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

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 4

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

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 Exclusion of duplicate bacterial isolates increased from 67% in 2005 to 93% in 2008 and has remained constant.

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.

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 Electronically submit Save the form to shared email account Save the form for later use

“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” Changes to be made: we need to

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

Give 1-2 examples of staph aureus and e coli state mean susceptibilities and hospital 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 24

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

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, gram-positive, 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.

Massachusetts Department of Public Health Questions? Alfred DeMaria Jr., MD Massachusetts Department of Public Health alfred.demaria@state.ma.us