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Role of the Laboratory in Antimicrobial Resistance Data


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Role of the Laboratory in Collection, Analysis and Circulation of Antimicrobial Resistance Data

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Role of the Laboratory in Antimicrobial Resistance Data

  1. 1. The Role of the Laboratory Collection, Analysis & Circulation of Antimicrobial Resistance Data Dr Anuj Sharma World Health Organization, India
  2. 2. Outline <ul><li>Role of Microbiology Lab in Antimicrobial Resistance (AMR) </li></ul><ul><li>Antibiogramme (ABGM) </li></ul><ul><li>Why prepare ABGM? </li></ul><ul><li>CLSI guidelines </li></ul><ul><li>ABGM – Features, Quality Indicators, Trends & Examples </li></ul><ul><li>WHONET </li></ul>
  3. 3. Role of Microbiology Lab <ul><li>Diagnostic lab work </li></ul><ul><li>Advice to clinicians - treatment of infected patients </li></ul><ul><li>Infection control </li></ul><ul><li>Close personal contact with clinicians in daily treatment of patients ensures rational AM use </li></ul>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
  4. 4. Uses of AMR Data <ul><li>Laboratory quality improvement </li></ul><ul><ul><li>Routine ABST testing </li></ul></ul><ul><ul><li>Better utilization of lab services by clinical staff </li></ul></ul><ul><li>Infection control & outbreak preparedness </li></ul><ul><ul><li>Identification of new & problem pathogens </li></ul></ul><ul><ul><li>Identification & investigation of HAI outbreaks </li></ul></ul><ul><ul><li>Drug resistance surveillance to monitor trends in infections and resistance - periodic review of MICs / zone inhibition diameters </li></ul></ul>
  5. 5. Uses of AMR Data <ul><li>Develop and implement Antimicrobial policy / guidelines </li></ul><ul><ul><li>Develop treatment guidelines </li></ul></ul><ul><ul><li>Characterization of cross-resistance </li></ul></ul><ul><li>Research </li></ul><ul><ul><li>New resistance mechanisms </li></ul></ul><ul><ul><li>Risk factors for resistance </li></ul></ul><ul><li>Evaluation of interventions </li></ul>
  6. 6. Antibiogramme (ABGM) <ul><li>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 </li></ul>
  7. 7. Why prepare an antibiogramme? <ul><li>Guidelines </li></ul><ul><ul><li>CDC - Campaign to Prevent Antimicrobial Resistance in Healthcare Settings </li></ul></ul>
  8. 8. 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults <ul><li>Fact : The prevalence of resistance can vary by locale, patient population, hospital unit & length of stay </li></ul><ul><li>Actions : </li></ul><ul><ul><li>Know your local ABGM </li></ul></ul><ul><ul><li>Know your patient population </li></ul></ul>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
  9. 9. Why prepare an antibiogramme? <ul><li>Guidelines </li></ul><ul><ul><li>CDC - Campaign to Prevent Antimicrobial Resistance in Healthcare Settings </li></ul></ul><ul><ul><li>IDSA/SHEA guidelines on Antimicrobial Stewardship (2007) </li></ul></ul>
  10. 10. Antimicrobial Stewardship <ul><li>Guidelines and clinical pathways </li></ul><ul><ul><li>Multidisciplinary development of evidence-based practice guidelines incorporating local microbiology and resistance patterns can improve antimicrobial utilization (A-I) </li></ul></ul><ul><ul><li>Clinical Microbiology Lab </li></ul></ul><ul><ul><ul><li>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) </li></ul></ul></ul>IDSA/SHEA – Guidelines for developing an Institutional Program to Enhance Antimicrobial Stewardship CID 2007:44;159-177
  11. 11. Why prepare an antibiogramme? <ul><li>Guidelines </li></ul><ul><ul><li>CDC - Campaign to Prevent Antimicrobial Resistance in Healthcare Settings </li></ul></ul><ul><ul><li>IDSA/SHEA guidelines on Antimicrobial Stewardship (2007) </li></ul></ul><ul><ul><li>CDC/HICPAC - Management of MDRO in healthcare settings (2006) </li></ul></ul><ul><li>JCI standards (IM.4/ IM.8) </li></ul><ul><ul><li>“The hospital collects and analyzes aggregate data to support patient care and operations” </li></ul></ul>
  12. 12. CLSI guidelines <ul><li>Pre-2000: No consistent guidelines </li></ul><ul><li>First version released in 2000 (M-39P) </li></ul><ul><li>Updated in 2002 (M39-A) </li></ul><ul><li>Nov 2005 </li></ul><ul><ul><li>Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data: Approved Guideline – Second Edition (M39-A2); Vol.25 No.28 </li></ul></ul>
  13. 13. Antibiogramme (ABGM) <ul><li>Guide empiric AM therapy while culture results pending </li></ul><ul><li>Clinical application depends on organism, AM agent (Pk / Pd) & clinical context </li></ul><ul><li>Reflect patient care needs & hospital formulary </li></ul><ul><li>Critical role in monitoring AMR patterns/trends </li></ul>CLSI. Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data. M39-2A, 2005
  14. 14. Antibiogramme Desirable features <ul><li>Annual reporting of results </li></ul><ul><li>Report results in “percent susceptible” (Pen & Strept. pneumo) </li></ul><ul><li>Only results from first isolates/patient; duplicate isolate notification </li></ul><ul><li>Exclude surveillance isolates </li></ul><ul><li>Number of isolates for each organism Best to report for bacteria with >30 isolates (earlier 10 isolates) Organisms morphological grouping </li></ul><ul><li>Description of exact collection period </li></ul><ul><li>Use of Generic names of antimicrobials </li></ul><ul><li>Utilization of “dash” to describe susceptibility data not reported </li></ul>CLSI. Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data. M39-2A, 2005
  15. 15. 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
  16. 16. Antibiogramme Quality indicators <ul><li>Inconsistent beta lactam susceptibility of S. aureus </li></ul><ul><li>Vancomycin susceptibility <100% for S. aureus / Strept. pneumoniae </li></ul><ul><li>Isolates of Enterococcus spp. tested against cephalosporin or cotrimoxazole </li></ul><ul><li>Imipenem susceptibility <100% for E. coli </li></ul><ul><li>Imipenem susceptibility for Stenotrophomonas maltophilia </li></ul><ul><li>Third generation Cephalosporins susceptibility <100% for Haemophilus influenzae </li></ul><ul><li>Ampicillin susceptibility in Kleb. pneumoniae </li></ul><ul><li>Frequency of S. pneumoniae susceptibility performed </li></ul>JCM. Nationwide ABGM analysis using NCCLS M39-A Guidelines. Jun2005:43(6);2629-33
  17. 17. Verify the data &quot;It checks out OK on the computer… now let's confirm it with the pendulum&quot;
  18. 18. 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
  19. 19. 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
  20. 20. Distribution of ABGM <ul><li>Prescribers, Infection Control, pharmacists & microbiology personnel </li></ul><ul><li>Format </li></ul><ul><ul><li>Pocket guides </li></ul></ul><ul><ul><li>Laminated cards </li></ul></ul><ul><ul><li>Website – intranet / internet </li></ul></ul><ul><ul><li>Printed newsletters </li></ul></ul>CLSI M39-A2
  21. 21. SGRH
  22. 22. <ul><li>Microbiology </li></ul><ul><li>Newsletter SGRH </li></ul><ul><li>Started in July 1995 </li></ul><ul><li>Online from May 2000 </li></ul>
  23. 23. CNBC
  24. 24. FH-N/VK Courtesy: Dr Ashok Rattan
  25. 25. FH-N/VK Courtesy: Dr Ashok Rattan
  26. 26. WHONET A Microbiology Data Management Tool <ul><li>Software developed by </li></ul><ul><ul><li>Thomas O Brien, Boston </li></ul></ul><ul><ul><li>John Stelling, WHO </li></ul></ul><ul><li>Goals </li></ul><ul><ul><li>Enhanced local use of lab data and analysis </li></ul></ul><ul><ul><li>Promote collaboration through exchange of data between national and international networks </li></ul></ul>
  27. 27. Lab Networking in India <ul><li>Networking amongst labs at local/regional and national levels for </li></ul><ul><ul><li>Data sharing </li></ul></ul><ul><ul><li>Strengthening Quality Assurance </li></ul></ul><ul><ul><li>National guidelines </li></ul></ul>
  28. 28. WHONET facilitates <ul><li>Simple reporting </li></ul><ul><li>Selection of antimicrobial agents </li></ul><ul><li>Identification of hospital outbreaks </li></ul><ul><li>Recognition of QC problems in lab testing </li></ul><ul><li>+ Review of antimicrobial results permits characterization of </li></ul><ul><li>Resistance mechanisms </li></ul><ul><li>Epidemiology of resistant strains </li></ul>
  29. 29. WHONET <ul><li>In-built mechanism for “expert” analysis of >400 antimicrobial agents (codes) </li></ul><ul><li>Customise locations – OPD / hospital wards / facilities </li></ul><ul><li>>2000 pathogens </li></ul><ul><li>>85 specimens </li></ul><ul><li>Methods of AST </li></ul><ul><ul><li>Disk Diffusion / Etest / MIC </li></ul></ul><ul><li>Performs 14 types of analyses for monitoring drug resistance </li></ul><ul><li>Windows version; 18 languages </li></ul>
  30. 30. 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
  31. 31. Laboratory Information Systems & Other Formats <ul><li>Laboratory Information Systems </li></ul><ul><ul><li>ADBakt (Sweden) – MEDITECH Client/Server* </li></ul></ul><ul><ul><li>Cerner Classic – MEDITECH Magic </li></ul></ul><ul><ul><li>Cerner Millenium* – MYSIS* </li></ul></ul><ul><ul><li>MADS (Denmark) – Oman Laboratory Information System </li></ul></ul><ul><ul><li>Medicom – WinPath </li></ul></ul><ul><li>Other formats </li></ul><ul><ul><li>CDC ELR format* – NARMS (United States) </li></ul></ul><ul><ul><li>EARSS (European Union) – NORM (Norway) </li></ul></ul><ul><ul><li>JIAQA (Japan) – WHO-AFRO Bacteriology Lab (Africa) </li></ul></ul><ul><li>* = In development </li></ul>
  32. 32. Susceptibility Test Instruments <ul><li>Microdilution systems </li></ul><ul><ul><li>ATB </li></ul></ul><ul><ul><li>Mast Scan </li></ul></ul><ul><ul><li>MIC 2000 </li></ul></ul><ul><ul><li>Microscan </li></ul></ul><ul><ul><li>Pasco </li></ul></ul><ul><ul><li>Phoenix </li></ul></ul><ul><ul><li>Sceptor </li></ul></ul><ul><ul><li>Sensititre </li></ul></ul><ul><ul><li>Vitek </li></ul></ul><ul><ul><li>Wider </li></ul></ul><ul><li>Disk diffusion readers </li></ul><ul><ul><li>Aura </li></ul></ul><ul><ul><li>Biomic </li></ul></ul><ul><ul><li>Mast Radius </li></ul></ul><ul><ul><li>Osiris </li></ul></ul><ul><ul><li>SirScan </li></ul></ul><ul><ul><li>Videobac </li></ul></ul><ul><ul><li>Wider </li></ul></ul>
  33. 33. WHONET Use in the World >1300 laboratories in >90 countries <ul><li>African Regional Office of WHO (AFRO) </li></ul><ul><ul><li>Algeria, Kenya, Namibia, South Africa, Tanzania, Zambia </li></ul></ul><ul><li>Eastern Mediterranean Regional Office of WHO (EMRO) </li></ul><ul><ul><li>Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Saudi Arabia, Tunisia </li></ul></ul><ul><li>European Regional Office of WHO (EURO) </li></ul><ul><ul><li>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 </li></ul></ul><ul><li>Pan-American Health Organization (PAHO) </li></ul><ul><ul><li>Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Cuba, Dominican Republic, Ecuador, El Salvador, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, United States, Uruguay, Venezuela </li></ul></ul><ul><li>South-East Asian Regional Office of WHO (SEARO) </li></ul><ul><ul><li>India, Indonesia, Sri Lanka, Thailand </li></ul></ul><ul><li>Western Pacific Regional Office of WHO (WPRO) </li></ul><ul><ul><li>China, Hong Kong (China), Japan, Republic of Korea, Malaysia, Philippines, Singapore, Taiwan, Viet Nam </li></ul></ul>
  34. 34. Free download
  35. 35. Summary <ul><li>Labs play an important role in collection, analysis and circulation of AMR data </li></ul><ul><li>ABGMs help in </li></ul><ul><ul><li>Choice of empiric AMs </li></ul></ul><ul><ul><li>Developing an Antimicrobial Policy </li></ul></ul><ul><ul><li>Monitor and evaluate trends of AMR </li></ul></ul><ul><li>All labs should publish ABGM </li></ul><ul><li>WHONET can help foster national & international collaboration / national guidelines </li></ul>
  36. 36. Thank you