Dr Neeraj Goel Sr. Consultant Department of Clinical Microbiology. Sir Ganga Ram Hospital

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1 Dr Neeraj Goel Sr. Consultant Department of Clinical Microbiology Sir Ganga Ram Hospital

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3 Resistance profile of MDROs in ICU: Quinolone: 80% Amikacin: 75% Cefaperazone sulbactum: 79% Carbapenems: 79%

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6 Super BUGs MDR/Nosocomial Gm + MRSA Gm Klebsiella E.Coli Pseudomonas Acinetobacter ESBLs Adapted from Infectious Diseases Society of American (IDSA). Available at Accessed July 2005; Cosgrove SE et al Arch Intern Med 2002;162: ; Ben-David D, Rubenstein E Curr Opin Infect Dis 2002;15: ; Colodner R et al Eur J Clin Microbiol Infect Dis 2004;23:

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9 Association b/w antibiotic use and AMR

10 Autoregressive Integrated Moving Average Model

11 Significant correlation between carbapenem use and its resistance in A. baumannii

12 Campaign to Prevent Antimicrobial Resistance in Healthcare Settings 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults 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 Using Antibiogram 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 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

13 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

14 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

15 Pre-2000: No consistent guidelines - Diversity in calculation algorithims - Poor comparability of data b/w institutes First version released in 2000 (M-39P)

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

17 Data should be analyzed annually If there are large number of isolates then it can be done 6 monthly.

18 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

19 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

20 Surveillance/ screening cultures eg., MRSA, VRE screening. Repeat isolates Lowers 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: Wilkinson ST et al. Presented at the annual meeting of the American College of Clinical Pharmacy, San Francisco, CA, October 23-26, 2005

21 Patient based (recommended by M 39,CLSI) First isolate per patient irrespective of the site. Fewer assumptions Simpler calculations Eliminates maximum number of isolates

22 Description of exact collection period Use of Generic names of antimicrobials Utilization of dash to describe susceptibility data not reported

23 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);

24 Prescribers, Infection Control, pharmacy & microbiology personnel Format Pocket guides Laminated cards Printed newsletters Website CLSI M39-A2

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26 Online from May Publication Microbiology NL

27 Data of your own hospital is needed

28 Drug E. coli Pseud. aeruginosa Kleb. pnuemo. Proteus mirabilis Enterob. cloacae Serratia marcescens Enterob. aerogenes Ampicillin Amp-Sul Pip-Tzp Ceftriaxone 65 Ceftazidime Cefipime 62 Levofloxacin Cipro Gentamicin Tobramycin Cotrimoxazole 57 Imipenem 77 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

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30 % Resistance - S. aureus -- IPD Penicillin Oxacillin 60 Clindamycin Gentamicin 30 Vancomycin

31 % Vancomycin Resistance Enterococci spp. (IPD) Ward ICU

32 % Resisance - E.coli - Blood Isolates - IPD Ampicillin Ceftriaxone Gentamicin 50 Amikacin Ciprofloxacin Piperacillin + Tazobactum Cefaperazone + Sulbactum Imipenem

33 % Resistance - Klebsiella - Blood Isolates - IPD Ceftriaxone Gentamicin Amikacin Ciprofloxacin Piperacillin + Tazobactum Cefaperazone + Sulbactum Imipenem Colistin 0

34 Ampicillin Ceftriaxone Ceftazidime Gentamicin 60 Amikacin Ciprofloxacin Piperacillin + Tazobactum Cefaperazone + Sulbactum Imipenem Tigecycline 10 Colistin

35 % Resistance - Pseudomonas - Blood Isolates - IPD Ceftazidime 80 Gentamicin Netilmicin/Amikacin Ciprofloxacin Piperacillin + Tazobactum Cefaperazone + Sulbactum Imipenem 10 Colistin 0

36 Antibiotic trend analysis at SGRH

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38 Antibiogram: In formulating empirical antibiotic policy Incorporates local microbiology and resistance patterns.

39 - Optimum Empirical Antibiotic Therapy If appropriate antibiotic therapy in the 1 st hr: survival rates of 80 % Each of hour of delay in institution of appropriate therapy decreases survival by 7% Crit Care Med, 34: , 2006.

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41 Blood Steam Infections (ICU) Identify the Five most common pathogens Burkholderia cepacia 5% Enterobacter spp. 5% Staph aureus 6% Pseudomonas aeruginosa 7% Others 17% E.coli 13% Klebsiella spp. 30% Acinetobacter spp. 17% Klebsiella spp. Acinetobacter spp. E.coli Pseudomonas aeruginosa Staph aureus Enterobacter spp. Burkholderia cepacia Others Identify the Five most sensitive antibiotics Ampi Cefurox Ceftriax Ceftaz Cefep Aztreo Ampi+s Pipera+ Cefo+sul Quin Genta Amik Netil Erta Imi Coli ulbactutazobac bctum m tum Klebsiella spp Acinetobacter spp E.coli P. aeruginosa Enterobacter spp

42 S. No Most common pathogens Tool Kit for Blood culture- ICU % prevalence Hospital surveillance data 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%) 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

43 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)

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45 The risk stratification is based on 3 factors: 1) Contact with Health Care System 2) Prior use of antibiotic 3) Patient Characteristics

46 Type 1 Type 2 Type 3 Health Care Contact No +ve Prolonged Antibiotic Rx History No in last 90 days +ve in last 90 days Repeat multiple antibiotics. Patients Characteristics Young No comorbid conditions. Elderly Few Co-morbid conditions. Immunocompromised, or with many comorbid conditions. Causative Pathogen could be ESBL+/- Susceptible to Common narrow spectrum antibiotics ESBLs +/MRSA CRE / MDR Pseudomonas /Acinetobacter+/- VRE

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48 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.

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50 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

51 A Microbiology Data Management Tool

52 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

53 Comp Software Excel Access EpiInfo Lab Systems Mysis MEDITECH ADBakt Lab Instruments MIC systems Disk diffusion readers BacLink Data Conversion WHONET Data analysis

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55 Hospital Information system Infection Control LIS Server Pharmacy INFORMATION MANAGEMENT WORKFLOW WORKFLOW Purchase CONNECTIVITY VITEK 2 BacT/ALERT PREVI Isola Vitek-MS VITEK 2 VITEK 2

56 Prodigious software Manual Entry, retrieval and calculation

57 Speedminer Automated entry and retrieval Manual calculation

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62 SGRH is publishing microbiology newsletter since: : Manual software (Foxpro) Manual data entry, retrieval, calculations > 2000 sheets of paper > 1000 manhours Chances of error in entry, retrieval and calculation 2008: Speedminer Data entry and retrieval automated, manual calculation Electronic data: No paper 50 manhours to compile the data Manual calculations of data Chances of error due to calculations 2010: SGRH Protech software No paper 0 manhours Data entry and retrieval automated No errors

63 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

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65 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

66 Paradigm for empiric therapy: In Early, Hit Hard, Out Early

67 Total # New Antibacterial Agents '83-'87 '88-'92 '93-'97 '98-'02 '03-'07 '08-'

68 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

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70 PAN RESISTANT BACTERIA