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7/28/2019 Clinical Reporting (4)
1/15
Clinically-Oriented AST Reporting &
Antimicrobial Stewardship
Hsu Li Yang
27th September 2013
Potential Conflicts of Interest
Research Funding: Pfizer Singapore AstraZeneca Janssen-Cilag Merck, Sharpe & Dohme
Advisory Board: Doripenem (Janssen-Cilag) Adult pneumococcal vaccine & Tigecycline (Pfizer)
Conference sponsorships: Pfizer Singapore Janssen-Cilag Merck, Sharpe & Dohme
Reporting AST
Results that impact clinician antimicrobialprescribing and make a difference in patient
outcomes.
Time
Resistance results
Caveats against certain drugs
Evidence-based guidance
Schematic
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Time to Antibiotics Susceptibility Results
Blood culture: MRSA PENICILLIN R
AMPICILLIN R
CLOXACILLIN R
CEPHALOTHIN R
GENTAMICIN S
COTRIMOXAZOLE S
CLINDAMYCIN R
VANCOMYCIN S
CIPROFLOXACIN S FUSIDIC ACID S
RIFAMPICIN S
Susceptibility Results (1)
Blood culture: MRSA PENICILLIN R
AMPICILLIN R CLOXACILLIN R
CEPHALOTHIN R
GENTAMICIN S
COTRIMOXAZOLE S
CLINDAMYCIN R
VANCOMYCIN S
CIPROFLOXACIN S
RIFAMPICIN S
Susceptibility Results (2)
Blood culture: Enterobacter cloacae AMPICILLIN R
AMPICILLIN/SULBACTAM S CEFTRIAXONE S
PIPERACILLIN/TAZOBACTAM S
IMIPENEM S
GENTAMICIN S
COTRIMOXAZOLE S
CIPROFLOXACIN S
Comment: intrinsic and inducible ampCproduction cephalosporins and penicillins not
recommended for treatment of severe infections
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Susceptibility Results (3)
Blood culture: Enterobacter cloacae AMPICILLIN R AMPICILLIN/SULBACTAM S
CEFTRIAXONE R
PIPERACILLIN/TAZOBACTAM S
IMIPENEM S
GENTAMICIN S
COTRIMOXAZOLE S
CIPROFLOXACIN S
Comment: intrinsic and inducible ampCproduction cephalosporins and penicillins not
recommended for treatment of severe infections
Susceptibility Results (4)
Blood culture: MRSA COTRIMOXAZOLE S VANCOMYCIN S
Message: This is not to be regarded as acontaminant. The optimal antibiotics according to
current guidelines are IV Vancomycin or IV
Daptomycin (in the absence of MRSA
pneumonia). Please repeat blood cultures and
exclude endocarditis by echocardiography.
Intermission
Ability to Prevent and/or Treat Bacterial Infections is a Building
Block of Medicine
Images from the Internet (including http://www.nature.com).
7/28/2019 Clinical Reporting (4)
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Treatment Spectrum
Shorter duration of
antibiotics
(Under-treatment)
Longer duration of
antibiotics
(Over-treatment)
Optimal Treatment
Narrower-Spectrum Antibiotics Broader-Spectrum Antibiotics
Physician Risk-Aversion Practices
Treatment Spectrum
Shorter duration of
antibiotics
(Under-treatment)
Longer duration of
antibiotics
(Over-treatment)
Adverse Outcome
- Mortality/Morbidity
- Higher cost/stay
- Antibiotic resistance
- Drug adverse effects
Narrower-Spectrum Antibiotics Broader-Spectrum Antibiotics
Antibiotic Fallacies:
Spiralling Empiricism
Broader is better
Failure to respond is failure to cover
When in doubt, change drugs or add another
More diseases = more drugs
Antibiotics are nontoxic
Kim JH, et al. Am J Med. 1989;87:201-6.
Vicious Cycle of Antibiotics and
Resistance
New Broad-SpectrumAntibiotics
RisingResistance
Trends to OldAntibiotics
AppropriateEmpiricalTherapy
Saves Lives
More Broad-SpectrumAntibioticsPrescribed
HigherResistance
Rates
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World Economic Forum 2013
Global Risks 2013: Available at:
http://www3.weforum.org/docs/WEF_GlobalRisks_Report_2013.pdf
Conserving Existing Antibiotics
Antimicrobial Stewardship
National Call for ASP
Hsu LY, et al. Singapore Med J. 2008;49:749.
ASP: Objectives
Reduce inappropriate prescribing and use ofantimicrobials.
Reduce emergence of antimicrobialresistance.
Reduce preventable adverse drug events andlength of stay for patients due to infections.
Improve cost-effective use of antimicrobials.
Safety.
Slide courtesy of Ms ChayLeng Yeo
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Forms of Stewardship
Prospective audit and feedback.
Antibiotic restriction.Permission required for prescription
Automatic stop orders
Antibiotic cycling
Other elements:Education of providersGuidelines
Computerized clinical decision support
Dellit, et al. Clin Infect Dis. 2007;44:159-77.
National University Hospital
ASP commenced July 2009.
- IV to PO switch
- Recommendation for
duration of therapy
Singapore General Hospital
Formal prospective audit and feedback ASP in2008.
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Patient is on ceftriaxone
Click on ARUS-C guidance buttonARUS-C History contains selected
patients ARUS-C record
Summary of data
ARUS-C recommends2 weeks of IV Ampicillin
ARUS-C helps you stopCeftriaxone unless you
want to keep by over-riding
ARUS-C
ARUS-C briefly updatesyou on the ID condition
Issues and Barriers
Sustainability of current AS programs.Financial
Personnel: passion and career tracks
Continued opposition from prescribers due toperceived challenge to autonomy.
Lack of awareness and adherence toguidelines and clinical pathways.
Barriers: Prescribing Etiquette
Non-interference with prescribing decisions of colleagues: Autonomous decision of prescribing.
Accepted non-compliance to policy:
Hierarchy and expertise (not policy) as determinants of prescribing behavior.
Hierarchy of prescribing: Senior doctors decide, junior doctors prescribe.
Charani E, et al. Clin Infect Dis. 2013. In press.
7/28/2019 Clinical Reporting (4)
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Thank You!
Email:
Antibiotic Resistance Surveillance:
Cumulative Antibiogram & Software for
Resistance Surveillance
Hsu Li Yang
27th September 2013
Potential Conflicts of Interest
Research Funding: Pfizer Singapore AstraZeneca
Janssen-Cilag Merck, Sharpe & Dohme
Advisory Board: Doripenem (Janssen-Cilag) Adult pneumococcal vaccine & Tigecycline (Pfizer)
Conference sponsorships: Pfizer Singapore
Janssen-Cilag Merck, Sharpe & Dohme
Why Perform Surveillance
Monitor trends in resistance and prescription.
Try to correlate the above.
Helps guide empirical antibiotic therapy.
Define thresholds for interventions.
Detect emergence of new resistant pathogens.
O'Brien TF, Stelling J. Integrated Multilevel Surveillance of the World's Infecting Microbes and Their
Resistance to Antimicrobial Ag ents. Clin Microbiol Rev. 2011; 24: 281-295.
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Alphabet Soup of Resistance
Multidrug-resistant (MDR): Acquired non-susceptibility
to 3 or more antibioticcategories.
Extensively drug-resistant(XDR): Non-susceptibility to all but
2 or fewer antibioticcategories.
Pandrug-resistant (PDR): Resistant to all drugs in all
antibiotic categories.
Magiorakos AP, et a l. Clin Microbiol Infect. 2012;18:268-81.
CRE
Acinetobacter baumannii
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Carbapenems Carbapenems
Correlation: Prescription/Resistance Antibiogram
periodic summary of antimicrobial susceptibilitiesof local bacterial isolates
Uses:
1. Assess local susceptibility rates
2. Guide to empiric therapy
3. Formulating guidelines & formulary
4. Monitoring resistance trends
5. Quality control tool
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Antibiogram: limitations
Representative population
Duplicate patients / isolates
Isolates, not infection
Aggregate data may not reflect local data
No clinical data
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-10 11-20 21-30 31-40 41-50 51-60 61-70 >70
R
I
S
Ciprofloxacin & E. coli:
by age
Age range
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Quality control
Boehme MS et al. Systematic Review of Antibiograms: A National Laboratory Syst em Approach for Improving
Antimicrobial Suscep tibility Testing Practices in Michigan. Public Health Rep. 2010; 125(Suppl 2): 6372.
Guidance documents
Hindler, J. F., & Stelling, J. (2007). A nalysis and presen tation of cumulative
antibiograms: a new con sens us guideline from the Clinical and Laboratory
Standards Inst itute. Clinical Infectious Diseas es, 44(6), 867-873.
Guidance
1. definitions for classifying isolates as clinically relevantor as contaminants
2. definitions of duplicate isolates
3. procedures for eliminating contaminant and duplicateisolates from data sets
4. criteria for classifying isolates as susceptible orresistant on the basis of current published criteria
5. criteria to define and separate isolates recoveredfrom inpatients from those recovered fromoutpatients
6. criteria for the minimal number of isolates necessaryfor statistical analysis.
Wilson ML. Ass uring the Quality of Clinical Microbiology Test Results. Clin Infect Dis. 2008; 47: 1077-1082.
Tools
Laboratory
Information
System
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Tools
Laboratory
Information
System
Baclink:
Capture and standardizing of data from existing
information systems.
WHONET:
Desktop application for the entry and analysis of
microbiology data.
Baclink:
Capture and standardizing of data from existing
information systems.
WHONET:
Desktop application for the entry and analysis of
microbiology data.
Tools
Laboratory
Information
System
WHONET Software WHONET Software
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WHONET SoftwareWHONET Software
WHONET SoftwareWho gives a d**n?
74% used Sanford Guide antibiograms
64% never used hospital antibiogram
61% did not know where to find hospital
antibiogram
Mermel LA, Jefferson J, Devolve J.
Knowledge and Use of Cumulative A ntimicrobial Suscept ibility Data at a University Teaching Hos pital. Clin Infect Dis. 2008; 46: 1789-1789.
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Thank You!
Email: