dr neeraj goel sr. consultant department of clinical...
TRANSCRIPT
Dr Neeraj Goel
Sr. Consultant
Department of Clinical MicrobiologySir Ganga Ram Hospital
Resistance profile of MDROs in ICU:Quinolone: 80%
Amikacin: 75%
Cefaperazone sulbactum: 79%
Carbapenems: 79%
Adapted from Infectious Diseases Society of American (IDSA). Available at http://www.idsociety.org/pa/IDSA_Paper4_final_web.pdf. Accessed July
2005;
Cosgrove SE et al Arch Intern Med 2002;162:185–190; Ben-David D, Rubenstein E Curr Opin Infect Dis 2002;15:151–156; Colodner R et al Eur J
Clin Microbiol Infect Dis 2004;23:163–167.
Super BUGsMDR/Nosocomial
Gm +MRSA
Gm –Klebsiella
E.ColiPseudomonas
Acinetobacter
ESBLs
Association b/w antibiotic use and AMR
Autoregressive Integrated Moving Average Model
Significant correlation between carbapenem use and its resistance in A. baumannii
12 Steps to Prevent Antimicrobial
Resistance: Hospitalized Adults
Campaign to Prevent Antimicrobial Resistance in Healthcare Settings
12 Break the chain11 Isolate the pathogen
10 Stop treatment when cured9 Know when to say “no” to vanco
8 Treat infection, not colonization7 Treat infection, not contamination
6 Using Antibiogram5 Practice antimicrobial control
4 Access the experts3 Target the pathogen
2 Get the catheters out1 Vaccinate
Prevent Transmission
Use Antimicrobials
Wisely
Diagnose & Treat
Effectively
Prevent Infections
▪ 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
Guidelines
CDC - Campaign to Prevent Antimicrobial
Resistance in Healthcare Settings
IDSA/SHEA guidelines on Antimicrobial
Stewardship (2007)
JCI standards (IM.4/ IM.8)
“The hospital collects and analyzes aggregate
data to support patient care and operations”
Recommends providing Antibiogram
to the clinicians as mandatory to control the spread of MDRO
Definition
Report generated by analysis of isolates
from a particular institute in a defined
period of time that reflects the percentage
susceptibility to each of the antimicrobial
agents routinely tested
Pre-2000: No consistent guidelines- Diversity in calculation algorithims
- Poor comparability of data b/w institutes
First version released in 2000 (M-39P)
CLSI. Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data. M39-2A, 2005
Data should be analyzed annually
If there are large number of isolates then it
can be done 6 monthly.
Number of Isolates
Minimum no of isolates: 30
Adequate numbers is required for statistically meaningful data.
N= 10 Sensitivity= 90% 95% CI= 55%-100%
N= 100 Sensitivity= 90% 95% CI= 88%-92%
If < 30 isolates: Acceptable to include isolates over a longer period.
Report only % susceptibility
Clinicians: focus on likelihood of a successful response
Microbiologists: % R is more important
Focus on changing trends of resistance
IS results should be reported as R
Location: OPD, WARD, ICU
OPD data excludes the community data
Sensitivity of A. baumannii in blood to IMP is 20% ICU vs 43% in wards
Specimen type Blood, urine, respiratory tract, pus and fluids
Organism type GPC
GNB
Surveillance/ screening cultureseg., MRSA, VRE screening.
Repeat isolatesLowers the % susceptibility as MDROs are more often from:
Patients with longer hospital stays
Patients on multiple antibiotics
Examples:
- 6 year period study on S. aureus 1
MRSA contributed 39% duplicate (1.90 mean ratio).
MSSA contributed 23% duplicates (1.35 mean ratio)
- 4 years study on P. aeruginosa % sensitivity 2
All isolates included Repeat isolates excluded
Imipenem 70% 80%
Ceftazidime 56% 69%
Ciprofloxacin 67% 74%
Gentamicin 72% 84%
1. Horvat RTet al. J Clin Microbiol 2003;41:4611-16
2. Wilkinson ST et al. Presented at the annual meeting of the American College of Clinical Pharmacy, San Francisco, CA, October 23-26, 2005
Patient based (recommended by M 39,CLSI)
• First isolate per patient irrespective of the site.
• Fewer assumptions
• Simpler calculations
• Eliminates maximum number of isolates
Description of exact collection period
Use of Generic names of antimicrobials
Utilization of “dash” to describe
susceptibility data not reported
1. Vancomycin susceptibility <100% for S. aureus
/ Strept. pneumoniae
2. Isolates of Enterococcus spp. tested against
cephalosporin or cotrimoxazole
3. Imipenem susceptibility for Stenotrophomonas
maltophilia
4. Ampicillin susceptibility in Kleb. pneumoniae
5. Sudden changes in the sensitivity patterns.
JCM. Nationwide ABGM analysis using NCCLS M39-A Guidelines. Jun2005:43(6);2629-33
Prescribers, Infection Control, pharmacy &
microbiology personnel
Format
Pocket guides
Laminated cards
Printed newsletters
Website
CLSI M39-A2
✓Online from May 2002
http://www.sgrh.com Publication Microbiology NL
Data of your own hospital is needed
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. coliPseud.
aeruginosaKleb. 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 62Levofloxacin 85 34 46 75
Cipro 85 56 46 75
Gentamicin 57 62
Tobramycin 58 87 86
Cotrimoxazole 57
Imipenem 77
0
10
20
30
40
50
60
70
80
90
100
Penicillin
Oxacillin
Clindamycin
Gentamicin
Vancomycin
% Resistance - S. aureus -- IPD
0
10
20
30
40
50
60
70
80
90
100
2010 2011 2012 2013 2014 2015 2016
Ward
ICU
% Vancomycin Resistance Enterococci spp. (IPD)
0
10
20
30
40
50
60
70
80
90
100
Ampicillin
Ceftriaxone
Gentamicin
Amikacin
Ciprofloxacin
Piperacillin + Tazobactum
Cefaperazone + Sulbactum
Imipenem
% Resisance - E.coli - Blood Isolates - IPD
0
10
20
30
40
50
60
70
80
90
100
Ceftriaxone
Gentamicin
Amikacin
Ciprofloxacin
Piperacillin + Tazobactum
Cefaperazone + Sulbactum
Imipenem
Colistin
% Resistance - Klebsiella - Blood Isolates - IPD
0
10
20
30
40
50
60
70
80
90
100
1999 2000 2001 2002 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Ampicillin
Ceftriaxone
Ceftazidime
Gentamicin
Amikacin
Ciprofloxacin
Piperacillin + Tazobactum
Cefaperazone + Sulbactum
Imipenem
Tigecycline
Colistin
0
10
20
30
40
50
60
70
80
90
100
Ceftazidime
Gentamicin
Netilmicin/Amikacin
Ciprofloxacin
Piperacillin +Tazobactum
Cefaperazone +Sulbactum
Imipenem
Colistin
% Resistance - Pseudomonas - Blood Isolates - IPD
Antibiotic trend analysis at SGRH 1999-2008
Antibiogram: In formulating empirical antibiotic policy Incorporates local microbiology and resistance
patterns.
Crit Care Med, 34: 1589-1596, 2006.
- Optimum Empirical Antibiotic Therapy
•If appropriate antibiotic
therapy in the 1st hr:
survival rates of 80 %
• Each of hour of delay in
institution of appropriate
therapy decreases
survival by 7%
Ampi Cefurox Ceftriax Ceftaz Cefep Aztreo Ampi+sulbactum
Pipera+tazobactum
Cefo+sulbctum
Quin Genta Amik Netil Erta Imi Coli
Klebsiella spp. 10 11 19 12 18 21 21 22 25 22 21 21 87
Acinetobacter spp. 2 8 0 18 8 12 16 10 21 50 14 96
E.coli 12 12 12 29 12 50 50 12 48 76 72 64 63 98
P. aeruginosa 71 71 38 67 75 74 71 71 73 67 100
Enterobacter spp. 20 41 47 47 53 65 63 71 82 92 71 72 88
Identify the Five most sensitive antibiotics
Klebsiella spp.30%
Acinetobacter spp.17%
E.coli13%
Pseudomonas aeruginosa7%
Staph aureus6%
Enterobacter spp.5%
Burkholderia cepacia5%
Others17%
Klebsiella spp.
Acinetobacter spp.
E.coli
Pseudomonas aeruginosa
Staph aureus
Enterobacter spp.
Burkholderia cepacia
Others
Identify the Five most common pathogens
Blo
od S
team
Infe
cti
ons
(IC
U)
Hospital surveillance data
S. No Most common
pathogens
%
prevalence
Most sensitive antibiotics
1 Klebsiella
spp.
30% Colistin (87%), Amikacin(25%), Imipenem (22%),
Netilmicin (22%), Cefoperazone+sulbactum (21%)
2 Acineobacter
spp.
16% Colistin (96%), Netilmicin (50%), Amikacin (21%),
Ampicillin+sulbactum (18%),Imipenem(14%)
3 E.coli 12% Colistin (98%), Amikacin (76%), Netilmicin (72%),
Ertapenem (64%), Imipenem / Meropenem (63%)
4 P. aeruginosa 7% Colistin (100%), Imipenem (75%), Quinolones (74%),
Netilmicin (73%), Ceftazidime (71%)
5 Staph aureus 6% Glycopeptide (100%), Linezolid (100%), Daptomycin
(100%), Clindamycin (44%), Gentamicin (44%)
Tool Kit for Blood culture- ICU
Note: Cut off value to be used as empiric antibiotic is 80%
*Choices written in red have sensitivity less than 80%
Preferably Use Colistin as reserved drug, not as empiric
In the same way Tool kit can be made for :
BSI (Ward and ICU)
UTI (Ward and ICU)
SSTI (Ward and ICU)
Pneumonia (Ward and ICU)
IAI (Ward and ICU)
The risk stratification is based on 3 factors:
1) Contact with Health Care System
2) Prior use of antibiotic
3) Patient Characteristics
Health Care
Contact
Antibiotic Rx
History
Patients
Characteristics
No
No in last 90 days
Young – No co-
morbid conditions.
+ve
+ve in last 90 days
Elderly
Few Co-morbid
conditions.
Prolonged
Repeat multiple
antibiotics.
Immunocompromised,
or with many co-
morbid conditions.
Type 1 Type 2 Type 3
Causative
Pathogen could
be
ESBL+/-
Susceptible to
Common
narrow
spectrum
antibiotics
ESBLs +/MRSA CRE / MDR
Pseudomonas
/Acinetobacter+/-
VRE
• Antimicrobial resistance ? (MRSA, VRE, ESBL, CRE)
• Antimicrobial survellance ?
• Antimicrobial use?
If the answer is NO -----
Information systems are not available to retrieve the data
automatically.
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
A Microbiology Data Management Tool
In-built mechanism for “expert” analysis of
antimicrobial agents
Customise locations – OPD / hospital wards / ICUs
>2000 pathogens
>85 specimens
Methods of AST
Disk Diffusion / Etest / MIC
Windows version; 18 languages
Comp Software Lab Systems
WHONET
BacLink
Excel
Access
EpiInfo
Lab Instruments
Mysis
MEDITECH
ADBakt
MIC systems
Disk diffusion
readers
Data analysis
Data Conversion
LIS Server
Hospital
Information
systemInfection Control
Pharmacy
CONNECTIVITY
WORKFLOWWORKFLOW
INFORMATION
MANAGEMENT
PREVI Isola™BacT/ALERT®
VITEK® 2
VITEK® 2
VITEK® 2
Vitek-MS
Purchase
Prodigious software
Manual Entry, retrieval and calculation
Speedminer
Automated entry and retrieval
Manual calculation
SGRH is publishing microbiology newsletter since: 1995
1998: Manual software (Foxpro)Manual data entry, retrieval, calculations > 2000 sheets of paper > 1000 manhoursChances of error in entry, retrieval and calculation
2008: Speedminer Data entry and retrieval automated, manual calculation
Electronic data: No paper50 manhours to compile the dataManual calculations of dataChances of error due to calculations
2010: SGRH Protech software –No paper
0 manhoursData entry and retrieval automatedNo errors
Increasing prevalence of AMR
Antibiotics should be conserved
Antibiogram
Prepared according to CLSI document
Helps in
Formulating in antibiotic policy
AMR surveillance
Detection of new AMR
IT support is essential for making ABG
If you cannot measure , you cannot
manage.
If you cannot manage, you can not
improve.
We measure what we value.
Let us value our data and start
measuring it
Paradigm for empiric therapy:
“In Early, Hit Hard, Out Early”
0
2
4
6
8
10
12
14
16
'83-'87 '88-'92 '93-'97 '98-'02 '03-'07 '08-'12
To
tal
# N
ew
An
tib
acte
ria
l A
gen
ts
’83-’87
1. Annual reporting of results
2. Report results in “percent susceptible” (Pen & Strept.
pneumo)
3. Only results from first isolates/patient; duplicate isolate
notification
4. Exclude surveillance isolates
5. Number of isolates for each organism
Best to report for bacteria with >30 isolates (earlier 10
isolates)
Organisms morphological grouping
6. Description of exact collection period
7. Use of Generic names of antimicrobials
CLSI. Analysis and Presentation of Cumulative Antimicrobial Susceptibility Test Data. M39-2A, 2005
PAN RESISTANT BACTERIA