Speed 2014-Antibiogram How to Interpret

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Text of 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

  • 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.