PODACI O HOSPITALNOJ USTANOVI KOJA U SVOM SASTAVU IMA LABORATORIJU ZA KLINIČKU MIKROBIOLOGIJU

I KOJA UČESTVUJE

U STUDIJI PREVALENCIJE REZISTENCIJE NA ANTIMIKROBNE LEKOVE

2014.

WHOglobal(laboratory-based) surveyon

multidrug-resistantorganisms (MDROs)in health care

DATA COLLECTION FORM

Durationofsurvey:

Anyonecontinuous weekbetween1and28March2014

Nameof theacute health-care facility_ Name of the laboratory City Postcode Country

Laboratorystaffmembercompletingthesurvey

Surname (Capital letter) First name (Capital letter) Email

Typeofacutehealth-carefacility

Public □Private□Not-for-profit□General□Teaching □

Other …………..…………

Total number of acutecare inpatientbedsin the facility:

≤200 □201-500 □ 501-1000 □≥ 1000□

IsthefacilityregisteredforWHOSAVELIVES:CleanYourHands?(

YES□ / NO□
Is a ClinicalMicrobiologist employed inthe laboratoryservice? / YES□ / NO□
CLINICALLABORATORYISOLATESFROM

BLOODANDURINECULTURESOVERAONEWEEKPERIOD

Instructions forcompletion

  • Complete thisform with data related to ONECONTINUOUSWEEKbetween 1 and 28 March 2014
  • Includeonlyfirst isolatefrominpatients during thestudyweek.
  • For urine,use both Midstreamand CatheterSpecimens(MSU, CSU).
Dates of survey period:from ………..…………. to …………………..……..

Total no. of blood cultures set (aerobic &anaerobic)processed per year (approx.)………

Total no. of blood cultures set (aerobic &anaerobic)processed during the week ofthe survey ……….. Totalno.of inpatient urine specimensprocessed per year (approx.)…………...…..………

Total no. of inpatient urine specimensprocessed duringthe weekof the survey ….………

Positive bloodcultures (survey week)

Positive urine cultures (survey week)

Totalno.ofall Grampositive microorganismsidentified

Total no. of Staphylococcusaureus

No. of MRSA

Total no. of Enterococci spp

No. of VRE

Totalno.ofall Gramnegativemicroorganismsidentified

Totalno.ofEnterobacteriaceaespp

Total no.ofE.coli No.of ESBL E.coli No.of CREE.coli

Total no.ofKlebsiella spp

No.of ESBL Klebsiella spp

No.of CREKlebsiellaspp.

No.of ESBL other inEnterobacteriaceae spp. (excludingE.coliandKlebsiella spp)No.of CREin otherEnterobacteriaceaespp (excludingE.coliandKlebsiellaspp)

Total no. of Acinetobacterspp

No.ofmultidrug resistant Acinetobacterspp

Totalno. of fungi(includingyeast)

Total no. ofother non-bacterial,nonfungal species

LABORATORYIDENTIFICATIONOFMDROs

IdentificationofStaphylococcusaureus

GramstainYES□NO□

Slideor TubecoagulaseYES□NO□

Non-automatedmethodYES□NO□

Ifyes, statethe method(APIetc.):…………………………………….....……….……… Automated method YES□NO□

Ifyes,statethemethod(Vitek, Phoenix,MALDI-TOF etc):……………………………… Otheridentification methods: (molecularnon-molecular):………………………………….…

IdentificationofEnterococcusspp

GramstainYES□NO□

StreptococcalLancefeildgroupingYES□NO□

Non-automatedmethodYES□NO□

If yes, statethe method(API etc.):……………………………………….……….………

Automated methodYES□NO□

Ifyes,statethemethod(Vitek, Phoenix,MALDI-TOF etc):……………………………… Otheridentificationmethods: (molecularnon-molecular):………………………………….…

IdentificationofEnterobacteriaceaespp

GramstainYES□NO□

ChromogenicAgarYES□NO□

If yes, manufacturer’s name………………………………………..…………….

Non-automatedmethodYES□NO□

If yes, statethe method(API etc.):………………………….……….………

Automated methodYES□NO□

Ifyes,statethemethod(Vitek, Phoenix,MALDI-TOF etc):………………………… Otheridentificationmethods: (molecularnon-molecular):…………………….……….…

LABORATORYCONFIRMATIONOFRESISTANCE

Whichantibiotic interpretativecriteriaisusedfordiscdiffusion,breakpointandMIC(MinimumInhibitoryConcentration)inyourlaboratory?

CLSIYES□NO□

EUCASTYES□NO□

BSACYES□NO□

Other: …………………………………………………………..……………………………

MRSA (Methicillin-resistantStaphycoccusaureus)

Discdiffusion methodYES□NO□

IfYes,whichantibioticdiscisused?

Methicillin 10μgYES□NO□

Oxacillin 1μgYES□NO□

Cefoxitin10μgYES□NO□

Cefoxitin30μgYES□NO□

E testYES□NO□

MIC(Broth methodor agardilution) YES□NO□ Non-automatedsusceptibilitytestingmethod YES□NO□ If yes, statethe method………………………….……….………

AutomatedsusceptibilitytestingmethodYES□NO□

If yes, statethe method(Vitek, Phoenix etc.)…………………………………….….. Other methods: (molecularnon-molecular):………………….………………………………

VRE (Vancomycin-resistantenterococci)

Discdiffusion methodYES□NO□

IfYes,whichantibioticdiscisused:

Vancomycin5 μgYES□NO□

Vancomycin30μgYES□NO□

Teicoplanin 30 μgYES□NO□

E testYES□NO□

MIC(Broth methodor agardilution)YES□NO□

Non-automatedsusceptibilitytestingmethodYES□NO□

If yes, statethe method………………………….……….………

AutomatedsusceptibilitytestingmethodYES□NO□

Ifyes, statethemethod(Vitek, Phoenixetc.)…………………………………….….. Other methods: (molecularnon-molecular):………………….………………………………

ESBL(Extended-Spectrum Beta-Lactamase)

PresenceofanESBL isconfirmedby:

ChromogenicESBL agarYES□NO□

If yes, manufacturer’s name………………………………..……………. ESBLcombi-discs YES□NO□

If yes, manufacturer’s name………………………………..……………. Discapproximation YES□NO□

ESBLE-testsYES□NO□

MIC(Brothmethodoragardilution)for3rdgenerationcephalosporins YES□NO□

Non-automatedsusceptibilitytestingmethodYES□NO□

If yes, statethe method………………………….……….………

AutomatedsusceptibilitytestingmethodYES□NO□

Ifyes, statethemethod(Vitek, Phoenix etc.)…………………………………….…..

Other methods: (molecularnon-molecular):………………….………………………………

CRE(CarbapenemResistantEnterobacteriaceae)

PresenceofCPE isconfirmedby:

ChromogenicCPEagarYES□NO□

If YES, productand manufacturer’s name……………………………………….. Modified Hodge Test YES□NO□

MIC(Broth methodoragardilution) for CarbapenemsYES□NO□

Non-automatedsusceptibilitytestingmethodYES□NO□

If yes, statethe method………………………….……….………

AutomatedsusceptibilitytestingmethodYES□NO□

If yes, statethe method(Vitek, Phoenix etc.)…………………………………….….. Other methods: (molecularnon-molecular):………………….………………………………

LABORATORYQUALITYCONTROL

Agarplatesusedinthe laboratoryare :

Purchasedpre-poured mediaYES□NO□

Prepared inthe laboratoryYES□NO□

If preparedin the laboratory,do youquality controlyourmedia?YES□NO□

Qualitycontrolorganisms used or susceptabilityinyourlaboratorytesting

MRSANO□ATCC □NCTC□other□

If other, pleasespecify………………………………………………………..…………….

VRENO□ATCC □NCTC□other□

If other, pleasespecify…………………………………………………………………….

CRENO□ATCC □NCTC□other□

If other, pleasespecify………………………………………………………..…………….

ESBLNO□ATCC □NCTC□other□

If other, pleasespecify………………………………………………………..…………….

Doesyour laboratory participateinthe ExternalQualityControlScheme?YES□NO□

DoesyourcountryhaveaReference LaboratorytoconfirmCREand other multidrug-resistantorganisms?

YES□NO □Don't know□ Additionalcomments

WHOthanksyouverymuchforyourcontributiontothisimportantglobalsurveyinsupportoftheSAVELIVES:CleanYourHands5May2014calltoaction.

Pleaseunderstandthatdatasubmittedafter31March2014willnotbeincludedinthesummaryreportthatWHOwillmakeavailableon5May2014.