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Antibiogram Based Antimicrobial Resistance Policy

Antimicrobial resistance has a tremendous impact in health-care settings; where the combination of highly susceptible patients; including the immunocompromised, intensive prolonged antimicrobial use, and cross infection has resulted in hospital acquired infections with highly resistant bacterial pathogens (Santajit and Indrawattana, 2016). The increasing risk for morbidity and mortality associated with such resistant infections, will further attribute to inappropriate, inadequate or delayed therapy and hence to the emergence and spread of resistant organisms to other patients. (WHO, 2011) Lack of compliance to basic standard infection control procedures also contributes to the spread of resistant organisms between patients, medical personnel and the community as a whole further posing a serious public health problem, since future generations may contract infections that are resistant to any treatment (Cecchini et al, 2015).


Introduction
Antimicrobial resistance has a tremendous impact in health-care settings; where the combination of highly susceptible patients; including the immunocompromised, intensive prolonged antimicrobial use, and cross infection has resulted in hospital acquired infections with highly resistant bacterial pathogens (Santajit and Indrawattana, 2016). The increasing risk for morbidity and mortality associated with such resistant infections, will further attribute to inappropriate, inadequate or delayed therapy and hence to the emergence and spread of resistant organisms to other patients. (WHO, 2011) Lack of compliance to basic standard infection control procedures also contributes to the spread of resistant organisms between patients, medical personnel and the community as a whole further posing a serious public health problem, since future generations may contract infections that are resistant to any treatment (Cecchini et al, 2015). resistant organisms as antimicrobial stewardship and implementation of infection prevention and control measures are therefore, essential. One of the most important criteria in antimicrobial stewardship is establishing a system for monitoring bacterial resistance and practice guidelines or antibiotic policies to control the use of antibiotics, and respond to data from the monitoring system (CDC, 2017).
Hospitals whether large or small, should design their own local antimicrobial policy according to the trend and pattern of resistant organisms within their facility, and hence clinicians must follow such policies (WHO,2015) This study aimed to assess the antimicrobial resistance pattern of organisms revealed from culture and sensitivity antibiograms for long term inpatients; including intensive care unit [ICU] patients from a public hospital and accordingly present a simple means to construct an antibiotic resistance policy.

Materials and Methods
Culture and sensitivity was performed for all samples (urine, sputum, blood, wounds) using Bauer and Kirby method. The antibiotic discs [Oxoid ]represented a combination of narrow and broad spectrum antibiotics as displayed in tables 1, 2 and 3. Inhibition zones were measured. The resistance pattern revealed from antibiograms for all samples was recorded for a 12 months period. Results were tabulated and an antibiotic resistance policy was constructed according to the pattern of resistance (Jorgensen et al, 2009 andCLSI,2009)

Results and Discussion
Based on the results of antibiograms the following was revealed: The primary aim of the hospital antibiotic policy is to minimize themorbidity and mortality due to antimicrobial-resistant infection; and to preserve the effectiveness of antimicrobial agents in the treatment and prevention of communicable diseases. It is essential for prophylaxis, empirical and definitive therapy (WHO 2011 Collectively, S. aureus isolates displayed a 65% to a 100% resistance to first and third generation cephalosporins, 71.43% resistance to Meropenem and fortunately only 7.14% for Vancomycin and no resistance to Linezolid (Table 1).
E. coli isolates and K.pneumoniae isolates showed a similar range of resistance (65% to 100%) to first, second and third generation cephalosporins, and approximately a 93.0% resistance to Ampicillin-Clavulanic acid. E. coli demonstrated a 90.0% résistance to Ampicillin -Sulbactam however, K. pneumoniae displayed a lower percentage of resistance(79.0%).
The percentage of resistance to fluoroquinolones was much higher for E. coli isolates compared to K.pneumoniae; namely Ofloxacin 68.18% to 41.67%, Ciprofloxacin 56.25% to 29.63%. (Table 2) P.aeruginosa isolates were 100% resistant to Ampicillin-Clavulanic acid, Tetracyclin, Rifampicin, and some third and fourth generation cephalosporins, and a range of 80% to 90% resistance to second generation cephalosporins (Table 3).

Figure.2
Urine culture sensitivity pattern for isolated pathogens All pathogens showed an equal percentage of resistance (40.0%) to all tested antibiotics Figure.3 Blood culture sensitivity pattern for isolated pathogens S.aureus isolates showed the least percentage of resistance (30.0%) to all tested antibiotics, whereas E.coli isolates showed the highest percentage of resistance (74.3%).

Figure.4
Wound culture sensitivity pattern for isolated pathogens K.pneumoniae isolates displayed the least percentage of resistance (19.4%) to all tested antibiotics, whereas E.coli isolates showed the highest percentage of resistance (65.8%).
Laboratories should use standards for reporting quantitative resistance data (e.g. minimal inhibitory concentrations or zone diameters) that will detect decreased susceptibility. This is necessary because antimicrobial test results reported qualitatively (e.g., as susceptible, intermediate, or resistant) may hide an emerging resistance character in microorganisms with a small decrease in susceptibility that may still be classified as susceptible.
A reliable cumulative antibiogram should only include final, verified results of diagnostic species with at least ≥ 30 tested isolates. It should also include the first isolate obtained per patient during the assigned period for analysis, irrespective of the site of specimen collection or the antimicrobial susceptibility pattern. Isolates with intermediate susceptibility should not be included in the calculation of the percentage of isolates that are susceptible (WHO, 2015).
The conclusions of the study are as follows

Antibiotic policy
An antibiotic policy is divided into levels for prescribing antibiotics; first choice antibiotics can be prescribed by all clinicians, while restricted choice and reserve antibiotics can only be prescribed after consulting an infectious disease expert clinician and a clinical microbiologist (Marston et al., 2016, CDC, 2017

First choice antibiotics for non-restricted use (empirically)
The antimicrobials that showed the least resistance patterns for all pathogens may be prescribed without approval by all clinicians orphysicians. Antibiotics may be written individually by generic name or as a group [eg. second or third generation cephalosporins].
The specimen for the culture and sensitivity testing must be taken before the beginning of the empirical course of antibiotics, which includes the antibiotic disc that represents the empirical antibiotic. If the antibiotic was found to be sensitive according to the results of the antibiogram, then the empirical therapy may be continued; however if found resistant, therapy must be altered to another sensitive antibiotic.

Restricted choice antibiotics
These antibiotics may be more expensive and/or have a wider spectrum of activity and should only be used for specified more serious clinical conditions such as empirical emergency treatment of suspected serious or life-threatening infections pending the result of culture and sensitivity testing.

Reserved antimicrobials
These antibiotics should be reserved for multidrug resistant pathogens causing lifethreatening infections[ eg. Vancomycin for MRSA].They should only be used when culture and sensitivity testing has indicated resistance to other antibiotics. The intermediate sensitive drugs are only used as an alternative if no sensitive antibiotics were revealed in the antibiogram results, or are commercially.

Recommendations
The most important strategy to decrease antibiotic resistance is to apply an antibiotic stewardship system to change the pattern of prescription and use. This may be achieved by developing policies for appropriate use of antibiotics in each hospital, based on local resistance surveillance data from antibiograms, and monitoring the compliance and proper implementation of the policy. Moreover, ensuring a quality controlled performance and procedures for microbial identification and antibiotic susceptibility of key pathogens.