Role of the Laboratory in Antimicrobial Resistance Data

The Role of the Laboratory Collection, Analysis & Circulation of Antimicrobial Resistance Data Dr Anuj Sharma World Health Organization, India

Outline

Role of Microbiology Lab in Antimicrobial Resistance (AMR)

Antibiogramme (ABGM)

Why prepare ABGM?

CLSI guidelines

ABGM – Features, Quality Indicators, Trends & Examples

WHONET

Role of Microbiology Lab

Diagnostic lab work

Advice to clinicians - treatment of infected patients

Infection control

Close personal contact with clinicians in daily treatment of patients ensures rational AM use

Interaction between the microbiology laboratory and clinician: what the microbiologist can provide Journal of Hospital Infection Vol. 43, Supplement 1, Dec99, S285-S291; 4th International Conference of the Hospital Infection Society

Uses of AMR Data

Laboratory quality improvement

Routine ABST testing

Better utilization of lab services by clinical staff

Infection control & outbreak preparedness

Identification of new & problem pathogens

Identification & investigation of HAI outbreaks

Drug resistance surveillance to monitor trends in infections and resistance - periodic review of MICs / zone inhibition diameters

Uses of AMR Data

Develop and implement Antimicrobial policy / guidelines

Develop treatment guidelines

Characterization of cross-resistance

Research

New resistance mechanisms

Risk factors for resistance

Evaluation of interventions

Definition Report generated by analysis of isolates from a particular institution in a defined period of time that reflects the percentage of first isolates (per patient) of a given species that is susceptible to each of the antimicrobial agents routinely tested

Why prepare an antibiogramme?

Guidelines

CDC - Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

Fact : The prevalence of resistance can vary by locale, patient population, hospital unit & length of stay

Actions :

Know your local ABGM

Know your patient population

Campaign to Prevent Antimicrobial Resistance in Healthcare Settings 12 Break the chain 11 Isolate the pathogen 10 Stop treatment when cured 9 Know when to say “no” to vanco 8 Treat infection, not colonization 7 Treat infection, not contamination 6 Use “local” data 5 Practice antimicrobial control 4 Access the experts 3 Target the pathogen 2 Get the catheters out 1 Vaccinate Prevent Transmission Use Antimicrobials Wisely Diagnose & Treat Effectively Prevent Infections

Guidelines

IDSA/SHEA guidelines on Antimicrobial Stewardship (2007)

Antimicrobial Stewardship

Guidelines and clinical pathways

Multidisciplinary development of evidence-based practice guidelines incorporating local microbiology and resistance patterns can improve antimicrobial utilization (A-I)

Clinical Microbiology Lab

Critical role in Antimicrobial Stewardship by providing patient-specific culture and susceptibility data to optimize individual antimicrobial management, and by assisting infection control efforts in the surveillance of resistant organisms and in the molecular epidemiologic investigation of outbreaks (A-III)

IDSA/SHEA – Guidelines for developing an Institutional Program to Enhance Antimicrobial Stewardship CID 2007:44;159-177

Guidelines

IDSA/SHEA guidelines on Antimicrobial Stewardship (2007)

CDC/HICPAC - Management of MDRO in healthcare settings (2006)

JCI standards (IM.4/ IM.8)

“The hospital collects and analyzes aggregate data to support patient care and operations”

CLSI guidelines

Pre-2000: No consistent guidelines

First version released in 2000 (M-39P)

Updated in 2002 (M39-A)

Nov 2005

Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data: Approved Guideline – Second Edition (M39-A2); Vol.25 No.28

Guide empiric AM therapy while culture results pending

Clinical application depends on organism, AM agent (Pk / Pd) & clinical context

Reflect patient care needs & hospital formulary

Critical role in monitoring AMR patterns/trends

CLSI. Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data. M39-2A, 2005

Antibiogramme Desirable features

Annual reporting of results

Report results in “percent susceptible” (Pen & Strept. pneumo)

Only results from first isolates/patient; duplicate isolate notification

Exclude surveillance isolates

Number of isolates for each organism Best to report for bacteria with >30 isolates (earlier 10 isolates) Organisms morphological grouping

Description of exact collection period

Use of Generic names of antimicrobials

Utilization of “dash” to describe susceptibility data not reported

CLSI. Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data. M39-2A, 2005

Antibiogramme Analysis ABGM Variability in 65 US hospitals Analysis and Presentation of Cumulative Antimicrobial Susceptibility Data (Antibiograms) Substantial Variability Across Medical Centers in the United States. Infect Control Hosp Epidemiol Apr2006; 27:409-412

Antibiogramme Quality indicators

Inconsistent beta lactam susceptibility of S. aureus

Vancomycin susceptibility <100% for S. aureus / Strept. pneumoniae

Isolates of Enterococcus spp. tested against cephalosporin or cotrimoxazole

Imipenem susceptibility <100% for E. coli

Imipenem susceptibility for Stenotrophomonas maltophilia

Third generation Cephalosporins susceptibility <100% for Haemophilus influenzae

Ampicillin susceptibility in Kleb. pneumoniae

Frequency of S. pneumoniae susceptibility performed

JCM. Nationwide ABGM analysis using NCCLS M39-A Guidelines. Jun2005:43(6);2629-33

Verify the data "It checks out OK on the computer… now let's confirm it with the pendulum"

GNB trends ABC hospital: 2005-2007 Green = susceptibility increased by greater than 10% during the study period Red = susceptibility decreased by greater than 10%, Yellow = change less than 10% but clinically significant resistance exist Drug E. coli Pseud. aeruginosa Kleb. pnuemo. Proteus mirabilis Enterob. cloacae Serratia marcescens Enterob. aerogenes Ampicillin 63 49 Amp-Sul 64 75 Pip-Tzp 59 83 Ceftriaxone 65 Ceftazidime 71 68 89 Cefipime 62 Levofloxacin 85 R 46 75 Cipro 85 R 46 75 Gentamicin 57 62 Tobramycin 58 87 86 Cotrimoxazole 57 Imipenem 77

GPC R-trends XYZ hospital: 2004-2007 MRSA and VRE trends 20% 40% 60% 80% 2004 2005 2006 2007 MRSA % 0% 1% 2% 3% 4% 5% 6% VRE % MRSA VRE

Distribution of ABGM

Prescribers, Infection Control, pharmacists & microbiology personnel

Format

Pocket guides

Laminated cards

Website – intranet / internet

Printed newsletters

CLSI M39-A2

SGRH http://www.sgrh.com/newsletters/mb%20jul%202007.pdf

http://www.sgrh.com/category.aspx?id=10

Microbiology

Newsletter SGRH

Started in July 1995

Online from May 2000

CNBC http://cnbc.delhigovt.nic.in/pdf/Newsletter.pdf

FH-N/VK Courtesy: Dr Ashok Rattan

WHONET A Microbiology Data Management Tool

Software developed by

Thomas O Brien, Boston

John Stelling, WHO

Goals

Enhanced local use of lab data and analysis

Promote collaboration through exchange of data between national and international networks

Lab Networking in India

Networking amongst labs at local/regional and national levels for

Data sharing

Strengthening Quality Assurance

National guidelines

WHONET facilitates

Simple reporting

Selection of antimicrobial agents

Identification of hospital outbreaks

Recognition of QC problems in lab testing

+ Review of antimicrobial results permits characterization of

Resistance mechanisms

Epidemiology of resistant strains

WHONET

In-built mechanism for “expert” analysis of >400 antimicrobial agents (codes)

Customise locations – OPD / hospital wards / facilities

>2000 pathogens

>85 specimens

Methods of AST

Disk Diffusion / Etest / MIC

Performs 14 types of analyses for monitoring drug resistance

Windows version; 18 languages

BacLink software Import & analyze antimicrobial susceptibility data from software / automated ABST instruments Comp Software Lab Systems WHONET BacLink Excel Access EpiInfo Lab Instruments Mysis MEDITECH ADBakt MIC systems Disk diffusion readers Data analysis Data Conversion

Laboratory Information Systems & Other Formats

Laboratory Information Systems

ADBakt (Sweden) – MEDITECH Client/Server*

Cerner Classic – MEDITECH Magic

Cerner Millenium* – MYSIS*

MADS (Denmark) – Oman Laboratory Information System

Medicom – WinPath

Other formats

CDC ELR format* – NARMS (United States)

EARSS (European Union) – NORM (Norway)

JIAQA (Japan) – WHO-AFRO Bacteriology Lab (Africa)

* = In development

Susceptibility Test Instruments

Microdilution systems

ATB

Mast Scan

MIC 2000

Microscan

Pasco

Phoenix

Sceptor

Sensititre

Vitek

Wider

Disk diffusion readers

Aura

Biomic

Mast Radius

Osiris

SirScan

Videobac

Wider

WHONET Use in the World >1300 laboratories in >90 countries

African Regional Office of WHO (AFRO)

Algeria, Kenya, Namibia, South Africa, Tanzania, Zambia

Eastern Mediterranean Regional Office of WHO (EMRO)

Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Saudi Arabia, Tunisia

European Regional Office of WHO (EURO)

Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Iceland, Ireland, Israel, Italy, Latvia, Luxembourg, Malta, Netherlands, Norway, Poland, Portugal, Romania, Russia, Slovakia, Slovenia, Spain, Sweden, Ukraine, United Kingdom

Pan-American Health Organization (PAHO)

Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, United States, Uruguay, Venezuela