1. Massachusetts Department of Public Health
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

2. 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.

3. Antibiograms in Massachusetts
Since 2002, MDPH has received an average of 53 antibiograms per year (range 43-57) from 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

4. Antibiogram example 4

5. Antibiograms submitted by hospitals in a wide variety of formats, often not following CLSI guidelines 5

7. Data collection
An 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 , 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

8. Data entry

9. CLSI (Clinical and Laboratory Standards Institute)
Documents that provide laboratories with guidance for standardization
Antibiograms: Developing Cumulative Reports for Your Clinicians:
M39-A:
M39-A2: 2005
M39-A3: 2009
M39-A4: ?

10. 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)

11. Reporting of Duplicate Results and <30 Isolates
Exclusion of duplicate bacterial isolates increased from 67% in 2005 to 93% in 2008 and has remained constant.

12. Reporting a S. aureas only, MRSA and MSSA Separately and Total Plus MRSA and MSSA
Separate reporting of S. aureus susceptibilities increased from 20% in 2002 to 50% in 2010.

13. 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

14. Data collection 2012 and beyond
An 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 submission
At MDPH: Each form is downloaded from the , data are extracted using Adobe Acrobat, and analyzed using SAS

15. 2013 Submission Form

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

17. “Rules” built into form

18. Variable “N” entry

19. S. pneumoniae reporting

20. 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”
Changes to be made: we need to

21. 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

22. Give 1-2 examples of staph aureus and e coli state mean susceptibilities and hospital data

24. 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 24

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

26. Escherichia coli Susceptibility to Ciprofloxacin and Levofloxacin Over Time

27. 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, gram-positive, and if applicable anaerobic bacteria and yeasts

28. 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)

29. Regulatory Change
Proposed requirement for submission of antibiogram data:
105 CMR : 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.

30. Massachusetts Department of Public Health
Questions?
Alfred DeMaria Jr., MD
Massachusetts Department of Public Health