1. WISCONSIN STATE LABORATORY OF HYGIENE 1 Analysis and Comparison of Cumulative Statewide Antibiograms for Wisconsin, 2006 and 2008 Christina M. Carlson 1, Tam T. Van 2, Steve A. Marshall 2, David M. Warshauer 2, and Peter A. Shult 2 1 MPH Program, University of Wisconsin - Madison 2 Wisconsin State Laboratory of Hygiene, Communicable Diseases Division

2. WISCONSIN STATE LABORATORY OF HYGIENE 2 Antimicrobial Resistance: An ever- increasing public health problem U.S. Healthcare-associated infections: -1.7 million infections (1 in 10 patients) -99,000 associated deaths/yr -6.7 billion annual economic burden (2002) Staphylococcus aureus ->95% of penicillin resistant -60% methicillin resistant >20% of all Enterococcus infections resistant to Vancomycin Source: CDC. 2009. Antimicrobial resistance in healthcare settings fact sheet.

3. WISCONSIN STATE LABORATORY OF HYGIENE 3 Antimimicrobial Resistance: Trends Methicillin (oxacillin)-resistant Staphylococcus aureus (MRSA) Among ICU Patients, 1995-2004 Vancomycin-resistant Enterococi Among ICU Patients, 1995-2004 3 rd generation cephalosporin-resistant Klebsiella pneumoniae Among ICU Patients,1995-2004 Fluoroquinolone-resistant Pseudomonas aeruginosa Among ICU Patients,1995-2004 Source: CDC: National Nosocomial Infections Surveillance System. 2009.

4. WISCONSIN STATE LABORATORY OF HYGIENE 4 Antibiogram: An overall profile of the antibiotic susceptibility of an organism to a collection of antimicrobial agents routinely tested and used Monitor resistance trends Reveal emergence of potential novel resistance Aid clinicians in empiric treatment of infections Problem: Lack of standardized data Clinical Laboratory Standards Institute guidelines for preparation of antibiograms

5. WISCONSIN STATE LABORATORY OF HYGIENE 5 A Cumulative Statewide Antibiogram for Wisconsin Compare WI’s antimicrobial susceptibility status in 2006 and 2008 Assess current challenges and needs regarding antimicrobial susceptibility testing (AST) in WI Study Goals:

6. WISCONSIN STATE LABORATORY OF HYGIENE 6 Methods Preparation of cumulative antibiogram -requested 2008 antibiograms from 135 clinical/ reference laboratories in WI -calculated average % susceptibility for selected antimicrobial agent-organism combinations -2008 cumulative susceptibility patterns compared with 2006 Evaluation of antibiograms -CLSI M39-A2 and M100-S19 documents -WI adherence to CLSI guidelines compared with adherence nationally

7. WISCONSIN STATE LABORATORY OF HYGIENE 7 Local & regional anti-biograms received from WI healthcare facilities performing AST 47 of the 87 (54%) healthcare facilities performing AST contributed antibiograms in 2006 and 2008 28 common sites provided antibiograms in 2006 and 2008 Provided an antibiogram in 2008 Provided an antibiogram in 2006 Provided an antibiogram in both 2006 & 2008

8. WISCONSIN STATE LABORATORY OF HYGIENE 8 Comparison of local/regional antibiograms in WI and nationwide meeting CLSI recommendations WI antibiograms showed at least 70% compliance to 4 of the 6 CLSI elements analyzed Adherence to CLSI guidelines in 2008 WI antibiograms, as compared to 2006, improved in all elements analyzed, except 1) reporting verified susceptibility results and 2) indicating the use of duplicates Nationwide data is from: Zapantis et. al. 2005 JCM, 43:2629. It includes antibiograms from 2000 – 2002.

9. WISCONSIN STATE LABORATORY OF HYGIENE 9 WI cumulative statewide antibiogram for 2008 Indicates a ≥10% decrease in susceptibility as compared to 2006 Indicates a ≥10% increase in susceptibility as compared to 2006

10. WISCONSIN STATE LABORATORY OF HYGIENE 10 WI cumulative statewide antibiogram for 2008 Indicates a ≥10% decrease in susceptibility as compared to 2006 Indicates a ≥10% increase in susceptibility as compared to 2006

11. WISCONSIN STATE LABORATORY OF HYGIENE 11 Conclusions WI healthcare facilities can improve on current antibiograms by: 1) excluding duplicates from their data and indicating so 2) excluding susceptibility data for organisms with <10 isolates WI susceptibility data for 2008 is largely comparable to that of 2006, and overall susceptibility patterns in WI show less resistance compared to the nation Susceptibility patterns among multiple organism-agent combinations between 2006 & 2008 statewide antibiograms suggest the need for increased adherence to CLSI practice guidelines in WI Statewide antibiograms should only be used for surveillance purposes and not to guide empiric therapy for individual patients YET…

12. WISCONSIN STATE LABORATORY OF HYGIENE 12 Future Directions Develop a standardized & sustainable strategy to the development of an annual statewide antibiogram for WI -survey a subset of high capacity laboratories in each public health region -a more precise and accurate statewide antibiogram useful to facilities that cannot/do not compile their own Continued development of WSLH-sponsored surveys, workshops, teleconferences, webinars aimed at monitoring & improving AST practices in WI healthcare facilities

13. WISCONSIN STATE LABORATORY OF HYGIENE 13 Acknowledgements Capstone Committee  Steve Marshall, MS  David Warshauer, PhD  Christopher Olsen, DVM, PhD WI State Laboratory of Hygiene  Charles Brokopp, DrPH  Peter Shult, PhD  Tam Van, PhD (CDC EID Fellow) UW MPH Program  Patrick Remington  Barbara Duerst  Heather Cote