ce Sede SL pS nn. | Sy Green Crescent Health Services Infection Prevention | Date Issued Date of Renewal Effective From | Valid Till Departesnt and Control | mi SRV-P-IC-AB71 01 January 2016 | 05 Apri 2018 | 18 Api 2018 | 22 March 2021 Policy Title Antibiogram \pP Rev. No.1 1. STATEMENT OF PURPOSE 1.1 To provide guidance to clinicians in the selection of drugs for treatment of bacterial infections, 1.2 To encourage responsible use of antibiotics throughout the facility. Prescribing clinicians can consult this tool before initiating empiric antibiotic therapy, which may improve outcomes with patients with infections. 1.3 Antibiogram is a good way to detect changes in resistance patterns to an entire facility or for locations within a facility 2. SCOPE 2.1 Applied to: All Medical Staff of Green Crescent Hospital 3. DEFINITIONS 3.1 Antibiogram - the profile of an organism's usually susceptibility/resistance to a panel of antibiotics, which can be used to determine genetic relatedness of various bacteria 4.1 The Infection Control Department shall do a systemic collection, tabulation and analysis of the susceptibility testing date to profile species-specific susceptibility patterns and to monitor change in these pattems that may be of clinical significance. 4.2. Bacterial antibiotic sensitivities are performed in the laboratory in order to determine the efficacy of various antibiotics on bacterial species. 5. PROCEDURE 5.1 Microbiology Laboratory shalt 5.1.1. Provide the Infection Control Department with a list of antibiotics used in sensitivity testing for each bacterial species. Report any additions to or deletions from these lists 5.1.2 Perform antibiotic susceptibility tests and report results to the IC Department. Laboratory Department Page | of 4 Policy and Procedures LGe eb Sle bob] SHH Infection Prevention and Control Date Issued | Date of Renewal | Effective From | Valid Till T T SRV-PAC-AB71 Ot January 2018 | 05 Apri2018 | 18Aprii2018 | 22 March 2021 Department Policy Title Antibiogram IPP Rev. No.1 5.2 Infection Control Department shall: 5.2.1 On daily basis, enter the data in computerized database. The information to be entered includes. 5.2.1.1 Organism, species-specific 5.2.1.2 Antibiotic sensitivity pattern for the organism 5.2.1.3 Date the culture was taken 5.2.1.4 Inpatient or Outpatient 5.2.1.5 For inpatients, whether hospital acquired or community acquired status 5.2.2 Analyze the data on a regular basis as follows: 5.2.2.1 Monthly - a summary of tabulation of antibiotic sensitivities of nosocomial infectious agents. 5.2.2.2 Annually — an in-depth analysis identifying trends and areas of concen 5.2.3 Disseminate reports to: 5.2.3.1 Infection Control Committee 5.2.3.2 Clinicians 5.2.3.3 Pharmacy and Therapeutics Committee 5.3 Clinical Laboratory Services Division shall: 5.3.1. Receive the report 5.3.2 Assess and advice clinician of the clinical significance of any pattern change. 6. RESPONSIBILITY 6.1 Hospital Director 62 Infection Control Staff 63 Quality Management Director 64 Pharmacy Staff 6.5 Medical Staff 6.6 Nursing Staff 7. REFERENCES 7.1 GCC Infection and Prevention Control Manual 3” edition. Laboratory Department Page 2 of Policy and ProceduresInfection Prevention and Control Ce aby Sb es | te Green Crescent Health Servicer | Date Issued Date of Renewal Effective From Valid Tilt, SRV-P-IC-ABT71 01 January 2016 05 April 2018 18 April 2018 22 March 2021 Antibiogram 8. FORMS/MATERIALS AND EQUIPMENTS 8.1 Antibiogram form 9. REVISION 9.1 # 0344-IC-01-15 IPP Rev. No. 1 Will be reviewed every 3 years according to QMS-P-QM-DM13 and to be revised as needed. Page 3 of 4. Ee Seta lope bY] JH Green Crescent Health Services Infection Prevention ‘and Control Date Issued | Date of Renewal Effective From Valid Till, Department SRV-P-IC-AB71 01 January 2016 | 05 April2018 | 18 April2018 | 22 March 2021 Policy Title Antibiogram \PP Rev. No. 1 APPROVAL: Prepared b Date 03-03 -1§ Head of infection Controlinfection | Con ARRNESRIP ERE P | Signature ead fab 8 | ‘Groen Crescent Hospital Chief Nursing Officer Recomono See Pate 10 [oa |SCFHS Lic. No. 8806 Head of Pharmacy Ph, Adnan El Robea, Head of Pharmacy ‘SCFHS No. 1227 Medical Director Dr. Mostafa A-Shamii Medical Director Director of Planning and Development Emad J. Subih ee a Signature Chief Executive Officer Engy. Say Wael Bora, ‘Signature (CED Preset Green Crescent Hospital Laboratory Depariment Page 4 of Policy and Procedures