STATE OF NEW HAMPSHIRE

2017 STATE ANTIBIOGRAM &

IMPLICATIONS FOR ANTIBIOTIC PRESCRIBING

Released:
October 2018

New Hampshire Department of Health and Human Services

Division of Public Health Services
 New Hampshire DPHS Healthcare Associated Infections Program
2017 State Antibiogram Executive Summary

The New Hampshire Department of Health and Human Services, Division of Public Health Services (DPHS),
Healthcare Associated Infections (HAI) Program has released the 2017 statewide antibiograms for non-urine and urine
clinical isolates. Included is one presentation of the data showing the percent susceptibility, and a second presentation
which shows the total number of isolates in the numerator and denominator that corresponds to each percent
susceptible value. Methodology and data limitations can be found in the Appendix at the end of the document.

Purpose

 The information contained in these antibiograms can help clinicians choose appropriate empiric antibiotics to
treat common infectious syndromes and avoid overuse of broad spectrum antibiotics. Antibiotics should be
chosen based on the clinical syndrome and the most likely pathogen(s) associated with the clinical syndrome.

 Annual antibiogram analysis allows the New Hampshire DPHS to evaluate temporal trends and geographic
patterns of antibiotic resistance to guide antibiotic stewardship efforts at the local, regional, and state level.
Antibiotic stewardship refers to the implementation of coordinated efforts to promote the appropriate use of
antibiotics in order to improve patient outcomes, reduce antibiotic resistance, and prevent the spread of
multidrug-resistant organisms.

Clinical Implications

This year’s Executive Summary expands on the 2016 State Antibiogram and Executive Summary guidance (released in
2017) and focuses on improving treatment of urinary tract infections (UTIs), pneumonia, and skin and soft tissue
infections. Each patient should be treated based on a clinician’s assessment of the type of infection and acuity, and a
patient’s antibiotic regimen should always be tailored to susceptibility testing results once they are available.

Important Notes for Interpreting the Antibiogram:

• “High” resistance to an antibiotic is when more than 20% of isolates are resistant
• The following antibiotics indicate susceptibility to others in the same/related class
o Oxacillin predicts nafcillin susceptibility
o Tetracycline predicts doxycycline susceptibility
o Erythromycin predicts azithromycin susceptibility
o Ampicillin predicts amoxicillin susceptibility
o Cefazolin predicts cephalexin susceptibility
o Ampicillin/sulbactam predicts amoxicillin/clavulanate susceptibility

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Table 1: Short Course Antibiotic Therapy for Specific Infectious Syndromes in Adults
Syndrome Short Course of Therapy (Days)
Uncomplicated urinary tract infections 3-5 days (depending on antibiotic)
Complicated urinary tract infections, including acute May be as short as 7 days
pyelonephritis
Community-acquired pneumonia (CAP) May be as short as 5 days
Hospital-acquired pneumonia (HAP) 7 days
Skin and soft tissue infections (SSTI), including Cellulitis May be as short as 5 days
Note: Antibiotic duration should be based on clinical response. The suggested short course duration of
antibiotics is not intended to supplant physician judgement about individual patients or special clinical
situations.
References:
• Spellberg B. The new antibiotic mantra – “shorter is better”. JAMA Intern Med 2016;176(9):1254-5
• IDSA treatment guidelines for HAP/VAP
• IDSA treatment guidelines for CAP in adults
• IDSA treatment guidelines for UTIs
• IDSA treatment guidelines for skin and soft tissue infections (SSTIs)

Urinary Tract Infections (UTIs):

• In most patients, asymptomatic bacteriuria should not be treated with antibiotics. Treatment may be
indicated during pregnancy, before certain urologic procedures, and in first three months after renal
transplant.
• The most common Gram-negative bacteria to be isolated from urine were Escherichia coli (70% of isolates)
followed by Klebsiella spp. (14%) and Proteus mirabilis (5%). Pseudomonas aeruginosa was recovered in
fewer than 5% of urine specimen cultures; therefore, empiric UTI coverage with a fluoroquinolone to cover
Pseudomonas is not usually needed.
• Nitrofurantoin remains the most likely active agent against Escherichia coli (98% susceptible), followed by
cephalexin (predicted by cefazolin, 92% susceptible). Trimethoprim-sulfamethoxazole and ciprofloxacin are
less likely to be active, and we recommend avoiding ciprofloxacin as first-line therapy because of the
potential for toxicity and C. difficile infection.
• We recognize that many providers are prescribing antibiotic therapy for UTIs by phone. We recommend that
providers obtain a urine culture before antibiotics are started in cases where the provider elects initial broad
spectrum antibiotic therapy (e.g., third-generation cephalosporin or fluoroquinolone), or when a patient has
failed the above recommended narrow spectrum therapy.

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 • For patients with antibiotic allergies or risk for resistant bacteria, fosfomycin can be considered for E.coli and
enterococcal UTIs. While most hospital laboratories do not routinely test susceptibilities for this antibiotic,
testing can be requested. According to national data, >90% of E. coli were sensitive to fosfomycin and, at
two New Hampshire hospitals in 2017, 100% of the 81 E.coli isolates tested were susceptible to fosfomycin.
• The most common Gram-positive bacteria to be isolated from urine are Enterococcus spp. (81%). The
majority of Enterococcus spp. isolates in the urine were susceptible to ampicillin/amoxicillin (93%
susceptible). Susceptible uncomplicated enterococcal UTIs can be treated with high-dose amoxicillin.
• Staphylococcus aureus is an infrequent isolate from urine. In the absence of ureteral hardware (e.g., stents),
finding Staphylococcus aureus in an aseptically obtained urine specimen (either MSSA or MRSA) should lead
a provider to consider an intravascular source (e.g., bacteremia).
• For most patients hospitalized for a complicated UTI or acute pyelonephritis, empiric initial treatment with
ceftriaxone while awaiting culture results is appropriate, if there is no history of a UTI with a ceftriaxone-
resistant bacteria. Ceftriaxone maintains very good activity against the most common Gram-negative
bacteria in the urine.

Community Acquired Pneumonia (CAP) and Hospital Acquired Pneumonia (HAP):

• National data shows that 44% of outpatient antibiotic prescriptions are written for acute respiratory
conditions, at least half of which are caused by viruses and will not respond to antibiotics (JAMA
2016;315:1864-73).
• The most commonly prescribed antibiotic in the outpatient setting is azithromycin (Clinical Infectious
Disease 2015;60:1308-16), but 41% of Streptococcus pneumoniae (Pneumococcus) isolates in NH are
resistant to azithromycin (predicted by erythromycin susceptibility). As a result, azithromycin should not be
prescribed for suspected Pneumococcal pneumonia (e.g., when the clinical presentation is acute with a focal
infiltrate on chest x-ray).
• Preferred antibiotics to treat an acute outpatient bacterial pneumonia suspected due to Streptococcus
pneumoniae include amoxicillin, amoxicillin-clavulanate, and cefpodoxime. Historically cefuroxime had been
a good choice, but this year we have found 21% of Streptococcus pneumoniae strains are resistant to
cefuroxime (increased from 16% resistance in 2016).
• The respiratory fluoroquinolones (e.g., levofloxacin and moxifloxacin) remain highly active against
Streptococcus pneumoniae; however, quinolones should be avoided for the treatment of outpatient CAP
because of class toxicities, their ability to cause C. difficile infection even months after antibiotics have
completed, and the availability of suitable alternatives.

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 • For patients with CAP requiring hospitalization, we recommend treatment with ceftriaxone and either
doxycycline or azithromycin (for atypical bacterial pathogens).
• As of 2016, national guidelines have moved away from the diagnosis of “healthcare-associated pneumonia”
(HCAP). Studies have shown that patients meeting the former HCAP criteria did NOT have a higher risk of
multi-drug resistant organisms (MDROs) than patients meeting the CAP criteria (Clin Infect Dis 2014;58:330-
9). Multiple studies failed to demonstrate benefits on length of stay, time to clinical stability, or mortality in
patients treated with empiric broad-spectrum antibiotics for HCAP (Lung 2013;191:229-37). Standard
therapy for CAP is often appropriate for non-critically ill patients meeting the former HCAP criteria.
• Hospital-acquired pneumonia (HAP) is the onset of pneumonia more than 48 hours after hospitalization.
HAP still warrants treatment with broad-spectrum empiric therapy pending respiratory culture results;
however, vancomycin is not needed in all cases of HAP. Indications for empiric vancomycin include septic
shock, worsening respiratory failure (+/- necrotizing pneumonia or empyema), IV antibiotics within the past
90 days, prior MRSA colonization or infection, and MRSA known to be cultured in >5% of all respiratory
cultures sent (Clin Infect Dis 2016;63:e61-e111).
• Patients who are hospitalized for CAP with concern for MDROs or patients being treated for HAP should
have sputum obtained for culture, ideally before antibiotic administration, to help guide and narrow
antibiotic therapy.

Skin and soft tissue infections (SSTIs), including cellulitis:

• Most SSTIs are due to either streptococcal infection or Staphylococcus aureus. Non-purulent SSTIs (e.g.
cellulitis) are usually not caused by methicillin-resistant Staphylococcus aureus (MRSA), so coverage of this
organism is not necessary. 68% all non-urine Staphylococcus aureus isolates in New Hampshire were
methicillin-sensitive Staphylococcus aureus (MSSA). There are many options that treat both streptococci and
MSSA, including ceftriaxone, cefazolin, cephalexin, and dicloxacillin.
• Two studies have now demonstrated no benefit in adding an empiric MRSA antibiotic to the more standard
therapy targeted at streptococci and MSSA in cases of non-purulent SSTIs (Clin Infect Dis 2013;56:1754-62
and JAMA 2017;317:2088-96).
• In the case of skin abscess (i.e. purulent SSTI), the abscess should be incised and drained with drainage sent
for bacterial Gram-stain and culture. Empiric outpatient therapy with either trimethoprim-sulfamethoxazole
or doxycycline (97% and 94% susceptibility against MRSA, respectively) are the preferred antibiotic regimens
for MRSA SSTIs. Adjunctive antibiotic therapy does improve cure rates when paired with incision and
drainage (N Engl J Med 2016;374:823-32 and N Engl J Med 2017;376:2545-5).

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 • Clindamycin should not be prescribed empirically for MRSA, because approximately one-third (32%) of
isolates are resistant.

Specific Antibiotic Recommendations:

• Meropenem remains active against almost all Enterobacteriaceae. In 2017 there were only 50 CRE cases in
NH residents reported to the NH DPHS. We recommend that antimicrobial stewardship programs continue
to restrict the use of carbapenem antibiotics, because healthcare settings with more liberal use of
carbapenems have seen a more rapid rise in carbapenem-resistance.
• The U.S. Food and Drug Administration (FDA) Drug Safety Communication recommends restricting
fluoroquinolone antibiotic use for certain uncomplicated infections (U.S. Food and Drug Administration
2018). In July of 2008, the FDA issued a safety alert for the potential development of tendinitis and tendon
rupture in patients while taking a fluoroquinolone (U.S. Food and Drug Administration 2008). The warning
has since been expanded to include potential mental health side effects and severe hypoglycemia (U.S. Food
and Drug Administration 2018).

• Over 90% of patients with a penicillin allergy listed in their medical record are not actually allergic to
penicillin, and over 80% of penicillin allergic patients "outgrow" their allergy after 10 years. Additionally, in
patients with a confirmed penicillin allergy, less than 2% have a reaction to cephalosporins. Therefore,
patients with any history of a penicillin allergy should be evaluated by taking a thorough history of their
allergy, and providers should consider: 1) de-labeling the penicillin allergy, 2) providing a supervised
penicillin challenge (if patient reports a mild reaction), or 3) penicillin skin testing (for moderate or serve
reactions). In a setting without access to penicillin skin testing, patients with mild penicillin allergy, such as
morbilliform drug rash or hives alone, can safely receive 3rd and 4th generation cephalosporins.

• In hospitalized patients with a presumed Gram-negative infection, use of two different classes of antibiotics
as empiric treatment may be indicated in cases with septic shock, respiratory failure, intravenous antibiotics
in the prior 90 days, and/or structural lung disease (e.g. bronchiectasis, cystic fibrosis). Otherwise,
monotherapy is typically appropriate when selecting an antibiotic for which resistance on the local
antibiogram is <10%.

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Public Health Implications
1. NH DPHS will continue to monitor and analyze antibiotic resistance data on a yearly basis and track patterns and
trends over time. Future reports may highlight changes in susceptibility patterns and overall state and regional
trends.
2. The statewide antibiogram can be used as a baseline to compare local data and can be used by healthcare
facilities without access to a local antibiograms (i.e. outpatient care, long-term care facilities, assisted living,
ambulatory surgery, etc.) to assist with appropriate antibiotic prescribing.
3. The data and information presented is intended to encourage statewide coordinated antibiotic stewardship
efforts to prevent antibiotic resistance and slow the spread of multidrug-resistant organisms. The data reveals
levels of resistance consistent with national trends, which have been steadily increasing.
https://www.cdc.gov/hai/surveillance/ar-patient-safety-atlas.html. For more information on how to develop a
stewardship program in your facility, explore the CDC Core Elements of Stewardship resources.
4. Antibiotic resistance is an issue that crosses multiple different but connected disciplines, including: human,
veterinary, and environmental health. The New Hampshire Antibiotic Resistance Advisory Workgroup (ARAW) 1
is working to integrate efforts across multiple disciplines to address antibiotic resistance through a One Health
perspective to reduce the development and spread of antimicrobial resistance for people, animals, and our
environment. For more information on One Health visit the CDC’s One Health Page.

The NH DPHS HAI Program is a resource for guidance in developing and strengthening your facilities stewardship
program, please contact us at haiprogram@dhhs.nh.gov or (603) 271-4496.

1
ARAW is a group of subject matter experts and stakeholders across the State of New Hampshire who meet regularly to discuss and
work to combat issues of antimicrobial resistance in NH. This is a forum for stakeholder input facilitated by NH DPHS.
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 New Hampshire Statewide Antibiogram 2017 Bureau of Infectious Disease Control
Infectious Disease Surveillance Section
All Sources Other Than Urine
Percent Susceptible

Tetracycline (Doxycycline)
Tigecycline
Ampicillin/Sulbactam

Piperacillin/Tazobactam
Ampicillin (Amoxicillin)

Gentamicin
Levofloxacin

Amikacin

Tobramycin
Ciprofloxacin
Cefuroxime

Ceftriaxone

Ceftazidime

Cefepime
Cefoxitin

Imipenem
Meropenem

Doripenem

Trimethoprim/Sulfamethoxazole
Aztreonam

Ertapenem
Total Number of Isolates

Cefazolin (Cephalexin)
Gram Negative Organisms

Escherichia coli 2669 60 65 97 88 91 94 95 95 96 94 100 100 100 100 84 84 100 93 94 100 78 80

Enterobacter aerogenes (Klebsiella aerogenes) 129 88 84 85 100 92 99 100 91 100 99 99 99 99 99 99 91 100
Enterobacter cloacae 634 93 82 88 96 87 98 100 98 100 97 99 100 98 99 97 90 95
Klebsiella pneumoniae 858 89 97 94 92 94 97 97 97 97 100 100 100 100 97 97 99 98 97 98 88 93
Klebsiella oxytoca 446 79 97 58 92 98 98 98 97 98 100 100 100 100 100 100 100 99 99 100 93 96
Proteus mirabilis 601 82 91 100 90 97 97 98 99 99 96 100 100 100 83 86 100 93 93 85
Serratia marcescens 424 86 90 84 100 87 100 100 96 100 97 99 99 99 91 98 9 98
Citrobacter freundii 159 96 83 87 99 91 99 99 95 --- 97 96 99 95 97 99 86 94
Morganella morganii 186 6 98 88 88 87 98 87 99 100 95 84 89 99 88 94 10 21 84
Pseudomonas aeruginosa 1562 97 94 92 83 95 92 98 87 86 98 89 97
Acinetobacter baumannii 165 86 --- 53 94 91 96 --- --- 94 96 98 93 95 --- 88 88
Stenotrophomonas maltophilia 355 48 80 97
Haemophilus influenzae 293 72 --- --- 100 --- --- --- --- 76

Tetracycline (Doxycycline)

Vancomycin
Ampicillin/Sulbactam
Ampicillin (Amoxicillin)
Penicillin

Oxacillin

Moxifloxacin
Levofloxacin

Clindamycin

Erythromycin (Azithromycin)

Daptomycin
Cefuroxime

Ceftriaxone

Linezolid

Rifampin
Trimethoprim/Sulfamethoxazole
Total Number of Isolates

Cefazolin (Cephalexin)

Gram Positive Organisms

Methicillin-Sensitive Staphylococcus aureus (MSSA) 7759 13 100 100 100 --- 100 93 96 95 98 80 100 100 100 99
Methicillin-Resistant Staphylococcus aureus (MRSA) 3598 57 70 94 97 68 100 100 100 99
Enterococcus faecalis 1100 99 99 --- 98 99 100
Enterococcus faecium 156 23 29 --- 39 97 94
Enterococcus spp. (all hospital data) 1642 91 92 --- 92 99 99
Coagulase negative Staphylococcus 1727 8 52 52 53 52 69 77 85 69 67 100 100 100 99
Streptococcus pneumoniae (non-meningitis) 445 85 --- --- --- 79 98 98 100 81 80 83 59 100 100

Indicates data have been censored because of intrinsic resistance and/or inappropriate clinical use.
--- Indicates data have been censored because of insufficient sample. CLSI guidelines suggest total isolate counts of less than 30 are excluded.

NH Department of Health and Human Services

Division of Public Health Services October 2018
Bureau of Infectious Disease Control 2017 NH State Antibiogram
 New Hampshire Statewide Antibiogram 2017 Bureau of Infectious Disease Control
Infectious Disease Surveillance Section
All Sources Other Than Urine
Total Number of Susceptible Isolates/Total Tested

Cefuroxime

Ceftriaxone

Meropenem
Cefoxitin

Trimethoprim/Sulfamethoxazole
Tigecycline
Cefepime

Ciprofloxacin

Levofloxacin
Ceftazidime
Ampicillin (Amoxicillin)

Tetracycline (Doxycycline)
Cefazolin (Cephalexin)

Imipenem
Aztreonam

Ertapenem

Doripenem
Total Number of Isolates

Amikacin

Gentamicin
Ampicillin/Sulbactam

Tobramycin
Piperacillin/Tazobactam
Gram Negative Organisms

1516/ 1513/ 2594/ 2153/ 1639/ 1486/ 2522/ 2016/ 2551/ 1818/ 2531/ 2074/ 1420/ 634/ 2223/ 1598/ 1802/ 2396/ 2272/ 1419/ 1124/ 2110/
2669
Escherichia coli 2518 2337 2663 2453 1811 1576 2660 2113 2661 1929 2534 2074 1422 634 2645 1897 1808 2570 2421 1423 1446 2639
115/ 112/ 104/ 135/ 93/ 134/ 105/ 63/ 49/ 133/ 97/ 109/ 134/ 131/ 87/ 82/ 129/
129
Enterobacter aerogenes (Klebsiella aerogenes) 131 134 123 135 101 135 105 69 49 134 98 110 135 132 88 90 129
572/ 516/ 459/ 609/ 423/ 598/ 512/ 282/ 208/ 617/ 442/ 503/ 623/ 576/ 364/ 368/ 602/
634
Enterobacter cloacae 614 628 519 633 487 613 514 289 209 633 447 505 634 583 375 408 631
691/ 818/ 734/ 586/ 513/ 830/ 681/ 811/ 625/ 827/ 679/ 443/ 205/ 830/ 563/ 607/ 841/ 753/ 470/ 405/ 793/
858
Klebsiella pneumoniae 779 839 784 634 546 857 702 832 645 828 679 443 205 857 579 612 858 775 478 461 852
321/ 418/ 231/ 324/ 309/ 435/ 373/ 431/ 356/ 439/ 371/ 201/ 139/ 445/ 307/ 349/ 443/ 410/ 266/ 258/ 427/
446
Klebsiella oxytoca 405 431 400 352 316 445 380 446 365 439 371 201 139 446 308 349 446 414 266 276 446
463/ 476/ 599/ 490/ 415/ 345/ 589/ 456/ 593/ 417/ 568/ 472/ 150/ 495/ 352/ 402/ 552/ 477/ 504/
601
Proteus mirabilis 568 525 601 546 428 355 601 462 601 434 568 472 150 594 409 404 596 511 593
324/ 378/ 280/ 403/ 285/ 404/ 354/ 158/ 108/ 413/ 282/ 334/ 420/ 353/ 245/ 21/ 404/
424
Serratia marcescens 376 422 333 405 328 406 355 164 108 424 284 336 424 388 250 228 413
152/ 131/ 119/ 158/ 126/ 156/ 137/ 71/ 154/ 109/ 135/ 151/ 147/ 110/ 91/ 150/
159 ---
Citrobacter freundii 158 157 137 159 139 158 138 75 159 113 136 159 152 111 106 160
11/ 183/ 112/ 163/ 141/ 183/ 135/ 184/ 155/ 62/ 155/ 116/ 158/ 162/ 169/ 12/ 26/ 153/
186
Morganella morganii 171 186 127 185 162 186 156 185 155 65 185 130 159 185 179 121 121 183
1507/ 1376/ 1295/ 940/ 1203/ 722/ 426/ 1352/ 954/ 1107/ 1392/ 1367/
1562
Pseudomonas aeruginosa 1556 1466 1411 1126 1263 789 435 1555 1113 1133 1556 1407
130/ 86/ 140/ 135/ 128/ 154/ 101/ 111/ 153/ 146/ 82/ 145/
165 --- --- --- ---
Acinetobacter baumannii 152 163 149 148 133 164 105 113 165 153 93 165
145/ 225/ 344/
355
Stenotrophomonas maltophilia 304 280 355
157/ 133/ 105/
293 --- --- --- --- --- ---
Haemophilus influenzae 219 133 138

Moxifloxacin
Cefuroxime

Ceftriaxone

Trimethoprim/Sulfamethoxazole
Oxacillin

Levofloxacin
Ampicillin (Amoxicillin)

Tetracycline (Doxycycline)
Cefazolin (Cephalexin)
Total Number of Isolates

Penicillin

Ampicillin/Sulbactam

Clindamycin

Vancomycin

Linezolid

Daptomycin

Rifampin
Erythromycin (Azithromycin)
Gram Positive Organisms

821/ 7753/ 6156/ 5870/ 4833/ 7063/ 6034/ 7173/ 7471/ 5871/ 7582/ 6435/ 6337/ 7304/
7759 ---
Methicillin-Sensitive Staphylococcus aureus (MSSA) 6370 7758 6213 5928 4855 7580 6316 7586 7591 7325 7582 6444 6350 7354
2000/ 1999/ 3307/ 3406/ 2327/ 3614/ 3077/ 3171/ 3408/
3598
Methicillin-Resistant Staphylococcus aureus (MRSA) 3514 2855 3520 3524 3402 3614 3078 3176 3439
850/ 1091/ 1073/ 887/ 916/
1100 ---
Enterococcus faecalis 857 1100 1095 894 918
30/ 45/ 61/ 128/ 112/
156 ---
Enterococcus faecium 133 156 156 132 119
1245/ 1504/ 1512/ 1396/ 1354/
1642 ---
Enterococcus spp. (all hospital data) 1375 1641 1636 1412 1364
103/ 855/ 609/ 580/ 483/ 1177/ 989/ 1445/ 1124/ 1088/ 1716/ 1414/ 1373/
1727
Coagulase negative Staphylococcus 1283 1639 1170 1104 925 1704 1283 1704 1637 1630 1720 1417 1377
345/ 118/ 345/ 300/ 88/ 205/ 189/ 141/ 164/ 270/ 87/
Streptococcus pneumoniae (non-meningitis) 445 407 --- --- --- 150 352 305 88 253 235 170 276 270 87

Indicates data have been censored because of intrinsic resistance and/or inappropriate clinical use.
--- Indicates data have been censored because of insufficient sample. CLSI guidelines suggest total isolate counts of less than 30 are excluded.

NH Department of Health and Human Services

Division of Public Health Services October 2018
Bureau of Infectious Disease Control 2017 NH State Antibiogram
 New Hampshire Statewide Antibiogram 2017 Bureau of Infectious Disease Control
Infectious Disease Surveillance Section
Urine Only Sources
Percent Susceptible

Tigecycline
Cefuroxime

Ceftriaxone

Ceftazidime

Cefepime

Aztreonam

Meropenem

Imipenem

Levofloxacin
Cefoxitin

Ertapenem

Doripenem

Ciprofloxacin

Amikacin

Gentamicin

Tobramycin
Piperacillin/Tazobactam

Trimethoprim/Sulfamethoxazole

Nitrofurantoin
Ampicillin (Amoxicillin)

Tetracycline (Doxycycline)
Cefazolin (Cephalexin)
Total Number of Isolates
Gram Negative Organisms

Escherichia coli 29741 65 98 92 94 96 96 96 97 96 100 100 100 100 87 87 99 94 94 100 81 83 98

Enterobacter aerogenes (Klebsiella aerogenes) 521 92 87 89 100 92 99 100 94 100 97 98 100 100 100 99 91 97 19
Enterobacter cloacae 797 86 77 82 98 83 97 99 97 100 97 98 100 99 99 98 89 91 33
Klebsiella pneumoniae 5152 98 95 93 95 97 98 98 97 100 100 100 99 97 98 100 99 98 99 87 92 48
Klebsiella oxytoca 825 96 50 89 96 96 97 98 96 100 100 100 100 98 99 100 98 98 100 94 95 86
Proteus mirabilis 2282 78 99 91 99 99 98 99 98 97 100 100 99 76 79 100 89 92 79
Serratia marcescens 327 92 90 86 98 91 99 100 96 100 91 95 100 97 90 99 6 98
Citrobacter freundii 782 93 83 86 99 88 100 100 98 100 94 96 100 96 96 100 86 88 96
Morganella morganii 265 99 84 94 90 99 91 100 100 99 83 88 100 91 95 4 16 86
Pseudomonas aeruginosa 1909 97 94 92 83 95 92 98 81 80 97 87 96
Acinetobacter baumannii 89 --- 42 90 85 96 --- --- 91 96 91 88 93 --- 86 82

Ceftriaxone

Levofloxacin

Moxifloxacin

Clindamycin

Vancomycin

Linezolid

Daptomycin
Penicillin

Oxacillin

Rifampin

Nitrofurantoin
Trimethoprim/Sulfamethoxazole
Ampicillin (Amoxicillin)

Cefazolin (Cephalexin)

Tetracycline (Doxycycline)
Total Number of Isolates

Gram Positive Organisms

Methicillin-Sensitive Staphylococcus aureus (MSSA) 711 18 100 100 100 93 82 98 98 76 100 100 100 99
Methicillin-Resistant Staphylococcus aureus (MRSA) 393 21 21 94 94 41 100 100 99 98
Enterococcus faecalis 2806 99 99 98 99 100 99
Enterococcus faecium 299 17 20 44 97 90 39
Enterococcus spp. (all hospital data) 4625 92 93 94 99 99 94

Indicates data have been censored because of intrinsic resistance and/or inappropriate clinical use.
--- Indicates data have been censored because of insufficient sample. CLSI guidelines suggest total isolate counts of less than 30 are excluded.

NH Department of Health and Human Services

Division of Public Health Services October 2018
Bureau of Infectious Disease Control 2017 NH State Antibiogram
 New Hampshire Statewide Antibiogram 2017 Bureau of Infectious Disease Control
Infectious Disease Surveillance Section
Urine Only Sources
Total Number of Susceptible Isolates/Total Tested

Tigecycline
Levofloxacin
Total Number of Isolates

Cefoxitin

Amikacin

Gentamicin

Tobramycin

Nitrofurantoin
Ceftriaxone

Cefepime

Ciprofloxacin
Cefuroxime

Ceftazidime

Aztreonam

Ertapenem

Imipenem

Doripenem
Ampicillin (Amoxicillin)

Meropenem

Tetracycline (Doxycycline)

Trimethoprim/Sulfamethoxazole
Piperacillin/Tazobactam

Cefazolin (Cephalexin)
Gram Negative Organisms

18185/ 29241/ 27164/ 20889/ 18437/ 28521/ 23684/ 28858/ 23783/ 28414/ 23888/ 15079/ 9038/ 25951/ 19061/ 21165/ 27817/ 25705/ 18372/ 15075/ 23707/ 28594/
29741
Escherichia coli 28177 29700 29682 22261 19157 29719 24658 29722 24710 28518 23939 15122 9038 29661 21787 21276 29704 27221 18398 18517 28558 29164
466/ 450/ 377/ 518/ 410/ 512/ 415/ 254/ 174/ 504/ 397/ 398/ 519/ 487/ 323/ 330/ 506/ 99/
521
Enterobacter aerogenes (Klebsiella aerogenes) 506 520 425 520 448 515 415 271 174 521 407 398 521 488 327 361 520 514
671/ 611/ 535/ 782/ 588/ 760/ 666/ 392/ 224/ 774/ 567/ 634/ 789/ 734/ 481/ 450/ 722/ 258/
797
Enterobacter cloacae 783 792 650 797 711 784 671 406 224 797 581 634 797 743 490 503 794 776
4934/ 4912/ 3614/ 3161/ 5011/ 4195/ 5033/ 4155/ 4937/ 4152/ 2619/ 1506/ 4983/ 3629/ 3770/ 5071/ 4653/ 3156/ 2746/ 4748/ 2406/
5152
Klebsiella pneumoniae 5048 5145 3906 3333 5148 4299 5148 4269 4956 4166 2625 1516 5145 3719 3788 5148 4758 3190 3163 5135 5044
763/ 367/ 541/ 503/ 790/ 654/ 806/ 658/ 820/ 623/ 439/ 281/ 807/ 622/ 621/ 812/ 734/ 511/ 504/ 782/ 699/
825
Klebsiella oxytoca 793 734 607 523 823 671 824 683 821 623 439 281 824 629 621 825 749 512 539 824 814
1696/ 2262/ 2062/ 1673/ 1425/ 2231/ 1922/ 2241/ 1707/ 2155/ 1776/ 669/ 1729/ 1341/ 1622/ 2037/ 1940/ 1789/
2282
Proteus mirabilis 2182 2275 2272 1694 1444 2281 1946 2281 1751 2155 1776 675 2262 1691 1630 2277 2110 2266
261/ 292/ 234/ 322/ 218/ 302/ 274/ 123/ 96/ 297/ 222/ 255/ 318/ 279/ 196/ 11/ 319/
327
Serratia marcescens 284 324 273 327 240 306 275 128 96 327 233 256 327 309 197 198 327
710/ 652/ 549/ 764/ 577/ 724/ 659/ 360/ 236/ 735/ 531/ 577/ 749/ 689/ 487/ 410/ 669/ 743/
782
Citrobacter freundii 763 782 642 769 657 726 659 369 236 782 555 577 781 715 489 475 756 778
261/ 139/ 250/ 192/ 262/ 191/ 265/ 208/ 83/ 219/ 164/ 229/ 242/ 240/ 5/ 27/ 228/
265
Morganella morganii 264 166 265 213 265 209 265 209 84 264 186 229 265 252 141 168 264
1844/ 1747/ 1638/ 1088/ 1527/ 920/ 460/ 1544/ 1080/ 1219/ 1649/ 1762/
1909
Pseudomonas aeruginosa 1904 1861 1771 1304 1614 998 471 1895 1347 1254 1895 1833
36/ 60/ 57/ 64/ 78/ 155/ 49/ 77/ 75/ 49/ 72/
89 --- 85 67 67 67 --- --- 86 161 54 88 81 --- 57 88
Acinetobacter baumannii

Levofloxacin
Total Number of Isolates

Penicillin

Nitrofurantoin
Oxacillin

Clindamycin

Vancomycin

Linezolid

Daptomycin

Rifampin
Moxifloxacin
Ceftriaxone
Ampicillin (Amoxicillin)

Tetracycline (Doxycycline)

Trimethoprim/Sulfamethoxazole
Cefazolin (Cephalexin)

Gram Positive Organisms

106/ 680/ 495/ 361/ 551/ 75/ 655/ 680/ 104/ 92/ 692/ 648/ 527/
711
Methicillin-Sensitive Staphylococcus aureus (MSSA) 590 680 495 361 690 92 692 691 137 130 692 650 528
77/ 14/ 348/ 350/ 35/ 8/ 384/ 373/ 315/
393
Methicillin-Resistant Staphylococcus aureus (MRSA) 373 68 383 372 85 83 384 374 317
1965/ 2781/ 39/ 2728/ 2611/ 1007/
2806
Enterococcus faecalis 1979 2803 378 2785 2639 1869
41/ 57/ 1/ 131/ 277/ 39/
299
Enterococcus faecium 247 287 30 296 285 222
3422/ 4265/ 61/ 4324/ 4378/ 1692/
Enterococcus spp. (all hospital data) 4625 3732 4599 604 4589 4441 3352

Indicates data have been censored because of intrinsic resistance and/or inappropriate clinical use.
--- Indicates data have been censored because of insufficient sample. CLSI guidelines suggest total isolate counts of less than 30 are excluded.

NH Department of Health and Human Services

Division of Public Health Services October 2018
Bureau of Infectious Disease Control 2017 NH State Antibiogram
 New Hampshire DPHS Healthcare Associated Infections Program
Appendix: Methodology and Data Limitations
Methodology
Reporting Requirements:

Reporting requirements are governed by RSA 141:C6 with authority given to DHHS to develop administrative rules to
provide specific reporting instructions and methodology. Administrative rules He-P 301 were adopted in fall 2016 “He-P
300 Diseases, PART He-P 301.02 Communicable Diseases,” were updated in 2016 with stakeholder input and approved
by the Joint Legislative Committee on Administrative Rules. The updated rules require hospital laboratories to report
antibiogram data annually to the State of New Hampshire.

Collection Process and Validation:

NH DPHS developed a standardized antibiogram fillable form for reporting susceptibility data, and requested data from
hospital microbiology laboratories in January 2018. This form was developed to encompass most relevant antibiotic and
organism combinations, created in collaboration between the NH DPHS and stakeholder subject matter experts. All 26
NH hospitals reported antibiogram data as required under He-P301; along with the Veteran’s Affairs Hospital whom
voluntarily reported data.

The HAI Program reconciled data to confirm reported data and evaluate accuracy and reliability of the data. The HAI
Program first conducted an internal assessment to identify outliers or implausible data by comparing the percent
susceptibilities between all hospitals for every organism and antibiotic combination and then corrected or confirmed
data with each respective microbiology laboratory. The program subsequently convened an infectious disease medical
and pharmacy advisory group to review the clinical implications of the data and ensure data was clinically accurate and
relevant. The advisory group determined which antibiotic-organism combinations to censor due to clinical
inappropriateness. Lastly, the antibiogram data was reviewed by the NH Antimicrobial Resistance Advisory Workgroup
(ARAW) 2 to provide feedback and suggestions for use.

Antibiogram Development:

The Clinical and Laboratory Standards Institute (CLSI) guidelines were followed in the aggregation of data from all
reported hospital antibiograms. Antibiotic and organism combinations that are either intrinsically resistance or not
clinically appropriate were censored from the antibiogram. Per CLSI guidelines, any antibiotic and organism combination
with a total number of isolate counts of less than 30 isolates were excluded.

An ARAW subcommittee, made up of infectious disease clinical specialists, drafted and reviewed the antibiogram
executive summary to assist with clinical interpretation. The summary focused on treatment of common infections
syndromes and was based on review of NH antibiogram data and current national treatment guidelines
(https://www.idsociety.org/PracticeGuidelines/).

2
ARAW is a group of subject matter experts and stakeholders across the State of New Hampshire who meet regularly to discuss and
work to combat issues of antimicrobial resistance in NH. This is a forum for stakeholder input facilitated by NH DPHS.
NH Department of Health and Human Services October 2018
Division of Public Health Services
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Data Limitations
 Antibiotic susceptibility data from regional reference labs is not included in this data set and therefore the
antibiogram is limited in its representativeness to hospital laboratory isolates.
 The urine only antibiogram includes all urine isolates, not necessarily only those pertaining to urinary tract
infections. These isolates may represent other types of infections where bacteria were cultured from other clinical
isolates in addition to the urine (e.g. bacteremia with seeding of the urine).
 The lack of reported susceptibility results for an antibiotic against a specific organism doesn’t necessarily mean
that the antibiotic isn’t active. In some cases activity is reliably predicted by the activity of another agent (e.g.
cefazolin activity against Staphylococcus aureus is predicted by oxacillin susceptibility); while in some other cases
it is not possible to test susceptibility due to lack of testing reagents. Conversely, reported activity on in vitro
susceptibility results does not necessarily mean an agent is clinically effective (or as effective as alternatives). For
example, ciprofloxacin may show in vitro activity against Staphylococcus aureus, but ciprofloxacin should never be
used to treat infections caused by this organism. This is because of the potential for rapid development of
resistance while being treated with ciprofloxacin.
 The values presented in the antibiogram are rounded and do not show exact values.

Note: All the data in this report are based upon information provided to the New Hampshire Department of Health and
Human Services under specific legislative authority. The numbers reported may represent an underestimate of the true
absolute number in the state. Any release of personal identifying information is conditioned upon such information
remaining confidential. The unauthorized disclosure of any confidential medical or scientific data is a misdemeanor
under New Hampshire law. The department is not responsible for any duplication or misrepresentation of surveillance
data released in this report. Data are complete as of 10/01/18. Report prepared by the Healthcare-Associated
Infections Program, Infectious Disease Surveillance Section, haiprogram@dhhs.nh.gov, (603)-271-4496.

Acknowledgements
The New Hampshire State 2017 Antibiogram was facilitated and promoted by the ARAW, which is comprised of a diverse
group of stakeholders from around the state. We would like to thank the ARAW for their time and input into creating a
useful tool for clinicians and continuing antibiotic resistance surveillance in New Hampshire.
We would also like to thank the many people that contributed directly to the creation and clinical content outlined in
this report. Their work and input has been invaluable:

Hannah Leeman Benjamin Chan, MD, MPH Michael Calderwood, MD, MPH
Carly Zimmermann, MPH, MLS(ASCP)cm Elizabeth Talbot, MD Apara Dave, MD
Katrina Hansen, MPH Daniel Tullo, MS, SM (ASCP) Paul Santos, PharmD
Yvette Perron, MPH Rachelle Markham, MLS(ASCP)cm Erin Reigh, MD

Lisa Tibbitts, RN, BSN, MSNed, BC Maureen Collopy, MPH, MT(ASCP) Joshua White, MD

NH Department of Health and Human Services October 2018

Division of Public Health Services
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