Intensive Care Unit Antibiogram – HGH/JH/SJH – 2019 data
Brody Duncan
July 3, 2020
Updates from last version
- For SPICE bugs and ESBL/AmpC, I have re-calculated what the % susceptible for ceftriaxone/ceftazidime/pip-tazo would be based on the VITEK MIC result. These results have been put in parentheses underneath the “typical” reporting of resistant for all those antibiotics. Note that quite a significant number of ESBL E coli and Enterobacter are in vitro susceptible to pip-tazo
- I also made a 2017-2019 “respiratory GNB” antibiogram for Juravinski hospital (table 11 at the bottom). I do not have the 2017-2018 data for St. Joe’s so cannot do that for comparison.
Methods:
Antimicrobial susceptibility testing results were recorded for bacterial isolates collected in the ICU from HGH, JH, and SJH from 1 January to 31 December 2019. Isolates collected in the ED or ward prior to ICU transfer were not included. Surveillance isolates were not included.
A cumulative antibiogram was constructed using guidelines published in CLSI document M-39. Only the first isolate obtained in the ICU per patient was included. If two isolates were collected at the exact same time, the more resistant was chosen for inclusion. Only antibiotics routinely tested were included.
Separately, a “respiratory” antibiogram was created using the first Gram-negative bacillus isolated from a sputum or BAL sample per patient during the time period. If two different organisms were isolated in the same respiratory specimen, both were included. Not all antibiotics were tested on all organisms; to better reflect empirical antibiotic use for pneumonia, any antibiotic that was not tested for a particular organism was considered resistant (ex: ceftriaxone for Pseudomonas). In addition, a cumulative respiratory antibiogram for HGH from 2017-2019 was made using the same methods, in order to increase the sample size.
We did deviate from CLSI M-39 in one aspect: organisms with ESBL/AmpC/CPE expression were considered resistant to penicillins, beta-lactamase combinations, and cephalosporins regardless of MIC result. This change was made to reflect our institutions’ current practices for susceptibility reporting and clinical management for these organisms. Note that with our current method of susceptibility testing (Vitek AST) a large proportion of these organisms (especially those with chromosomal AmpC) would otherwise be recorded as susceptible to 3rd generation cephalosporins and piperacillin-tazobactam.
Tables 1+2: Hamilton General Hospital – first isolate per patient, any specimen type – % susceptible
| Gram Negatives | AMP | CTX | CEFTAZ | PIPTAZ | ERTA | MERO | GENT | TOBRA | SEPTRA | CIPRO | |
| E coli (n=64)3 | 42.2 | 75.0 (75.0) | 75.0 (75.0) | 71.4 (89.1) | 98.4 | 98.4 | 93.8 | 92.2 | 68.8 | 70.3 | |
| ESBL/AmpC/CPE E coli (n=16)1,5 | – | – (0) | – (0) | – (75.0) | 93.8 | 93.8 | 81.3 | 75.0 | 50.0 | 31.3 | |
| Other E coli (n=48) | 56.3 | 100 | 100 | 95.7 | 100 | 100 | 97.9 | 97.9 | 75.0 | 83.3 | |
| K pneumoniae (n=29)3,5 | 0 | 89.7 (89.7) | 89.7 (89.7) | 86.0 (89.7) | 100 | 100 | 89.7 | 89.7 | 86.2 | 82.8 | |
| ESBL/AmpC/CPE K pneumoniae (n=3)1,5 | – | – (0) | – (0) | – (66.7) | 100 | 100 | 0 | 0 | 0 | 0 | |
| Other K pneumoniae (n=26)5 | 0 | 100 | 100 | 96.0 | 100 | 100 | 100 | 100 | 96.2 | 92.3 | |
| Enterobacter cloacae (n=24)2,5 | – | – (41.7) | – (50.0) | – (54.2) | 91.7 | 100 | 83.3 | 83.3 | 75.0 | 91.7 | |
| Pseudomonas aeruginosa (n=50)4 | – | – | 84.0 | 84.0 | – | 78.0 | 90.0 | 94.0 | – | 84.0 | |
1. Rate of ESBL/AmpC/CPE resistance is 25.0% for E coli and 10.3% for K pneumoniae
2. E cloacae has intrinsic AmpC
3. For piperacillin-tazobactam, n=63 for E coli and n=28 for K pneumoniae
4. Rate of multi-drug resistant P aeruginosa is 10.0%
5. Results for organisms with n<30 should be interpreted with caution due to decreased statistical validity
| Gram Positives | AMP | ANCEF | CLOX | ERYTHRO | CLINDA | SEPTRA | CIPRO2 | TETRA | RIFAMPIN2 | VANCO | |
| Staphylococcus aureus (n=158) | – | 74.7 | 74.7 | – | – | – | – | – | – | – | |
| MSSA (n=118)1 | – | 100 | 100 | 75.2 | 82.1 | 100 | 87.9 | 95.7 | 100 | 100 | |
| MRSA (n=40)1 | – | 0 | 0 | 15.0 | 52.5 | 100 | 17.5 | 82.5 | 97.5 | 100 | |
| Enterococcus spp. (n=62) | 72.6 | – | – | – | – | – | – | – | – | 90.3 | |
1. MSSA = Methicillin-susceptible S. aureus, MRSA = Methicillin-resistant S aureus
2. Ciprofloxacin and rifampin are not appropriate as monotherapy for serious infections
Table 3: Hamilton General Hospital – first respiratory GNB per patient – % susceptible
| Respiratory GNB | AMP | CTX | CEFTAZ | PIPTAZ | ERTA | MERO | GENT | TOBRA | SEPTRA | CIPRO |
| All GNB combined (n=123)1 | 4.9 | 21.1 (45.5) | 55.3 (80.5) | 52.0 (70.7) | 53.7 | 86.2 | 84.6 | 85.4 | 59.3 | 78.9 |
1. The breakdown of organisms by species is as follows:
PEcK (29/123, 23.6%): E coli (11), K pneumoniae (12), K oxytoca (4), P mirabilis (1), Raoultella spp (1)
SPICE (39/123, 31.7%): Serratia spp (14), E cloacae (14), E aerogenes (6), Citrobacter spp (4), P vulgaris (1)
Pseudomonas (40/123, 32.5%): P aeruginosa (40)
Other (15/123, 12.2%): S maltophilia (7), Acinetobacter spp (4), Burkholderia spp (3), Achromobacter spp (1)
| Blood GNB | AMP | CTX | CEFTAZ | PIPTAZ | ERTA | MERO | GENT | TOBRA | SEPTRA | CIPRO |
| All GNB combined (n=45)1 | 11.1 | 31.1 (57.8) | 42.2 (68.9) | 46.7 (68.9) | 75.6 | 91.1 | 88.9 | 86.7 | 68.9 | 82.2 |
1. The breakdown of organisms by species is as follows:
PEcK (18/45, 40.0%): E coli (12), K pneumoniae (4), K oxytoca (1), Kluyvera spp (1)
SPICE (17/45, 37.8%): Serratia spp (6), E cloacae (6), E aerogenes (1), Enterobacter spp (1) Citrobacter spp (3)
Pseudomonas (6/45, 13.3%): P aeruginosa (6)
Other (4/45, 8.9%): S maltophilia (1), Acinetobacter spp (2), Salmonella typhimurium (1)
| Blood GNB | Alone | +Gent | +Tobra | +Cipro |
| Ceftriaxone | 86.7 | 84.4 | 80.0 | |
| Ceftazidime | 86.7 | 84.4 | 82.2 | |
| Piptazo | 86.7 (88.9) | 84.4 (88.9) | 84.4 (88.9) | |
| Erta | ||||
| Merto |
Tables 4+5: Juravinski Hospital – first isolate per patient, any specimen type – % susceptible
| Gram Negatives | AMP | CTX | CEFTAZ | PIPTAZ | ERTA | MERO | GENT | TOBRA | SEPTRA | CIPRO | |
| E coli (n=33) | 36.4 | 54.5 (54.5) | 54.5 (57.6) | 57.6 (90.9) | 97.0 | 97.0 | 78.8 | 81.8 | 63.6 | 51.5 | |
| ESBL/AmpC/CPE E coli (n=14)1,4 | – | – (0) | – (14.3) | – (78.6) | 92.9 | 92.9 | 57.1 | 57.1 | 42.9 | 14.3 | |
| Other E coli (n=19)4 | 63.2 | 94.7 | 89.5 | 100 | 100 | 100 | 94.7 | 100 | 78.9 | 78.9 | |
| K pneumoniae (n=19)1,4 | 0 | 78.9 (78.9) | 78.9 (78.9) | 78.9 (78.9) | 100 | 100 | 84.2 | 78.9 | 78.9 | 78.9 | |
| ESBL/AmpC/CPE K pneumoniae (n=4)4 | – | – (0) | – (0) | – (0) | 100 | 100 | 25.0 | 0 | 25.0 | 0 | |
| Other K pneumoniae (n=15)4 | 0 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 93.3 | 100 | |
| Enterobacter cloacae (n=11)2,4 | – | – (9.1) | – (9.1) | – (27.3) | 81.8 | 90.9 | 72.7 | 54.5 | 72.7 | 63.6 | |
| Pseudomonas aeruginosa (n=26)3,4 | – | – | 61.5 | 73.1 | – | 76.0 | 88.5 | 92.3 | – | 69.2 | |
1. Rate of ESBL/AmpC/CPE resistance is 42.4% for E coli and 21.1% for K pneumoniae
2. E cloacae has intrinsic AmpC
3. Rate of multi-drug resistant P aeruginosa is 19.2%
4. Results for organisms with n<30 should be interpreted with caution due to decreased statistical validity.
| Gram Positives | AMP | ANCEF | CLOX | ERYTHRO | CLINDA | SEPTRA | CIPRO2 | TETRA | RIFAMPIN2 | VANCO | |
| Staphylococcus aureus (n=60) | – | 68.3 | 68.3 | – | – | – | – | – | – | – | |
| MSSA (n=41)1 | – | 100 | 100 | 82.9 | 90.2 | 100 | 90.2 | 100 | 100 | 100 | |
| MRSA (n=19)1,3 | – | 0 | 0 | 0 | 42.1 | 100 | 0 | 100 | 94.7 | 100 | |
| Enterococcus spp. (n=41)3 | 56.1 | – | – | – | – | – | – | – | – | 92.7 | |
1. MSSA = Methicillin-susceptible S. aureus, MRSA = Methicillin-resistant S aureus
2. Ciprofloxacin and rifampin are not appropriate as monotherapy for serious infections
3. Results for organisms with n<30 should be interpreted with caution due to decreased statistical validity.
Table 6: Juravinski Hospital – first respiratory GNB per patient – % susceptible
| Respiratory GNB | AMP | CTX | CEFTAZ | PIPTAZ | ERTA | MERO | GENT | TOBRA | SEPTRA | CIPRO |
| All GNB combined (n=37)1 | 2.7 | 18.9 (18.9) | 45.9 (45.9) | 51.4 (62.2) | 40.5 | 75.7 | 67.6 | 70.3 | 45.9 | 51.4 |
1. The breakdown of organisms by species is as follows:
PEcK (12/37, 32.4%): E coli (4), K pneumoniae (8)
SPICE (3/37, 8.1%): E cloacae (3)
Pseudomonas (16/37, 43.2%): P aeruginosa (16)
Other (6/37, 16.2%): S maltophilia (6)
Tables 7+8: St. Joseph’s Hospital – first isolate per patient, any specimen type – % susceptible
| Gram Negatives | AMP | CTX | CEFTAZ | PIPTAZ | ERTA | MERO | GENT | TOBRA | SEPTRA | CIPRO | |
| E coli (n=30) | 36.7 | 76.7 (76.7) | 76.7 (83.3) | 73.3 (83.3) | 100 | 100 | 93.3 | 90.0 | 73.3 | 63.3 | |
| ESBL/AmpC/CPE E coli (n=7)1,5 | – | – (0) | – (28.6) | – (42.9) | 100 | 100 | 85.7 | 71.4 | 28.6 | 0 | |
| Other E coli (n=23)3,5 | 47.8 | 100 | 100 | 95.7 | 100 | 100 | 95.7 | 95.7 | 87.0 | 82.6 | |
| K pneumoniae (n=13)1,5 | 0 | 61.5 (61.5) | 61.5 (61.5) | 61.5 (69.2) | 84.6 | 84.6 | 92.3 | 69.2 | 61.5 | 61.5 | |
| ESBL/AmpC/CPE K pneumoniae (n=5)1,5 | – | – (0) | – (0) | – (20.0) | 60.0 | 60.0 | 80.0 | 20.0 | 0 | 0 | |
| Other K pneumoniae (n=8)5 | 0 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | 100 | |
| Enterobacter cloacae (n=6)2,4 | – | – (33.3) | – (50.0) | – (50.0) | 100 | 100 | 100 | 100 | 100 | 100 | |
| Pseudomonas aeruginosa (n=31)3,4 | – | – | 77.4 | 74.2 | – | 80.6 | 96.8 | 96.8 | – | 74.2 | |
1. Rate of ESBL/AmpC/CPE resistance is 23.3% for E coli and 38.5% for K pneumoniae
2. E cloacae has intrinsic AmpC
3. For piperacillin-tazobactam, n=30 for P aeruginosa
4. Rate of multi-drug resistant P aeruginosa is 9.7%
5. Results for organisms with n<30 should be interpreted with caution due to decreased statistical validity.
| Gram Positives | AMP | ANCEF | CLOX | ERYTHRO | CLINDA | SEPTRA | CIPRO2 | TETRA | RIFAMPIN2 | VANCO | |
| Staphylococcus aureus (n=48) | – | 62.5 | 62.5 | – | – | – | – | – | – | – | |
| MSSA (n=30)1 | – | 100 | 100 | 66.7 | 76.7 | 100 | 93.3 | 100 | 100 | 100 | |
| MRSA (n=18)1,3 | – | 0 | 0 | 5.6 | 33.3 | 100 | 5.6 | 100 | 100 | 100 | |
| Enterococcus spp. (n=33) | 72.7 | – | – | – | – | – | – | – | – | 100 | |
1. MSSA = Methicillin-susceptible S. aureus, MRSA = Methicillin-resistant S aureus
2. Ciprofloxacin and rifampin are not appropriate as monotherapy for serious infections
3. Results for organisms with n<30 should be interpreted with caution due to decreased statistical validity.
Table 9: St. Joseph’s Hospital – first respiratory GNB per patient – % susceptible
| Respiratory GNB | AMP | CTX | CEFTAZ | PIPTAZ | ERTA | MERO | GENT | TOBRA | SEPTRA | CIPRO |
| All GNB combined (n=47)1 | 4.3 | 17.0 (19.1) | 57.4 (66.0) | 55.3 (59.6) | 31.9 | 76.6 | 80.9 | 80.9 | 42.6 | 63.8 |
1. The breakdown of organisms by species is as follows:
PEcK (10/47, 21.3%): E coli (5), K pneumoniae (4), Klebsiella oxytoxa (1)
SPICE (4/47, 8.5%): E cloacae (2), Citrobacter freundii (1), Serratia spp (1)
Pseudomonas (23/47, 48.9%): P aeruginosa (23)
Other (10/47, 21.3%): S maltophilia (4), Acinetobacter spp (4), Salmonella infantis (1), Pantoae spp (1)
Table 10: Hamilton General Hospital 2017-2019 – first respiratory GNB per patient – % susceptible
| Respiratory GNB | AMP | CTX | CEFTAZ | PIPTAZ | ERTA | MERO | GENT | TOBRA | SEPTRA | CIPRO | |
| All GNB combined (n=395)1 | 6.6 | 27.3 (51.6) | 51.6 (77.0) | 50.9 (69.4) | 61.3 | 87.1 | 87.1 | 85.8 | 67.6 | 80.5 | |
| E coli/Kleb/ Proteus (n=130) | 19.2 | 80.8 (80.8) | 82.3 (82.3) | 77.7 (86.9) | 95.4 | 95.4 | 91.5 | 89.2 | 78.5 | 81.5 | |
| SPICE (n=127)2 | – | – (75.6) | – (78.7) | – (48.0) | 92.9 | 96.9 | 96.1 | 92.9 | 96.1 | 95.3 | |
| Pseudomonas (n=93) | – | – | 83.9 | 90.3 | – | 87.1 | 94.6 | 97.8 | – | 80.6 | |
1. The breakdown of organisms by species is as follows:
E coli/Kleb/Proteus (130/395, 32.9%): E coli (56), K pneumoniae (43), K oxytoxa (25), P mirabilis (3), P penneri (1), Raoultella spp (2)
SPICE (127/395, 32.2%): Serratia spp (37), E cloacae (53), E aerogenes (24), Citrobacter spp (10), P vulgaris (2), Morganella spp (1)
Pseudomonas (93/395, 23.5%): P aeruginosa (93)
Other (45/395, 11.4%): S maltophilia (23), Acinetobacter spp (13), Burkholderia cepacia complex (5), B gladioli (1), Achromobacter xylosidans (1), Chryseobacterium indologenes (1), Pseudomonas fluorescens (1)
2. “SPICE” organisms have intrinsic AmpC
Table 11: Juravinski Hospital 2017-2019 – first respiratory GNB per patient – % susceptible
| Respiratory GNB | AMP | CTX | CEFTAZ | PIPTAZ | ERTA | MERO | GENT | TOBRA | SEPTRA | CIPRO | |
| All GNB combined (n=99)1 | 1.0 | 16.2 (24.2) | 45.5 (53.5) | 43.4 (58.6) | 42.4 | 78.8 | 70.7 | 68.7 | 49.5 | 58.6 | |
| E coli/Kleb/ Proteus (n=32) | 3.1 | 50.0 (53.1) | 50.0 (53.1) | 46.9 (65.6) | 93.8 | 93.8 | 75.0 | 68.8 | 75.0 | 65.6 | |
| SPICE (n=12)2 | – | – (58.3) | – (58.3) | – (75.0) | 100 | 100 | 75.0 | 66.7 | 83.3 | 75.0 | |
| Pseudomonas (n=38) | – | – | 73.7 | 71.1 | – | 86.8 | 97.4 | 100 | – | 73.7 | |
1. The breakdown of organisms by species is as follows:
E coli/Kleb/Proteus (32/99, 32.3%): E coli (10), K pneumoniae (20), K oxytoca (2)
SPICE (12/99, 12.1%): Serratia (1), E cloacae (7), E aerogenes (4)
Pseudomonas (38/99, 38.4%): P aeruginosa (38)
Other (17/99, 17.2%): S maltophilia (14), Acinetobacter spp (2), Achromobacter xylosidans (1)
2. “SPICE” organisms have intrinsic AmpC