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HOSPITAL

ANTIBIOGRAMS

principles interpretation and documentation


Dr.T.V.Rao MD

03-08-2016

Dr.T.V.Rao MD

Different methods to Test Antibiotic Sensitivity


patterns

03-08-2016

Dr.T.V.Rao MD

What is an antibiogram
An antibiogram is a
laboratory test used to
determine the
sensitivity pattern of a
given microorganism
to a range of
antibiotics.
03-08-2016

Dr.T.V.Rao MD

What is a Hospital Antibiogram


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
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Dr.T.V.Rao MD

Helps in identifying the Antibiotic


Resistance patterns
Antibiograms can
also used to
compare
susceptibility rates
across institutions
and track
resistance trends
03-08-2016

Dr.T.V.Rao MD

Why we need An Antibiogram


Antimicrobial-resistant bacterial infections
are a challenging problem in the hospital
setting. Infections caused by resistant- and
multidrug-resistant (MDR) bacteria not
only increase morbidity and mortality, but
also increase overall healthcare costs,
primarily by prolonging hospital length of
stay.
03-08-2016

Dr.T.V.Rao MD

Hospital Associated Infections can be Monitored


with Antibiograms
In situations when
hospital-acquired
infections do occur, the
preponderance of MDR
bacteria as the causative
pathogen challenges
clinicians in selecting
appropriate therapy and
treatment regimens.
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Dr.T.V.Rao MD

We need better methods to monitor


Antibiotic Therapy
Inappropriate
therapy can have
significant
clinical and
economic
consequences
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Dr.T.V.Rao MD

Wrong Antibiograms add to


MDR Strains

Inappropriate
antimicrobial
selection also has
the potential to
increase the risk for
resistance
development.

03-08-2016

Dr.T.V.Rao MD

Antibiograms are also used to


Check if the causative agent belongs to a
species capable of exhibiting resistance to
commonly used antibiotics.
Study the epidemiology of resistance
Evaluate the efficacy of a new antibiotics
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Dr.T.V.Rao MD

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Hospital Antibiograms are essential tools


Hospital antibiograms can be an
essential tool to monitor local
epidemiology and emerging
resistance trends.
Antibiograms, if generated and
utilized appropriately, can
monitor resistance at
healthcare facilities by
reporting susceptibility rates of
common pathogens over a
period of time
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Selecting an Appropriate Antibiotic a Priority


They can, therefore,
serve as an invaluable
guide in selecting
appropriate empiric
therapy and influence
institutional
antimicrobial use
policies
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Dr.T.V.Rao MD

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Growing Importance of Antibiograms


Over the last twenty
years, new categories
of antibiotics have
entered the market
and numerous forms
of resistance have
appeared and
multiplied
03-08-2016

Dr.T.V.Rao MD

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Antibiograms are also used to


Check if the causative agent
belongs to a species capable
of exhibiting resistance to
commonly used antibiotics.
Study the epidemiology of
resistance
Evaluate the efficacy of a
new antibiotic
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Dr.T.V.Rao MD

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Why should you develop and use an antibiogram


at your Hospital facility?
Antibiograms encourage responsible use of antibiotics
throughout facilities. Prescribing cliniciansphysicians,
nurse practitioners, and physician assistantscan consult
these tools before initiating empiric antibiotic therapy, which
may improve outcomes among patients with infections.
Antibiograms are a good way to detect changes in resistance
patterns for an entire facility or for locations within a facility.
Antibiograms can be inexpensive to develop and maintain.
The results are easily accessible to health care providers.
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Dr.T.V.Rao MD

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How to begin our Work with Antibiograms


Isolation, identification of the
pathological Microbe and
antibiogram of a pathogenic
agent are normally carried out
when a bacterial disease has
produced a problem

We have specific and


General methods to identify
the pathogenic bacterial
isolate
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Mechanism in Testing the Antibiograms


The basic idea of
diffusion assays is as
follows: the tested
antibiotics are
impregnated in paper
discs which are placed on
plate of agar medium
inoculated with the
bacteria in question.
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Mechanism in Testing the Antibiograms


Following diffusion of the
compounds through the
agar, a "halo" or zone of
inhibition forms where a
concentration of the
specific diffused
antibiotic is sufficient to
inhibit that microbial
growth
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Interpreting an antibiogram
The correct
interpretation of the
antibiogram will be of
interest to
Microbiologists and
laboratory technicians
alike. Standardized
methods are established
and can be found in the
WHO manuals.
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Still we have not


Understood Problems with
Antibiograms

One of the most frequently


asked questions relates to in-

vitro (in the lab)/in-vivo (in


the field) relationships. Why is
it that satisfactory in vitro or
laboratory test results can
translate into poor clinical
efficacy In these situations,
thought should be given to:
clinical and laboratory
coordination

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To have a better Understanding of


Antibiograms
a) Whether or not the diagnosis correct?
b) Whether the problem is really caused by the isolated
bacteria?
c) Whether the product was administered correctly, at the
right dose level, for the correct number of days?
d) Whether the activity level of the drug coincides with
label specifications
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Factors influencing the interpretation of an


antibiogram
Based on this reasoning, the
diffusion method is sometimes
mistakenly interpreted as a
quantitative method. The more
potent an antimicrobial
compound, the less
concentrated it need be, and
consequently at points further
from the disc with consequently
lower concentrations, microbial
growth will still be inhibited
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Basic Interpretation of
Zone Sizes
Therefore, it is often
assumed that the
larger the diameter
of the zone of
inhibition, the more
potent the
antimicrobial
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Why Concentration of the Antibiotic


matters
A number of factors however,
may interfere with this
interpretation. Firstly, the
concentration of the antibiotic in
the disc must be taken into
account. The higher the
concentration in the disc, the
more concentrated the
compound will be at a given
distance from the disc itself.
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Time too matters in optimal Reading of


Antibiograms
Also, the length of time
allowed for the process to
occur can greatly influence
the diameter of the zone of
inhibition as the longer
diffusion is allowed to take
place the higher the
concentrations at any given
point in the gradient will be.
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Zone sizes are Interpreted with consideration of


many factors
Related to this, the infusibility of
the antimicrobial compound
through the agar can greatly
impact on the observed zone of
inhibition, such that a very
potent inhibitor may produce a
relatively small "halo" simply
because it is unable to diffuse
adequately through the
medium. In addition, the extent
of the growth of the microbe
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Outcome of Antibiograms depend


on many factors

03-08-2016

In relation to the
degree of diffusion,
can influence the
resulting zone of
inhibition, such that
the timing of both
factors, microbial
growth and
diffusion, interplay.

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What are the Isolates to be Taken for


Reporting Antibiograms
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
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Basis of Choosing Antibiotic Discs


The selection of the most appropriate antibiotics
to test is a decision best made by each clinical
laboratory in consultation with the field
veterinarian. To avoid unnecessary duplication,
only one antibiotic from each family should be
used. Agents of the same family have similar
clinical efficacy, show nearly the same spectrum
of activity and have similar cross-resistance and
cross-susceptibility.
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How to prepare the inoculum for Testing


the Antibiograms
At least three to five wellisolated colonies of the
same morphological type
bacteria are selected from a
primary agar plate culture
and transferred into a tube
containing 4-5 ml of broth
medium.
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Preparing inoculum for Testing


Antibiograms
This is incubated at 35C for
2-6 hours and then applied
with a sterile cotton swab on a
dried surface of a MuellerHinton agar plate.
Alternatively the inoculums
can be prepared by making a
direct broth or saline
suspension of isolated colonies
selected from a primary agar
plate
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Placement of Antibiotic Discs for Optimal


Antibiograms
The predetermined battery of
anti-microbial disks is dispensed
onto the surface of the
inoculated agar plate. Each disk
must be pressed down to ensure
complete contact with the agar
surface. The disk must be
distributed evenly no closer than
24mm from Center to centre.
The plates are inverted and
placed in an incubator at 35C.
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Reading the Zones of Inhibition

03-08-2016

After 16-18 hours of


incubation, each plate is
examined. The resulting
zones of inhibition (halo) will
be uniformly circular and
there will be a confluent
lawn of growth. The
diameters of the zone of
complete inhibition are
measured, including the
diameter of the disk

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Measuring Zone Sizes in


Antibiograms
The measurement can be
done using a sliding calliper,
ruler or compass as
demonstrated in picture .
The zone margin should be
taken as the area showing
no obvious, visible growth
that can be detected by the
naked eye.
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Formulating the Concentration of Antibiotic and


relevance of zones depend on
Comparing zone diameters to
minimum inhibitory
concentrations (MICs) of a
large number of isolates,
including those with known
mechanisms of resistance
relevant to the particular
class of drug
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Pharmaco kinetics play a Major Role


Analysing the MICs
and correlated zone
sizes in relation to
the pharmacokinetics of the drug
from normal dose
range schedules
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Choosing Antibiotics to the


effectiveness of isolated pathogens
Analysing whenever
possible the tentative
in vitro interpretive
criteria in relation to
studies of clinical
efficacy in the
treatment of specific
pathogens
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What is Susceptible
This category implies that an
infection due to this
bacterium may be
appropriately treated with
the dosage of antibiotic
recommended for that type
of infection and infecting
species, unless otherwise
contraindicated
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Dr.T.V.Rao MD

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Intermediate
This category implies that an
infection due to this
bacteria, may be treated
when possible with higher
than normal dosage of this
antibiotic, or when the drug
is physiologically
concentrated in certain body
sites, like Quinolones in
urine
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Resistant
Resistant strain will
probably not respond to
any treatment, as they
are not inhibited by the
usually achievable
systemic concentrations
of the antibiotic when
normal dosage schedules
are used.
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How we express the Results


Because of these
complexities in the
diffusion method, it is
perhaps best to consider
the results of the
diffusion assay as
qualitative only,
expressed as: Sensitive,
Intermediate and
Resistant
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Do not Process the specimens Directly


for Antibiotic Sensitivity testing
The practice of
conducting susceptibility
tests directly with clinical
material should be
avoided except in clinical
emergencies when direct
gram staining suggests
the presence of a single
pathogen
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Document Antibiograms with


WHONET

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.
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WHONET AND CLSI HELPS IN


ANALYSIS OF THE ANTIBIOGRAMS
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
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How to modernized Hospital Antibiograms


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.

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Dr.T.V.Rao MD

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Critical Thinking on Antibiograms


Antibiograms only
capture the aggregate
proportion of
susceptible isolates for a
given organismantibiotic combination.
They do not provide the
prevalence resistance to
multiple antibiotics.
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Dr.T.V.Rao MD

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Antibiograms helps for taking decisions on Empiric


Antibiotics
Antibiograms provide
guidance for empiric
antibiotic use in patients,
but other factors including
patient characteristics and
prevalence of other risk
factors should be
incorporated when making
therapeutic decisions
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Future of Antibiograms

03-08-2016

The future of
antibiograms would
be the incorporation
of patient related
data to make
information more
reliable and for
predicting outbreaks

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Mobile Application on Iphone and IPad


Antibiograms help healthcare
professionals and clinical
microbiologists choose the most
effective antibiotics to
empirically treat infections,
based on local susceptibility
patterns. Now this valuable
information can be available to
them on iPhone/iPad mobile
devices.
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Antibiogram app
With the

Antibiograms app,
you simply select a
bacterium, select a
patient group, and you
are given the proportion
of susceptible organisms
for each antibiotic tested
in your local laboratory.
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For Better Understanding on


Antibiograms

For more detailed information, look at the WHO's


technical manual.

Ref 1 The Facts about Antibiogram - Dr Yonatan Segal


2 Hospital antibiogram: a necessity. Joshi PubMed . Indian J
Med Microbiol. 2010 Oct-Dec;28(4):277-80. doi:
10.4103/0255-0857.71802
3 Concise Antibiogram Toolkit - EFwww.ahrq.gov/NH-ASP
Guide May 2014 AHRQ Pub. No. 14-0012-1-EFwww
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Program Created By Dr.T.V.Rao MD for basic understanding


on Creation and Documentation of Hospital Antibiograms
for New Generation of Medical Microbiologists practicing
World Wide for better health care

Email

doctortvrao@gmail.com
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