National Guidelines and Statewide Antimicrobial Susceptibility Testing Reporting

National Guidelines and Statewide Antimicrobial Susceptibility Testing, Reporting and Surveillance In Massachusetts Barbara Bolstorff Kerri Barton Johanna Vostok Hilary Placzek Lynda Glenn Alfred De. Maria Massachusetts Department of Public Health

Antibiograms • Antibiograms, generated by hospital microbiology laboratories, report the susceptibility of bacterial isolates tested against specific antibiotics (usually aggregated by year). • The Massachusetts Department of Public Health (MDPH) has requested hospitals in Massachusetts send antibiograms since 1999.

Antibiograms in Massachusetts • Since 2002, MDPH has received an average of 53 antibiograms per year (range 43 -57) from 71 -73 facilities. • Organisms routinely reported include: Acinetobacter baumannii Staphylococcus aureus Pseudomonas aeruginosa Methicillin-resistant Staphylococcus aureus Escherichia coli Klebsiella pneumoniae Serratia marcescens Stenotrophomonas maltophilia Enterobacter cloacae Klebsiella oxytoca Enterobacter aerogenes Streptococcus pneumoniae

Antibiogram example

Data collection 1999 -2011 • An email is sent to all acute-care hospital microbiology supervisors each year (Feb-March) requesting the previous year’s antibiogram data • Prior to electronic submission form (2012) – Data were received in a variety of formats, usually through email, fax, or snail mail – Missing information (i. e. patient type, duplicate isolate reporting) required a follow-up phone call – Data were entered manually into a large Microsoft Office Access Database and analyzed using SAS

Data entry 1999 -2011

CLSI (Clinical and Laboratory Standards Institute) • Documents that provide laboratories with guidance for standardization Antibiograms: Developing Cumulative Reports for Your Clinicians: • M 39 -A: 2002 • M 39 -A 2: 2005 • M 39 -A 3: 2009 • M 39 -A 4: ? http: //www. clsi. org/

CLSI adherence in MA • • MDPH evaluated antibiogram data from 2002 -2010 Focused on 5 important recommendations from CLSI 1 - Exclude duplicate bacterial isolates (2002) 2 - Separate reporting of Staphylococcus aureus isolates by methicillin (oxacillin)-susceptibility (2002) 3 - Format of data into a grid (2002) 4 - Report species only when 30 or more isolates are tested annually (2005) 5 - Summarize data by patient type (2005)

Reporting of Duplicate Results and <30 Isolates

Reporting a S. aureas only, MRSA and MSSA Separately and Total Plus MRSA and MSSA

Results, cont’d. • In 2010, 80% of submitted antibiograms were in a one-page grid format, consistent with the CLSI recommendation • Hospitals reporting organisms isolated <30 times per year decreased from 86% in 2002 to 57% in 2010 • During the time period from 2002 to 2010: – Hospitals consistently reported all patient isolates (range: 63 -78% ) – Range of hospitals that reported inpatient only isolates: 22 -31% – Less than 10% of hospitals reported ICU isolate data separately

Data collection 2012 and beyond • An email is sent to all acute-care hospital microbiology supervisors with a standardized electronic submission form – Each hospital is asked to enter their data into the form (using Adobe Reader for free) and electronically submit the data via email submission – At MDPH: Each form is downloaded from the email, data are extracted using Adobe Acrobat, and analyzed using SAS

2013 Submission Form

Required fields Save the form for later use Electronically submit to shared email account

“Rules” built into form

Variable “N” entry

S. pneumoniae reporting

Challenges and Lessons Learned • IT issues within the hospital laboratory created barriers – In most cases, the latest version Adobe Reader had to be downloaded – Free program, but IT services do not regularly update laboratories with new programs • The new electronic submission process should have been first piloted with a select few “consistent reporters”

Final Product • MDPH creates annual reports for every acute-care hospital in Massachusetts – Report shows the state mean susceptibilities of 11 organisms of interest for a variety of antibiotics – Hospitals that submit data receive a report showing their hospital-level data compared to the state mean data

Additional data analysis • MDPH creates annual reports for every acute-care hospital in Massachusetts • Data monitored over time for trends in susceptibility – S. aureus and oxacillin – E. coli and fluoroquinolones

Staphylococcus aureas Susceptibility to Oxacillin Over Time, Massachusetts Antibiograms Caveats: Hospitals reporting varies somewhat over time Changes in handling of duplicate isolates

Escherichia coli Susceptibility to Ciprofloxacin and Levofloxacin Over Time

Standardized data • In order to aggregate data across hospitals, antibiograms must be standardized: – MRSA and MSSA susceptibilities should be presented separately – Report the first isolate tested per patient only (regardless of body site) – Report separate tables for gram-negative, grampositive, and if applicable anaerobic bacteria and yeasts

CLSI Guidelines • Standard antimicrobial susceptibility testing and reporting are equally as important • CLSI (Clinical Laboratory Standards Institute) for the most up-to-date recommendations: – M 100 -S 22: Performance Standards for Antimicrobial Susceptibility Testing; Twenty Second Informational Supplement – M 39 -A 3: Antibiograms: Developing Cumulative Reports for Your Clinicians Quick Guide (M 39 -A 3 QG) http: //www. clsi. org/

Regulatory Change • Proposed requirement for submission of antibiogram data: 105 CMR 300. 171: Reporting of Antimicrobial Resistant Organisms and Cumulative Antibiotic Susceptibility Test Results (Antibiograms) (B) All hospitals shall report annual cumulative antibiotic susceptibility test results (antibiograms). This report shall include information specified by the Department and be sent in the manner deemed acceptable by the Department.

Questions? Alfred De. Maria Jr. , MD Massachusetts Department of Public Health alfred. demaria@state. ma. us