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Antibiogram 2002-2009 in Washoe County Nevada – Know the Local Data, Prevent Antimicrobial Resistance Lei Chen, Ph.D., Senior Epidemiologist, Washoe County Health District, Reno, Nevada. Email: [email protected]. BACKGROUND. RESULT. - PowerPoint PPT PresentationTRANSCRIPT
Antibiogram 2002-2009 in Washoe County Nevada – Know the Local Data, Prevent Antimicrobial ResistanceLei Chen, Ph.D., Senior Epidemiologist, Washoe County Health District, Reno, Nevada. Email: [email protected]
TO READERS
This antibiogram was compiled by the Division of Epidemiology & Public Health Preparedness (DEPHP), Washoe County Health District in collaboration with all four hospital laboratories in the community. Data covered all inpatients in local hospitals and outpatients seen at hospital emergency rooms. This antibiogram can be used as a reference for clinicians but shouldn't serve as a basis for therapy. The antibiotic susceptibility test for individual patients is still encouraged, if needed. This antibiogram only represents antibiotic susceptibility in vitro. Please address your questions, comments, and/or suggestions to DEPHP at 775-328-2447 or e-mail to [email protected]. The online version and pocket size version can be downloaded from the Health Department’s website at www.washoecounty.us/health/cdpp/warr.html
ACKNOWLEDGEMENTSNorthern Nevada Medical Center Laboratory, Renown Regional Medical Center Laboratory, Saint Mary’s Regional Medical Center Laboratory, Veteran’s Affairs Medical Center Laboratory (Reno).
To read this antibiogram: 1) Each organism is presented in two rows. The top row represents susceptibility in percent to that antibiotic. The 2nd row represents number of isolates tested for that specific antibiotic. 2) Susceptibility greater than or equal to 90% is highlighted in light GREEN, 60%-89% in YELLOW, and less than 60% in RED. 3) Nitrofurantoin is tested for urine specimens only. 4) The susceptibility result for Streptococcus pneumoniae is a combination of screening test and E-test results. 5) CLSI performance standards for antimicrobial susceptibility testing were applied. CLSI stands for Clinical and Laboratory Standards Institute (Formerly NCCLS, The National Committee for Clinical Laboratory Standards). 6) Black empty shaded cells indicate that susceptibility testing for that specific organism is not recommended or complete testing data was not available or number is too small for valid reporting.
ANTIBIOTIC SUSCEPTIBILITY (%) TREND, 2002-2009, WASHOE COUNTY (Published December, 2010)
To read these graphs: Each graph represents an organism; X-axis represents the abbreviation of an antibiotic (see tables above graphs for full name of antibiotics); Y-axis represents susceptibility in percent; legends indicate each year and number of isolates identified for that year in parentheses. Attention! Readers should be aware that resistance rate calculation for 2004 from some hospitals was different compared to prior years due to removing duplicates in 2004. Susceptibility result for Acinetobacter Baumanii was available in 2006, 2007, and 2009 therefore only three year trend data was available. Antibiogram 2005 and 2008 were not available.
# Is
olat
es id
entif
ied
Am
pici
llin
(Am
)
Am
ikac
in (A
k)
Am
oxic
illin
/cla
vula
nate
(Aug
)
Am
pici
llin/
sulb
acta
m (A
/S)
Cef
azol
in (C
fz)
Cef
otax
ime
(Cft)
- N
on-m
enin
gitis
Cef
otax
ime
(Cft)
- M
enin
gitis
Cef
triax
one
(Cax
)
Clin
dam
ycin
(Cd)
Cip
roflo
xaci
n (C
p)
Ery
thro
myc
in (E
)
Gat
iflox
acin
(Gat
)
Gen
tam
icin
(Gm
)
Gen
tam
icin
500
(Gm
500
)
Imip
enem
(Im
p) /
Mer
open
em (M
er)
Levo
floxa
cin
(Lvx
)
Line
zolid
(Lzd
)
Nitr
ofur
anto
in (F
d)
Nor
floxa
cin
(NO
R)
Oxa
cilli
n (O
x)
Pen
icill
in-G
(P)
Rifa
mpi
n (R
/F)
Stre
ptom
ycin
200
0 (S
T200
0)
Tetra
cycl
ine
(Te)
Trim
etho
prim
/sul
fa (T
/S)
Van
com
ycin
(Va)
99% 56% 15% 67% 58% 100% 100% 99% 73% 72% 16% 99%
748 169 484 95 169 380 169 748 116 95 653 748
22% 8% 100% 97% 19% 4% 69% 34% 33%
162 124 29 73 158 25 26 133 162
88%
966
55% 76% 52% 42% 59% 98% 49% 100% 95% 53% 12% 100% 94% 99% 100%
930 1693 1271 1947 254 1472 307 815 86 2033 1184 762 1103 2033 2033
58% 100% 52% 16% 74% 77% 100%
31 31 31 31 31 31 31
25% 53% 25% 24% 56% 69% 28% 98% 100% 29% 14% 100% 83% 53% 100%
255 293 314 352 59 314 118 156 59 411 94 97 156 411 411
89% 79% 69% 97% 75% 95% 91%*** 70% 100%
103 101 112 67 57 63 135 77 111* Enterococcus faecalis and Enterococcus faecium ** Data from Washoe County Health District's surveillance project *** Non-meningitis breakpoint
# Is
olat
es id
entif
ied
Am
pici
llin
(Am
)
Am
ikac
in (A
k)
Am
oxic
illin
/cla
vula
nate
(Aug
)
Am
pici
llin/
sulb
acta
m (A
/S)
Azt
reon
am (A
zt)
Cef
epim
e (C
pm)
Cef
azol
in (C
fz)
Cef
urox
ime
(Crm
)
Cef
otax
ime
(Cft)
Cef
oxiti
n (C
fx)
Cef
tazi
dim
e (C
az)
Cef
triax
one
(Cax
)
Cep
halo
thin
(Cf)
Cip
roflo
xaci
n (C
p)
Gat
iflox
acin
(Gat
)
Gen
tam
icin
(Gm
)
Imip
enem
(Im
p)
Levo
floxa
cin
(Lvx
)
Nal
idix
ic A
cid
(NA
)
Nitr
ofur
anto
in (F
d)
Pip
erac
illin
(Pi)
Pip
erac
illin
-tazo
bact
am (P
/T)
Tetra
cycl
ine
(Te)
Tica
rcill
in/c
lavu
lana
te (T
/C)
Tobr
amyc
in (T
o)
Trim
etho
prim
/sul
fa (T
/S)
68% 64% 79% 93% 96% 93% 79%
28 28 28 28 28 28 28
27% 7% 73% 86% 89% 89% 93% 100% 84% 73% 93% 77%
44 44 44 44 44 44 44 44 44 44 44 44
4% 9% 73% 84% 88% 99% 100% 100% 100% 100% 91% 98% 97%
51 68 51 51 68 68 68 68 25 68 43 51 68
9% 100% 27% 77% 5% 31% 72% 70% 88% 97% 98% 95% 79% 71% 98% 94%
141 30 30 30 153 141 141 153 153 153 153 42 153 111 141 153
53% 100% 85% 58% 97% 95% 91% 93% 100% 98% 94% 82% 89% 100% 82% 97% 97% 73% 89% 82% 75%
2717 1517 759 1005 892 1271 2717 2205 759 2301 2717 2717 2717 2717 1517 1122 2717 1200 646 2717 2717
4% 44% 82% 95% 92% 96% 100% 100% 89% 82% 100% 97%
92 92 92 92 92 92 92 92 92 78 92 92
3% 99% 97% 82% 98% 99% 97% 89% 99% 98% 98% 86% 95% 98% 100% 96% 64% 97% 90% 95% 97% 94%
578 224 150 224 160 150 578 506 150 442 506 86 578 578 578 296 144 578 282 86 506 578
9% 100% 9% 100% 5% 5% 14% 86% 7% 57% 37% 100% 63% 50% 31% 89% 21% 80% 34%
35 21 35 35 21 21 14 35 14 35 35 35 35 14 35 35 14 35 35
66% 98% 69% 99% 78% 80% 99% 99% 51% 85% 96% 59% 99% 67% 61%
189 100 68 68 189 157 157 157 189 189 157 100 189 189 189
93% 69% 78% 16% 84% 21% 70% 84% 84% 63% 93% 72% 95%
266 266 261 71 580 329 580 580 580 261 580 71 524
0% 1% 83% 86% 90% 97% 97% 83% 7% 94% 96%
70 70 70 70 70 70 70 70 58 70 70
41% 100%
42 42* 2007-2009 data was not available. This row represents 2006 data.
Organism
Organism
Gra
m N
egat
ive
Acinetobacter Baumanii
Enterobacter aerogenes
Enterobacter cloacae
Escherichia coli
Proteus mirabilis
Gra
m P
ositi
ve
Enterococcus faecalis
Enterococcus faecium
Staphylococcus aureus
Staphylococcus spp. Coag neg
Staphylococcus Epidermidis
Streptococcus pneumoniae**
2033
Klebsiella oxytoca
Klebsiella pneumoniae
31
Stenotrophomonas maltophilia
Citrobacter freundii 44
68
578
189
580
2717
92
966
ANTIBIOGRAM 2009, WASHOE COUNTY
35
411
224
28
Enterococcus species*
748
162
153
Serratia marcescens
Morganella morganii*
Pseudomonas aeruginosa
42
70
E . f eac al i s
0
100
P E Fd Te Van
2001 (1052)
2002 (1282)
2003 (1517)
E . f aec i um
0
100
P E Fd T e Van
2001 (187)
2002 (254)
2003 (230)
S. aur eus
050
100
Cfz Cd E Gm Lvx Ox P Te T/S Van
2001 (2919)
2002 (3059)
2003 (3440)
S. coagulase neg.
050
100
Cfz Cd E Gm Lvx Ox P Te T/S Van
2001 (360)
2002 (272)
2003 (226)
S. epi der mi di s
050
100
Cfz Cd E Gm Lvx Ox P Te T/S Van
2001 (995)
2002 (1004)
2003 (1002)
S . pn eumon iae
0
50
100
Cft E Gat P Van
2001 (338)
2002 (301)
2003 (308)
E . c l oac ae
050
100
Am Cfz Cp Gm To T/S
2001
2002 (362 )
2003 (361)
C . f r eundi i
050
100
Am Cfz Cp Gm To T/S
2001
2002 (144)
2003 (211)
E . aer ogen es
0
50
100
Am Cfz Cp Gm To T/S
2001
2002 (140)
2003 (191)
K . pn eumon iae
0
50
100
Am Cfz Cp Gm To T/S
2001 (1045)
2002 (705)
2003 (1272)
E . c ol i
050
100
Am Cfz Cp Gm To T/S
2001 (5587)
2002 (6018)
2003 (6796)
K . oxytoc a
0
50
100
Am Cfz Cp Gm To T/S
2001
2002 (205)
2003 (193)
S. mar c es c ens
050
100
Am Cfz Cp Gm To T/S
2001
2002 (157)
2003 (152)
M . mor gani i
050
100
Am Cfz Cp Gm To T/S
2001
2002 (56)
2003 (72)
P . mir abilis
0
50
100
Am Cfz Cp Gm To T/S
2001
2002 (285)
2003 (455)
P . aer ugi nos a
050
100
Ak Caz Cft Gm Lvx P/T To
2001 (968)
2002 (1097)
2003 (1180)
S. mal tophi l i a
0
50
100
Ak Caz Cft Gm Lvx To T/S
2001
2002 (66)
2003 (109)
SUMMARY OF MAJOR FINDINGS
DRSP
ESBLs & CRE
The rate of drug-resistant Streptococcus pneumoniae (DRSP) decreased in the past several years in Washoe County. The rate for penicillin non-susceptible streptococcus pneumoniae (PNSSP) decreased from 29% in 2002 to 23% in 2007, a 21% decrease, which did not show a statistical significance (X2 = 5.562, P=0.234). The decrease might be associated with the introduction of pneumococcal conjungate vaccine in 2000. The resistance to erythromycin and gatifloxacin was 31% and 3%, respectively, in 2009. The rate for PNSSP was significantly decreased to 9% in 2009 from 23% in 2007, this was associated with CLSI standard change in 2008 to separate breakpoints for meningitis and non-meningitis.
Strains of Klebsiella spp., E. coli, Proteus mirabilis that produce extended-spectrum beta-lactamase (ESBLs) may be clinically resistant to therapy with penicillins, cephalosporins, or aztreonam, despite apparant in vitro susceptibility to some of these agents. ESBL screening data reported from one laboratory showed 2.3% of E. coli/Klebsiella spp./Proteus mirabilis produced ESBLs. The rate of carbapenem-resistant enterobacteriaceae (CRE) was 0.7% (26/3879) in 2009. An enhanced surveillance for CRE began in June 2010 and is ongoing in Washoe County.
The rate of vancomycin-resistant enterococci (VRE) increased from 9.8% in 2002 to 11.6% in 2007, which showed a statistical significance (X2 = 65, P<0.001). The VRE rate was 11.9% in 2009, no statistical difference compared to 11.6% in 2007 (X2=0.0255, P=0.87)
The rate of Methicillin-resistant Staphylococcus aureus (MRSA) significantly increased from 35% in 2002 to 48% in 2007, a 37% increase from 2002 to 2007, which showed a statistical significance (X2 = 145, P<0.001). The MRSA rate was 47% in 2009, no statistical difference compared to 48% in 2007 (X2=0.8545, P=0.36).
Vancomycin-intermediate resistant Staphylococcus aureus (VISA) or Vancomycin-resistant Staphylococcus aureus (VRSA) has not been found yet in Washoe County. Please report VISA or VRSA to the Washoe County Health District at 775-328-2447. Please also have your laboratory save the VISA/VRSA isolate for further confirmation at Nevada State Public Health Laboratory.
VRE
MRSA
VISA / VRSA
P. aeruginosa
0
20
40
60
80
100
Ak Caz Cpm Gm Imp Lvx P/T To
2002 (1097)
2003 (1180)
2004 (1042)
2006 (742)
2007 (427)
2009 (580)
S. maltophilia
0
20
40
60
80
100
Ak Caz Gm Lvx To T/S
2002 (66)
2003 (109)
2004 (44)
2006 (31)
2007 (41)
2009 (42)
S. marcescens
0
20
40
60
80
100
Am Cfz Cp Cpm Gm Imp P/T To T/S
2002 (157)
2003 (152)
2004 (118)
2006 (93)
2007 (43)
2009 (70)
E. feacalis
020
406080
100
P E Fd Te Van
2002 (1282)
2003 (1517)
2004 (1147)
2006 (555)
2007 (607)
2009 (748)
E. faecium
0
20
40
60
80
100
P E Fd Te Van
2002 (254)
2003 (230)
2004 (216)
2006 (118)
2007 (131)
2009 (162)
S. aureus
0
20
40
60
80
100
Cfz Cd E Gm Lvx Ox P Te T/S Van
2002 (3059)2003 (3440)2004 (3660)2006 (4369)2007 (2030)2009 (2033)
S. coagulase neg.
0
20
40
60
80
100
Cfz Cd E Gm Lvx Ox P Te T/S Van
2002 (272)
2003 (226)
2004 (336)
2006 (414)
2007 (33)
2009 (31)
S. epidermidis
0
20
40
60
80
100
Cfz Cd E Gm Lvx Ox P Te T/S Van
2002 (1004)
2003 (1002)
2004 (800)
2006 (430)
2007 (372)
2009 (411)
S. pneumoniae
0
20
40
60
80
100
Cft E Gat P Van
2002 (301)
2003 (308)
2004 (297)
2006 (185)
2007 (184)
2009 (224)
C. freundii
0
20
40
60
80
100
Am Cfz Cp Cpm Gm Imp P/T To T/S
2002 (144)
2003 (211)
2004 (165)
2006 (139)
2007 (39)
2009 (44)
E. aerogenes
0
20
40
60
80
100
Am Cfz Cp Cpm Gm Imp P/T To T/S
2002 (140)2003 (191)2004 (165)2006 (110)2007 (32)2009 (68)
E. cloacae
0
20
40
60
80
100
Am Cfz Cp Cpm Gm Imp P/T To T/S
2002 (362)2003 (361)2004 (318)2006 (306)2007 (118)2009 (153)
E. coli
0
20
40
60
80
100
Am Cfz Cp Cpm Gm Imp P/T To T/S
2002 (6018)2003 (6796)2004 (7697)2006 (8040)2007 (2482)2009 (2717)
K. oxytoca
0
20
40
60
80
100
Am Cfz Cp Cpm Gm Imp P/T To T/S
2002 (205)2003 (193)2004 (157)2006 (119)2007 (87)2009 (92)
K. pneumoniae
0
20
40
60
80
100
Am Cfz Cp Cpm Gm Imp P/T To T/S
2002 (705)
2003 (1272)2004 (1125)
2006 (1236)
2007 (463)2009 (578)
M. morganii
0
20
40
60
80
100
Am Cfz Cp Cpm Gm Imp P/T To T/S
2002 (56)
2003 (72)
2004 (65)
2006 (35)
2007 (NA)
2009 (NA)
P. mirabilis
0
20
40
60
80
100
Am Cfz Cp Cpm Gm Imp P/T To T/S
2002 (285)2003 (455)2004 (452) 2006 (503)2007 (121)2009 (189)
A. baumanii
0
20
40
60
80
100
Ak Caz Cax Cp Gm Imp To T/S
2002 (NA)
2003 (NA)
2004 (NA)
2006 (32)
2007 (136)
2009(28)
RESULTRESULT
Antibiogram is an overall profile of antimicrobial susceptibility of a microbial species to a battery of antimicrobial agents. One of the 12 steps to prevent antimiobial resistance in various healthcare settings recommended by CDC is to encourage clinicians to use local data. Since 2002, Washoe County Health District (WCHD) has been collaborating with local laboratories to produce an aggregated community-wide antibiogram every year. Antibiogram has been well received by local medical community. The objectives of this paper are:
to summarize findings on major drug resistant organism such as Methicillin-resistant staphylococcus aureus(MRSA), Vancomycin-resistant enterococci (VRE), drug-resistant streptococcus pneumoniae (DRSP),extended-spectrum beta-lactamase (ESBLs), and carbapenem resistant enterobacteriaceae (CRE);
to present detailed antibiotic susceptibility data and their trends on 18 commonly seen organisms inhealthcare setting for 2002-2009.
BACKGROUNDBACKGROUND
Between 2002 and 2006, WCHD collected institutional antibiograms from local laboratories every year. Between 2007 and present, only local clinical laboratories provided such data. An excel template was developed for each organism to covert susceptibility percent to the number of isolates susceptible and then aggregate them together to produce an overall antibiotic susceptibility percentage. Number of isolates tested less than 10 was excluded fromdata conversion process. Aggregated number of isolates less than 30 was excluded from final calculation and therefore not reported. All isolates reported represented inpatients seen in local hospitals and outpatients seen in emergency departments. The resistance rate comparison between years was assessed by Chi-square statistics using OpenEpi Program.
METHODSMETHODS
The antibiotic resistant rate increased significantly between 2002 and 2007 but was stable between 2007 and 2009. The rates of ESBLs and CRE were low in Washoe County.
CONCLUSIONSCONCLUSIONS