AUDITING

ANTIBIOGRAMS
Dr.T.V.Rao MD

3/7/16

Dr.T.V.Rao MD

What is a Antibiogram
Antibiogram
Microbiology The
profile of an
organism's
susceptibility/resistanc
e to a panel of
antibiotics, which can
be used to determine
genetic relatedness of
various bacteria Cf
Molecular strain typing
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Dr.T.V.Rao MD

It also Means

antibiogram (antbgram),

A method of testing the

efficacy of antibiotics by
introducing an antibiotic into
the middle of a bacterialaden petri dish. A clear zone
indicates the bactericidal
activity. The greater the
diameter of the zone, the
higher the efficacy of the
antibiotic.
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Dr.T.V.Rao MD

Antibiograms create the Vitro Sensitivity and

Resistance patterns of the Antibiotics used in Clinical
practice

An antibiogram is the
result of an antibiotic
sensitivity test, a
laboratory test for the
sensitivity of an isolated
bacterial strain to
different antibiotics. It is
by definition an in vitro
sensitivity, but the
correlation of in vitro to in
vivo sensitivity is often
high enough for the test Dr.T.V.Rao MD
3/7/16
to be clinically useful.

Purpose of the Antibiograms

growing importance
The prevalence of antimicrobial resistance
in the hospital setting and its associated
clinical and economic impact. With this as
the background, the basics of antibiograms
are discussed their purpose, how to read
them, and how to avoid common pitfalls
when using them. Understanding these
aspects is an important first step when
utilizing antibiograms as a routine part of

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Dr.T.V.Rao MD

Once a culture is established, there are two

possible ways to get an antibiogram:
A semi-quantitative way
based on diffusion
(Kirby-Bauer method);
small discs containing
different antibiotics, or
impregnated paper discs, are
dropped in different zones of
the culture in the petri dish.
The antibiotic will diffuse in
the area surrounding each
tablet, and a disc of bacterial
lysis will become visible.
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Dr.T.V.Rao MD

Understanding about the Inhibition of

the bacterial growth
Since the concentration of
the antibiotic was the
highest at the centre, and
the lowest at the edge of
this zone, the diameter is
suggestive for the Minimum
Inhibitory Concentration
(conversion of the diameter
in millimetre to the MIC, in
g/ml, is based on known
linear regression curves).
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Dr.T.V.Rao MD

What is Minimal Inhibiting

Concentration
Quantitative way
based on dilution: a
dilution series of
antibiotics is
established (this is
a series of reaction
vials with
progressively lower
concentrations of
antibiotic
substance). The last
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Dr.T.V.Rao MD

MIC Estimation will help the

Clinicians in prescription

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Once the MIC is calculated, it can be compared to

know values for a given bacterium and antibiotic: e.g.
a MIC > 0,06g/ml may be interpreted as a penicillinresistant Streptococcus pneumoniae. Such information
may be useful to the clinician, who can change the
empirical treatment, to a more custom-tailored
treatment that is directed only at the causative
bacterium

Dr.T.V.Rao MD

What we routinely
Prescribe
In clinical practice, antibiotics
are most frequently prescribed
on the basis of general
guidelines and knowledge about
sensitivity: e.g.
uncomplicated urinary tract
infections can be treated with a
first generation quinolone, etc.
This is because Escherichia coli
is the most likely causative
pathogen, and it is known to be
sensitive to quinolone treatment
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Drug Resistance Creates

Importance to create
Antibiograms
However, many bacteria
are known to be resistant
to several classes of
antibiotics, and treatment
is not so straightforward.
This is especially the case
in vulnerable patients,
such as patients in the
intensive care unit. When
these patients develop a
hospital-acquired
pneumonia, more hardy Dr.T.V.Rao MD
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bacteria like Pseudomonas

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Surveillance with
Antibiograms helps to
initiate
Treatments
Treatment
is then
generally started on the
basis of surveillance data
about the local pathogens
probably involved. This
first treatment, based on
statistical information
about former patients,
and aimed at a large
group of potentially
involved microbes, is
called empirical
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Dr.T.V.Rao MD
treatment.

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Two possible ways

to get an
antibiogram

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Kirby-Bauer
method
Semi-quantitative way
based on diffusion
(Kirby-Bauer method);
small discs containing
different antibiotics, or
impregnated paper
discs, are dropped in
different zones of the
culture on an agar
plate, which is a
nutrient-rich
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Minimal Inhibiting
Concentration.
A quantitative way based
on dilution: a dilution series
of antibiotics is established
(this is a series of reaction
vials with progressively
lower concentrations of
antibiotic substance). The
last vial in which no
bacteria grow contains the
antibiotic at the Minimal
Inhibiting Concentration.
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Minimal Inhibiting Concentration

Once the MIC is calculated,
it can be compared to
known values for a given
bacterium and antibiotic:
e.g. a MIC > 0,06 g/ml
may be interpreted as a
penicillin-resistant
Streptococcus
pneumoniae. Such
information may be useful
to the clinician, who can
change the empirical
treatment, to a more
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Dr.T.V.Rao MD
custom-tailored treatment

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E-Test is

Epsilometer
test

Etest, (previously known as

Epsilometer test)
manufactured by bioMrieux,
is a manual in vitro
diagnostic device used by
laboratories to determine the
MIC (Minimum Inhibitory
Concentration) and whether
or not a specific strain of
bacterium or fungus is
susceptible to the action of a
specific antimicrobial.
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E-Test
This type of test is

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most commonly used

in healthcare settings
to help guiding
physicians in
treatment of patients
by indicating what
concentration of
antimicrobial would
successfully treat an
infection

Dr.T.V.Rao MD

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Intended use of E Test

Etest is a quantitative
technique for
determining the
antimicrobial
susceptibility (AST)
and MIC (in g/mL) of
Gram-negative and
Gram-positive aerobic
bacteria such as
Enterobacteriaceae,
Pseudomonas,
Staphylococcus, and Dr.T.V.Rao MD
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Enterococcus species

21

Dissemination and Use of

Antibiogram for Education:
After
the
Antibiogram
An overlooked aspect of antibiogram

development and surveillance is the decision

of what to do with the antibiogram data and
analyses how are recommendations to be
conveyed to prescribers, how is education to
be conducted, and how will impacts of the
education be assessed. Not infrequently, the
development and publication of the
antibiogram marks the endpoint of the process

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Steps in Antibiogram Creation

Ensure a process of
identification,
preferably as part of
the day-to-day
function of data
verification, of new
patterns of resistance
during or after
treatment,since the
first isolate per patient
is insensitive to second
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Antibiograms helps to
Educational
efforts to
forecast Growing
Antibiotic
present charts to
Trends
highlight resistance

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trends Disseminate
information on
appearances of rare
phenotypes which may
have been missed
through the first
isolate approach
Teaching to facilitate
understanding and use

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Create Documentation with

Antibiograms
Describe by case
examples how the
antibiogram may be
used as a general
guide to empiric
therapy Include
antibiogram and
education on
institutions intranet or
website application
Include copies of
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Start using WHONET in Your Laboratory

WHONET Software
WHONET is a free
Windows-based database
software developed for
the management and
analysis of microbiological
and clinical data with a
special focus on
antimicrobial
susceptibility test results.
WHONET supports
participation of national
surveillance programmesDr.T.V.Rao MD
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in the Global AMR

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WHONET Software
Data entry of clinical and
microbiological information
at surveillance sites
Exporting of AMR statistics
into the format required for
the production of local and
national reports and for
uploading to the GLASS
web interface
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WHONET Software
Simple data file structure and
output formats compatible with
major database, spreadsheet,
statistical and word processing
software
WHONET runs on Microsoft
Windows and through Windows
emulators, can be run
successfully on Linux and Mac
OS X
The software is multilingual and
is available in over 20 languages
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Principles of Reporting
and Auditing
Supply printed versions to microbiology, infection control
and epidemiology, quality improvement departments,
nursing, and pharmacy personnel
Discuss development of chart dividers, empiric therapy
guidelines by disease state
Disseminate information on the web which is useful for
antibiogram analysis
Become familiar with Chi-square analysis tables (in M39)
to interpret significance of trend changes
Analyse culture positivity and improve culturing practice
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Design and Presentation

The design style,
of Antibiogram
presentation, and

3/7/16

stratification of data
will dictate the clinical
usefulness of the
cumulative
antimicrobial
susceptibility report.
Allotment of space
should be considered
for other data of
clinical relevance

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Design the Antibiograms in

Friendly approach
Design is user
friendly, readable,
and well-organized
Antibiogram should
be published in a
readable font size

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Can Create Specific

Antibiograms as per the
Location of the Patients

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Organisms are listed in tables by prevalence (preferable) or

alphabetically

There is a section for footnotes which are relevant, i.e.,

prevalence of beta-lactamase in H.influenzae.

A section for analysis of longitudinal antibiogram data

(trends) may focus on emerging resistance trends

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Parts of the Antibiogram

Number of Isolates and
Clinical Utility

Number of isolates reflects the number

of isolates which have yielded positive
for colonies of the given organism
Clinical utility: The greater the
number of isolates, the more accurate
the sensitivity results for the given
organism
The greater the number of isolates, the

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Parts of the Antibiogram

% Susceptible
Pitfalls: Concentration differences
between site of infection and in vitro
Penetration to
the site of infection Inactivation of drug at
site of infection
Declining levels in vivo vs
continuous level in vitro Rapid
development of resistance in vivo vs in

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What Resistance Means

Reflects the % of organism which
are resistant to certain Antibiotic
Clinical Utility: Assists in
determining if coverage for MDR
organisms in the empiric therapy
are necessary
Information

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Specific Objective
To determine the
demographic profile
of the patient as to:
age sex
To determine the
most common
microorganism(s) in
biologic specimens

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HOW THE ANTIBIOGRAMS

HELPS CLINICAL PRACTICE

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Documentation Helps Auditing

The research sought
to construct
antibiogram wall
chart for quick
reference intended
for the hospital use
and to address the
growing problem of
antibiotic resistance
with many
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Documentation is highly essential

in
This includes drug-resistant
Streptococcus pneumoniae
methicillin-resistant
Staphylococcus aureus
Vancomycin-resistant
Enterococcus and emerging
resistance patterns.
Recent emerging resistance
among Gram negative
bacteria
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Outcome of Antibiogram
Documentation
Laboratory: to make
available a quick
reference guide of
antibiogram, to know
emerging trends or
patterns in antimicrobial
resistance and; Patients:
to ensure that they are
given the most effective
yet inexpensive antibiotic
course of therapy for their
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Infection Control
Noncompliance with
infection control policies
Spread of resistant clones
through contact with
colonized healthcare
personnel
Entry of resistant
pathogens into hospital
Changes in resistance
patterns within the
community
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Over use of Antibiotic

Over-utilization of a specific class Suboptimal antibiotic

dosing

Over-the-counter antibiotic use (border areas) and foreign

travel Improper antibiotic selection
Use of unnecessary antibiotic combinations

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Excessive antibiotic duration

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Do you Know who Prescribe

Antibiotics

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Demographics
Average length of stay Number of long-term care
facilities in-service area Changes in case-mix
index, severity of diseases, number of ICU beds
Addition of transplantation services,
oncologycare, burn unit, etc.
Changes in patient populations who
arepredisposed to nosocomial pathogens
Acute care versus ICU beds
Interhospital transfers
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Antibiograms guide the

future use of Antibiotic
Prescriptions
In an era of
antimicrobial
misuse, increasing
anti-infective
resistance, and
reduced emphasis
on antibiotic
development by
pharmaceutical
manufacturers, the
need for reliable,

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What we achieve by Auditing

Antibiograms
Increasing antibiotic
drug resistance is a
problem that is
global in scale and
that has practical
implications for the
treatment and
outcome of invasive
infections and
other bacteria of
public health
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Surveillance data Helps to

Forecast happenings at our
Hospitals
Surveillance data are
needed to monitor the
success pf campaigns and
to raise awareness of the
problem. Because most
local laboratories
generate antibiograms
routinely, collecting
aggregating antibiogram
data is an inexpensive
and readily available
method of measuring
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Dr.T.V.Rao MD
local antibiotic resistance

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Surveillance of antimicrobial
resistance
In May 2015, the Sixtyeighth World Health
Assembly adopted the
global action plan on
antimicrobial
resistance. One of the
five strategic
objectives of the action
plan is to strengthen
the evidence base
through enhanced
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AMR surveillance
Emerging Trends

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New Happenings in
Tracking Antibiotic
Resistance
AMR surveillance is the cornerstone for

assessing the burden of AMR and for providing

the necessary information for action in
support of local, national and global
strategies. The Global Antimicrobial
Resistance Surveillance System (GLASS) is
being launched to support a standardized
approach to the collection, analysis and
sharing of data on AMR at a global level, in
order to inform decision-making, drive local,
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New Happenings in Tracking

Antibiotic Resistance
GLASS aims to combine clinical, laboratory
and epidemiological data on pathogens
that pose the greatest threats to health
globally. The GLASS manual details the
proposed approach for the early
implementation of the surveillance system,
that will focus on antibiotic-resistant
bacteria, and outlines the flexible and
incremental development of the system
over time that will incorporate lessons
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Participation in GLASS
Countries can benefit from
participation in GLASS through
enhanced capacity building,
access to training and
implementation tools, and
support in collecting AMR data
at local and national levels.
Country participation in GLASS
must be with the agreement of
the national government and
is subject to the fulfilment of a
number of criteria.
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References
Surveillance of antimicrobial resistance Global Antibiotic
Ressitance system WHO World Health Organization
WHONET org

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 Program Created by Dr.T.V.Rao MD for

Benefit of Medical and Paramedical
Professionals in the Developing World
Created from World Wide Resources
Email
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