Using hospital antibiogram data to assess regional pneumococcal resistance to antibiotics

Antibiotic utilisation in adult and children patients in Kosovo hospitals

Objectives

There are no reliable data on antibiotic use in Kosovo hospitals. The aim of this survey was to monitor volumes and patterns of antibiotic use in hospitalised patients in order to identify targets for quality improvement.

Methods

Data on antimicrobial use were collected from seven hospitals in Kosovo during 2013 using the standardised point prevalence survey (PPS) methodology as developed by the ESAC (European Surveillance of Antimicrobial Consumption) and ARPEC (Antibiotic Resistance and Prescribing in European Children). The survey included all inpatients receiving an antimicrobial agent on the day of the PPS.

Results

Overall, 1667 patients were included in the study: adults 1345 (81%) and children 322 (19%). Of the hospital inpatients, 579/1345 (43%) adults and 188/322 (58%) children received at least one antibiotic during a hospital stay. The top three antibacterial subgroups (ATC level 3) were β-lactam antibiotics, cephalosporins and aminoglycosides. In all hospital centres, the most commonly prescribed antibiotic was ceftriaxone (39% for adult and 36% for children). Antibiotics were administered mainly parenterally in 74% of adults and 94% of children. Empirical prescribing was higher in adults 498/579 (86%) and children 181/188 (96%), compared with targeted treatment based on susceptibility testing-81 (14%) and 8 (4%), respectively.

Conclusions

Antibiotic use in Kosovo's hospitals is very high. Gathered data will be an important tool to identify targets for quality improvement and will support preparation of guidelines and protocols for the prudent use of antibiotics.

Development of a Statewide Antibiogram to Assess Regional Trends in Antibiotic-Resistant ESKAPE Organisms

Background:

Hospitals and other facilities utilize antibiograms as tools for optimal antibiotic selection. Currently, no measures compare broad trends on the regional level, despite interest for more comprehensive data, particularly for antibiotic-resistant ESKAPE organisms.

Objective:

To collect and compare regional health-care facility antibiogram data for ESKAPE organisms to form a cumulative antibiogram.

Methods:

Health-care facilities were identified using the publicly accessible Pennsylvania Department of Health web site. Facilities were contacted by phone from June 2015 to 2016 to ascertain participation/consent for the study. An electronic questionnaire ascertained baseline facility characteristics. Facilities provided quantitative antibiotic susceptibility data via antibiograms. Antibiogram data were synthesized as cumulative susceptibilities, stratified by urban/suburban versus rural location.

Results:

Forty-five facilities were included in the study (n = 18 urban/suburban, n = 27 rural). The overall prevalence of methicillin-resistant S aureus was 41.5%, stratified at 40.6% and 43.3% in urban/suburban and rural facilities, respectively ( P < .001). Vancomycin-resistant Enterococcus prevalence was 18.8% overall, with 27.7% in urban/suburban and 14.0% in rural facilities ( P < .001). Generally, lower susceptibility rates were found for high-utilization beta-lactams across gram-negative organisms in urban/suburban facilities.

Conclusions:

Development of a regional cumulative antibiogram that targets key ESKAPE pathogens is feasible, while observed trends may help aid future antimicrobial stewardship efforts.

Use of Local Community Hospital Data for Surveillance of Antimicrobial Resistance

We sought to determine whether antimicrobial susceptibility data from a nonteaching community hospital could be used to detect statistically significant local increases in resistance among Streptococcus pneumoniae over a 5-year period. Minimum inhibitory concentrations (MICs) of penicillin and ceftriaxone from 1997-1998 were compared with those from 2000-2001. MICs of penicillin and ceftriaxone for organisms collected in a nonteaching community hospital in central Illinois were used for analysis. The hospital has 224 beds and a catchment area of approximately 40 miles. There were significant increases in MICs of penicillin and ceftriaxone between 1997-1998 and 2000-2001. The MIC of penicillin increased from 0.042 to 0.121 μg/mL (P = .001; 95% confidence interval, -1.713 to -0.388), and the MIC of ceftriaxone increased from 0.028 to 0.071μg/mL (P = .005; 95% confidence interval, -1.353 to -0.188). There were no significant changes in the percentage of S. pneumoniae isolates that were resistant, intermediate, or susceptible to penicillin and ceftriaxone. MIC data from a community hospital can be used to detect local increases in the rate of resistance before antibiogram data show significant changes. This information is important for demonstrating to physicians the need to review local antibiotic use in the attempt to slow the development of resistant organisms in the community.

Hospital antibiogram: a necessity

The hospital antibiogram is a periodic summary of antimicrobial susceptibilities of local bacterial isolates submitted to the hospital's clinical microbiology laboratory. Antibiograms are often used by clinicians to assess local susceptibility rates, as an aid in selecting empiric antibiotic therapy, and in monitoring resistance trends over time within an institution. Antibiograms can also used to compare susceptibility rates across institutions and track resistance trends. Some hospitals have adequate support from the computer department to be able to extract data from their reporting module. The WHONET software can be freely downloaded and used for analysis. Consensus guidelines have been developed by the Clinical and Laboratory Standards Institute (CLSI) to standardise methods used in constructing antibiograms. These guidelines can be incorporated into the WHONET software for analysis. Only the first isolate from the patient is to be included in the analysis. The analysis should be done on the basis of patient location and specimen type. The percentage susceptibility of the most frequently isolated bacteria should be presented in the antibiogram, preferably in a tabular form. The antibiogram must be printed or put up in the intranet for easy access to all clinicians. Antibiotic policy is one of the mandatory requirements for accreditation, and making an antibiogram is the first step before framing the antibiotic policy. The future of antibiograms would be the incorporation of patient related data to make information more reliable and for predicting outbreaks.

First Report of a Case of Pneumococcal Meningitis Which Did Not Respond to the Ceftriaxone Therapy despite the Isolated Organism Being Sensitive to This Antibiotic In Vitro

A 60-year-old man presented with pneumococcal meningitis which did not respond to the ceftriaxone therapy, in spite of in-vitro susceptibility (minimal inhibitory concentration of 0.016 μg/dLit) of the isolated organism to this antibacterial agent, although ceftriaxone is still the drug of choice for such pneumococcal meningitis. Review of published articles revealed no report of clinical resistance in organisms which were susceptible to the same antimicrobial agent in vitro. This alarming emergence of isolates with in vivo resistance should be considered and even could lead to a shift in the empirical antibiotic therapy for pneumococcal infections.

Otitis Media: A Review, with a Focus on Alternative Treatments

Otitis media (OM) is the accumulation of fluids in the middle ear, with or without symptoms of inflammation. The infection is caused by dysfunction or obstruction of the eustachian tube and is most commonly diagnosed in children under the age of two. The microbiology of OM differs, with Streptococcus pneumoniae, non-typeable Haemophilus influenzae and Moraxella catarrhalis the most commonly isolated pathogens. The emergence of penicillin-resistant Strep. pneumoniae, β-lactamase-producing strains, Haem. influenzae and Mor. catarrhalis is a major concern and health care costs associated with treatment are substantial, especially in cases of unresponsive treatment as a result of incorrect diagnosis. Alternative treatments such as vaccines and a nasal spray containing α-haemolytic streptococci with antimicrobial activity against OM pathogens, have been developed. The rationale behind such treatments is to induce an appropriate immune response against the pathogens and decrease bacterial colonisation in the nasopharynx. Another approach may be treatment with bacteriocins (natural antimicrobial peptides) or bacteriocin-like inhibitory substances (BLIS) produced by lactic acid bacteria. We have recently described an antibacterial peptide produced by Enterococcus mundtii ST4SA and have published on bacteriocins (enterocins) with antibacterial and antiviral activity. This review discusses the condition OM, summarises current methods used to treat the infection, and suggests alternative safe and natural treatments that need to be explored.

Usefulness of antibiogram surveillance for methicillin-resistant Staphylococcus aureus in outpatient pediatric populations

We assessed the impact of distributing an outpatient age-specific methicillin-resistant Staphylococcus aureus (MRSA) antibiogram on physician knowledge of MRSA prevalence and choice of empiric therapy. Questionnaires were given to 125 physicians at outpatient pediatric clinics in Monroe County, NY, before and after antibiogram distribution (response rates, 42% and 24%, respectively). The median physician-estimated MRSA prevalence (among S. aureus skin infections) was 15% before they received the antibiogram and 20% after. According to the antibiogram, the true 2005 prevalence was 25% among skin infections. When asked to select empiric therapy for a pediatric outpatient with a skin abscess, while assuming varying levels of MRSA prevalence, most selected cephalexin when the prevalence was assumed to be 20% or less, and trimethoprim-sulfamethoxazole when the prevalence was assumed to be 30% or greater. These data suggest that antibiograms may improve empiric therapy decision making by increasing knowledge of local outpatient prevalence of antibiotic resistance.

Emergence and trends of penicillin non-susceptible Streptococcus pneumoniae in Saudi Arabia and Kuwait - perspective and outstanding issues

For many years in the past Streptococcus pneumoniae was uniformly susceptible to penicillin until the sudden and unexpected emergence of clinical infections caused by penicillin-resistant S. pneumoniae (PRSP) in 1967. Within the following decade, reports of nosocomial and community outbreaks of infections due to PRSP became widespread all over the world. Recent reports suggest that the incidence of resistance rates is rising in many countries although there are geographical variations in the prevalence and patterns of resistance between countries. The problem of antibiotic resistance is further compounded by the emergence of resistance to many beta-lactam antibiotics. The first report of PRSP in Saudi Arabia was in 1991. Barely a year after, PRSP infection was reported in Kuwait in 1992. Since then, studies from various parts of these countries have recorded prevalence rates ranging from 6.2% in Riyadh to 34% in Jeddah and 20% to 56% in neighboring Kuwait. These suggest considerable variation in the prevalence of PRSP in different cities in the Saudi Kingdom and Kuwait. The mechanism of resistance is due to chromosomally mediated alteration of penicillin-binding proteins (PBPs), which are target sites for beta-lactam antibiotics. It would appear that the spread of PRSP strains in Saudi Arabia is driven by the selective pressure created by excessive use and misuse of antimicrobial agents made possible by the easy availability of these agents, often frequently obtainable over the counter. In Kuwait, irrational and misguided use of antibiotics may be the major driving force favoring the spread of PRSP. The serotypes of strains encountered in Saudi Arabia and Kuwait are almost identical, with serotypes 19, 6, 15, 14 and 23 being the most common; together they constitute about 70% of the isolates circulating in these countries. In general, almost 90% of the serotypes included in the 23-polyvalent vaccine are present in the general population. However, a much lower percentage of these serotypes is found in the conjugated vaccines, which are more relevant to our communities. This paper reviews the emergence and the steady increase in the prevalence of penicillin-resistant pneumococcal strains in Saudi Arabia and Kuwait during the last 10 years. It discusses the trends, mechanisms of resistance and factors associated with the emergence, dissemination, and colonization of resistant organisms and suggests options available to clinicians for management of infections due to PRSP.

Evaluating antibiograms to monitor drug resistance

We used hospital antibiograms to assess predominant pathogens and their patterns of in vitro antimicrobial resistance in central Illinois, USA. We found a lack of information about national guidelines for in vitro antimicrobial susceptibility testing and differences in interpretation among laboratories in the region.

Nationwide antibiogram analysis using NCCLS M39-A guidelines

Lack of standardization in antibiogram (ABGM) preparation (the overall profile of antimicrobial susceptibility results of a microbial species to a battery of antimicrobial agents) has not been addressed until recently. The objective of this study was to analyze current antibiograms using the recently published NCCLS M39-A guidelines for preparation of antibiograms to identify areas for improvement in the reporting of antibiogram susceptibility data. Antibiograms from across the United States were obtained by various methods, including direct mailings, Internet searches, and professional contacts. Each ABGM collected was analyzed using prospectively defined elements from the M39-A guidelines. Additionally, seven quality indicators were also evaluated to look for the reporting of any atypical or inappropriate susceptibility data. The 209 antibiograms collected from 149 institutions showed at least 85% compliance to 5 of the 10 M39-A elements analyzed. Clinically relevant elements not met included annual analysis, duplicate isolate notation, and the exclusion of organisms with fewer than 10 isolates. As for the quality indicators evaluated, unexpected results included the 7% of antibiograms that reported <100% vancomycin susceptibility for Staphylococcus aureus, 24% that had inconsistent beta-lactam susceptibility for Staphylococcus aureus, 20% that reported <100% imipenem susceptibility for Escherichia coli, and 37% that reported >0% ampicillin susceptibility for Klebsiella pneumoniae. 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.

Wise use of perioperative antibiotics

NOSOCOMIAL SURGICAL SITE INFECTIONS (SSIs), especially those caused by antibiotic-resistant organisms, are a major concern for perioperative nurses. Administering the correct antibiotic at its effective dose within the optimal time frame can help prevent SSIs. THE SIGNIFICANT RELATIONSHIP between microbial resistance and overuse of antibiotics justifies an examination of practices and a move away from widespread antibiotic administration. NEW ANTIBIOTIC GUIDELINES and research support recommendations for antibiotic administration for specific cardiac, colorectal, gynecologic, ophthalmologic, orthopedic, and urinary surgical procedures. Perioperative nurses can help protect their patients from nosocomial SSIs by using this clinical evidence.

Microbiology of middle ear effusions from 292 patients undergoing tympanostomy tube placement for middle ear disease

OBJECTIVE

Otitis media is one of the most commonly diagnosed childhood illnesses. Ideally, culture directed therapy for otitis media would be available, however, the common approach is to treat infections with antibiotics that cover the most common pathogens. The objective of this study is to describe the pathogens cultured from the middle ear effusions (MEE) of patients that underwent tympanostomy tube placement for middle ear disease, compare these results with previous studies, and assess for trends suggestive of changes in the microbiology of these patients.

METHODS

Patients were invited to participate after the decision to place ventilation tubes had been made. A standard anterior-inferior myringotomy was made for placement of the ventilation tube. After myringotomy, patients had their ears suctioned and all effusions were collected for microbiologic analysis.

RESULTS

A total of 292 patients were enrolled in the study, a total of 270 MEE samples were taken. Haemophilus influenzae and Moraxella catarrhalis were seen in 24 of 148 (16.2%) and 15 of 148 (10.1%), respectively. Neisseria meningitidis, Staphylococcus aureus and Corynebacterium species were each identified in 11 of the 148 pathogens isolated (7.4%). Streptococcus pneumoniae was identified in 6 of the 148 isolated pathogens (4.1%).

CONCLUSION

Despite a high number of non-pathogenic bacteria, and a high number of culture negative effusions, we demonstrated pathogen rates consistent with other reports in the literature. Future directions include using more specific techniques such as PCR to better understand the microbiology of middle ear effusions.