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Selective Reporting of Antimicrobial

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Selective Reporting of Antimicrobial

Susceptibility Testing Results:


A Primer for Antibiotic Stewardship
Programs
August 2020

Document Purpose
The primary purpose of antimicrobial susceptibility testing is to provide information that will
assist healthcare professionals in the management of their patients. This document provides
reasons why antimicrobial susceptibility testing data may not be reported in the electronic
health record.

Highlighting these examples may assist antibiotic stewardship programs in validating,


interpreting and applying antimicrobial resistance tracking and reporting at their hospitals.
Examples are provided to illustrate key points and are not intended to be comprehensive or
imply endorsement. For additional information, the Clinical and Laboratory Standards Institute
M100 document provides further details for many of these situations.

Key Terms and Abbreviations


Term/Abbreviation Description
AST Antimicrobial Susceptibility Testing

ASP Antibiotic Stewardship Program

CLSI Clinical and Laboratory Standards Institute

FDA Food and Drug Administration

Selective Testing AST results for a particular bug-drug combination are not tested.

Selective Reporting AST results for a particular bug-drug combination are obtained but
results are not reported in the electronic health record.

Cascade Reporting AST results for a particular bug-drug combination are obtained but
results are not reported for broader-spectrum agents unless the bug is
resistant to narrow-spectrum agents. Cascade reporting is a subset of
selective reporting.

Updated: August 2020 Page 1 of 4


Selective Reporting of Antimicrobial Susceptibility Testing Results:
A Primer for Antibiotic Stewardship Programs

Microbiology laboratory may not perform AST for a particular bug-drug


combination for the following reasons:
• AST may not be performed on bacteria suspected of being contaminants or usual
flora.
Example: Two blood cultures are performed and one of the two cultures reveals
growth of Staphylococcus epidermidis. AST isn’t performed as the isolate is a
suspected contaminant.

• AST may not be performed if susceptibility or resistance can be predicted


based on the organism identification alone (i.e., no resistance yet identified
or intrinsic resistance).
Example: AST isn’t performed for ceftriaxone and Pseudomonas aeruginosa because P.
aeruginosa is intrinsically resistant to ceftriaxone.

• AST may not be performed if susceptibility or resistance can be predicted


based on the results of other drugs tested.
Example: An isolate that is susceptible to ceftazidime can be inferred to be
susceptible to ceftazidime-avibactam.

• A particular bug-drug combination may not be tested by the laboratory.


Example: Laboratories often use automated instruments to perform routine AST.
Certain drugs may not be on the chosen panel and thus are not routinely tested.
Example: A recently approved drug does not yet have an FDA-cleared testing method.

• A particular bug-drug combination may not have interpretative breakpoints.


Example: There are no CLSI or FDA breakpoints for Acinetobacter baumannii and
tigecycline.

Selective Reporting may occur for the following reasons:


• A particular bug-drug combination may be inappropriate for a given site of infection.
Example: Daptomycin AST results are not reported on isolates from a respiratory
source.

• A drug is not on the facility formulary.


Example: A laboratory’s AST panel for Enterobacteriaceae contains three
carbapenems, but only two carbapenems are on the facility formulary. The AST
results for the non-formulary drug are not reported.

Updated: August 2020 Page 2 of 4


Selective Reporting of Antimicrobial Susceptibility Testing Results:
A Primer for Antibiotic Stewardship Programs

• A particular testing method may have a bug-drug combination limitation.


Example: A penicillin disk susceptibility test on a S. aureus isolate can be reported if
the result is resistant but a confirmatory test is required before reporting a
susceptible result.

Example: Automated test instruments may have a drug on a panel, but a lack of
FDA-cleared criteria prevents results reporting for particular bug-drug
combinations.

• A drug may be inappropriate for a particular patient population.


Example: AST results for certain drug classes such as fluoroquinolones or
tetracyclines may not be reported for children.

• Facilities may perform selective reporting based on medical literature


suggesting suboptimal outcomes with particular drugs in the treatment of
specific resistance phenotypes or for serious infections.
Example: Some laboratories may not report piperacillin-tazobactam results for
ceftriaxone- resistant Escherichia coli isolates from blood cultures.

Example: Some laboratories may not report the results of an isolate that tests
susceptible to carbapenems but is positive for a carbapenemase test.

• Cascade reporting may be performed.


Example: Carbapenem AST results are not reported for Escherichia coli if the isolate is
susceptible to ceftriaxone.

AST results reporting may be modified for the following reasons:


• The performance of a secondary phenotypic test.
Example: A D-zone test on a S. aureus isolate is positive, indicating the presence of
inducible resistance to clindamycin; thus clindamycin is reported as resistant even
though it was susceptible based on the minimum inhibitory concentration (MIC).
Example: Some laboratories may change the interpretation of cephalosporin results
from susceptible to resistant based upon a positive extended-spectrum β-
lactamase test.

• The performance of a secondary molecular test.


Example: A nucleic acid amplification test (NAAT) is positive for mecA and thus a S.
aureus isolate is reported as resistant to methicillin, oxacillin, and nafcillin even
though it was susceptible based on the MIC result.

Updated: August 2020 Page 3 of 4


Selective Reporting of Antimicrobial Susceptibility Testing Results:
A Primer for Antibiotic Stewardship Programs

• The laboratory or an automated instrument used by the laboratory follows


“expert rules”.
Example: A laboratory changes an interpretation from susceptible to resistant
based on the organism identification because some species are intrinsically
resistant to the drug.
Example: Automated instrument software changes results from susceptible to
resistant based upon an algorithm for a given phenotype.

Comments may be added to AST results reporting for the following reasons:
 Adding a comment to influence prescribing.
Example: Third generation cephalosporins are not recommended for treating serious
infections caused by Enterobacter spp.

 Adding a comment to influence practice.


Example: ID consult recommended for Staphylococcus aureus bacteremia.

Resources
• Clinical and Laboratory Standards Institute, M100, Performance Standards for
Antimicrobial Susceptibility Testing, S29, 2019. Accessed August 12, 2019:
https://clsi.org/standards/products/free-resources/access-our-free-resources/
• Antibacterial Susceptibility Test Interpretive Criteria, U.S. Food and Drug
Administration. Accessed August 12, 2019: https://www.fda.gov/drugs/development-
resources/antibacterial-susceptibility-test-interpretive-criteria

Updated: August 2020 Page 4 of 4

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