National Guidelines and Statewide
Antimicrobial Susceptibility
Testing, Reporting and
Surveillance In Massachusetts
Barbara Bolstorff
Kerri Barton
Johanna Vostok
Hilary Placzek
Lynda Glenn
Alfred DeMaria
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:
• M39-A: 2002
• M39-A2: 2005
• M39-A3: 2009
• M39-A4: ?
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
100
Caveats:
Hospitals reporting varies somewhat over time
Changes in handling of duplicate isolates
% Susceptible to Oxacillin
90
80
70
60
50
40
30
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
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:
– M100-S22: Performance Standards for Antimicrobial
Susceptibility Testing; Twenty Second Informational
Supplement
– M39-A3: Antibiograms: Developing Cumulative
Reports for Your Clinicians Quick Guide (M39-A3
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 DeMaria Jr., MD
Massachusetts Department of Public Health
alfred.demaria@state.ma.us