Analysis of Cumulative Antibiogram Reports in Search for Optimal Empirical Urinary Tract Infection Treatment at the Central Teaching Hospital of the Medical University of Lodz, Poland: Results of a 3-Year Surveillance.

Urinary tract infections are among the most common bacterial infections, accounting for about two-fifths of all healthcare-associated infections. Appropriate antimicrobial therapy is crucial, e.g., to avoid prolonged hospitalization and limit antimicrobial resistance spread. This study was performed to analyze the microbiological profiles of urinary tract infections in the Central Teaching Hospital in Lodz, Poland, and develop local empirical therapy guidelines. This study was a 3-year retrospective surveillance of the cumulative antibiograms from urine cultures. The procedures were based on the current EUCAST and CLSI guidelines. In 2020-2022, a total of 4656 urine cultures were performed, of which 1134 were positive. The most common bacterial isolates were Escherichia coli, followed by Klebsiella spp. and Enterococcus spp. High levels of susceptibility (>90%) have been observed for carbapenems, piperacillin/tazobactam, amikacin, and nitrofurantoin. Development of the appropriate empirical antimicrobial is a challenging task with persistently high levels of resistance to commonly used antimicrobials. Eventually, we separated the uncomplicated and complicated urinary tract infections in local guidelines and recommended nitrofurantoin and amikacin, respectively, in empiric therapy. The clinicians should make a decision based on the presented symptoms and then-with the urine culture result-correct or continue the therapy.

Recomendaciones del Comité Español del Antibiograma (COESANT) para la realización de los Informes de Sensibilidad Antibiótica Acumulada / Spanish Antibiogram Committee (COESANT) recommendations for cumulative antibiogram reports

El Comité Español del Antibiograma (COESANT) presenta en este documento una serie de recomendaciones cuya finalidad es unificar la forma en la que los Servicios y Unidades de Microbiología Clínica españoles realizan los informes de sensibilidad acumulada de las bacterias, aisladas en muestras clínicas, frente a los antimicrobianos. Las recomendaciones se fundamentan en las recogidas en el Procedimiento de Microbiología Clínica n° 51, «Preparación de informes acumulados de sensibilidad a los antimicrobianos» de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), publicado en 2014, y recoge las modificaciones en las definiciones de las interpretaciones de las categorías clínicas publicadas en el año 2019 por el European Committee on Antimicrobial Susceptibility Testing (EUCAST). Su objetivo final es establecer una forma homogénea de elaborar estos resúmenes para poder comparar resultados de diferentes centros o sumar su información y así realizar una adecuada vigilancia local o incluso nacional de la evolución de la sensibilidad a los antimicrobianos.(AU)

The Spanish Antibiogram Committee (Comité Español del Antibiograma, COESANT) presents in this document a series of recommendations intending to unify how cumulative antibiogram reports must be made in Clinical Microbiology Spanish laboratories. This article is based on the information included in the Clinical Microbiology Procedure No. 51, «Preparation of cumulative reports on antimicrobial susceptibility» of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), published in 2014. The recommendations also include the modifications in the definition of clinical interpretive categories recently published by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) in 2019. Its final objective is to establish a homogeneous way of preparing these summaries to compare results from different centers or aggregate the information from these in order to carry out an adequate local or even national surveillance regarding the evolution of antimicrobial susceptibility.(AU)

Using an Antibiogram Profile to Improve Infection Control and Rational Antimicrobial Therapy in an Urban Hospital in The Gambia, Strategies and Lessons for Low- and Middle-Income Countries.

Antimicrobial resistance is a global health threat and efforts to mitigate it is warranted, thus the need for local antibiograms to improve stewardship. This study highlights the process that was used to develop an antibiogram to monitor resistance at a secondary-level health facility to aid empirical clinical decision making in a sub-Saharan African county. This retrospective cross-sectional descriptive study used 3 years of cumulative data from January 2016 to December 2018. Phenotypic data was manually imputed into WHONET and the cumulative antibiogram constructed using standardized methodologies according to CLSI M39-A4 guidelines. Pathogens were identified by standard manual microbiological methods and antimicrobial susceptibility testing was performed using Kirby-Bauer disc diffusion method according to CLSI M100 guidelines. A total of 14,776 non-duplicate samples were processed of which 1163 (7.9%) were positive for clinically significant pathogens. Among the 1163 pathogens, E. coli (n = 315) S. aureus (n = 232), and K. pneumoniae (n = 96) were the leading cause of disease. Overall, the susceptibility for E. coli and K. pneumoniae from all samples were: trimethoprim-sulfamethoxazole (17% and 28%), tetracycline (26% and 33%), gentamicin (72% and 46%), chloramphenicol (76 and 60%), and ciprofloxacin (69% and 59%), and amoxicillin/clavulanic (77% and 54%) respectively. Extended spectrum beta-lactamase (ESBL) resistance was present in 23% (71/315) vs. 35% (34/96) respectively. S. aureus susceptibility for methicillin was 99%. This antibiogram has shown that improvement in combination therapy is warranted in The Gambia.

Cumulative Antibiogram: A Rapid Method to Hinder Transmission of Resistant Bacteria to Oral Cavity of Newborn Babies.

BACKGROUND: A rapid bacterial diagnostic is needed more and more in the treatment of patients, because of the emergence of antibiotic resistance. The cumulative antibiogram, an annual report that monitors antimicrobial resistance trends in health care facilities, may provide a profile of empirical therapy useful in diverse emergency situations, such as transmission of resistant bacteria to oral cavity of newborn babies. We aimed to draw a profile of antibiotic resistance encountered. METHODS: We assessed the antibiotic resistance (ABR) profile in childbearing women and newborn babies in Ploiesti Obstetrics and Gynecology Hospital by the disk diffusion method characterizing the multidrug-resistant organisms after isolation and identification by phenotypic tests. Extended-spectrum ß-lactamase (ESBL)-producing Enterobacterales (ESBL-E), Carbapenem-resistant Enterobacterales (CRE), vancomycin-resistant Enterococci (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant Group B Streptococcus (VR-GBS) were detected. RESULTS: The prevalence of antibiotic resistance was 11.32% (53/468), while the prevalence of the ESBL-E, MRSA, VRE and VR-GBS strains was 8.34% (39/468). Within the bacteria isolated from fifty-three childbearing women, the prevalence of ESBL-E, MRSA, VRE and VR-GBS was 22.64% (12/53), 32.08% (17/53), 11.32% (6/53) and 7.55% (4/53). In the whole studied group, the prevalence was 2.56% (12/468), 3.63% (17/468), 1.28% (6/468) and 0.86% (4/468). Resistant bacteria were detected at birth in the oral cavity of the newborn babies in all cases. Maternal and neonatal isolates shared similar characteristics. CONCLUSIONS: Cumulative antibiogram is useful in case of empiric treatment needed in diverse emergencies, such as transmission of resistant bacteria to oral cavity of newborn babies.

Selective and Cascade Reporting of Antimicrobial Susceptibility Testing Results and Its Impact on Antimicrobial Resistance Surveillance-National Healthcare Safety Network, April 2020 to March 2021.

Selective or cascade reporting (SR/CR) of antimicrobial susceptibility testing (AST) results is a strategy for antimicrobial stewardship. SR/CR is often achieved by suppressing AST results of secondary drugs in electronic laboratory reports. We assessed the extent of SR/CR and its impact on cumulative antibiograms (CAs) in a large cohort of U.S. hospitals submitting AST data to the CDC's National Healthcare Safety Network (NHSN) through electronic data exchange. The NHSN calls for hospitals to extract AST data from their electronic systems. We analyzed the AST reported for Escherichia coli (blood and urine) and Staphylococcus aureus (blood and lower respiratory tract [LRT]) isolates from April 2020 to March 2021, used AST reporting patterns to assign SR/CR reporting status for hospitals, and compared their CAs. Sensitivity analyses were done to account for those potentially extracted complete data. At least 35% and 41% of the hospitals had AST data that were suppressed in more than 20% blood isolates for E. coli and S. aureus isolates, respectively. At least 63% (blood) and 50% (urine) routinely reported ciprofloxacin or levofloxacin for E. coli isolates; and 60% (blood) and 59% (LRT) routinely reported vancomycin for S. aureus isolates. The distribution of CAs for many agents differed between high SR/CR and low- or non-SR/CR hospitals. Hospitals struggled to obtain complete AST data through electronic data exchange because of data suppression. Use of SR/CR can bias CAs if incomplete data are used. Technical solutions are needed for extracting complete AST results for public health surveillance. IMPORTANCE This study is the first to assess the extent of using selective and/or cascade antimicrobial susceptibility reporting for antimicrobial stewardship among U.S. hospitals and its impact on cumulative antibiograms in the context of electronic data exchange for national antimicrobial resistance surveillance.

Spanish Antibiogram Committee (COESANT) recommendations for cumulative antibiogram reports.

The Spanish Antibiogram Committee (Comité Español del Antibiograma, COESANT) presents in this document a series of recommendations intending to unify how cumulative antibiogram reports must be made in Clinical Microbiology Spanish laboratories. This article is based on the information included in the Clinical Microbiology Procedure No. 51, «Preparation of cumulative reports on antimicrobial susceptibility¼ of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), published in 2014. The recommendations also include the modifications in the definition of clinical interpretive categories recently published by the European Committee on Antimicrobial Susceptibility Testing (EUCAST) in 2019. Its final objective is to establish a homogeneous way of preparing these summaries to compare results from different centers or aggregate the information from these in order to carry out an adequate local or even national surveillance regarding the evolution of antimicrobial susceptibility.

Utilising cumulative antibiogram data to enhance antibiotic stewardship capacity in the Cape Coast Teaching Hospital, Ghana.

BACKGROUND: Antimicrobial resistance (AMR) is a major public health challenge with its impact felt disproportionately in Western Sub-Saharan Africa. Routine microbiology investigations serve as a rich source of AMR monitoring and surveillance data. Geographical variations in susceptibility patterns necessitate regional and institutional tracking of resistance patterns to aid in tailored Antimicrobial Stewardship (AMS) interventions to improve antibiotic use in such settings. This study focused on developing a cumulative antibiogram of bacterial isolates from clinical samples at the Cape Coast Teaching Hospital (CCTH). This was ultimately to improve AMS by guiding empiric therapy. METHODS: A hospital-based longitudinal study involving standard microbiological procedures was conducted from 1st January to 31st December 2020. Isolates from routine diagnostic aerobic cultures were identified by colony morphology, Gram staining, and conventional biochemical tests. Isolates were subjected to antibiotic susceptibility testing using Kirby-Bauer disc diffusion. Inhibitory zone diameters were interpreted per the Clinical and Laboratory Standards Institute guidelines and were entered and analysed on the WHONET software using the "first isolate only" principle. RESULTS: Overall, low to moderate susceptibility was observed in most pathogen-antibiotic combinations analysed in the study. Amikacin showed the highest susceptibility (86%, n = 537/626) against all Gram-negatives with ampicillin exhibiting the lowest (6%, n = 27/480). Among the Gram-positives, the highest susceptibilities were exhibited by gentamicin (78%, n = 124/159), with clindamycin having the lowest susceptibility (27%, n = 41/154). Among the Gram-negatives, 66% (n = 426/648) of the isolates were identified phenotypically as potential extended-spectrum beta-lactamase producers. Multiple multidrug-resistant isolates were also identified among both Gram-positive and Gram-negative isolates. Low to moderate susceptibility was found against first- and second-line antibiotics recommended in the National standard treatment guidelines (NSTG). Laboratory quality management deficiencies and a turnaround time of 3.4 days were the major AMS barriers identified. CONCLUSIONS: Low to moderate susceptibilities coupled with high rates of phenotypic resistance warrant tailoring NSTGs to fit local contexts within CCTH even after considering the biases in these results. The cumulative antibiogram proved a key AMS programme component after its communication to clinicians and subsequent monitoring of its influence on prescribing indicators. This should be adopted to enhance such programmes across the country.

Importance of Susceptibility Rate of 'the First' Isolate: Evidence of Real-World Data.

Background and objectives: For proper antimicrobial therapy, cumulative antibiograms should be representative of geographic region and be accurate. Clinical and Laboratory Standards Institute (CLSI) guidelines recommend that only the first isolates (FI) of a species per patient are used when reporting cumulative antibiograms. However, >50% of hospitals in the United States report antibiograms of all isolates. We compared antibiograms from the FI with those from total isolates (TI). Materials and Methods: Antimicrobial data of all isolates identified in the Microbiology unit of Ilsan Paik Hospital in 2019 were retrospectively acquired from the hospital information system. The susceptibility rates to antimicrobials of Escherichia coli, Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus, Enterococcus faecium, and Enterococcus faecalis were analyzed by FI and TI, respectively. Isolate counts and susceptibility rates of each species for the reported antimicrobials were compared. Results: The numbers of isolates by FI/TI were as follows: 1824/2692 E. coli, 480/1611 A. baumannii, and 662/1306 K. pneumoniae, and 407/953 P. aeruginosa for gram-negative bacteria and 649/1364 S. aureus, 211/313 E. faecium, and 323/394 E. faecalis for gram-positive bacteria. All antimicrobial agents showed higher susceptibility rates when calculated as FI than as TI in gram-negative bacteria except colistin: 3.7% for E. coli, 14.5% for A. baumannii, 8.3% for K. pneumoniae, and 7.9% for P. aeruginosa. In S. aureus, 8/11 antimicrobial agents revealed higher susceptibility rates for FI than for TI. E. faecalis and E. faecium showed lower susceptibility rates for 7/10 antimicrobial agents for FI than for TI. The oxacillin susceptibility rates of S. aureus were 36.6%/30.2% with FI/TI and vancomycin susceptibility rates for E. faecium were 54.1% and 49.5%, respectively. Conclusions: When comparing cumulative antibiograms by FI with TI using real-world data, there is a large gap for critical species requiring hospital infection control. Although FI calculation is difficult, antibiograms must be calculated as FI for proper preemptive antimicrobial therapy because FI provides proper antimicrobial susceptibility data.

Can surgical site infections be controlled through microbiological surveillance? A three-year laboratory-based surveillance at an orthopaedic unit, retrospective observatory study.

OBJECTIVE: The aims of the study were to analyse the surgical site infections (SSIs) in patients operated at an orthopaedic ward and to describe the drug-resistance of the aetiology of those infections. Also, analyse the possibility of SSI control through microbiological surveillance. Additionally, we have studied the information inferred by aggregating cumulative antibiograms for the SSIs of the studied orthopaedic unit. DESIGN: Cross-sectional studies carried out in 2013-2015. SETTING AND PATIENTS: Orthopaedic and Trauma Surgery Unit in Sosnowiec, Poland; 5995 patients, 5239 operations. METHODS: Retrospective laboratory-based data collection study of surgical site infections. RESULTS: SSI incidence rate was 6.6%, in the implantations-hip prosthesis 5.8% and knee prosthesis 5.4%, about 6 times higher compared with European HAI-Net. SSIs were usually caused by Gram-positive bacteria (56%). The prevalence of MDR microorganisms was 22.6%, and mainly concerned the Gram-negative bacilli: 97.6% of Acinetobacter baumannii and 50.0% of Klebsiella pneumoniae were multidrug-resistant. On the basis of what the Formula for Rational Empiric Antimicrobial Therapy analysis has shown, the use of amikacin, imipenem and ciprofloxacin has been recommended as the most efficient in the empirical therapy of SSIs. CONCLUSIONS: The infection control was a significant problem at the studied orthopaedic unit, as evidenced by the SSI incidence rate significantly higher than expected. We suggest implementing the infection control and prevention based on evidence-based medicine, and a unit-based surveillance. A cumulative unit-based antibiogram reflects the drug-susceptibility pattern for the strains from the infections acquired at the unit.

A decision support system for antibiotic prescription based on local cumulative antibiograms.

BACKGROUND: Local cumulative antibiograms are useful tools with which to select appropriate empiric or directed therapies when treating infectious diseases at a hospital. However, data represented in traditional antibiograms are static, incomplete and not well adapted to decision-making. METHODS: We propose a decision support method for empiric antibiotic therapy based on the Number Needed to Fail (NNF) measure. NNF indicates the number of patients that would need to be treated with a specific antibiotic for one to be inadequately treated. We define two new measures, Accumulated Efficacy and Weighted Accumulated Efficacy in order to determine the efficacy of an antibiotic. We carried out two experiments: the first during which there was a suspicion of infection and the patient had empiric therapy, and the second by considering patients with confirmed infection and directed therapy. The study was performed with 15,799 cultures with 356,404 susceptibility tests carried out over a four-year period. RESULTS: The most efficient empiric antibiotics are Linezolid and Vancomycin for blood samples and Imipenem and Meropenem for urine samples. In both experiments, the efficacies of recommended antibiotics are all significantly greater than the efficacies of the antibiotics actually administered (P < 0.001). The highest efficacy is obtained when considering 2 years of antibiogram data and 80% of the cumulated prevalence of microorganisms. CONCLUSION: This extensive study on real empiric therapies shows that the proposed method is a valuable alternative to traditional antibiograms as regards developing clinical decision support systems for antimicrobial stewardship.

How to measure the impacts of antibiotic resistance and antibiotic development on empiric therapy: new composite indices.

OBJECTIVES: We aimed to construct widely useable summary measures of the net impact of antibiotic resistance on empiric therapy. Summary measures are needed to communicate the importance of resistance, plan and evaluate interventions, and direct policy and investment. DESIGN, SETTING AND PARTICIPANTS: As an example, we retrospectively summarised the 2011 cumulative antibiogram from a Toronto academic intensive care unit. OUTCOME MEASURES: We developed two complementary indices to summarise the clinical impact of antibiotic resistance and drug availability on empiric therapy. The Empiric Coverage Index (ECI) measures susceptibility of common bacterial infections to available empiric antibiotics as a percentage. The Empiric Options Index (EOI) varies from 0 to 'the number of treatment options available', and measures the empiric value of the current stock of antibiotics as a depletable resource. The indices account for drug availability and the relative clinical importance of pathogens. We demonstrate meaning and use by examining the potential impact of new drugs and threatening bacterial strains. CONCLUSIONS: In our intensive care unit coverage of device-associated infections measured by the ECI remains high (98%), but 37-44% of treatment potential measured by the EOI has been lost. Without reserved drugs, the ECI is 86-88%. New cephalosporin/ß-lactamase inhibitor combinations could increase the EOI, but no single drug can compensate for losses. Increasing methicillin-resistant Staphylococcus aureus (MRSA) prevalence would have little overall impact (ECI=98%, EOI=4.8-5.2) because many Gram-positives are already resistant to ß-lactams. Aminoglycoside resistance, however, could have substantial clinical impact because they are among the few drugs that provide coverage of Gram-negative infections (ECI=97%, EOI=3.8-4.5). Our proposed indices summarise the local impact of antibiotic resistance on empiric coverage (ECI) and available empiric treatment options (EOI) using readily available data. Policymakers and drug developers can use the indices to help evaluate and prioritise initiatives in the effort against antimicrobial resistance.