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HOW TO INTERPRET
Hendro Wahjono
Department of Microbiology
Dr.Kariadi Hospital
Fac. of Medicine, Diponegoro University
OVERVIEW
- Laboratory-based services
- Technical aspect
‘NEW’ Indonesian Clin Micr Services ?
4
POCT
Point of Care-Testing
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
1.0 jam 3.0 jam 3.0 hari 1.0 jam 1.0 jam
10
Objectives
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.
VRE
ESBL Klebsiella
3rd generation
cephalosporins -lactam-resistant
Acinetobacter
C. difficile
MDR Pseudomonas
Fluoroquinolones
C. difficile
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:
•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
•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
For example:
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
S = Susceptible R = Resistant
End of Report
Laboratory Report #4
Source: Urine (clean catch)
Status: Final
Isolate 1: >100,000 CFU Pseudomonas aeruginosa
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
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
Specific locations
By unit of the hospital (ICU vs non ICU)
Inpatient vs. Outpatient
Escherichia coli 18 20 50 66 56 50 80 40 33 83 66 82 93 16 33 93
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
Clinical Microbiologist
Policy Deals with
We discuss on the Broad basis
Clinicians / Microbiologists /
Pharmacists and Nurses do take
part.
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
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