumoniae
Antimicrobial Susceptibility Report
Antibiotic MIC Interpretation
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
S = Susceptible R = Resistant
End of Report
Laboratory Report #11
Source: Stool
Status: Final
Result: No Salmonella, no Shigella and no Campylobacter isolated.
End of Report
Enterobacteriaceae
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
CLSI M39-A2:Vol 25, No. 28, January 2006, p. 1-45.
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:
CLSI M39-A2:Vol 25, No. 28, January 2006, p. 1-45.
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
Pelayanan Mikrobiologi Klinik
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