Clinical Reporting

7/28/2019 Clinical Reporting

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Clinically-Oriented AST Reporting &

Antimicrobial Stewardship

Hsu Li Yang

27th September 2013


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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


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Reporting AST

Results that impact clinician antimicrobial

prescribing and make a difference in patient

outcomes.

Time

Resistance results

Caveats against certain drugs

Evidence-based guidance


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Schematic


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Time to Antibiotics


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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


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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


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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 ampC

production cephalosporins and penicillins not

recommended for treatment of severe infections


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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 ampC

production cephalosporins and penicillins not

recommended for treatment of severe infections


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Blood culture: MRSA COTRIMOXAZOLE S

VANCOMYCIN S

Message: This is not to be regarded as a

contaminant. The optimal antibiotics according to

current guidelines are IV Vancomycin or IV

Daptomycin (in the absence of MRSApneumonia). Please repeat blood cultures and

exclude endocarditis by echocardiography.


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Intermission


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Ability to Prevent and/or Treat Bacterial Infections is a Building

Block of Medicine

Images from the Internet (including http://www.nature.com).


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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


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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


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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.


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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


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Conserving Existing Antibiotics

Antimicrobial Stewardship


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National Call for ASP

Hsu LY, et al. Singapore Med J. 2008;49:749.


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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 Chay Leng 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 providers Guidelines

Computerized clinical decision support

Dellit, et al. Clin Infect Dis. 2007;44:159-77.


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National University Hospital

ASP commenced July 2009.


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- IV to PO switch

- Recommendation for

duration of therapy


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Singapore General Hospital

Formal prospective audit and feedback ASP in

2008.


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Patient is on ceftriaxone

Click on ARUS-C guidance buttonARUS-C History contains selected

patients ARUS-C record


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Summary of data

ARUS-C recommends

2 weeks of IV Ampicillin

ARUS-C helps you stop

Ceftriaxone unless you

want to keep by over-riding

ARUS-C

ARUS-C briefly updates

you on the ID condition


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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.


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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.


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Thank You!

Email:

[email protected]


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Antibiotic Resistance Surveillance:

Cumulative Antibiogram & Software for

Resistance Surveillance

Hsu Li Yang

27th

September 2013


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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


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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 Agents. 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 al. Clin Microbiol Infect. 2012;18:268-81.

CRE


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Acinetobacter baumannii


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Carbapenems


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Carbapenems


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Correlation: Prescription/Resistance


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Antibiogram

periodic summary of antimicrobial susceptibilitiesof local bacterial isolates

Uses:1. Assess local susceptibility rates

2. Guide to empiric therapy

3. Formulating guidelines & formulary4. 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


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ANTIBIOTIC SURVEILLANCE

Period of surveillance: Jan 2012 - Dec 2012

Site of isolation: URINE CULTURE

Organism n (%)

1 Escherichia coli 1901 43

2Klebsiella sp.

663 15

3 Enterococcus sp. 477 11

4 Pseudomonas aeruginosa 227 5

5 Proteus sp. 185 4

6 Enterobacter sp. 136 3

7 Staphylococcus aureus 127 3

8 Streptococcus, beta-haem. Group B 100 2

9 Acinetobacter baumannii 96 2

10 Klebsiella pneumoniae ssp. pneum 93 2

11 Citrobacter koseri (diversus) 78 2

2012

Antibiotic susceptibilities

Escherichia coli

ESBL positive

Antibiotic name n %S

Amikacin 1900 98

Amoxicillin/Clavulanic acid 1901 74

Aztreonam 1896 75

Ceftriaxone 1900 71

Cefuroxime axetil 1896 39

Cephalothin 1883 35

Ciprofloxacin 1900 53

Gentamicin 1901 83

Imipenem 1901 100

Meropenem 1899 100

Nitrofurantoin 1900 95

Piperacillin/Tazobactam 1899 95

Trimethoprim/Sulfamethoxazole 1901 55

21.4%

Gram-negative organisms


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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 System Approach for Improving

Antimicrobial Susceptibility Testing Practices in Michigan. Public Health Rep. 2010; 125(Suppl 2): 6372.


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Guidance documents

Hindler, J. F., & Stelling, J. (2007). Analysis and presentation of cumulative

antibiograms: a new consensus guideline from the Clinical and Laboratory

Standards Institute. Clinical Infectious Diseases, 44(6), 867-873.


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Guidance

1. definitions for classifying isolates as clinically relevantor as contaminants

2. definitions of duplicate isolates

3. procedures for eliminating contaminant and duplicate

isolates from data sets4. criteria for classifying isolates as susceptible or

resistant on the basis of current published criteria

5. criteria to define and separate isolates recovered

from inpatients from those recovered fromoutpatients

6. criteria for the minimal number of isolates necessaryfor statistical analysis.

Wilson ML. Assuring the Quality of Clinical Microbiology Test Results. Clin Infect Dis. 2008; 47: 1077-1082.


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Tools

Laboratory

Information

System


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Tools

Laboratory

Information

System


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Baclink:

Capture and standardizing of data from existinginformation systems.

WHONET:

Desktop application for the entry and analysis of

microbiology data.

Tools

Laboratory

Information

System


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WHONET Software


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WHONET Software


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WHONET Software

WHONET Software


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WHONET Software

WHONET Software


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WHONET Software


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Who 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 Antimicrobial Susceptibility Data at a University Teaching Hospital. Clin Infect Dis. 2008; 46: 1789-1789.


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Thank You!

Email:

[email protected]

Documents

Clinical Reporting