ANTIBIOGRAM,

HOW TO INTERPRET

Hendro Wahjono

Department of Microbiology
Dr.Kariadi Hospital
Fac. of Medicine, Diponegoro University
 OVERVIEW

Operasionalisasi dan Workflow

Pelayanan Mikrobiologi Klinik
di Rumah Sakit
‘OLD’ Indonesian Clin Micr Services ?

- Laboratory-based services
- Technical aspect
‘NEW’ Indonesian Clin Micr Services ?

(Clin Micro Specialist)

Three steps
1. Entire Lab-Based Services on Clin Micr
2. Consultative-Based Services on Clin Micr
3. Team work for Patient Care
Finch et al, 2005
 Pelayanan Mikrobiologi Klinik
 Laboratorium Mikrobiologi
 Identifikasi dan uji sensitivitas
 Hasil pemeriksaan
 Konsultasi / Visitasi / Patient care
 Bersama klinisi ikut terlibat merawat pasien
infeksi.
 Turn Around Time report.
 Informasi Peta medan kuman
 Pengelolaan data mikroba
 menerbitkan informasi peta medan secara
berkala

4
 POCT
Point of Care-Testing

 Diagnostic Testing Performed at or near

Site of Patient Care
 Quality Assurance for POCT
Regulation for POCT

 Turn Around Time

 Impact on Health Care

 NACB- CLSI (NCCLS)

 Data Management of POCT

 Quality Assessment in the Analytical Phase

 Mostly Critical Quality Assurance Pre-Post

Analytical Phase
 PATIENT

STAINING/SAMPLING

OPD/WARD CULTURE/SAMPLING

BACTEC 9050/9120,
PHOENIX/VITEK2 / GENE
EXPERT,PCR
MICROBIOLOGY SEROLOGI : DENGUE
BLOT/NS1,WIDAL/
COUNTERSECTION TUBEX, TPHA /VDRL
MAT/LAT.FLOW

HOSPITAL INFECTION
CONTROL PROGRAM
CONTINUING
CONSULTATION
 ALUR PEMERIKSAAN KULTUR / TES RESISTENSI

DARAH
AGAR DARAH

LCS
MC CONKEY
VITEK2 AGAR
PHOENIX CAIRAN -
PLEURA,
AGAR SS PERICARDIUM,
TES Bactec9050/9120
SENDI, PEND.
RESISTENSI , Bacti Alert
ASCITES
AGAR NUTRIEN URIN

PUS

DOKTER PENDERITA
Critical value
In handl. spec.
 TURN AROUND TIME

Ambil Hasil Hasil

Permintaan  Spec.  di lab. Mikro  Selesai  diambil  Dibaca
T1 T2 T3 T4 T5 T6

1.0 jam 3.0 jam 3.0 hari 1.0 jam 1.0 jam

Point for improvement

Telephone / Fax

3.0 hari, 6 jam

Alur pemeriksaan kultur dihubungkan dengan waktu

 Objectives

 Review the Clinical and Laboratory Standards

Institute (CLSI) guidelines for cumulative
antibiotic susceptibility reporting in term of
CLINICAL MANIFESTATION but NOT
ANTIBIOGRAM MANIFESTATION !!

 Clinical impact of rapid reporting

(Turn Around Time, LOS,Mortality Rate and
Total Cost )

10
 Objectives

 Review the Clinical and Laboratory Standards

Institute (CLSI) guidelines for antibiotic
susceptibility reporting in the field of ESBL
producing Enterobacteriaceae

 Discuss how you can utilize this information at

your institution
 The NCCLS (now known as the CLSI
[Clinical and Laboratory Standards Institute])

defines an antibiogram (ABGM)

as an overall profile of antimicrobial susceptibility results

of a microbial species to a battery of antimicrobial agents
which should reflect patient care needs
along with the institution's formulary

When properly prepared and interpreted,

ABGMs are an important resource for healthcare providers.

(Antibiogram is an in-vitro testing for the sensitivity of an isolated bacteria strain

to different antibiotics.)
 ANTIBIOGRAM REPORT

In an era of antimicrobial misuse,

increasing anti-infective resistance,
and reduced emphasis on antibiotic development
by pharmaceutical manufacturers,

the need for reliable,

accurate ABGM data
to guide appropriate antibiotic selection is critical
 The antibiogram report
contains the following information

1. Organisms isolated (ESBL)

2. Source (blood, urine, wound)

3. Number of isolates (ISO)

4. List of antibiotics tested*

5. Percent susceptible (100%, 75%, 67%, etc.)

 Why prepare an antibiogram?
 Fits into several national guidelines
 CDC 12-step
 IDSA guidelines on antimicrobial stewardship
(2007)
 CDC/HICPAC Management of multi-drug resistant
organisms in health care settings (2006)
 Part of Joint Commission’s standards (IM.4/
IM.8)
 “The hospital collects and analyzes aggregate data to support
patient care and operations.”
 Strategic action
“Core members”
 Menyusun kebijakan yang terkait dengan
penggunaan antibiotik rasional/ bijak
 Membangun kerjasama multidisiplin
 Mengendalikan “suseptibility hospital pathogen”
 Implementasi
 Surveillan penggunaan antibiotik dan Universal
Precaution
 Membangun sistim informasi bersama

16
 Improving Reporting of Antimicrobial
Susceptibility Testing Results: the
Importance of Post Analytical Analysis
Describe the importance
antimicrobial susceptibility testing
in term of handling spec.

Describe the interpretation

of susceptibility testing data and clin.manifest.

Describes the post analytical

errors associated with interpreting
susceptibility testing results
 Facilitate appropriate antimicrobial use
through stewardship and infection control
 Collateral damage of antibiotic therapy

VRE

ESBL Klebsiella
3rd generation
cephalosporins -lactam-resistant
Acinetobacter

C. difficile

MDR Pseudomonas
Fluoroquinolones
C. difficile

Song, Jae-Hoon; The Changing Face of Polymicrobial Infections; presented

at 24th ICC, Manila, June 4-, 2005
 Interpretation
The antibiogram table is very easy to interpret

Biogram Report on Organism Sensitivities

Client’s Name
12-01-00 - 12-31-00
Organism ISO1 AM2 CIP GM
Escherichia coli
45 753 88 100
Urine

1Isolates
2Antibiotic codes
3 Percent susceptible
There were a total of 40 isolates cultured in urine.
75% of the isolates were susceptible to ampicillin (AM);
88% of the isolates were susceptible to ciprofloxacin (CIP);
100% of the isolates were susceptible to gentamycin (GM);
 Interpretation:

If you wish to know the number of isolates

that were susceptible to ampicillin,
simply multiply the percent susceptible
(75% = 0.75) x the total number of isolates:

(40): 0.75 x 40(ISO) = 30

This means that out of a total number of 40 isolates of E. coli,

30 were susceptible to ampicillin and 10 were resistant.

Accumulation of data over a period of months

may indicate resistant patterns developing within your facility.
Interpretation:
?
 Interpretation:

Patient fails to respond to antibiotics

•Depressed immune system

•Undrained abscess
•Foreign bodies
•Severe underlying disease
•Misdiagnosis
•Mixed infection
•Superinfection
 Interpretation:

Dangers of indiscriminate use of antibiotics

•Widespread sensitization of population

•Changes in indigenous (normal) flora
•Masking serious infections
•Drug toxicity
•Development of drug resistance
 Interpretation:

Factors guiding the choice of an antibiotic

•Susceptibility patterns
•Safe achievable serum levels
•Distribution of antibiotic in tissues
•Route of excretion
•Toxic side effects
•Existing or developing renal or hepatic failure
•Absorption characteristics
•Existing or developing allergic reactions
•Antibiotic interactions with other drugs
•Cost
 Ten steps to improve the effective use
of the microbiology laboratory REPORT by physicians

•Continuing education programs

•Significance of submitting cultures
•Obtain specimens before antibiotic therapy
•Obtain adequate volumes and numbers
•Complete requisition form
•Perform Gram stains (i.e., sputum, wounds, internal fluids and tissues)
•Transport specimens promptly
•Interpret microbiology report in light of clinical conditions
•Understand the value and limitation of susceptibility testing
•Open lines of communication
 Demographics of a requisition form

•Patient/resident name
•Age/sex
•Time specimen taken
•Patient/resident location
•Type of specimen
(i.e., clean catch urine, right knee drainage, sputum, etc.)
• Is patient/resident on forced fluids?
•Is patient/resident on antibiotics? If so, which ones? For how long?
•Is this specimen an intermittent or foley cath specimen?
•Type of test required
•Clinical disease of patient/resident if known
(i.e., bacterial endocarditis, fungemia, symptomatic UTI, etc.)
 Reasons for not routinely testing
and reporting numerous antibiotics

•Selection of drug is influenced by laboratory report

Restricted reporting should help control the following:

1. indiscriminate use of more costly and/

or more toxic drugs

2. inappropriate or unnecessary use of new agents

3. development of resistance through inappropriate use

Many new drugs are very similar to each other,
to older agents or to both,
and testing of one drug from each group is usually sufficient
 Reasons for not routinely testing
and reporting numerous antibiotics

Some antimicrobial agents are inappropriate for

treatment of infections
even if in vitro results indicate susceptibility.

For example:

-first and second generation cephalosporins and

Salmonella sp.

-beta-lactams and MRSA

-cephalosporins and enterococci

 Laboratory Report #2
Source: Right ankle drainage
Status: Final
Gram Stain: Numerous WBC; many Gram positive cocci in chains

Isolate #1: Heavy growth of: Enterococcus faecalis

Antimicrobial Susceptibility Report

Antibiotic MIC Interpretation

Ampicillin 8 S
Penicillin G 8 S
Tetracycline >16 R
Vancomycin >32 R

S = Susceptible R = Resistant

End of Report
 Laboratory Report #3
Source: Coccyx
Status: Final
Gram stain: Numerous WBC; many Gram positive cocci seen in clusters
Isolate 1: Heavy growth of: Staphylococccus aureus
S. aureus culture on a blood agar plate showing beta hemolysis

Antimicrobial Susceptibility Report

Antibiotic MIC Interpretation

Ampicillin/sublactam >32 R
Cephalothin >32 R
Ciprofloxin >4 R
Clindamycin >8 R
Oxacillin >8 R
Penicillin G >16 R
Tetracycline <1 S
Trimeth-sulfa <1 S
Vancomycin 1 S

S = Susceptible R = Resistant

End of Report
Laboratory Report #4
Source: Urine (clean catch)
Status: Final
Isolate 1: >100,000 CFU Pseudomonas aeruginosa

Antimicrobial Susceptibility Report

Antibiotic MIC Interpretation

Ampicillin >32 R
Carbenicillin >512 R
Ceftriaxone >64 R
Cephalothin >32 R
Ciprofloxacin >4 R
Gentamicin >16 R
Nitrofurantoin >128 R
Norfloxacin >16 R
Tetracycline >16 R
Tobramycin >16 R
Trimeth-sulfa >320 R

S = Susceptible R = Resistant

End of Report
 Laboratory Report #6
Source: Urine (clean catch)
Status: Final
Result: >100,000 CFU/ml
Multiple organisms isolated. May represent normal flora
from external genitalia rather than urinary bladder.
Please repeat culture if clinically indicated.

End of Report
Laboratory Report #8
Source: Urine (clean catch)
Status: Final
Isolate 1: >100,000 CFU/ml Klebsiella pneumoniae

Antimicrobial Susceptibility Report

Antibiotic MIC Interpretation

Ampicillin >32 R
Carbenicillin >512 R
Ceftriaxone <8 S
Cephalothin >32 R
Ciprofloxacin >4 R
Gentamicin >16 R
Nitrofurantoin >128 R
Norfloxacin >16 R
Tetracycline >16 R
Tobramycin >16 R
Trimeth/sulfa >320 R

S = Susceptible R = Resistant

End of Report
 Laboratory Report #11

Source: Stool
Status: Final
Result: No Salmonella, no Shigella and no Campylobacter isolated.

End of Report
Enterobacteriaceae
Enterobacteriaceae
 Klebsiella
pneumoniae Antibiotic name %S
ESBL + Meropenem 81
(ICUDr Kariadi Moxifloxacin 79
Hospital)
May-June 2011 Cefoperazone/Sulbactam 81
n=26 Piperacillin/Tazobactam 80
Amikacin 75
Tigecycline 85
Fosfomicin 80
Dibekacin 67
Cefepime 68
Ampicillin /Sulbactam 70
Cefotaxime 0
Ceftazidime 0
Ciprofloxacin 67
Adapted from Nosocomial Surveillance System Data Dr Kariadi Hospital, 2012
Microbiologic surveillance Same
strain?

No
Yes
Organisms
identified Antibiotics?
Investigate
No Yes

Molecular typing Stop Refer

Control
 Primary recommendations:
Analysis and presentation of data
• Optimal number of isolates to report
Modified from 10 → 30
 CLSI suggestions for achieving 30 isolates
 Combine several years of data
 Combine for more than one species in a genus
 Combine data from geographically similar institutions
 Provide data from published summaries and guides

CLSI M39-A2:Vol 25, No. 28, January 2006, p. 1-45.

 Data validation:
 Include only final verified results
 Look for inconsistencies
 Imipenem resistant E. coli very rare
 Vancomycin resistance in S. pneumoniae

 Amikacin resistance in K. pneumoniae

 Vancomycin resistant S. aureus

 Recentchanges in breakpoint may influence vancomycin
intermediate results

CLSI M39-A2:Vol 25, No. 28, January 2006, p. 1-45.

 Data presentation:

 Specific locations
 By unit of the hospital (ICU vs non ICU)
 Inpatient vs. Outpatient

 Long term care or nursing home

 By culture source (urine vs. non-urine)

 Notations regarding specific resistance patterns

CLSI M39-A2:Vol 25, No. 28, January 2006, p. 1-45.

 Additional suggestions

 Avoid information overload

 Organize in an easy to read format
 Prepare empiric guidelines at the same time as
antibiogram
 # PRESENTASE SENSITIVITAS TERHADAP ANTI BIOTIK DI BANGSAL ICU
RSUP Dr. Kariadi ( BULAN JANUARI - JUNI 2010 )
1. DARAH
JML AMP ERY TCY CHL GEN CIP FEP CTX CAZ CSL DKB FOS MEM MFX FOX SXT VAN AMK
Organisma ISOLAT %S %S %S %S %S %S %S %S %S %S %S %S %S %S %S %S %S %S
Staphylococcus
epidermidis 26 0 10 50 33 26 13 33 21 50 37 72 57 75 26 60 100 90

Escherichia coli 18 20 50 66 56 50 80 40 33 83 66 82 93 16 33 93

Pseudomonas aeruginosa 16 0 0 50 0 26 33 40 20 14 57 33 60 33 40 0 18 100 53

Staphylococcus aureus
ss. aureus 15 50 60 42 75 100 78 100 100 100 100 86 88 100 93 57 100 100

Acinetobacter baumannii 11 0 25 16 0 10 0 0 80 0 80 20 54 0 57

Enterobacter aerogenes 6 0 50 0 16 40 16 0 0 66 50 50 16 83
Klebsiella pneumoniae ss.
pneumonia 5 0 50 100 0 80 25 40 100 0 100 100 60 0 100

Candida albicans 2
Streptococcus
pneumoniae 1 0 0 100 0 100 100 100 100 100 100 0
AMP Ampicillin
ERY Erythromycin
TCY Tetracyline
CHL Chloramphenicol
NOTE : Staphylococcus epidermidis = MRSE = Positif =Fox GEN Gentamicin
Escherichia coli dan Klebsiella pneumoniae = ESBL = CIP Ciprofloxacin
CTX + CAZ ( Resisten ) FEP Cefepime
CTX Cefotaxime
Pseudomonas, Acinetobacter baumannii dan CAZ Ceftazidime
Enterobacter aerogenes = MDRO DKB Dibekacin
* Berhati - hati Pemakaian Terapi Antibiotik Empirik Dengan FOS Fosfomycin
MEM Meropenem
Cephalosporin Generasi 3 MFX Moxifloxacin
* Telah Terjadi Infeksi Nosokomial SXT Trimethoprim/Sulfatmethoxazole
FOX Ce foxitin
VAN Vancomycin
AMK Amikacin
 Rapid diagnosis
Appropriate treatment

Microbiology Lab
Reliable answers
Least possible
risk

Clinician

Communication

Understand the importance of

appropriate antimicrobial for patient safety

Clinical Microbiologist
 Policy Deals with
We discuss on the Broad basis

Clinicians / Microbiologists /
Pharmacists and Nurses do take
part.

Policies are framed on demands

of the Clinical areas, depending
on recent Infection surveillance
data contributed from
Microbiology Departments.
 GOALS

1. Patient safety
2. Cost reduction
3. Antimicrobial resistance control

Komite Medik
Pelayanan Farmasi Klinik
Tim Pengendalian Infeksi RS
Pelayanan Mikrobiologi Klinik
 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults
Step 4: Access the experts

Infectious Diseases Expert Resources

Infectious Diseases
Specialists
Healthcare Infection Control
Epidemiologists Professionals

Clinical Optimal
Pharmacists Patient Care
Clinical
Clinical Pharmacologists
Microbiologists
Surgical Infection
Experts
 Conclusion
 These findings suggest that antibiograms
should be reviewed thoroughly by infectious
disease specialists (physicians and pharmacists),
clinical microbiologists, and infection control
personnel for identification of abnormal
findings prior to distribution.
 Aggregate antimicrobial resistance data can be
used in a number of ways to benefit patient
care
 Resources
 CLSI website
 www.clsi.org
 IDSA Guidelines on Antimicrobial Stewardship
 www.idsociety.org
 CDC 12 step program
 www.cdc.gov/drugresistance/healthcare/tools.htm
 Guidelines for the Management of MDRO
 www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf
Sir Alexander Fleming