clinical reporting (4)

7/28/2019 Clinical Reporting (4)

1/15

Clinically-Oriented AST Reporting &

Antimicrobial Stewardship

Hsu Li Yang

27th September 2013

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

Reporting AST

Results that impact clinician antimicrobialprescribing and make a difference in patient

outcomes.

Time

Resistance results

Caveats against certain drugs

Evidence-based guidance

Schematic


2/15

Time to Antibiotics 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

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


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 ampCproduction cephalosporins and penicillins not

recommended for treatment of severe infections


3/15


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 ampCproduction cephalosporins and penicillins not

recommended for treatment of severe infections


Blood culture: MRSA COTRIMOXAZOLE S VANCOMYCIN S

Message: This is not to be regarded as acontaminant. The optimal antibiotics according to

current guidelines are IV Vancomycin or IV

Daptomycin (in the absence of MRSA

pneumonia). Please repeat blood cultures and

exclude endocarditis by echocardiography.

Intermission

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

Block of Medicine

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


4/15

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

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

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.

Vicious Cycle of Antibiotics and

Resistance

New Broad-SpectrumAntibiotics

RisingResistance

Trends to OldAntibiotics

AppropriateEmpiricalTherapy

Saves Lives

More Broad-SpectrumAntibioticsPrescribed

HigherResistance

Rates


5/15

World Economic Forum 2013

Global Risks 2013: Available at:

http://www3.weforum.org/docs/WEF_GlobalRisks_Report_2013.pdf

Conserving Existing Antibiotics

Antimicrobial Stewardship

National Call for ASP

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

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 ChayLeng Yeo


6/15

Forms of Stewardship

Prospective audit and feedback.

Antibiotic restriction.Permission required for prescription

Automatic stop orders

Antibiotic cycling

Other elements:Education of providersGuidelines

Computerized clinical decision support

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

National University Hospital

ASP commenced July 2009.

- IV to PO switch

- Recommendation for

duration of therapy

Singapore General Hospital

Formal prospective audit and feedback ASP in2008.


7/15

Patient is on ceftriaxone

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

patients ARUS-C record

Summary of data

ARUS-C recommends2 weeks of IV Ampicillin

ARUS-C helps you stopCeftriaxone unless you

want to keep by over-riding

ARUS-C

ARUS-C briefly updatesyou on the ID condition

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.

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.


8/15

Thank You!

Email:

[email protected]

Antibiotic Resistance Surveillance:

Cumulative Antibiogram & Software for

Resistance Surveillance

Hsu Li Yang

27th September 2013

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

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 Ag ents. Clin Microbiol Rev. 2011; 24: 281-295.


9/15

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 a l. Clin Microbiol Infect. 2012;18:268-81.

CRE

Acinetobacter baumannii


10/15

Carbapenems Carbapenems

Correlation: Prescription/Resistance Antibiogram

periodic summary of antimicrobial susceptibilitiesof local bacterial isolates

Uses:

1. Assess local susceptibility rates

2. Guide to empiric therapy

3. Formulating guidelines & formulary

4. Monitoring resistance trends

5. Quality control tool


11/15

Antibiogram: limitations

Representative population

Duplicate patients / isolates

Isolates, not infection

Aggregate data may not reflect local data

No clinical data

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


12/15

Quality control

Boehme MS et al. Systematic Review of Antibiograms: A National Laboratory Syst em Approach for Improving

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

Guidance documents

Hindler, J. F., & Stelling, J. (2007). A nalysis and presen tation of cumulative

antibiograms: a new con sens us guideline from the Clinical and Laboratory

Standards Inst itute. Clinical Infectious Diseas es, 44(6), 867-873.

Guidance

1. definitions for classifying isolates as clinically relevantor as contaminants

2. definitions of duplicate isolates

3. procedures for eliminating contaminant and duplicateisolates from data sets

4. criteria for classifying isolates as susceptible orresistant on the basis of current published criteria

5. criteria to define and separate isolates recoveredfrom inpatients from those recovered fromoutpatients

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

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

Tools

Laboratory

Information

System


13/15

Tools

Laboratory

Information

System

Baclink:

Capture and standardizing of data from existing

information systems.

WHONET:

Desktop application for the entry and analysis of

microbiology data.

Baclink:

Capture and standardizing of data from existing

information systems.

WHONET:

Desktop application for the entry and analysis of

microbiology data.

Tools

Laboratory

Information

System

WHONET Software WHONET Software


14/15

WHONET SoftwareWHONET Software

WHONET SoftwareWho 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 A ntimicrobial Suscept ibility Data at a University Teaching Hos pital. Clin Infect Dis. 2008; 46: 1789-1789.


15/15

Thank You!

Email:

[email protected]

clinical reporting (4)

Documents