Infectious Disease Program Research Articles

Medical Center Support for Transplant Infectious Diseases Programs.

Introduction: Transplant Infectious Diseases (TxID) as a subspecialty has gained popularity in the past decade. However, the number and characteristics of formal TxID programs are unknown, and TxID program and personnel support varies. We sought to provide insight into these issues through a survey of members of the ID Community of Practice (COP). Methods: An electronic survey was sent to ID specialists registered with the AST ID COP. Each transplant center received one survey to limit duplication. Survey questions related to transplant center demographics, TxID program structure, and sources of financial support for the TxID program. Results: Of 116 questionnaires, 51 (44.0%) were returned (41 adult, 7 pediatric centers, 3 incomplete). Of the 41 evaluable surveys from adult programs, 36 (87.8%) had a dedicated TxID program. The median number of solid organ transplants (SOT) annually was 250 (range 0 - 565), hematopoietic stem cell transplants (HCT) 55 (range 0-450), and total transplants 260 (range 50 to 780). In programs that provided staffing details, there was a range of 1 to 12 TxID specialists (median 3.0, mean 3.8). Ratio of TxID staff per SOT per year was calculated (mean 60, range 15-254), but no association was seen between ratio and institutional salary support. There was a greater likelihood of salary support for TxID in larger SOT programs (>250 SOT/year) as compared with small or medium sized programs (13/15 large programs vs. 1/6 small programs), provided as direct funds (47.6%) or full-time equivalents (FTE) (52.4%). Non-salary support was more common in larger programs and included office space (37.2%), administrative (27.9%), and research support (16.3%). The majority of support came from the medical center or the ID division. Five programs offered a TxID fellowship program. Conclusions: Larger transplant programs were more likely to offer institutional support for TxID Programs, via FTEs as well as non-salary support. Analysis of these patterns may offer prospects for obtaining assistance to programs lacking support, with the goal of improving outcomes after SOT and HCT transplantation.

International Issues: Expanding neurologic education to resource-poor countries

It is well-recognized that there is a disparity in health care resources and availability in low- and middle-income countries, often due to a combination of poverty, lack of clean water, inadequate nutrition, and political conflict. Yet it seems less attention is given to challenges specific to the provision of medical education in such developing nations. Besides war, famine, drought, and the AIDS epidemic, eastern African nations carry a heavy burden of neurologic disease1 and insufficient infectious disease programs,2 coupled with a paucity of subspecialty-trained providers. Over the past decade, there has been increasing concern over the so-called “brain drain”—the ongoing relocation of African doctors to more profitable parts of the world,3 presumably due to the challenges inherent to practicing in resource-limited settings. This is exemplified by the estimated 0.03 neurologists per 100,000 people in low-income African countries (compared to 1 to 10 per 100,000 in Western countries), and further by the lack of neurologists in all of sub-Saharan Africa.4 Similar estimates in sub-Saharan Africa suggest that there is only 1 neurosurgeon for every 4,000,000 people, with dedicated neurologic and neurosurgical services available in only a few private centers—institutions that are financially inaccessible to 90% of the population due to the nonexistence of health insurance systems.5

Financial Impact of Coagulase-Negative Staphylococcal (CoNS) Bacteremia at a Cancer Hospital

Objective: To determine the financial impact of Coagulase-Negative Staphylococcus (CoNS)- positive blood cultures. Design: Retrospective chart review. Setting: Tertiary care cancer hospital. Patients: All episodes of CoNS bacteremia during the first 6 months of 2001 were identified. Episodes from the intensive care unit, those never treated, and those treated with antibiotics before the culture was drawn or became positive were excluded. Chart review was performed in a random sample of patients to estimate the cost of each component of medical care attributable to the management of CoNS. Each patient-episode was retrospectively designated as infection or contaminant by an expert reviewer. Results: In the 6 month study period, 137 episodes of CoNS were treated. Medical records for 43 (39%) of 111 eligible patients were extracted. The average cost of managing the 43 CoNS episodes was $7,594. For the subset of 16 patients with increased length of stay (LOS) attributable to CoNS, the mean cost was $15,919, 77% due to hospital day charges. The 43 episodes were retrospectively designated either infection (n=31) or contaminant (n=12); attributable cost differed by assigned category. The mean cost for 31 patients with infection was $8,858. Six episodes, designated as contaminants by both primary team and expert review, had a mean cost of $1,881. Six additional episodes, treated as infection by the primary team but reassigned as contaminant on retrospective review, had a mean cost of $7,127. Applying the proportion of patients (6/43 or 14%) reclassified as contaminant to the annual number of treated blood cultures (2×137) would project to an annual savings of $201,237 ($7,127 minus $1,881 or $5,246/episode) at our hospital. Conclusion: In the management of CoNS bacteremia, unneeded treatment of contaminants as true infection costs up to $200,000 a year at our hospital. Infectious disease or antibiotic management program management may result in a reduction of this cost.

Molecular Biomarkers at the Interface of Basic and Clinical Dengue Research

1Infectious Diseases, Singapore-MIT Alliance for Research and Technology, Singapore 2Biosystems and Micromechanics Interdisciplinary Groups, Singapore-MIT Alliance for Research and Technology, Singapore 3Emerging Infectious Diseases Program, Duke-NUS Graduate Medical School, Singapore 4DSO National Laboratories, Singapore Address for Correspondence: Dr Yie Hou Lee, 1 CREATE Way, Enterprise Wing, #04-13/14, Singapore 138602. Email: yie.hou@smart.mit.edu Translational Biomarkers of Dengue—Yie Hou Lee and Eng Eong Ooi Commentary

Detection of Resistance to Beta-Lactamase Inhibitors in Strains with CTX-M Beta-Lactamases: a Multicenter External Proficiency Study Using a Well-Defined Collection of Escherichia coli Strains

Under the auspices of the Spanish Society for Infectious Diseases and Clinical Microbiology Quality Control program, 14 Escherichia coli strains masked as blood culture isolates were sent to 68 clinical microbiology laboratories for antimicrobial susceptibility testing to β-lactam antibiotics. This collection included three control strains (E. coli ATCC 25922, an IRT-2 producer, and a CMY-2 producer), six isogenic strains with or without the OmpF porin and expressing CTX-M β-lactamases (CTX-M-1, CTX-M-15, and CTX-M-14), one strain carrying a double mechanism for β-lactam resistance (i.e., carrying CTX-M-15 and OXA-1 enzymes), and four strains carrying CTX-M variants with different levels of resistance to β-lactams and β-lactam-β-lactamase inhibitor (BLBLI) combinations. The main objective of the study was to ascertain how these variants with reduced susceptibilities to BLBLIs are identified in clinical microbiology laboratories. CTX-M variants with high resistance to BLBLIs were mainly identified as inhibitor-resistant TEM (IRT) enzymes (68.0%); however, isogenic CTX-M mutant strains with reduced susceptibilities to BLBLIs and cephalosporins were mainly associated with extended-spectrum β-lactamase production alone (51 to 80%) or in combination with other mechanisms (14 to 31%). Concerning all β-lactams tested, the overall interpretative discrepancy rate was 11.5%, of which 38.1% were the consequence of postreading changes in the clinical categories when a resistance mechanism was inferred. Therefore, failure to recognize these complex phenotypes might contribute to an explanation of their apparent absence in the clinical setting and might lead to inadequate drug treatment selection. A proposal for improving recognition is to adhere strictly to the current CLSI or EUCAST guidelines for detecting reduced susceptibility to BLBLI combinations, without any interpretative modification.

Efficacy, safety, and immunology of an inactivated alum-adjuvant enterovirus 71 vaccine in children in China: a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial

A vaccine for enterovirus 71 (EV71) is needed to address the high burden of disease associated with infection. We assessed the efficacy, safety, immunogenicity, antibody persistence, and immunological correlates of an inactivated alum-adjuvant EV71 vaccine. We did a randomised, double-blind, placebo-controlled, phase 3 trial. Healthy children aged 6-35 months from four centres in China were randomly assigned (1:1) to receive vaccine or alum-adjuvant placebo at day 0 and 28, according to a randomisation list (block size 30) generated by an independent statistician. Investigators and participants and their guardians were masked to the assignment. Primary endpoints were EV71-associated hand, foot, and mouth disease (HFMD) and EV71-associated disease during the surveillance period from day 56 to month 14, analysed in the per-protocol population. This study is registered with ClinicalTrials.gov, number NCT01508247. 10,245 participants were enrolled and assigned: 5120 to vaccine versus 5125 to placebo. 4907 (with three cases of EV71-associated HFMD and eight cases of EV71-associated disease) versus 4939 (with 30 cases of EV71-associated HFMD and 41 cases of EV71-associated disease) were included in the primary efficacy analysis. Vaccine efficacy was 90·0% (95% CI 67·1-96·9) against EV71-associated HFMD (p=0·0001) and 80·4% (95% CI 58·2-90·8) against EV71-associated disease (p<0·0001). Serious adverse events were reported by 62 of 5117 (1·2%) participants in the vaccine group versus 75 of 5123 (1·5%) in the placebo group (p=0·27). Adverse events occurred in 3644 (71·2%) versus 3603 (70·3%; p=0·33). EV71 vaccine provides high efficacy, satisfactory safety, and sustained immunogenicity. China's 12-5 National Major Infectious Disease Program, Beijing Vigoo Biological.

Immunogenicity and safety of an enterovirus 71 vaccine in healthy Chinese children and infants: a randomised, double-blind, placebo-controlled phase 2 clinical trial

Enterovirus 71 (EV71) outbreaks are a socioeconomic burden, especially in the western Pacific region. Results of phase 1 clinical trials suggest an EV71 vaccine has a clinically acceptable safety profile and immunogenicity. We aimed to assess the best possible dose and formulation, immunogenicity, and safety profile of this EV71 vaccine in healthy Chinese children. This randomised, double-blind, placebo-controlled, phase 2 trial was undertaken at one site in Donghai County, Jiangsu Province, China. Eligible participants were healthy boys or girls aged 6–36 months. Participants were randomly assigned (1:1:1:1:1) to receive either 160 U, 320 U, or 640 U alum-adjuvant EV71 vaccine, 640 U adjuvant-free EV71 vaccine, or a placebo (containing alum adjuvant only), according to a blocked randomisation list generated by SAS 9.1. Participants and investigators were masked to the assignment. The primary endpoint was anti-EV71 neutralising antibody geometric mean titres (GMTs) at day 56, analysed according to protocol. The study is registered with ClinicalTrials.gov, number NCT01399853. We randomly assigned 1200 participants, 240 (120 aged 6–11 months [infants] and 120 aged 12–36 months [children]) of whom were assigned to each dose. 1106 participants completed the study and were included in the according-to-protocol analysis. The main reasons for dropout were withdrawal of consent and refusal to donate a blood sample. Infants who received the 640 U adjuvant vaccine had the highest GMTs on day 56 (742·2 [95% CI 577·3–954·3]), followed by those who received the 320 U formulation (497·9 [383·1–647·0]). For children, those who received the 320 U formulation had the highest GMTs on day 56 (1383·2 [1037·3–1844·5]). Participants who received the vaccine had significantly higher GMTs than did who received placebo (p<0·0001). For the subgroup of participants who were seronegative at baseline, both infants and children who received the 640 U adjuvant vaccine had the highest GMTs on day 56 (522·8 [403·9–676·6] in infants and 708·4 [524·1–957·6] in children), followed by those who received the 320 U adjuvant vaccine (358·2 [280·5–457·5] in infants and 498·0 [383·4–646·9] in children). 549 (45·8%) of 1200 participants (95 CI 42·9–48·6%) reported at least one injection-site or systemic adverse reaction, but the incidence of adverse reactions did not differ significantly between groups (p=0·36). The 640 U alum-adjuvant vaccine group had a significantly higher incidence of induration than did the 640 U adjuvant-free group (p=0·001). Taking immunogenicity, safety, and production capacity into account, the 320 U alum-adjuvant formulation of the EV71 vaccine is probably the best possible formulation for phase 3 trials. The National Science and Technology Major Project (2011ZX10004-902) of the Chinese Ministry of Science and Technology, China's 12–5 National Major Infectious Disease Program (2012ZX10002-001), and Beijing Vigoo Biological.

Factors associated with utilization of HAART amongst hard-to-reach HIV-infected individuals in Atlanta, Georgia.

The study is aimed at identifying clinical, demographic and behavioral factors, including participation in HIV care, associated with the utilization of antiretroviral therapy (ART), among hard-to-reach HIV-positive individuals in Atlanta, GA. The study included 184 HIV-positive participants of the Infectious Disease Program (IDP) of the Grady Health System between February 1999 to March 2001. Individuals were categorized as regular attendees (those who consistently kept their outpatient appointments, n = 65), irregular (those who inconsistently kept their appointments, n = 60) or non-attendees (those who failed routinely to keep their appointments, n = 59). Univariate and multivariate analyses using log-binomial regression modeling were done. HIV-infected individuals who consistently kept their appointments at the IDP received ART at a frequency (86%) that is twice that of those who missed some appointments (42%) and four times that of those who routinely failed to keep appointments (20%). In multivariate analysis, category of clinic attendance (regular, irregular or non-attendee) was the only risk factor independently associated with utilization of ART: Regular attendees (RR = 3.59, 95% CI 2.12 to 6.08) and irregular attendees (RR = 2.26, 95% CI 1.28 to 4.01) compared to non-attendees. The positive association between routine clinic attendance and use of antiretroviral therapy observed in this study should encourage the development of strategies to retain patients in outpatient HIV care.

Use of a Catalytic Model to Estimate Hepatitis A Incidence in a Low-Endemicity Country

Evaluating the cost-effectiveness of vaccine programs with dynamic modeling requires accurate estimates of incidence over time. Because infectious diseases are often underreported, supplementary data and statistical analyses are required to estimate true incidence. This study estimates the true incidence of hepatitis A virus (HAV) infection in Canada using a catalytic model. A catalytic model was used to reconcile HAV seroprevalence data with the corresponding true cumulative risk of infection estimated from incidence data. The average annual reported incidence was 6.2 cases per 100,000 from 1980 to 1989 and 7.7/100,000 from 1990 to 1999, indicating that Canada is a low-incidence country. The seroprevalence in Canadian-born individuals (n = 7 studies) was approximately 1%-8% in ages <20, 1%-11% in ages 20-29, 7%-29% in ages 30-39, and higher in older age groups. Between 1980 and 1995, the catalytic model estimated an average annual incidence of 60/100,000 (95% confidence interval, 33-524); approximately 7.73 (4.21-67.33) times the average annual reported incidence of 7.78/100,000. For a typical birth cohort of 403 434 Canadians born in 1990, the model predicted 32 750 HAV cases by age 39, with a corresponding seroprevalence of approximately 8.12% by the year 2029. Reliable estimates of true incidence of infectious disease are required for cost-effectiveness analysis of infectious disease programs. Catalytic models enable the synthesis of dispersed data, quantification of data limitations, and reconciliation of these limitations to estimate true incidence for economic evaluations.

Neglected Funding for Vector-Borne Diseases: A Near Miss This Time, a Possible Disaster the Next Time

Vector-borne diseases (VBDs) are some of the world's most common and devastating maladies. Despite this truth, the United States government had decided to drastically cut funding for the Division of Vector-Borne Infectious Diseases (DVBID) program of the Centers for Disease Control and Prevention (CDC) in the Fiscal Year 2011 Labor, Health and Human Services and Education appropriations bill [1]. Nearly US$27 million had been removed from the DVBID financial plan in the President's FY 2011 budget, slashing DVBID funding from US$39 million to US$12 million. Although the program is minimally supported by other agencies, this 70% funding cut would have virtually eliminated the DVBID program. Many organizations, including the American Society of Tropical Medicine and Hygiene, the Infectious Disease Society of America, the American Society for Microbiology, the American Red Cross, and others, appealed to restore funding for the DVBID program. At the end of July, the Senate restored this funding completely at US$26.7 million in their version of the FY 2011 appropriations bill, and currently we are waiting for the House to reveal its version. It is our hope that after reconciling the two bills, DVBID program funding will be completely restored. VBDs are easily targeted for cutbacks in public health funding because their incidence, prevalence, morbidity, and associated mortality are routinely underestimated. Their impact is not adequately captured by current disease burden assessments, and therefore VBDs are often not included in top-level discussions of disease-control priorities [2]–[5]. We feel strongly that funding cuts are short-sighted and that continued surveillance and control are worth the investment. In the absence of a proactive surveillance system that provides valid national and regional data on VBD transmission, outbreak epidemiology would likely be done by “official denial”, and subsequent public health responses would likely be poorly managed and of limited effectiveness [6], [7].

Clinical safety and tolerability issues in use of triazole derivatives in management of fungal infections

There has been an increase in the number of patients susceptible to invasive fungal infections (IFIs) leading to a greater need for effective, well tolerated, and easily administered antifungal agents. The advent of triazoles has revolutionized the care of patients requiring treatment or prophylaxis for IFIs. However, triazoles have been associated with a number of adverse events and significant drug-drug interactions. While commonly used, physicians and patients should be aware of the distinct properties of these agents in order to ensure that patients are optimally treated with the least amount of toxicity possible. Clinicians should have a full understanding of the basic pharmacokinetics, absorption, and bioavailability of triazoles. Moreover, knowledge of the drug-drug interactions and potential toxicities of each agent is critical prior to administering a triazole. Careful history taking, thorough review of the patient's medication list, and detailed discussion with the patients and their families about the efficacy, safety, and tolerability of these agents should be performed. Clinicians treating patients with triazoles should closely follow them, monitor pertinent laboratory tests, and consider measuring drug levels as needed. This article will review the basic pharmacokinetic properties and most frequently encountered adverse events and pitfalls associated with triazoles in clinical practice.

From biological anthropology to applied public health: Epidemiological approaches to the study of infectious disease

This article describes two large, multisite infectious disease programs: the Tuberculosis Epidemiologic Studies Consortium (TBESC) and the Emerging Infections Programs (EIPs). The links between biological anthropology and applied public health are highlighted using these programs as examples. Funded by the Centers for Disease Control and Prevention (CDC), the TBESC and EIPs conduct applied public health research to strengthen infectious disease prevention and control efforts in the United States. They involve collaborations among CDC, public health departments, and academic and clinical institutions. Their unique role in national infectious disease work, including their links to anthropology, shared elements, key differences, strengths and challenges, is discussed.

Serological prevalence of echinococcosis and risk factors for infection among children in rural communities of southern Ningxia, China

To assess the usefulness of serology as an indicator of Echinococcus transmission for developing preventive measures against echinococcosis in rural communities. Cross-sectional survey in 2002 among 861 children aged 7 to 18 years in Xiji County, Ningxia, China. Before ultrasound abdominal examination, a questionnaire was used to identify socioeconomic, sanitary and hygiene risk factors for echinococcal infection; filter paper blood samples were collected from each child for specific antibody detection using EmP (Echinococcus multilocularis) and EgB (Echinococcus granulosus) antigens. Transmission of both E. multilocularis and E. granulosus occur in this area. Serological prevalence was far higher than disease prevalence in this age range. We found no gender-related differences of seroprevalence among the children, suggesting an equal chance of exposure to echinococcal egg-contaminated environments. The seroprevalence distribution was associated with changes in the ecology of wild hosts for E. multilocularis contamination, and with changes in socio-geographic features of the communities for E. granulosus contamination. Serological data obtained for children in mass surveys of echinococcosis appear to be a comprehensive and useful tool to monitor changes of transmission dynamics in humans and provide 'warning signals' to decision makers for the instigation of specific control measures against the disease.

10th Annual Conference on New and Re-emerging Infectious Diseases

10th Annual Conference on New and Re-emerging Infectious Diseases

PHARMA RESEARCH AstraZeneca adds R&amp;D jobs in U.S.

Even as several drugmakers are paring back R&D in the U.S., Europe-based AstraZeneca is deepening its roots here with a $100 million expansion of its R&D center in Waltham, Mass., near Boston. The investment will create space for up to 100 scientists and expand the company's infectious disease and oncology programs. Construction on the expansion will begin this quarter and is expected to be completed by mid-2009. By then, the facility will house up to 500 employees. The Waltham site was conceived by the Swedish drug company Astra and opened in 2000 soon after Astra and Zeneca merged. The facility was endowed with the freedom to create its own culture in the hope that scientists could overcome some of the bottlenecks that have slowed down drug discovery. Since its opening, the site has contributed three cancer agents and two novel antibiotics to the AstraZeneca pipeline. The expansion is aimed primarily ...

Eight Months Later: Hurricane Katrina Aftermath Challenges Facing the Infectious Diseases Section of the Louisiana State University Health Science Center

The effects of Hurricane Katrina have caused the long-term sequelae of a diminished patient base, of a reduced number of available health care professionals, and of closing hospitals in New Orleans, Louisiana. These changes have substantially impacted the academic infrastructure of New Orleans. This article outlines the post-Katrina response of the Louisiana State University Health Science Center (LSUHSC) Infectious Diseases Section and Health Care Services Division to maintain existing HIV and infectious diseases programs. Although several challenges delayed the immediate reopening of the New Orleans location of the HIV Outpatient Program clinic, the LSUHSC Infectious Diseases Section and Health Care Services Division established clinics outside New Orleans for the care of HOP patients immediately following the hurricane. The HOP clinic reopened in New Orleans (in a temporary location) in early November 2005. Several recommendations for academic clinical, training, and research programs are outlined, to assist other centers that might face disaster aftermath challenges.

Ecology of Infectious Disease: Forging an Alliance

The Ecology of Infectious Diseases (EID) program is a joint National Science Foundation–National Institutes of Health initiative to produce predictive understanding of disease dynamics, with a focus on diseases with an environmental component. The interdisciplinary research projects funded by this program take advantage of the wide range of theoretical and methodological advances developed over the past 30 years. The challenge for disease ecology is to unravel these systems, discover how complex they truly are, and to determine if they can be predicted and controlled using targeted environmental, public health, or medical interventions. Between 1999 and 2005, a total of 42 research awards were made under the EID program. EID projects have had affects on policy in two areas: adoption of novel interventions on a local scale and use of models by government agencies for the purpose of allocating public health resources. The past 6 years have been an exciting time for the field of disease ecology; we expect the coming years to be even more exciting and productive.

Concurrent comparison of three water contact measurement tools in four endemic villages of the Philippines. The schistosomiasis transmission ecology in the Philippines project (STEP)

Schistosomiasis japonica is a chronic helminthic infection contracted through contact with water infested with Schistosoma japonicum. The infection is associated with severe disease and is an important public health concern in Philippines. To estimate the agreement in the frequency of water contact between bimonthly interviews, self-administered diaries and observations. A total of 286 individuals were followed over either a 4 or a 6 months period. Agreement between direct observation and both the bimonthly and diary methods were estimated. The agreement between the observation and the bimonthly interview was 71.8% when days without any water contacts were considered, but decreased to 23.3% when only days with at least some water contact were considered. The agreement between the observation and the diary was 78.7% when days without any water contacts were considered and 40.8% when only days with some water contacts were considered. Agreement about the degree of water contact is poor between the different measurement tools. This has important implications for future research, since a high degree of measurement error can severely bias any results from studies involving water contact.

Uganda is learning from its Global Fund grant suspension

When in Kampala Victor Bampoe East Africa portfolio manager for the Global Fund to Fight AIDS Tuberculosis and Malaria (GFATM) works in an office with panoramic views of the downtown area of Ugandas capital city. In mid- November this area was thronged with riot police and dotted with cars torched by crowds protesting at Ugandan President Yoweri Kaguta Musevenis decision to jail his principal political opponent. Yet when Bampoe was recently asked how he was coping with the ongoing unrest he was momentarily confused about whether the question referred to the political protests or the Global Fund. Indeed the decision by the Geneva-based GFATM secretariat to suspend Ugandas five grants--totalling US$367 million--sent shock waves through a country whose robust response to AIDS is a point of national pride. At a meeting during the 11-week suspension one finance ministry staffer said: "This almost brought the country down." While this is more than a slight hyperbole the suspension did tarnish Ugandas reputation for AIDS programmes in sub-Saharan Africa. So the lifting of the suspension on Nov 10 was welcomed as an opportunity for the country to restore its reputation. (excerpt)

Use of the Chi-square Test to Determine Significance of Cumulative Antibiogram Data

An important function of a hospital’s Infectious Disease and Pharmacy programs is to review and compare the most recent antibiogram with that of the previous year to determine if significant changes in antibiotic susceptibility results are noted and to communicate this information and its consequences to the medical staff. However, there are currently no formal analytical (decision-making) models in use to determine if the rate of resistance to an antibiotic from one year to the next has significantly changed more or less than one would expect due to sampling error and test reliability. The purpose of this article, therefore, is to demonstrate the utility of using a well-established and simple nonparametric statistical technique (chi-square) for analyzing annual variations in cumulative antibiogram data and to determine whether such variations are significantly different from chance and to what to degree. The chi-square model outlined here is a simple, practical, quick, low burden and easy to understand and execute approach that greatly improves the analysis of antibiogram data and decisionmaking by practitioners. More work and research is needed to develop additional inferential statistical methods and models that can be applied to antibiogram data.