INTERPRETATIVE READING

Tan Thean Yen

To Interpret
interpret explain the meaning of (information, words, or actions)

To Interpret
What Women Say
Yes No You have to learn to communicate... Are you listening to me!?

What It Means
No Yes Just agree with me. (Too late, youre dead)

To Interpret
analyse susceptibility results based: organism identification all antibiotic results (pattern) interpret susceptibility based on above

Courvalin P. Interpretive reading of in vitro antibiotic susceptibility tests (the antibiogramme). Clinical Microbiology and Infection. 1996;2:S26S34.

Why interpret?
To detect unusual results that need further testing or confirmation To report appropriate antibiotic results for the organism-infection combination To detect emerging resistance

Expert rule
Description of action to be taken, based on current evidence, in response to specific antimicrobial susceptibility test results

E X P E R T R U L E

If you obey all of the rules, you miss all of the fun. - Katharine Hepburn

Actions
Recommendations on reporting
E X P E R T R U L E

Inference of susceptibility Edit results from S to I or R, from I to R, but NEVER I or R to S

Suppression of results Addition of comments Advice on further tests Advice on referral of isolates

Requirements
Identification of the organism (fully)
E X P E R T R U L E

May need to test an extended range of appropriate antibiotics Access to a set of expert rules

Three areas to cover

1. Intrinsic resistance 2. antibiogram reading
3. Exceptional phenotypes

Part One

INTRINSIC RESISTANCE

I N T R I N S I C

resistance which is a characteristic of the species

Susceptible results?
errors in identification or susceptibility testing drug should be used with caution

R E S I S T A N C E

Chromosomal
(born with it)

Examples
I N T R I N S I C

Organism

Antibiotic resistance

Enterobacteriaceae
Gram-positive organism Klebsiella species Proteus mirabilis Serratia marcescens

Vancomycin
Aztreonam Ampicillin Nitrofurantoin Polymyxins Polymyxins

R E S I S T A N C E

I N T R I N S I C

R E S I S T A N C E

Livermore DM, et al. Interpretative reading: recognizing the unusual and inferring resistance mechanisms from resistance phenotypes. J Antimicrob Chemother. 2001 Jul 1;48(suppl 1):87102

I N T R I N S I C

R E S I S T A N C E

http://www.eucast.org/expert_rules/

Part Two

ANTIBIOGRAM READING

A N T I B I O G R A M R E A D I N G

Test susceptibility Infer resistance mechanism Interpret clinical susceptibility on the basis of the resistance mechanism

Species identification

Antibiotic susceptibility

E X P E R T R U L E

REPORT

Species identification

Antibiogram interpretation

Antibiotic susceptibility

E X P E R T R U L E

deduce phenotype clinical relevance

additional tests deduce biochemical resistance 1. re-define susceptibility (categorical) 2. deduce susceptibility to non-tested antibiotics 3. clinical comments 4. clinical advice

REPORT

Simple..
A N T I B I O G R A M R E A D I N G

Staphylococcus aureus Result: Infer:

resistant to cefoxitin resistance mediated by mecA

Interpret:

resistant to all beta-lactams

More complicated..
A N T I B I O G R A M R E A D I N G

Enterobacteriaceae Result:
tobramycin non-susceptible amikacin & gentamicin susceptible

Infer: Interpret:

acquired AAC(6)-I enzyme report amikacin as Intermediate

Escherichia coli
A N T I B I O G R A M R E A D I N G

Antibiotic
Ampicillin Amoxicillin-clavulanate Piperacillin-tazobactam Cephalothin Ceftriaxone Ceftazidime Cefepime Cefoxitin

Category
R S S R R S R S

Infer: Extended spectrum beta-lactamase (CTX-M)

Ertapenem
Gentamicin Amikacin Ciprofloxacin Trimethoprim-sulfamethoxazole

S
S S S S

Interpret: Consider reporting ceftazidime as resistant OR Reporting presence of ESBL with comment

Klebsiella pneumoniae
A N T I B I O G R A M R E A D I N G

Antibiotic Ampicillin Amoxicillin-clavulanate Piperacillin-tazobactam Cephalothin Ceftriaxone

Category R R S R I

Infer: ampC enzyme (plasmid-acquired)

Ceftazidime
Cefepime Cefoxitin Ertapenem

R
S R S

Interpret: Consider reporting ceftriaxone as resistant

Gentamicin
Amikacin Ciprofloxacin Trimethoprim-sulfamethoxazole

S
S S S

Limitations
High complexity of resistance mechanisms Limited information about some mechanisms of resistance

Multifactorial multiresistance
Oversimplification of interpretative reading Mistakes when deducing mechanisms of resistance

Part Three

EXCEPTIONAL PHENOTYPE

E X C E P T I O N A L P H E N O T Y P E

Resistance in a species where resistance has not been seen or is rare

may change with time may also be regional or national differences

E X C E P T I O N A L P H E N O T Y P E

Resistance in a species where resistance has not been seen or is rare

errors in identification or susceptibility testing send the isolate to a reference laboratory for independent confirmation

Examples
E X C E P T I O N A L P H E N O T Y P E

Streptococcus pyogenes resistant to penicillin Staphylococcus aureus resistant to vancomycin Haemophilus inuenzae resistant to any thirdgeneration cephalosporin, carbapenems, and uoroquinolones

Examples
E X C E P T I O N A L P H E N O T Y P E

Anaerobes resistant to metronidazole Neisseria gonorrhoeae resistant to third-generation cephalosporin Enterobacteriaceae resistant to carbapenems

HOW TO BE AN EXPERT

ICU patient 28 days in hospital oxidase negative non-fermentative Gramnegative bacillus

Antibiotic Amoxicillin-clavulanate Piperacillin-tazobactam Ceftriaxone Ceftazidime Cefepime

Zone (mm) 6 6 6 26 18

Result R R R

ICU patient 28 days in hospital

oxidase negative non-fermentative Gramnegative bacillus

What is the likely organism?

Imipenem
Ertapenem Meropenem Amikacin Gentamicin Ciprofloxacin Trimethoprimsulfamethoxazole

6
6 6 6 6 30 35

R
R R R R

How would you report susceptibility to: ceftazidime imipenem ciprofloxacin

Enterobacter cloacae
Antibiotic
Amoxicillinclavulanate Cefoxitin

Zone (mm)
6 6

Result
R R

Isolate from blood culture Patient with suspected ventilatorassociated pneumonia

Ceftriaxone
Ceftazidime Cefepime Imipenem Ertapenem Meropenem Ciprofloxacin Trimethoprimsulfamethoxazole

27
26 24 24 23 24 25 20

S
S S S S S S S

Enterobacter cloacae
Antibiotic
Amoxicillinclavulanate Cefoxitin

Zone (mm)
6 6

Result
R R

Isolate from blood culture Patient with suspected ventilatorassociated pneumonia

How would you report susceptibility to: ceftriaxone cefepime imipenem

Ceftriaxone
Ceftazidime Cefepime Imipenem Ertapenem Meropenem Ciprofloxacin Trimethoprimsulfamethoxazole

27
26 24 24 23 24 25 20

S
S S S S S S S

ARTIFICIAL INTELLIGENCE

Computerised expert modification

Disc susceptibility Adagio Biomic MIC equivalent Phoenix Vitek

Microscan

Vitek AES

Changed cefepime to Resistant

Lab Information System Alerts

The Real Expert

Summary
Systems vary in accuracy design update frequency See Winstanley T, Courvalin P. Expert Systems in Clinical Microbiology. Clin Microbiol Rev. 2011; 24(3):51556.

Conclusions
Some resistant organisms may need supplemental methods to detect Susceptibility testing can be complicated Resistance mechanism or tested MIC? Not yet quite sure.