9 Tools for Building a Better Antibiogram

By Karen Blum

A patient presents to your hospital with signs of sepsis. While waiting for blood culture results to
return, what can you do?

A proven strategy is to check your facility’s antibiogram to determine the most likely effective
antibiotic. Doing so will factor in a critically important determinant of treatment success:
variable patterns of antimicrobial resistance, which “can change by region, even by hospital,”
said Romney M. Humphries, PhD, the section chief of clinical microbiology at the University of
California, Los Angeles Health System.

When done accurately, antibiograms can be used to make formulary decisions based on these
local resistance patterns, Dr. Humphries said. They also can be used to monitor the effect of
antibiotic stewardship programs—specifically, to determine whether limiting certain agents
yields a reduction in resistance. But none of these efforts will succeed without ensuring that best
antibiogram practices, detailed below, are being followed, Dr. Humphries noted.

1. Start with the basics

An antibiogram is a tool for tracking information from culture and sensitivity tests performed on
bacterial organisms found at your medical center within a given time. It provides the percentage
of samples of a given organism that were sensitive to particular antibiotics.

2. Use educational resources

The Clinical and Laboratory Standards Institute (CLSI) has a guidance document (M39) that
provides recommendations for creating an accurate antibiogram. Among other tips, it
recommends that antibiograms should feature the number of isolates that were included for a
given organism; only species with at least 30 isolates should be used; and the greater the number
of isolates, the more accurate the sensitivity results for a given organism. For more information
about the CLSI guidance document,
see clsi.org/?standards/?products/?microbiology/?documents/?m39.

3. Do the math
Antibiograms should list the percentage of isolates of a given organism that were susceptible to a
given antibiotic. Make sure to include only the first isolate taken from each patient and to include
only drugs that are routinely tested at your hospital.

4. Don’t set and forget

Antibiograms should be updated at least annually. “Most of us want to do so more frequently.

That’s fine, provided you are looking only at final, verified culture results,” Dr. Humphries said.

5. Use technology

“Some electronic medical record systems, such as Epic, allow you to perform up-to-the-minute
antibiograms to see susceptibility results,” she said. And if you choose a mobile app for
accessing antibiograms, be sure it follows the CLSI guidelines, she stressed.

6. Watch out for gram-negative organisms

Infections with these bugs present a challenge when a hospital is determining optimal empirical
therapy recommendations, so continual evaluation of antibiograms becomes critical, according to
Jason M. Pogue, PharmD, BCPS-ID, a clinical pharmacist in infectious diseases with Sinai-
Grace Hospital and Detroit Medical Center, in Michigan. For example, piperacillin-tazobactam
may have been a health system’s preferred agent at one point, but then, due to a lot of use or a
shift in the predominant epidemiological pathogen, cefepime could become more active, he
explained. “Every six months or so, look back and ask if you need to modify your empiric
therapy recommendations,” he said.

7. Don’t take a one-size-fits-all approach

Depending on your institution’s resources, you can create separate antibiograms for different
patient populations or units. At UCLA, the main antibiogram is 46 pages, Dr. Humphries said,
including separate tables for their pediatric and adult populations, for each of the two hospitals in
the health system, and for the ICUs, inpatient wards and outpatients. “That’s particularly
important because our ICU patients tend to have more resistant organisms,” she said.

The UCLA antibiogram also includes information on organisms such

as Haemophilus and Moraxella, which don’t require routine susceptibility testing. The
stewardship team also uses the comprehensive antibiogram document to track resistance trends
over time for methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci.

8. Consider combination antibiograms

This strategy is becoming more common, Dr. Pogue said, because it can guide optimal two-drug
regimens that provide coverage for the most likely involved pathogens. Such an approach also
can be helpful for ICU patients with hospital-acquired or ventilator-associated infections, for
whom appropriate empirical therapy has demonstrated a survival advantage. “Whatever your
favorite antibiotic is, you’re going to miss a huge chunk of organisms in your ICU if you use just
one agent, because these patients are more likely to have more resistant pathogens, such
as Pseudomonas, Acinetobacter or extended-spectrum beta-lactamase–producing
Enterobacteriaceae,” he explained.

9. Know your limits

Pharmacists need to be aware of antibiogram data because they’re going to be the ones who
verify medication orders, and in many cases will be asked what therapy to start, Dr. Pogue
added. Keep in mind, however, that there are limitations to antibiograms. “Pharmacists have to
go beyond the antibiogram and consider patient-specific factors,” he said, such as a history of
resistant organisms, history of antibiotic exposures and drug allergies when approving and filling
medication orders.