AST and the Clinician

Piotr Chlebicki Senior Consultant Department of Infectious Diseases SGH

The assignment
Use of antibiotics in clinical practice: - common infections - approach to diagnosis & treatment

I modified it a bit
1. How do clinicians prescribe antibiotics ? 2. How does microbiology lab influence prescribing? 3. A few clinical cases

How do clinicians prescribe antibiotics?

A. Based on culture results B. Empirically = 7 steps
1. Define the problem/disease/syndrome 2. Severe? 3. At risk of MDRO? 4. Immunocompromized? 5. List possible bugs and consider local resistance patterns 6. Pick the best antibiotic 7. Decide duration

How does microbiology lab influence prescribing?

Organism identification and pathogen susceptibility patterns
Selective reporting

MIC reporting Local epidemiology Choice of available tests Rapid diagnostic tests Automatic alerts for targeted pathogens

Antibiograms
How many isolates? Duplicates? Outpatient? When last updated? Impact on prescribing:
developing clinical pathways for empiric antimicrobial treatment monitoring resistance trends updating the drug formulary developing antimicrobial restriction policies

Antibiogram

Antibiogram single unit

Selective antimicrobial susceptibility reporting

Susceptibilities are reported for only the most appropriate and least expensive drugs to which the organism is susceptible. The use of a cascading microbiology report encourages clinicians to select more narrowspectrum and cost-effective antimicrobial agents. Very effective!!

Susceptibility pattern of urinary E. coli

Antibiotic Ampicillin Co-amoxiclav Cephalexin Cefuroxime Cefotaxime Ceftazidime Cefepime Cefoxitin Pip-tazobactam Meropenem Ciprofloxacin Nitrofurantoin Co-trimoxazole Amikacin Gentamicin Susceptibility R S S S S S S S S S S S S S S

Antimicrobial stewardship

there is an association between antibiotic susceptibility reporting from microbiology laboratories and antibiotic prescribing for the treatment of urinary tract infections.

Ciprofloxacin and risk of resistant organisms e.g. C. difficile

Prospective interrupted time series A. Before - susceptibility to amoxicillin, nitrof urantoin, trimethoprim and co-amoxiclav routinely reported B. After (9 months) - susceptibility to cefalexin was reported in place of susceptibility to co-amoxiclav.

Result

Antimicrobial stewardship

Prioritization of tested antimicrobials and selective reporting of susceptibility profiles (e.g., not routinely reporting susceptibility of S. aureus to rifampin to prevent inadvertent monotherapy with rifampin) can aid in the prudent use of antimicrobials and direct appropriate therapy based on local guidelines

How does microbiology lab influence prescribing?

Organism identification and pathogen susceptibility patterns
Selective reporting

MIC reporting Local epidemiology Choice of available tests Rapid diagnostic tests Automatic alerts for targeted pathogens

MRSA MIC
2012 in SGH Of the 112 tested isolates, 58 had MIC of 1.5 or greater (51.8%)

Case 1
52 year old man, PMH of DM, smoker complains of fever and cough for 3 days. 120/70 HR 100, RR 25, 38.6C Creps over rt lung

How do clinicians prescribe antibiotics?

A. Based on culture results B. Empirically = 7 steps
1. Define the problem/disease/syndrome 2. Severe? 3. At risk of MDRO? 4. Immunocompromized? 5. List possible bugs and consider local resistance patterns 6. Pick the best antibiotic 7. Decide duration

Diagnostic testing
Mild CAP = testing optional More severe CAP = more testing

How does microbiology lab influence prescribing?

Organism identification and pathogen susceptibility patterns
Selective reporting

MIC reporting Local epidemiology Choice of available tests Rapid diagnostic tests Automatic alerts for targeted pathogens

Gram stain

Quality of specimen
Please reject

Rapid diagnostic testing

Urinary streptococcal antigen Legionella urinary antigen Respiratory virus multiplex PCR

How does microbiology lab influence prescribing?

Organism identification and pathogen susceptibility patterns
Selective reporting

MIC reporting Local epidemiology Choice of available tests Rapid diagnostic tests Automatic alerts for targeted pathogens

Antibiotics
Likely pathogens Antimicrobial resistance Can he be treated with azithromycin alone? How about IV penicilln and Klacid?

Spectrum IPD - Singapore experience

Journal of Medical Microbiology (2009), 58, 101104

Methods
All invasive pneumococcal isolates cultured from sterile sites from adult patients hospitalized at SGH between 1 January 2000 and 31 December 2007

Results
Pneumococcal isolates from 192 patients
Blood cultures Pleural fluid Intraophthalmic CSF Synovium (92.7 %) (2.1 %) (1.6 %) (1.0 %) (1.0 %),

Resistance in SGH
The median penicillin MIC was 0.016 mg/ml (range 0.0162 mg/ml) Median ceftriaxone MIC 0.016 mg/ml (range 0.0041 mg/ml)

Resistance in SGH
All 186 non-meningitis isolates would be classified as penicillin-susceptible following the new CLSI breakpoints One isolate from a patient with meningitis had an MIC to penicillin of 2 mg/ml, but the other five isolates were susceptible.
Ceftriaxone MIC >0.5 = 6/192 cases (3.13%)

NARSS 2010

Guideline

Case 2
33 yo woman presents to Bedok polyclinic with dysuria, urgency and frequency x 2 days. She has no fever or flank pain. She had 2 similar episodes in the past 2 years

How do clinicians prescribe antibiotics?

A. Based on culture results B. Empirically = 7 steps
1. Define the problem/disease/syndrome 2. Severe? 3. At risk of MDRO? 4. Immunocompromized? 5. List possible bugs and consider local resistance patterns 6. Pick the best antibiotic 7. Decide duration

What is the bug?

Which antibiotic?
Depends on the prevalence of resistance in a community IDSA suggests thresholds above which a drug is not recommended
20% for trimethoprimsulfamethoxazole 10% for fluoroquinolones

How does microbiology lab influence prescribing?

Organism identification and pathogen susceptibility patterns
Selective reporting

MIC reporting Local epidemiology Choice of available tests Rapid diagnostic tests Automatic alerts for targeted pathogens

Old, good times (2002)

New, not that good times (2009)

Methods and patients

Bedok Polyclinic January 1 to December 31, 2009 1,352 patients coded as UTI
666 (49.3%) patients had urine cultures
333 (50%) culture-positive

34 , 299 1365 years = 214 > 65 years = 117

Limitations
No correlation with symptoms No correlation with pyuria No attempt to differentiate true community acquired vs healthcare associated

Case 3
Hematology department in SGH introduced febrile neutropenia protocol several years ago. Cefepime was the drug of choice for empiric therapy Recent studies and resistance trends suggest that it may not be the best choice Is there any other antibiotic that is better?

Cefepime versus other

All-cause mortality was significantly higher with cefepime as compared with other antibiotics, RR 1.39 [1.04, 1.86], without heterogeneity 21 trials, 3471 participants

Piperacillin-tazobactam versus other

All-cause mortality was lower with piperacillin-tazobactam versus all other antibiotics , RR 0.56 [0.34, 0.92], 8 trials, 1314 participants The difference was statistically significant also in the comparison restricted to carbapenems, RR 0.46 [0.22, 0.95].

How does microbiology lab influence prescribing?

Organism identification and pathogen susceptibility patterns
Selective reporting

MIC reporting Local epidemiology Choice of available tests Rapid diagnostic tests Automatic alerts for targeted pathogens

SGH data for hematology 2012

CGH data, ESBL E coli, 2012

Case 3
Febrile neutropenia protocol was changed Pip tazo or cefepime plus amikacin will be used for the empiric therapy of febrile neutropenia

How does microbiology lab influence prescribing?

Organism identification and pathogen susceptibility patterns
Selective reporting

MIC reporting Local epidemiology Choice of available tests Rapid diagnostic tests Automatic alerts for targeted pathogens

Summary
The impact of microbiology lab on prescribers is profound It not only influence the choice of antibiotics for individual patients but also hospital policies and guidelines