r a

L i b
r e
Selective Reporting of c t u
Antibiogram
L e
Results
e o r
l i n th
n M.D. au
O y
Onur KARATUNA,
D b
Acibadem University School of Medicine, Dept. of Medical Microbiology
I
Acibadem Labmed Medical Laboratories, Istanbul, Turkey

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 r a
management of bacterial infections L i b
Critical functions of clinical microbiology laboratory in the

r e
- Isolation of the causative agent c
t u
L e
- Correct identification e o r
l i n t h
n a u
O y
- Correct antimicrobial susceptibility testing (AST)

I D b
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Clinically Relevant Reporting of AST Results
L i b
• Timely and effective communication of ASTe results is crucial
t u r
• Laboratories play a critical role ine c the appropriate use
directing
of antibiotics
e L r
i n t h o
n l relevantu
• Development of clinically
O effective
ensure that appropriate y a policies and procedures that
guidance is provided by the
laboratory ID b
C M
= role of ©
the clinical microbiology in antimicrobial stewardship
S
How can the microbiology laboratory contributebto ther a
antimicrobial stewardship? L i
r e
• Preanalytical phase c t u
L e
e o r
• Analytical phase
l i n th
n u
O ya
• Post analytical phase
I D b
C M ©
S
How can the microbiology laboratory contributebto the r a
antimicrobial stewardship? L i
• Preanalytical phase r e
Specimen quality assessment ct
u
Rejection of inappropriateL e → No AST for
e
specimens
colonization o
or r
contamination
l i n th
n u
O ya
I D b
C M ©
S ↑ epithelial cells, ↓ leukocytes
Low quality sputum specimen
↓ epithelial cells, ↑ leukocytes
High quality sputum specimen
How can the microbiology laboratory contributebto the r a
antimicrobial stewardship? L i
r e
• Analytical phase
c t u
L e
Antimicrobial susceptibility testing
 Performance of AST onlye o r
l i n h
for clinically relevant
t specimens (when
n
a pathogen is isolated)
u
O y a to expert rules
 Analysis of AST results according

I Dof resistancebmechanisms
(Ampicillin susceptible Klebsiella pneumoniae)
 Detection
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(Testing of D-zone phenomenon for group B streptococci for intrapartum prophylaxis)

S
How can the microbiology laboratory contributebto the r a
antimicrobial stewardship? L i
r e
• Post analytical phase
c t u
L e
 Selective reporting ofeAST results or
i
 Communication lwithn physiciansth
n a u
O
 Surveillance
y
I D
 Cumulative b
antibiogram to guide empirical treatment

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decisions ©
S
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Role of selective reporting in antimicrobial
stewardship L i b
r e
c t u
IDSA-SHEA Guideline
L e
e o r
l
tested antibiotics.”i n
“We suggest selective and cascade reporting of antibiotics over reporting of all
th
n u
O ya
I D b
Barlam TF, et al. Implementing an antibiotic stewardship program: guidelines

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by the Infectious Diseases Society of America and the Society for Healthcare
Epidemiology of America. Clin Infect Dis 2016;62:e51–77.

S
 r a
What is selective reporting of AST results?
L i b
r e
 The goal of the clinical microbiology laboratory
c
which will direct the clinician to use the least t u is to create a report
toxic, most cost-effective
and most clinically effective agent thate
e L is available.
r
i n
 This is accomplished by using clinically
h
relevant
t o testing approaches and

n l
selective reporting of AST results
u
O results for a
instead of all tested antibiotics. y
= reporting susceptibility a limited number of antibiotics

I D b
C M
E.g., routinely
nonsusceptible
©
releasing linezolid results only when enterococci are
to ampicillin and vancomycin.
S
 r a
Selective reporting of AST results ib
e L
u
 improves the clinical relevance tof
r
the reports
produced e c
e L r
i th o
n of multiresistant
n l
 minimizes the selection u strains by
use of broada
avoiding the O spectrum agents when
I D
narrow spectrum y
b is susceptible
option

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S
 r a
Selective reporting of AST results ib
e L
u
 improves the clinical relevance tof r
the reports
produced
e c
e L r
i n th o
Factors considered:
n l u
O y a
- site of infection/specimen source
- age ofDthe patient
I b
M
- pregnancy
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 r a
Selective Reporting - Site of Infection
L i b
r e
E.g., cerebrospinal fluid samples (meningitis)
c t u
L e
e o r
l i n th
n u
O ya
I D
CLSI, M100-S27, 2017 b
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 r a
Selective Reporting - Site of Infection
L i b
• Macrolides
r e
• Clindamycin
• Chloramphenicol c t u
L e
infections. e o r
Should not be reported for bacteria isolated from urinary tract

l i n th
• Daptomycin n a u
O y
Should not be reported for bacteria isolated from lower respiratory
tract infections.ID b
C M ©
CLSI,S
M100-S27, 2017
 r a
Selective Reporting – Age of the patient
L i b
• Fluoroquinolones
r e
• Tetracycline
c t u
L e
Should not be reported for infants and
e r
young children
o
l i n th
n u
O ya
I D b
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S
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Selective Reporting – Pregnancy
L i b
e
FDA category C and D agents should be avoided if safer options from
r
category A and B are available:
• Fluoroquinolones (C) c t u
• Vancomycin (C)
L e
• Linezolid (C)
e o r
• Chloramphenicol (C)
l i n th
n
• Clarithromycin (C)
u
O ya
• Telithromycin (C)
• Imipenem (C)
I D
• Amikacin (C- D) b
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• Gentamicin (C - D)
C
• Tetracycline (D)
S
• Tigecycline (D)
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Selective reporting of AST results ib
e L
 improves the appropriateness of prescriptions
t u r
e c
In a randomized study for urinary tract infections:

results for 2–4 antibiotics, e

L
randomly assigned residents to an intervention r
group received AST

i n th o
n l
control group received full-length AST results
u for all 25 antibiotics
tested.
O
The increase in appropriateness y
a
D
of selectiveIreporting rangedbfrom 7% to 41%, depending upon the
of antibiotic prescription with the use
clinicalM
C
scenario. ©
S
Coupat C, et al. Eur J Clin Microbiol Infect Dis 2013; 32:627–36
 r a
Selective reporting of AST results ib
e L
u
 improves the clinical relevance tof
r
the reports
produced e c
e L r
i th o
n of multiresistant
n l
 minimizes the selection u strains by
use of broada
avoiding the O spectrum agents when
I D
narrow spectrum y
b is susceptible
option

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S
 r a
Selective reporting of AST results ib
 minimizes the selection of multiresistant strainse
L
broad spectrum agents when narrow spectrum
t u r by avoiding the use of
option is susceptible

e c
L r
ciprofloxacin susceptibility for all Enterobacteriaceae regardless of susceptibility to
e
other agents is reported.
i n t h o
n l u
Intervention (selective reporting of ciprofloxacin results)

O ya
the suppression of ciprofloxacin susceptibility to Enterobacteriaceae when there is
lack of resistance to the antibiotics on the Gram-negative panel.

I D b Outcome

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Selective reporting was associated with an immediate and sustained reduction in

C
ciprofloxacin usage and statistically significant improvement in E. coli

S
susceptibility to ciprofloxacin.
Langford BJ, et al. J. Clin. Microbiol. 2016;(54)9:2343-2347.
 r a
L i b
r e
c t u
L e
e o r
A controlled before–after study of modified reporting of urine cultures from noncatheterized
medical and surgical inpatients during January/June 2013 (Baseline period) and February/July 2013
(Intervention period)
l i n th
n u
O ya
Baseline period - All urine cultures from noncatheterized inpatients from study wards were
processed as usual in the microbiology laboratory

I D b
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Intervention period - Positive results from noncatheterized specimens were no longer reported
automatically. Instead, the following message was posted to the electronic medical record:
C
S
«The majority of positive urine cultures from inpatients without an indwelling urinary catheter
represent asymptomatic bacteriuria. If you strongly suspect that your patient has developed a
urinary tract infection, please call the microbiology laboratory»
 r a
L i b
r e
c t u
L e
e o r
l i n th
n u
O ya
The rate of antimicrobial therapy for ASB during the baseline period was 48% among noncatheterized
inpatients and 42% among catheterized inpatients.

I D b
Following introduction of modified reporting, treatment of ASB among noncatheterized inpatients
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decreased to 12% for an absolute risk reduction of 36% (P = .002).
C
S
The treatment rates among catheterized controls remained 41% during the intervention period,
significantly above those of noncatheterized inpatients (P = .01).
 r a
L i b
r e
c t u
L e
e o r
l i n th
n u
O ya
The rate of antimicrobial therapy for ASB during the baseline period was 48% among noncatheterized
inpatients and 42% among catheterized inpatients.

I D b
Following introduction of modified reporting, treatment of ASB among noncatheterized inpatients
M ©
decreased to 12% for an absolute risk reduction of 36% (P = .002).
C
S
The treatment rates among catheterized controls remained 41% during the intervention period,
significantly above those of noncatheterized inpatients (P = .01).
 r a
L i b
r e
c t u
L e
e o r
l i n th
n u
O ya
The rate of antimicrobial therapy for ASB during the baseline period was 48% among noncatheterized
inpatients and 42% among catheterized inpatients.

I D b
Following introduction of modified reporting, treatment of ASB among noncatheterized inpatients
M ©
decreased to 12% for an absolute risk reduction of 36% (P = .002).
C
S
The treatment rates among catheterized controls remained 41% during the intervention period,
significantly above those of noncatheterized inpatients (P = .01).
 r a
L i b
r e
Primary
test and c t u
report L e
e o r
l i n th
Optional
n a u
primary
test, O y
report I D b
selectively M
C ©
S
CLSI, M100-S27, 2017
http://em100.edaptivedocs.info/Login.aspx
Antimicrobial Groups and Selective Reporting b r a
L i
r e
The purpose of selective antibiotic reporting is to preserve the clinical utility of
broad-spectrum or newer agents when an isolate is susceptible to narrower
spectrum agents.
c t u
L e
e o r
Group A
l i n
Ampicillin
th
n u
O Groupy Ba Amoxacillin-clavulanic acid
Ampicillin-sulbactam
I D b Ceftolozane-tazobactam

C M © Piperacillin-tazobactam

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CLSI, M100-S27, 2017
http://em100.edaptivedocs.info/Login.aspx
Antimicrobial Groups and Selective Reporting b r a
L i
r e
The purpose of selective antibiotic reporting is to preserve the clinical utility of
broad-spectrum or newer agents when an isolate is susceptible to narrower
spectrum agents.
c t u
L e
e o r
Group A
l i n
Cefazolin
th
n u
O Groupy Ba Cefuroxime

I D b Cefotaxime or ceftriaxone

C M © Cefepime

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CLSI, M100-S27, 2017
http://em100.edaptivedocs.info/Login.aspx
 r a
L i b
CLSI’s cascade (selective)
reporting algorithm
r e
c t u
L e
e o r
l i n th
n u
O ya
I D b
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CLSI, M100-S27, 2017
http://em100.edaptivedocs.info/Login.aspx
 r a
Selective Reporting - Site of Infection
L i b
Meningitis / Escherichia coli r e
c t u
Group A
L e
Do not report if susceptible ne
st
1 generation cephalosporins
o r
l i u th
O n a
Group B
nd
I D
2 generation cephalosporins b y
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Fluoroquinolones
Do not report
©
if susceptible
S
 r a
Selective Reporting - Site of Infection
L i b
t re
u
A

e
Urinary tract infection /Staphylococcus c
spp.

e L r
Group A
i n th o
Macrolides n l u
O a
susceptible by
Clindamycin
Do not report if D
B
M I ©
S C
 r a
Selective Reporting
L i b
When to report results in group B? r e
c t u
e
- Primary agent in the same class is resistant
L
e o r
- Patient has reported allergy to one or more of the primary agents
- Always reported on specific sites/sources of infection (i.e., a 3rd generation
l i n th
cephalosporin for cerebrospinal fluid isolates)
n
- Failure of primary therapy u
O ya
- Polymicrobial or disseminated infection involving multiple body sites

I D b
©
Epidemiologic aid to infection control / surveillance
M
→ store in the laboratory (preferably in LIS), share the results with the
C
infection control committee
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Selective Reporting
L i b
Basic principles
r e
c t u
L e
- Ensure reporting is in line with local guidance on the use of
antimicrobial agents.
e o r
l i n
- Report all clinically relevant resistances for
t h
significant pathogens.

n u
[Escherichia coli vs. vancomycin]
a
[NDM-1 positive Proteus mirabilis vs. colistin]

O
- Report results for relevant antimicrobial
stated are in use, unless clinicallyy
agents that the requestor has

I D b inappropriate.

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[Stenotrophomonas maltophilia vs. carbapenems, aminoglycosides]

S
BSAC, version 14, Jan 2015
 r a
Selective Reporting
L i b
Basic principles (continued) r e
c t u
L e
- Whenever possible, always include a susceptibility result for a non-beta-lactam
agent, so there’s always a treatment option for those with penicillin allergy.

e o r
[Group A Streptoccus vs. penicillin]

i n h
- Whenever possible and appropriate include results for antimicrobial agents that
l t
can be given orally.
n u
O ya
- The order in which the laboratory reports susceptibility results is important, as
prescribers tend to choose the first listed.

D b
- Inform clinicians that susceptibility results for further antimicrobial agents may
I
be available.
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→ encourage clinicians for communication!
C
S
BSAC, version 14, Jan 2015
 r a
Testing Groups and Selective Reporting
L i b
r e
c t u
– A (Primary test and report)
L e
–
–
Optional primary test, report
B(
e o r
selectively )

–
l i n
C (Supplemental, report selectively)
U (Supplemental, for urine only)th
n u
O ya
I D b
– No antimicrobial agent groupings, no rules for selective reporting

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S
 r a
EUCAST Approach
L i b
Antimicrobial susceptibility testing
Performance of AST r e
t u
Categorization of results according to breakpoints (S/I/R)
c
e
The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone

L
diameters. Version 7.1, 2017

e
Detection of specific resistance mechanisms
o r
l i n th
Giske CG, Martinez-Martinez L, Cantón R et al. EUCAST guidelines for detection of resistance mechanisms and specific

n u
resistances of clinical and/or epidemiological importance. Version 2.0, March 2017 (draft document)

O ya
Implementation of expert rules

D
Intrinsic resistances
I b
Unexpected phenotypes (usually resistance)
M
Interpretive rules
C ©
S
Leclercq R, Cantón R, Brown DFJ et al. EUCAST expert rules in antimicrobial susceptibility testing. Clin Microbiol Infect
2013; 19:141–160. Version 2.0, 2013
EUCAST expert rules - intrinsic resistance and exceptional phenotypes tables. Version 3.1 , September 2016
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L i b
r e
c t u
L e
e o r
l i n th
n u
O ya
I D b
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S www.eucast.org
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L i b
r e
c t u
L e
e o r
l i n th
n u
O ya
I D b
C M ©
S www.eucast.org
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L i b
r e
c t u
L e
Int J Antimicrob Agent 2017;49(2):162-6.

e o r
l i n th
n u
O ya
Cross-sectional survey conducted in 36 European countries

I D b
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S 36
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L i b
Highlights
r e
t u
Nearly all respondents (34/36; 94%) perceived selective reporting as useful
c
L e
e
• Widely implemented 11/36 (31%)
o r
Limited implementation of selective reporting of AST results

l i n th
Belgium, Croatia, Czech Republic, Denmark, Ireland, Netherlands, Slovakia,
n u
Slovenia, Sweden, Turkey, United Kingdom
O ya
• Partially implemented 4/36 (11%)

D b
• Limited to local initiatives or is not adopted 21/36 (58%)
I
M ©
Endorsed as standard of care by health authorities
C
S
- only in 3 countries: Ireland, Turkey, United Kingdom
Int J Antimicrob Agent 2017;49(2):162-6.
 r a
L i b
r e
t u
- Several barriers to implementation were reported
c
•
L e
lack of guidelines
•
e
poor system support
o r
•
i n th
insufficient resources
l
•
n u
lack of professionals’ capability

O ya
Conclusion: selective reporting of AST results is poorly implemented in Europe
I D b
and is applied with a huge heterogeneity of practices

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S
Int J Antimicrob Agent 2017;49(2):162-6.
 r a
L i b
r e
The organisation of selective reporting and

t u
the degree of implementation in different
c
clinical situations varied significantly

L e
The most common uses are urinary tract
e o r
l i n
infections (UTIs), skin and soft-tissue
th
infections, pharyngitis and, less frequently,
n u
O ya
lower respiratory tract infections.

D b
The choice of reported and withheld
I
antibiotics is also quite variable.

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S
Int J Antimicrob Agent 2017;49(2):162-6.
 r a
Selective Reporting of AST Results
L i b
r
Selective reporting requires good communication betweene
laboratories and clinicians.
c t u
- microbiologist should receive relevante
L and reliable clinical
information (patient’s age, sex, diagnosis, drugrallergies,
e
pregnancy, etc.) to performn
i t h o
n l selective reporting
u
- clinicians need to beOaware that theyacan obtain hidden results if
I D
needed, without delay for b y
severe infections

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S
Int J Antimicrob Agent 2017;49(2):162-6.
 r a
Carbapenem-resistant K. pneumoniae in Europe
(EARS-Net and CAESAR), 2015
L i b
r e
c t u
L e
e o r
l i n th
n u
O ya
I D b
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S
Central Asian and Eastern European Surveillance of Antimicrobial Resistance (CAESAR) Annual Report 2016 (www.who.int)
 r a
Future Directions
L i b
r e
•
t u
Due to different antibiotic formularies, varied resistance rates for
c
particular pathogens and treatment guidelines in place, it seems
irrational to develop a “recommended
L e list of antimicrobials for
testing and selective reporting “ that
each country. e o r
will not be implementable in

l i n t h
n
be feasible to a
u
• O
For Europe, it might
y publish the principles of selective
reporting by an internationalbinitiative,
I D considering the current
the need to©
European treatment guidelines and the EUCAST breakpoint table,

C
resource
M
to address improve awareness, and provide a valuable
that can be endorsed by health authorities and adapted
S to their own conditions.
according
 r a
Selective Reporting of AST Results
L i b
r e
t u
The key philosophy: ec
e L r
i n th o
n l
Only report results that areu“need to know,”
O
not “nice to know”. y
a
I D b
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L i b
r e
c t u
L e
e o r
l i n th
n u
O ya
I D b
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Thank you for your attention.