Antimicrobial resistance is a growing threat to the public’s health, and local health departments (LHDs) have become increasingly involved to ensure their communities are prepared. LHDs serve as community chief health strategists and are uniquely positioned to facilitate a coordinated approach across healthcare settings, enhancing infection prevention and control, responding to antimicrobial resistant infections, and promoting antimicrobial stewardship. One tool for supporting antibiotic stewardship is an antibiogram, which displays data on bacterial pathogens and their susceptibility to different antimicrobials.
Healthcare facilities often generate antibiograms from their lab data, and it can be used to guide treatment options and monitor resistance patterns. Health departments at the state and local level have started to develop regional antibiograms, which look at resistance patterns beyond the scope of a single healthcare facility. These community-wide antibiograms allow for monitoring more widespread trends in resistance patterns, which can be useful for smaller facilities which may not have the resources to develop their own antibiograms and for informing empiric therapy selection. Regional antibiograms are meant to compliment but not replace facility-level antibiograms. NACCHO spoke with two local health departments who have developed regional antibiograms to see what prompted their efforts, how they go about it, and how they use the data.
Tarrant County Public Health’s Division of Epidemiology and Health Information has created a county-wide antibiogram since 2010. With each hospital or health system in the county developing their own antibiograms the health department identified that the process lacked standardization and while they did not want to tell the hospital what to be concerned about or dictate what the labs should test, they did want to be able to compare across facilities. The process started with a push from the department’s health authority, who at the time was an infectious disease doctor and able to leverage that position to reach out to ID colleagues at healthcare facilities. Developing an antibiogram at the community level allowed for broader insights to emerge and the ability to communicate back to facilities. This process also opened lines of communications between the epidemiology department and the clinical labs.
Coordinating and communicating with healthcare facilities can take some time and legwork—at the start of each summer, the health department emails the lab and infection prevention contacts at each facility reminding them to share the previous year’s data and communicating the format, considerations, and organisms requested. With some facilities, the process is straightforward, but with others there may be a new IP or point of contact at the facility, and the health department needs to start again with building a relationship and explaining the value of the work. Some facilities share their detailed data, others share just the antibiogram and the health department staff uses that to do manual data entry.
There are some challenges with the process—getting facilities to share data, getting the data in the right format, and getting data in a timely manner. Currently the antibiogram is developed retroactively, looking at data 6-9 months after the end of the year. There is also no requirement for facilities to share data. That said, it has proved to be a valuable tool for having conversations about what is happening at the community level and as a touchpoint for community-wide stewardship conversations. Facilities also like to be able to compare their data to the county-wide data.
Southern Nevada Health District
Southern Nevada Health District (SNHD) developed their first regional antibiogram in 2002 as a part of a grant-funded project. When the funding for this project ended, SNHD staff were unable to update the antibiogram after that initial year. Then, in 2015, the county began receiving Public Health Emergency Preparedness (PHEP) funding from the state, as well as Epidemiology and Laboratory Capacity (ELC) funding for Ebola response, which included support for healthcare-associated infection prevention and control. With renewed support for antibiogram development, they began to explore the best processes and ultimately decided to request the data directly from laboratories. Hospital labs were able to send raw data directly from automated machines, which the health department could then standardize, deduplicate, and enter into the WHONET application, an open access database software for microbial laboratory data specializing in susceptibility testing. To gather nursing home data, SNHD identified that most nursing homes in their region sent their specimens to Diagnostic Labs. SNHD was able to work directly with Diagnostic Labs, thereby circumventing the lengthy process of requesting data from individual facilities. SNHD also obtained patient-level data from Quest Diagnostics Lab, the biggest commercial lab in Clark County. Data from Quest Diagnostics Lab provides susceptibility results of patients in the community.
Using this process, SNHD has updated and published antibiograms twice per year on their website for the last three years. If enough isolates are available, SNHD separates the antibiogram into hospital, long-term care facilities, outpatient, and pediatric categories. They also support long-term care facilities who occasionally request facility-specific antibiograms. Once the antibiograms are published, the health department sends a health alert network (HAN) message to over 3,000 providers across the county, notifying them that the latest antibiogram is available. This continuity has allowed for year-to-year comparisons, which may be used to evaluate the progress of antibiotic stewardship efforts.
SNHD signed a Data Use Agreement with the CDC to access National Healthcare Safety Network data (NHSN), and Nevada state law requires that facilities with 25 or more beds report to NHSN. The Antimicrobial Use module in NHSN is not required for facility reporting, but about 20 facilities have already begun using it, and this could provide additional data useful for antibiogram development.
Leveraging Partnerships to Establish Community-wide Trends
These examples demonstrate the value of establishing the necessary relationships with facilities and creating a protocol that works for your organization and your facility partners. While the effort required to access the necessary data can be significant, the result proves to be a useful tool for communicating community-level trends and patterns while guiding antimicrobial decision-making.
More information about antibiograms and other examples of regional antibiograms developed by local health departments can be found in NACCHO’s Healthcare-Associated Infections Toolkit for Local Health Departments.