 Okay, good morning everyone. So if I remember correctly, there were at least two issues to discuss. One is so agenda for today is there was a request about the base so who net data files or who net database data files, compatibility problems very important and growing second one for and suggested on a previous call selecting a good minimal set of antibiotics one for testing and two for data analysis which of course is very related but one one the focus is the data analysts which is the data analysts pay attention to the other one is what should the laboratory people be testing so obviously the questions are similar okay good so I'm going to start with this first issue about debase and sequel light for different reasons I've mentioned it on previous calls during our calls together I personally have had these issues during our calls together it was always an inconvenience for the call but it was also a useful demonstration to you that these are real problems including on my own computer so for debase and sequel light so debase is a data structure it's a data structure that had its heyday in the 1980s I made the 19 when I started we use the very simple text file structure but around 1995 we started to work on the Windows version of who net and I wanted to use Microsoft access because Microsoft access existed and it was coming along so my first choice for a data structure was Microsoft access specifically access version two the problem is access version two was so buggy had so many problems had so many compatibility issues that it would very quote-unquote reliably corrupt large databases so my first choice access really was not realistic because the who net data files were getting corrupted once you were one because most people at that time were not working with large databases so it was debase because I didn't really have a choice there was nothing else robust around that we could utilize and access was not ready so I made the decision around 1995 to use this very old data structure even in 1995 even at that time debase was old so so debases was never a great choice but we went into it because of the access compatibility issues and it's also not a Microsoft product I'm very glad that debase has worked very very well for us for the last 25 years every couple of years Microsoft changes something and then we have to change to try to make sure we accommodate it and that's the way we've handled this for the last several years but we knew that we needed a new data structure for a number of reasons one is the compatibility problem two is debase is not suitable for a web software we want who net for web but debase is not suitable for that in terms of speed multi-user security so we always wanted to change to a newer more modern data structure some famous well-known ones are SQL server my SQL Oracle but SQLite has a number of advantages that we will come to so we've having slow but increasing issues with debase in the last few years but then in January we encountered the February we encountered an issue and when we started doing research into it Microsoft has quote unquote temporarily removed support for a technology that we use called DAO and they did not say when they would bring it back they did not say if it's high priority or low priority and when we could think about that so we were forced into the situation of coming up with a replacement very quickly and fortunately we were in that replacement a SQLite so as you can see at the bottom of the screen I will at the top you see two links where you can learn more and I will talk about those two links at the bottom of the screen you'll see there's nothing wrong with debase files a debase file is almost a text file you know you can open debase files so I'll just show you what a debase file looks like inside of Excel so if I go to open and I clicked on browse and I go to who net data and so here you see let's see back so here you see a file called who net January 95 overtures this is a debase file when you open up in Excel you see how extremely simple debase is it's just simply rows and columns that's one of things we always like with debase despite how primitive it was it was extremely compatible very good for large databases so it's a simple approach that matter met our needs if you want to save your changes now okay so there's nothing wrong with the debase files themselves who is it a very old technology called DAO that means data access objects from the 1990s to open and create and read these debase files we used to use some old engines called the Microsoft jet engines but then we were able to replace that by a Microsoft access database engine 2010 and then later by 2016 so the debase files themselves are fine so any debase files that you have there's nothing wrong with those files but who net is having trouble reading those files because we use these old technologies the DAO and the Microsoft access database engine so as you can see DAO is too old Microsoft no longer officially supports DAO quote-unquote it's temporary but who knows when or if they will bring it back I'm not going to show you these two links I'm going to click on the first one for debase so basically I'm on the who net website so it's who net org slash debase and here let me try to make the letters bigger I guess I can't okay summary so we've used debase for many years and then people who get these different messages this is not a valid file this is not a valid debase file but not decrypt cannot find cannot register thrown an exception could not find sometimes people simply get the message no isolates no records found which we need to put up on here so so this says along I think you told me you saw errors like this from two of the facilities or is that correct I don't hear you but yeah yes so so I received a message that on previous calls I've told you that this problem is growing in the world including on my own computer but we had not seen the problem in Ethiopia so Winslow I'm told me he's seeing it in Ethiopia it wasn't a surprise to me I'm just glad that we discovered this problem in February and now we have a solution whereas if in February if a lot of people had this issue we would have been stuck for a while so so and then I'm going to go to my next slide if you have debase compatibility issues we have three solutions in mind to those solutions are already ready solution one and solution two the other solution should be ready in a few weeks it's going to take us some time not because it's going to take a lot of time but we have some other priorities we're working on first so at these the first two solutions are described on our website so solution number one is the problem is the access database engine so simply if you just reinstall the access engine this is a long I don't know if that if you have access to one of those computers but you could try this during the phone call and if not you could try it later or tomorrow with those computers with the problem most of the time if you simply manually reinstall the Microsoft access database engine and they will show you how to do that on this call most of the time that fixes the debase problem so it's a solution and I've done this solution many times on my computer but it's only a short-term solution why because we have these Microsoft automatic updates people install other softwares so whatever fix you make for who net Windows messes up again later or installation of another software so solution one almost always works but it's not a permanent solution it just kind of helps you get through a few more days or weeks or months some people had this issue a few months ago and it has not come back basically depends on your updates and other softwares you install so the problem is not with debase the problem is with the Microsoft access database engine if you simply reinstall the file everything is usually fine again you can just install the file or you can uninstall everything and you can reinstall everything we'll talk about both of those solution number two is when simply switch from debase to SQLite and I will show you the advantages of why that can be helpful there's a solution that will be ready in a few weeks it's not ready yet basically we are currently accessing our debase files using this file I keep on mentioning the access database engine so we need this file to work to use debase files but we are now in the process of making our own version of the access database engine which doesn't need Microsoft so as long as we make our version then the debase will be perfectly fine again so basically if you if these computers have trouble with debase files if you simply wait a few weeks we'll have a new version of who that works perfectly well I do not know if they will be of the same speed faster but I doubt it because you know Microsoft gets paid more than we do so that our solution will work but our solution potentially might be slower than the the original Microsoft version of it we will just have to wait and see whether it's fast whether it's about the same speed which would be fine or a little bit slower or a lot slower and we will have to figure that out also in the future especially for the web version eventually we want people to switch over to SQLite right now some people switch to SQLite because they have to because of the compatibility issues we don't want them to switch to SQLite because they have to we would like to continue to support the debase files but we would like people to switch to SQLite because it does have other advantages so basically there's the carrot in the stick we'd like people to switch over because of the benefits we don't want this to switch over simply because the debase is not working so we think in a few weeks we will have that ready so if you want the debase now usually solution one or two will work good so now I'm going to go back to the web page so here you can see this who net page about the who net debase compatibility problems so potential solution is reinstall this file and I'm going to it says number one and then number two is another one is switched to SQLite and then if you quit the SQLite you know then you click on this other page and it gives all these advantages of SQLite let me just look at that for a moment and I can show you some time comparisons with our old minute 5.6 if we take a simple analysis of E coli and percent RIS that took 10 seconds and then before we switched we had six seconds so it's actually faster going so who net 5.6 was written in an old language called a visual basic version 6 and Microsoft stopped selling it 20 years ago once we switch it to net it went faster but within our new technology the debase is slower it's 18 seconds instead of 10 seconds but if you switch to SQLite at 6 seconds so in this case there are improvements of SQLite but it's not a big difference it goes from 10 seconds to 6 seconds or 18 seconds so it's all modest but let me look at this one called the glass export well glass export did not was not an option with our old who net with our normal recent who net it took two minutes with our newest who net it takes seven minutes but with the SQLite it takes 45 seconds so or another example the location summary analysis used to take five minutes then it went to six and a half minutes and now it went to one minute with the new who net and then it went to 19 seconds if you do SQLite so in every single case the last column is a smaller number than the first column ears net as a European project it went from six seconds to two seconds so as you can see one of the big advantages SQLite is that it is simply a lot faster I'm going to look at this one backlink backlink we took a very large amount of data 180 megabytes and that was too big for our old backlink and then the medium back the intermediate backlink was three minutes our newest backlink is 13 minutes so you see some of the disadvantages but with the new SQLite 3 so it's actually only it's only a little bit faster but it is faster it's a lot faster than our than our one here okay let me go back a page back oops right here just so okay so what are the two solutions one is to simply go to the Microsoft accent engine so if your computer is having trouble reading who net files you can try the following first of all remove who net remove the existing copies of the Microsoft access database engine okay so we'll start off with that okay so I'm going to go to Windows and of course normal who net users have no need to do any of the things I'm going to tell you this is more for people like Zalala or IT people providing technical support so we don't intend that normal who net users need to learn what I'm going to show you here so I'm going to go to Windows I'm going to do a quick search here for the word program and at the top it says add or remove programs there are different ways to find this icon so I'm going to add or remove programs I wait and now I'm in the settings add and remove programs and here on this screen you can see every software that's installed on my computer and I'm going to do two things I'm going to look for who net so you see who net is here there's who net 2020 which as you can see I just installed today so I'm going to uninstall that before I install that I'm going to look for the Microsoft access database engine it's an alphabetical order so here you see the Microsoft access database engine which was last updated in July and that's the last time I've had this issue fortunately Adam keeps on doing things to to make it better to make it better we don't have the complete solution yet so the last time I had a problem on my computer was in July and that was the last time I installed this manually so how do we manually so I'm going to uninstall let me first I'm going to leave this one here the access engine let me uninstall who net I'm going to who net who net 2020 I click on uninstall this app and its related info will be uninstalled I make sure that who net is closed which it is I click on uninstall I get a question that you probably cannot see do you want to allow the application to change your device I say yes I do it's I'm just giving you permission to do the uninstall which you now see so uninstall and I wait and I wait so this will completely uninstall who net it will not delete your data files it will not delete your configuration it will do nothing bad to anything that you did it's simply removing the files that we gave to you and replacing them and well right now it's removing all the files we gave to you and then the reinstallation will put them back so the software is now completely removed and I click on close you see who net has disappeared from my list here now that I've done that let me see if the Microsoft access engine has disappeared Microsoft do you see even though I did a complete install the access engine is still there so I'm now going to uninstall the Microsoft access engine so clicking uninstall that this app and its related info will be uninstalled I click on uninstall the reason it did not uninstall this is because my computer doesn't know if this file is needed by other applications so that's why the uninstall left this because maybe somebody besides who net also needs it that's interesting it says your computer is overloaded would you like to hide all webcams and stop showing your webcam if you're doing so I'm going to turn off my yeah let me turn off my webcam you don't need to see me right now I'll turn off webcams okay good I've never seen that issue before maybe it's a lot of people but if your webcam is on and you don't need it then please turn off the webcam Mikkel can you just confirm the audio is okay can you still hear me yep for you coming in yes fine great great thank you okay so let's see where was I okay I'm going back to here so yes I will now uninstall the access engine I click on uninstall the app and its information will be uninstalled I click on an install preparing to remove so this is basically making a clean build it has no who not it has no engine and it's telling me that the following should be let me just close my Microsoft access my outlook so outlook is now closed so I click on okay but and as you could see outlook still needed it so that's why it did not uninstall on its own in fact it was an outlook it was a support thing for outlook okay so good it's now removing the access database engine so now I once this is finished I will have a clean build that allows me to do a nice clean install so now that's gone so that's step one is completely remove everything step two go to the website well I did this at the beginning of the call if I go to the home page at the bottom of the page you see I can have the two softwares here 32 bit 64 bit I think I've discussed recently which one you should choose most cases it doesn't matter choose the 32 bit or the 64 bit but if you have 32 bit office I suggest the 32 bit if you have 64 bit office I suggest the 64 bit I have a 64 bit version of office so I already downloaded and I'm not going to download it again so where is my download it is under users John Stelling downloads it's the most recent file I downloaded it this morning at 735 so now that I have my download I simply run that we wait for it to start I agree install continue and I click next I agree next I choose my languages so I will choose on my computer I would like to choose all languages because I do demos for a lot of countries next install finish and close so now who net has been completely reinstalled and it probably will work so if I go to who net and the icon is there the icon disappeared before but now the icon is back everything is fine I can go to data I can go to data entry I can open and then I can open up my debase file okay and as you can see it did not fix the issue so you can see it's exactly this message that I had the Microsoft access engine is not registered on this computer so even though this is inconvenient it's actually a good teaching thing for you so even though I did everything exactly the correct way it still did not fix the problem the Microsoft access engine a CE or some I forget I don't know if it stands for that but a CE probably access engine is not registered so it did not install properly so I cannot open my debase file so this is showing you how frustrating it can be I'm not frustrated because I know that what the problem is and because we have a permanent solution that will happen about three weeks so since that didn't work what can I try next let me go back to this let me go back to my debase compatibility page where is that um yeah and the debase okay okay so on this web page it also so it tells you how to install not who net but just this file so I'm going to go so here you see a link for the Microsoft access database engine redistributable I click on this link and this is a page on Microsoft you can see at the top this is a Microsoft page and here it says download very simple I click on download gives me two options the first one is a 32 bit option which is an older technology and the other is a 64 bit option you can tell because it has the word 64 you can tell this is older because it's 32 it doesn't say 32 because that was the only option for a long time and again you just wanted to match who net hold on a second okay and so I have a 64 bit version of office so I am clicking the 64 bit version of the access engine I clicked on next it is now going to start downloading eight more seconds two more seconds finished it's now finished downloading I can now click on it and yes I would like to proceed so it is now manually installing just this one file I click on next I accept I click on next oh let me make sure who nets closed first yes when it is closed I click on install it's not just one file it's a package of files so the access engine has now completely installed successfully I click okay I can leave the web page and my hope is that everything is working now at least for a little bit so I'm doing this I'm opening this file I go to who net test I go back to the file and I go to find the who net the debase version of the file and let me see if it works this time I hope it does but if it doesn't it would not surprise me so open it up good it's now trying to open it I think it's fine it's just slow because everything with debase now is a bit slower good and it says continue with data entry view database and everything is here so as a lollum do you have any questions so basically this approach that I just told you almost always works it's annoying and at the end of this call it might stop working again that doesn't happen often but it usually will work for me for a couple more days and then I have to go through this process again so that's why I've just started using SQL light just to avoid this annoyance so Zalala is that relatively clear about how I did this I uninstall clear but yes maybe the procedure but because you are actually moving a long treat so maybe in short let me summarize that you first I mean told the who needs software we can you wait for a moment let me just bring up the page so I did notice something on our instructions we actually don't tell you to uninstall who net so we what we should do here is the instructions are here but we do need to add uninstall who net as well and reinstall who net well the reality is I did complete uninstall of who net usually that's not needed usually if you just do this but we just figure the best thing to do is uninstall reinstall so yes now can you summarize what you understood so Zalala if you can continue yeah so my concern for you maybe while you are installing while you are reinstalling the who needs software the access database engine will automatically installed or I don't know yes well when we do a normal who net installation we do try to do a proper installation of this file and sometimes that proper installation works and sometimes it doesn't so who net is supposed who net does install this file it copies this file it tries to install the file and usually that works but today you see it did not work from who net which is why I had to do that additional step of going to this page to download it and installed it manually so for most people there's no need to go to this Microsoft page to download and install this file separately but the who net installation process was not successful in this in a complete so basically the message that happened is it did download it did install but it wasn't registered so with the registration that registration step did not work so by doing this manually the registration step does work okay yeah I understand John quick question just for a normal reinstallation of who net 2020 for example if you want to get the latest updates do you suggest that we uninstall first the version that's on the computer and then reinstall or just install over it no in a normal situation there's no need to uninstall the only reason to uninstall is if you're having these compatibility issues so if you download the new who net and you download the new who net it will overwrite the previous version so don't uninstall it's just an extra unneeded step thanks there's nothing wrong with doing it but it's a step that should not be needed the only time I uninstall is when I'm having these compatibility issues okay so what what I just showed you all of those steps I think will be completely unnecessary in three weeks because in three weeks I'm that's just a rough guess but in three weeks we will completely remove reliance so we used to use this file this Microsoft x database engine for everything in who net now we replaced everything in who net by sequel light except for using debase file so right now we used to use this file for a look for everything now we only use this file for one thing which is to open and read a debase file once we have a different solution for reading a debase file then this file will be no longer needed and these compatibility issues will completely disappear so that's another solution is if you're having these compatibility issues now and if you're hitting your head against the wall and it's not working just wait a couple of weeks and the new who net will no longer need this Microsoft file that Microsoft no longer really supports it's not that the file the problem is that is specifically this file does many things one of the things it does is DAO it's specifically the DAO part that doesn't work okay good so so basically if this is too much too complicated if it doesn't work just wait a couple of weeks and then these issues will be a hundred percent resolved great now let me talk about the SQLite so let me click on advantages of SQLite because we want the people to switch over to SQLite eventually this year next year two years from now especially if they want to use the new web version of who net whenever it's ready and we're not working on it now we have other priorities so we want people to move over to SQLite eventually but we don't want to force them so we do want to support the debase and three weeks I think this will be able to do that so so here's some advantages of SQLite number one it is described as the most used database engine in the world because it's used on cell phones so it's widely used it's compatible it avoids those compatibility issues multi-user data entry you can have five people 20 people if it's on a website a hundred people at the same time it's compatible with modern browsers I'm going to come back to this point in a little bit because from a practical setting this is most convenient one all these other things I'm telling you are nice advantages behind this but that doesn't impact what you're doing SQLite is much simpler than my SQL or SQL server it's faster the files are much smaller than debase it also supports much larger data files modern security feature and if you have trouble with the base this avoids those issues and I've already talked about before how SQLite is is modestly or extremely faster than our older tools good so that's about some advantages of the SQLite I'm not going to close this web page I'm going to close who net I'm going to close who net and so basically how do I make a SQLite file if I go to data entry and I click on new data file you can see the new default is SQLite so anybody starting who not from the very beginning when it's going to suggest that you make a SQLite file instead of putting the the laboratory code in the country code at the end we now put them at the beginning so WTO test the year 2020 a SQLite extension save it already exists you want to replace it yes I do so so so basically that's as easy as it is so it's so extremely easy you don't have to change anything it's just that when you go to data entry and you do need to do the file who net is suggesting you make a SQLite file if you don't want to make the SQLite file simple just choose debase so we're basically just changing the default since about March we have had both of these options this is so for the last 30 years for the last 25 years we've had debase as the only option for the last six months we've had both of these as options but debase was the default but then in June we made SQLite the default so if you just go to who net and do a new data file who net is going to suggest you start with SQLite so in other words you don't replace because the file already exists so and through it you don't need to do anything different you just need to be aware that when you create a new data file who net is suggesting that it's a SQLite file instead of a debase file okay so other than that you know everything else in the network is exactly the same but it's going to be faster so if you're switching from debase to SQLite you're not doing anything different it's just basically you say SQLite who net is suggesting you SQLite and you can also have a mixture some of your files could be SQLite some of your files can be debase for example some people have been using who net for over 20 years so if they have 20 years of debase files there's no big reason why they should change them to SQLite unless if they just wanted to go faster so you can have some of your files in SQLite some of your files in debase and who net should have no trouble with that so that's in who net how you make a SQLite file extremely simple you just say new data file who net is recommending that it's a SQLite file but if you don't want SQLite you just say debase so in other words you do no additional work that's in that's the case in who net now instead if I go to backlink same thing in backlink if you want to make a new data file you have the two choices I can be a who net file or SQLite file so who net SQLite who net debase so if I do a new format if I click a new format and I call this you know junk junk junk and I click on save junk so you see that who net who net is automatically suggesting SQLite so again there's when I say change from debase to SQLite you're really not changing anything you're just saying that well instead of making a debase file today I want to make a SQLite file today okay so I'll stop for some questions any questions on that so it's the same who net the same screens everything is the same it's just that you're just saving it let me go to Excel it's a little bit similar in Excel I'm here inside of Excel and I clicked on open or no I clicked on new database so here and all of you have done Excel if I click on file you have two choices when you save it you can do save if you save it it will save it as an Excel file but Excel does have other options I can save it as and then I can say save it as Excel or save it as text file save it as a web page save it as you know Macintosh save it as a PDF file so Excel is compatible with many different structures of course Excel usually works with Excel but Excel can work with other kinds of files Excel can open or close or save different kinds of files and now same thing with who net for 20 years who net would only read and open and save debase files but now you have a choice you can choose debase or you can choose SQLite and if you're having big compatibility issues with debase you can either wait three weeks and we'll have that fixed or you can switch to SQLite or if you just want everything to be faster and more modern and ready for the web version in the future you may just want to start over for SQLite so now when I'm getting so when I started working with you several months ago the SQLite wasn't really ready yet which is why I wasn't recommending it and also you started who net a few years ago so that's why I wasn't really pushing it but now and I'm not pushing it yet I basically I don't want to push people basically I want to get through these three weeks so that we have zero trouble with the base if we have zero trouble with debase then you can change over whenever you like and you don't have to change over you continue to use debase so so in three more weeks I think we will completely eliminate the access engine we should have a hundred percent support for debase and the only limitation of debase in that case will be that it's lower and it won't be ready for the web because it's not secure okay any questions or comments maybe I have one question regarding the possibility of converting SQLite file to glass the last year we did debase to glass and we submitted the data to glass so we it was successful I don't know I'm not sure regarding the the possibility of converting this SQLite data to black zero problems who net doesn't care it'll be exactly the same so let me go into it so I'm going to go into who net right now I'm going to open my WHO test hospital we click an open laboratory I'm going to go to just a normal data analysis I'm going to go to analysis type percent resistance organisms I'm going to choose E. coli okay data files so I'm going to choose two copies of the same file so here you see the old debase version of the file who net has no trouble with that here you see the SQLite version of the same file and you see the SQLite version is smaller that's not a very it's a little bit smaller so these are two I these are the format is different one is debase and one is equal light but the contents of these two file are identical so let me just do one of them and you'll see that there are 86 isolates so if I click on this analysis so the debase is perfectly fine at the top of the screen it says E. coli 86 isolates so that's using the debase file if I remove the debase file and I put the SQLite file it's also 86 isolates so even though the structure is different that I data content is identical what happens if I choose one of them is debase and one of them is SQLite when I do that 86 times 2 is 172 so who net did not care whether it was the debase or SQLite it's just simply double the number of isolates I'm going to click on exit I'm going to go to data entry I'm going to go combine export or encrypt I'm going to go to data files and I'm going to choose the SQLite version of my data I click okay I click okay I say save as glass and the data are from 1995 I see combine it's my it's a this is also much much faster than the old who net I'm going to say the old who net I'm just talking about oh six months ago the show validation forms yes so it's 150 I say yes everything is perfectly fine so answer to your question who net doesn't care as long as when it can read the file it doesn't it doesn't so when it cares does not care at all the only time it cares if it is it is if it has trouble reading the debase if it is no trouble running the debase there's no difference between debase and SQLite so does that answer your question yeah exactly okay there's one other thing I did not show you yet exact is here there is an option called update data files to SQLite so if you have some old debase files that you so so for the old files you do not have to combine you do not have to update them to SQLite unless if you have these debase compatibility issues which we will fix but if you do want to take your old data and change it to SQLite we do describe that on the website so let me go back to the website who net org slash SQLite when it's SQLite files comparison and this is so here I already showed you in data entry you choose SQLite back in your to SQLite and here I'm in this other section now when it also has a convenient feature called update data files to SQLite available from the data entry screen and then it tells you here what the steps are but I'll just go ahead and show you so data entry I'll do update data files to SQLite and I'm going to go to data files and this is one of my old debase files I just selected that this is an old debase file so what who not will do is it's going to have the debase version on the left and you can choose five files 200 files you can choose as many files as you want and here on the right it's going to rename this file so instead of being called WTO 0195 of your test it's simply going to add SQLite onto the end of it when it's done I can leave the two files in the same location in the who net data folder or I can move the original into a backup folder so I'm going to move it to the backup folder so I'm going to click on begin conversion the conversion has now been complete so this new file so let me click let me get out of here and I'll show you what happened who net data and so so you see this file here W0195 WTO .tst.sqlite created it's here in Boston it's a 24 in the morning so this file was created just now this is a SQLite version of my older debase file so where's the older debase file who net moved it you see there's a folder here called archive I'm sorry there's a folder here called backup if I go to backup there it is so it did not delete the debase file it just got it out of the way why did I do that because you know it's just going to be an inconvenient if you have two copies of every file if you have 12 debase files and 12 SQLite files it just you know it just makes it harder to choose the 12 files so so what when it does by default is it updates the file to SQLite into a new file which is this file right here and then it back it moves the backup into a backup folder so that you didn't lose anything it just moved it out of the way you know just like cleaning up you know I just updated made a nice and clean and fixed let me just I don't want to delete it let me just basically sweep it under the rug just put it off to the side just in case we ever want to go back to it so I think I showed you everything about SQLite that I had in mind any other questions in these next three weeks we're going to try to get completely rid of the Microsoft access engine there's still some things you know just to finish so that the SQLite solution is a hundred percent complete and I think three weeks if we dedicated all of our time to it I think we just take a week but we have some other well you know one of things we're doing now is we have another we have something I'm going to go to the website whonet.org just to give you a sense of the kinds of things that we spend our time on clicking on the software so the software page you see this thing called the whonet automation tool we utilize that we have a project with the CDC with 80 hospitals for automated outbreak detection every day every day they have that it's a hospital network with 80 hospitals so all the data are centralized in one location so every day they export the data to a text file at 1 o'clock in the morning at 115 who net runs back link or back then changes it to a who net file and the 130 who net runs it who net runs you know runs a series of analyses and creates Excel outputs so this automation tool is extremely important for our CDC project because it's automatic it's an active live project with 80 hospitals they need this this one they have not yet had trouble with debase so the focus of our next two weeks is we need to update the automation tool so that it avoids the debase problems so basically we're still dealing with these debase issues who net is fixed mostly back think is fixed so we need to fix this automation tool because the CDC does not yet have a problem with it but if they do the whole project is going to come to a halt until we can get it working again so we're doing this week and next week is we're just updating the automation tool to move to SQL light instead of debase this automation tool will also be useful for other people around the world who do want to process automate everything beginning to end if that's an interest like polytech polytech I think I think Jeff mentioned it could be scheduled so automation is needed now for our CDC project but we do talk about it on the website if somebody needs it we could certainly give it to them but right now the automation tool only works for debase files now with two weeks we should be able to have that fixed and then the third week we can get back to the debase issues for who net that I was talking about any other questions about SQL light if not we can move on to the next topic okay I think we better continue to the next topic John okay okay for those of you who who are not Zalala most of the last hour is not going to be useful for you in part because it will not be your responsibility to do this kind of technical troubleshooting and in part because in about three weeks I hope in about three weeks we should have a permanent solution which avoids the axis engine so so anyway so that just if you find the last hour confusing don't worry about it one is not your job and in about three weeks it will no longer be a relevant issue okay so I'm going to close the website let me close who net and good good so for the next topic okay one thing which is not on the agenda but which is now fixed it okay I'm going to go to data entry and I'm going to open up your data file that you sent to me previously the first file you sent to me if you all I think it was this one here nrl one-year encrypted SQL like open oh I'm in the WHO test let me go to Ethiopia 01 or all hospitals I'm not sure I'm open up to 01 let me click on Ethiopia 01 open laboratory data entry open nrl one-year encrypted data open view database so all of this you have seen before okay I have simply taken the file that you sent to me and I've taken the file you sent to me and I opened up in who net data entry and I clicked on view database there's nothing new and so for what I have shown you okay the new thing is if I click on edit table well here you remember the difference between 01 and 001 so I want us I now finally we can fix it I'm going to click on this once and I have 001 I click on it again I have 01 I'm going to click on edit table now and this did not work before when I tried to do it with you I can do 001 and that's fixed 001 I'm going to do copy as soon as I leave this row sorry so basically I told you how to fix this but this one partition of it didn't work because this column cannot be edited so that we did fix so I'm changing this word to 001 as soon as I change this one to 001 and I leave the row it disappears it doesn't disappear it just goes down in alphabetical order so it's now at the bottom of the list so I'm going to do so as many of you know there's a shortcut for copy which is controls T so if I do 001 001 I highlight this I can I'm going to click on I can I can right click on it and click on copy but there's a shortcut it's control C control C is copy and now I'm going to do control V control V is the shortcut for paste I'm doing paste paste paste paste paste well let's see every time I do it it resorts it so paste paste paste paste paste paste paste paste paste paste so I'm not going to finish it but as you can see it if you spent several minutes on this or is it mostly 01 or 001 I forget which is more common oh so I was doing it the wrong way I was changing 01 to 001 but in fact 001 was the less common one so all of them is that correct so I should change zeroes I could choose I should change 0 0 1 so here I'm just doing that 0 1 0 1 so do I like the column and just and just paste several cells so if I just to pay it will only do one at a time so one of that you so so basically you can fix it now when we have some more time you see your replace button here eventually we're going to activate that replace button right now that replace button doesn't do anything which is why it's just there's a concept so so now if you want to you could fix it just by doing paste paste paste paste and or alternatively you could wait I don't know maybe two months we've got other stuff to do but eventually we're going to do two things here we're going to activate the replace so that you can do all of them at the same time just like an Excel we're also going to put filters so right now I have you know I have everything mixed in here together but for example if I only wanted to see the assenita factor it would be nice if I could put a filter so these are not urgent things they're not bugs they're not compatibility issues they're just nice new features so nice new features that are simple to do we're doing now nice new features that are going to take us a little bit longer in September we should be able to start taking a look at some of those for the last six months our complete focus has been dedicated to the SQLite debase issue but now that that is almost finished we will start to be able to start putting new features in much more quickly so so now you have a version of Winnet that does allow you to change the zero zero one to zero one or you can just wait longer and eventually we'll just have the we'll have we will have the replace button working okay great that was one thing I mentioned because Adam just got to that it was a simple thing to do but you know you just go ahead yeah you are doing manually one by one right yes that's correct yeah I was expecting like to do it once to the old by filtering or by any mechanism right and we do play right so if that was a big priority for us we could have it in a day or two but the bigger issue for us is the debase compatibility issue because all these things are working on a who net that works so right now we're not taking a lot of detours so this was a quick and easy one so yes so you see the replace button here if we spend some time on the replace button then you can do all of them at the same time so right now if I wanted to do this myself and I did not want to do it one at a time then because I was good to see how often is it is it 100 which would take about three minutes to do or would it like 2000 which is going to take you know much more time so you want to see how often is this you know is this a big issue or small issue if it's a big issue what I personally do is I would either do it in Microsoft access or there's another thing for SQLite called the DB browser so let's see so if I go to SQLite DB browser DB browser is a software similar to Microsoft access so this would allow you to do all of them at the same time so if you do want to learn SQLite DB database browser that's another option that could fix them all at once or if you if this is a big priority you know we can discuss the best way forward but the eventual solution in who net is easy it's for us to replace it's just to put in this replace feature it just that the replace feature is less important than a deep then who net that works I can ask Adam on the specific feature how long would it take to fix it so I agree with you definitely it's better do them all at the same time that is our plan the question is when are we going to make it a programming task for that week and also the so in fact the replace feature is going to be relatively easy and fast the filtering one is going to take a bit more time because you're filtering dates you're filtering other things but you know so it's those two things that that you mentioned that we will put in the replace button you'll be active and you will have the ability to do filtering okay but we have to make a working who net is a higher priority than new features which are to do a balance if it's a simple new feature we do it quickly I can ask Adam about how long would it take to do the replace feature where we were Wednesday no with Thursday maybe I don't want to promise this but I will ask Adam is the replace feature realistic for the end next week okay other questions or comments okay if not I'll move on to the next topic which is coming up with a reasonable set of antibiotics a reasonable set of antibiotics for testing and a reasonable set of antibiotics for analysis and of course the two topics are very closely related okay I will click on continue click on exit and I'm just going to use for the first version of this I'm going to use the WHO test data so I'm going to open the WHO test data and first of all I want to see what antibiotics they're testing if I want to know what antibiotics they're testing there are two ways to do it one way is I could just ask the laboratory what antibiotics are you testing and then they'll give you a list and they'll tell you but if you do that if they do that sometimes they're not complete they forget some of the antibiotics or they forget that they changed it so one way to know what antibiotics a laboratory test is to simply to ask them what antibiotics do tests that's one way another way is to simply look at their data file and that's what I'm going to do now I'm going to go to data analysis data analysis analysis type so here in our analysis type I want the percent ris for this analysis percent resistant intermediate sensitive and I'm going to click okay and I'm going to go to organisms and I'm going to choose two organisms deaf aureus and E coli my options are on the left my selections are on the right I click okay I think these steps are very clear and understood that you understand these very well however if I do go too fast or I say something or I click on something you did not understand just interrupt me so the options are all of my bacteria are on the left and fungion parasites etc and the selections are on the right I want step or is first followed by E coli I click on okay data files and you here you'll see I need to get rid of the other one just to clean up my database but you know so here you can see is my WHO test 1995 January sequel like database I select that file I click on okay and I begin the analysis so here we we've seen this before this is percent resistant percent intermediate you know for example penicillin is 79% resistant oxycylone is 10% resistant what drugs are they testing while they're testing penicillin oxycylone amoxicillin polymeric acid gentamicin instead of looking at the tables I find it better to look at the graph there are many graphs here percent resistant percent intermediate percent susceptible but one of the graphs is called number tested so I this is the graph I like to look at when I want to know what people are testing they are testing one two three four five six seven eight nine ten drugs the testing ten drugs okay and the first question was so my first question is what drugs are they testing and that's correct it's ten drugs then the next question is are they appropriate drugs so are they testing are they testing vancomycin on E coli that's an obvious mistake it's just an inappropriate drug are they testing amoxicillin disc on E coli that is also a mistake it's not an obvious mistake because amoxicillin so you do not use vancomycin to treat E coli it just would not work it's always resistant however people do use amoxicillin to treat E coli infection so amoxicillin is a clinically appropriate drug but CLSI does not have breakpoints for it therefore what CLSI says don't test amoxicillin we didn't evaluate it test ampicillin and whatever you get for ampicillin it's the same information for amoxicillin so I want to see what are they testing is question number one question number two are the drugs they are testing appropriate and if they're not appropriate I talked to the laboratory and I say are you testing this drug and then you tell them no you shouldn't be testing them so penicillin is perfectly appropriate to test for staph aureus oximicillin it gets a little bit complicated because these data are from 1995 and in 1995 oximicillin was the recommended drug so in 1995 oximicillin was completely appropriate however the drug is no longer recommended it's now recommended to be the sephoxicin disc so my comment here is that oximicillin was perfectly appropriate for this time period but today if you're doing this now then oximicillin is not the correct test you should be doing the sephoxicin test similarly AMC AMC was valid in 1995 it is no longer valid genomicin is good sephro is good S60 is good okay good so question one what antibiotics are they testing we have seen that question two are the drugs appropriate and this example oximicillin and AMC are no longer appropriate vancomycin disc is also no longer appropriate it's just not a reliable test so so for 1995 everything you see here is perfectly appropriate but if these data are from today they should not be testing oximicillin AMC or vancomycin those are inappropriate drugs by today's recommendations that was question number two are the drugs appropriate question number three is how often are they testing these drugs do they test them systematically always haphazardly do they run out of discs do they change the discs in the middle of the year so if I look at this I see I can see this in the graph or I can see this in the table they tested penicillin here in the table the test dependent let me do that again here penicillin they test the penicillin 86 times genomicin 86 86 86 so and you see the same thing in the graph so almost all of these graphs they tested 86 times so I'm happy they are testing the same drugs consistently they always test the same things except for nitroferantoin nitroferantoin they only tested I don't I know it's in from the graph it's approximately I don't know 15 or so in the graph in the table you can see it's 14 so most of these antibiotics they tested 86 times they always test the same drugs but for nitroferantoin they only tested it 14 times this is a perfectly appropriate drug for urine so what one possible explanation is they ran out of discs like in January they tested it but the rest of the year they didn't test it but that's not the case here I do know this laboratory and what they do if it's a urine test if it's a urine sample they test nitroferantoin if it's not a urine sample they don't test it so by looking at this graph I know what they're testing I know what they test all the time and I know that they only test nitroferantoin infrequently and my guess and I can confirm this by asking the laboratory is that they're only testing nitroferantoin on the urine isolates if it's a blood or a sputum or wound they do not bother testing nitroferantoin because it is not useful clinically okay so nitroferantoin is perfectly valid for data entry for data analysis it's as supposed to be specific for the urine if I want to analyze blood I'm not interested in nitroferantoin so that's the small difference between that's one of the small differences between data entry and data analysis perfectly appropriate for data entry but for data analysis you know nitroferantoin is not it's interesting if your interest is urine but if you're not interested in urine you know then they didn't test it okay of course everything that you see here you can copy and paste to excel if I click on copy table and if I go to excel let me open up excel and I open up excel and I click on paste good so then I have my data in excel and and here let me just hide some of these columns or delete I don't need these three I don't need this I don't need this I don't need any of these so here you can see that most of the drugs they test 86 times the oxyline 85 times nitroferantoin they only tested 14 at this point I don't care about the sense I don't care about the results I just care that nitroferantoin is not tested all the time good so that's the situation for Steph or is they always test the same drugs except for urine if it's urine they also do nitroferantoin I'm gonna go to continue and you'll see that the situation now we're going to see the E. coli and the situation is a bit more complicated if I click here on the word number it sorts it and here you can see ampicillin 85 85 85 there's certain drugs that they tested 85 times mesosilin 84 times but then these three drugs were 57 nitroferantoin 57 norefloxacin 57 argumentin 57 and then you have these three drugs cipro 28 suffoxidin 28 peppercylin 28 and then at the bottom septazidin so here's a bit more complicated let's take a look at the graph so here you can see there are certain drugs that they always test ampicillin mesosilin cephalothin cepheroxin that's one two three four five six seven eight nine there are nine drugs that they always test that's great blood urine wounds but um these drugs are always tested if it's a urine they'll test nitroferantoin and of course E. coli is relatively common in urine and as you can see in the graph there were 57 so there are 85 E. coli's 57 of them were in urine so those 57 if it's a urine they always test it so if it's not your if it's a urine they test nitroferantoin norefloxacin and AMC so nine drugs they always test if it's a urine in addition they will also test these three drugs so nine plus three is 12 so if it's a urine they test 12 drugs the nine drugs that they always test plus these three urine specific drugs if it's not a urine they test cipro they test suffoxidin they test peppercylin so these three drugs are always tested if it's not a urine so if it's a blood if it's a wound if it's a cerebrospinal fluid they will test 12 drugs the original nine drugs that they always test and these three drugs they won't test nitroferantoin in other words they're always testing 12 drugs nine drugs plus the three urine or nine drugs plus the three nine urine that's what we call selective testing by specimen type you decide which antibiotics to test depending on which specimen type it is finally you see at the bottom these three drugs that they very rarely test tobromycin amiccation and sceptazidin though and you see they only tested the made times why did they only test the made times maybe they ran out of discs maybe they started testing it at the end of the year or maybe they tested it at the beginning of the year and they stopped those are different possible reasons but I think there's a different reason these are reserve agents that you don't use very often clinically in this particular facility so basically I think what's happening here is they're doing second-line testing on Monday they're setting up the antibody test with 12 drugs and then on Tuesday they look at the results and they see that it's sensitive to all drugs and then they're finished they just tell the doctor the 12 results but sometimes they test 12 drugs on Monday and they see the bacteria is resistant to eight of the drugs and the doctor says can you tell me any more drugs this is a nice you patient it's resistant to everything you most of the things you tested can you give me a few more options this is what we call selective testing for example in this particular facility they do not test amiccation routinely they do not test it on every blood they don't test it on every year and they only do it if it's resistant to some of the first-line drugs so on Monday they'll do most of the routine antibiotic first-line tests and then on Tuesday if needed they'll do a few additional tests so that's called second-line testing because of resistance like on day one they test genomicin if the genomicin is resistant then maybe they will go ahead and test the amiccation any questions on this I'm going to repeat this exact same thing I just showed you but I'm going to show you with the Ethiopia data next before I show you the Ethiopia data do you have any questions here just to summarize John that this is how they would select the core set of drugs that they would test systematically across all surveillance sites is that what you're suggesting well it's two things one is what should they be do so forget about the data one question is what should they be testing so you don't need any data to do that you just discuss it among the experts the clinicians the microbiologists consult with the celicide guidelines to come over the test of what they should be testing so this is a question at the reticle question it's also a practical question in the future what should Ethiopia be testing I'm answering the slightly I'm answering now I'm discussing the related question is what have they been testing what what they have been testing is it a good set is it appropriate is it inappropriate and then can be it improved for example maybe they're not testing maybe they're not testing I don't know imipenem and maybe they should so what I'm doing now is discussing how to evaluate what they have been testing and then the related question what should they be testing and hopefully we can get those two to match up what they should be testing should match what they are testing okay and I'm going to continue and I'm going to go back to who net and I'm going to go to file open laboratory and I'm going to open up the the aphi and national laboratory I'm going to go to data analysis data analysis I'm going to do exactly the same analysis RIS and test measurements I'm just going to start simple let me do step four is indeed Kolei and let me do this you know well I'm sorry with your data with it when you're encrypted data so I'm doing this now with one laboratory because I want to see what this one laboratory is doing after I can repeat this with your you gave me also like four or five laboratories so that I want to focus right now on just a single laboratory and then after that we can look at multiple laboratories to see what is the same and what is different so click on begin analysis what I have done now is no different from what I just did five ten minutes ago except I'm using Ethiopia data so let me look at the graph for number tested and you see it's different than the graph I showed you for example one thing they don't like is that the numbers are so bouncy they're not very systematic and and especially I know any Ethiopia people have been improving things so sometimes what happens at the beginning like in in the first few months of the project they're not they don't have a good set and then later in the project they pick out a good set so first let me look at what they're testing penicillin penicillin is perfectly appropriate it's not always tested but usually tested oxalin so oxalin should not be tested but in fact they are not tested let me just double check on this yes so what is usually happening I think someone at the door yeah maybe John yes yeah normally they are using tapoxidine but the result will be actually posted on their folks are seeing so they are using tapoxidine yes that and so what you when you're describing is called proxy reporting and that's perfectly excellent so when I see the oxalin here Mike they're either doing something very bad or very good the bad thing is if they are testing the oxalin disc that's a mistake but the other thing is a good thing the other thing is they are testing tapoxidine and using the tapoxidine result they are predicting the oxalin result they're simply putting an R and I or an S so that's called class reporting so you they did not do the oxalin disc but they did the tapoxidine disc and then they did not copy the tapoxidine measurement but they put R I and S that's just what you described and the reason people do that is the a lot of times the doctors they know oxalin but they don't know suffoxidine so so one of the reasons people change suffoxidine to oxalin for data entry purposes is so that the doctor sees a drug that they recognize same theorem oxalin if you're testing a moxalin that's a mistake but if you were testing ampicillin and telling the doctor that it's moxalin that's okay because you know it's it's the results are usable but you just don't test the drug itself I want to point out a small difference here let me show you these two similar columns we make this column a bit narrower let me make this column a bit narrower this column bit narrower just hide this one okay narrower good you see here there are two columns called number here it says the number 55 here it says the number 33 the question is why do we have two different columns called number and the difference is that this one is the number of penicillin test results there were 55 this is the number of quantitative results in other words the number of measurements so they tested 55 penis they tested penicillin 55 times they measured the zone diameter 33 times so there are 22 times where they simply type the letters r i and s so for example here tober mison they tested it twice and they had two measurements meaning they always measured it genomycin 35 tests 34 measurements so one time they didn't measure it they just type the letter r i or s so that the first number is the number of results the second number is the number of measurements so let's look at the oxycylind so they have 69 69 oxycylind results but there were 13 measurements so what you told me is a little bit incorrect what you told me is that they just they the test that's a foxy tin but they reported as an oxycylind and that happened 56 times so 69 minus 13 is 56 so for 56 times they just put a letter r i or s so for 56 times they did exactly what you described it tested the suffoxidin but they reported it out as oxycylind but 13 times they put a measurement and I can even show that to you here is here's the measurement I'm not that's the suffoxidin so here you see are the measurements for the oxycylind but that's not correct they should not have done oxycylind with the disc measurement and as you can see here you see there's a column here called question mark it says 10% question mark and that means let me go back a little bit let me go to the break points column there are there are break points for almost all of these drugs but there are no break points for oxycylind so the reason we have 10% question mark is somebody put a zone diameter for oxycylind so what you described is usually correct but in the number again 13 13 times they did put a measurement and that measurement is incorrect okay and I'm guessing maybe they were January February early before they knew you know the right way to do it okay good any other questions on that if not I'll continue with the interpretation of this what they're testing so penicillin perfectly fine oxycylind is perfectly fine if maybe I have one yes yes go ahead yeah yeah thank you is it a mess to have the same number of I mean the number of cases and the number of measurements necessarily be the same or not you like them to be the same it basically means they always you want them to always the same they okay okay go ahead you always want them to measure you don't want people just typing ours eyes and s's not about the statistics it gets back to it's the right way to do the test so if so I like this a foxy 10 suboxygen they had 71 test with 70 measurements so they measured it every single time except once once they just put a letter our IRS so if in a very good database the number of measurements should equal the number of tests except for something like oxycylind with a number of measurements should be zero and the number of tests should be you know the same as the number of suboxygen results okay okay good so I'll continue so then I'll continue here the gender mice in perfectly appropriate but they only tested it about half the time tober mice and they very rarely tests super they test a lot they tested a lot but they don't notice it all the time so I'm going to click here on the column number once again so the most common antibody the test is clindamycin I can see that in the graph they tested Clinton so how many step or is do we have I can't see the number at the top of my screen I don't have one of you can see it it's overlaid with the meeting controls next to Steph or is it has a number here it's 81 great I can't see it because it's hidden 91 okay good I actually just moved the control I see it so there were so there were 91 step or is and they tested clindamycin 75 times so there were 16 times where they did not do clindamycin where they probably did no susceptibility test so so clindamycin is tested 75 times suboxygen is tested 71 times sxt 68 times so it's not completely systematic you know there are drugs that they test a lot but it does vary why does it vary because they run out of discs because they switch discs because they do it by specimen they do it for other reasons but what you'd like is to see is what I showed you for my example for step 4 is you want to see the same drugs tested every single time because it doesn't help the doctor and it doesn't help the statistics if sometimes you test it and sometimes you don't so that's why you want to fairly you don't so here you have a lot of drugs you have one two three four five six seven eight nine ten eleven twelve thirteen fourteen fifty sixteen you're sixteen root drugs I would rather see eight drugs they're always tested than sixteen drugs that bounce around a lot okay so Tobromycin they do test but Tobromycin is very rare and you could ask the laboratory why did you test Tobromycin and then they say well we ran out of genomycin and so I'm not saying that they don't have a choice they have to do it but it's good to know what the reason was um CIPRA was good sxt is good Daptomycin it's it's they do test it they don't test it very often and it's also appropriate not to test this very often this drug is a very new drug it's highly effective it's probably a hundred percent sensitive where's my Daptomycin there is Daptomycin okay it's seventy five percent okay and there you see there are no break points for it meaning we should double check the disc potency but um okay so so so so Daptomycin is a reserve agent you don't need to test the reserve agents every single time of course in my hospital we do because we have intensive care units we're very sick people and because we have MIC panels it's just easier to test everything at once so we test Daptomycin routinely and Lenezolid and Vencomycin but if you're doing just diffusion testing and you want to have one plate or two plates and first line second line testing Daptomycin is not commonly used clinically it's an expensive agent I don't know if the drug is available in Ethiopia so I'm okay that they don't test Daptomycin very often it's useful in an ICU patient that has a lot of resistance so this isn't a good example of something that you don't have to test routinely so it's good that they have the ability to test it but you don't have to test it all the time if you have to make these kinds of choices. Azithromycin and erythromycin are very similar drugs you don't really need both of them so it's often better to choose one or the other Nitroferantoin well that's usually the urines and Stephorus exists in urine it's just not very common so if they're doing the Nitroferantoin in urine that's fine. Lenezolid, Vencomycin again these are more second-line agents the Vencomycin disc is not reliable. Chloramphenicol is not used in the United States because of concerns about toxicity it is usually a very effective drug so but here in Ethiopia they only tested it chloramphenicol they only tested it four times so they're not testing it very often and then tetracycline they tested it about half the time so in short they only have I'm going to ignore the oxycyline because it's just a copy of the suffoxidone they have one two three four five drugs that are tested most of the time they have four drugs that are tested about half of the time they have two drugs that are tested a modest amount and then they have four drugs that are very rarely tested so in the future what I would like to see perhaps is fewer drugs but more consistency so that we're testing a certain core set all of the time and then you can discuss with your epidemiologist with your clinicians with your pharmacist look at the CLSI documents to see what is it what is a good minimal set if people want to and and you also may want to consider what should a routine community hospital in the Ethiopia test and what should EPHI test you know that's often where the National Reference Lab should do routine testing of more stuff because it's a reference place other comments about that so it's those two points is one is what are their test practices and are their test practices appropriate and secondly what in theory what should we be testing and try to get those two to marry together so the practice does match or match what people want to see if no more questions on the staff forest I'm going to have this exact same conversation again about the E. coli so I'm going to click on continue and I'm going to jump immediately to that same graph I'm going to sort my table so you see sxt the term method himself a very important drug is a hundred and twenty two isolates I'm sorry let me see I can't see how many isolates let me move this around a little bit there were hundred and twenty six isolates so sxt they tested almost all the time one twenty two SIPRO not identical but it's close they almost always test SIPRO they almost always test maripenem but then you have this big drop off so these three drugs I would say are basically always almost always tested but there's only three drugs then you have Tobromycin, nitroferantoin and peptazone that are tested a lot but a lot is only about 80 out of 120 so that's only about it's only about 70% and then if I go down further it so then we have this bunch here from 83 to 68 to 67 so these drugs are tested a lot but the further down I go I'm going to go down to the bottom so for example here it's a penicillin once well penicillin is completely inappropriate that was probably I hope a typing mistake to put penicillin but it's not penicillin some of these what else is it through my son is it through my son is not appropriate for an E. coli so if I look at this list at the bottom penicillin completely inappropriate and the cylinder is good peppericillin peppericillin is a very old antibiotic you can't even buy it anymore in the United States you can buy peppericillin taserbactin let me do this an alphabetical order okay so here you see peppericillin and peppericillin taserbactin you see they have the same break points because the taserbactin is not an antibiotic taserbactin is a beta-lactamase inhibitor so it's just helping peppericillin do its job so it's normal that the break plus should be the same so I want so for this you'd want to so sometimes you would ask the laboratory are you testing peppericillin and they'll tell you yes I am testing peppericillin and then you can ask them why you're testing peppericillin you can't even buy it anymore because what you usually buy is peppericillin taserbactin which is much more effective or sometimes I'll ask them are they testing peppericillin and they'll say no no we're not testing peppericillin we're testing peppericillin taserbactin and then I'll tell them well you made a who-knit mistake you called it purpose you called it peppericillin but it isn't peppericillin it's peppericillin taserbactin so peppericillin is an example of a drug that they shouldn't be testing at least in the United States so you want to discuss it with your pharmacist can actually people buy peppericillin for an E. coli peppericillin is not a lot the peppericillin is better for pseudomonas than ampicillin but peppericillin is not a lot better for an E. coli let's look at the two results so look at the percent resistance for peptazone it is 15.8 percent resistant peppericillin is 83.9 percent resistant if it's 84 percent resistant why in the world are they testing it it's not a good drug it's probably not even available on the market so I'm so one point I have is that you should not always do more testing sometimes you should be doing doing less testing and in this case I don't personally see why they would want to test peppericillin I don't know the Ethiopia situation so of course your pharmacist may give you a good reason but look at it is 84 percent resistant so even if it's available it's still not a good drug so peppericillin not a good drug AMC perfectly appropriate TGP is peptazoprfectly appropriate sephazolansepheroxine sephazodine sephraxin so here it gets complicated because you know they have a lot of similar drugs like these two drugs let me look I'm going to go in alphabetical order okay sephazoline sephotaxin so here I'm going to look at these two drugs sephotaxin and sephraxin are practically the same drug there's no difference pharmacist pharmaceutical and pharmaceutical there's no difference pharmacologically there's no difference microbiologically they tested sephotaxin 30 times the test itself traction 46 times so if I add 46 and 30 that's 76 so so basically they're testing sephotaxin or sephraxin a lot but why are they switching from one to the other and sometimes what they do in the first half the year they see sephotaxin the second half the year they use sephraxin they shouldn't be testing both drugs at the same time you know because there's no and look at the percent resistance one is 67 one is 61 so microbiologically the results are usually about the same so I would recommend don't test sephraxin and sephotaxin pick one of the two and use use that one and then make that same recommendation around the country like if some lives do sephraxin and some lives do sephotaxin there's nothing really wrong with that it just makes it harder at the national level to integrate the statistics so like imipenem meri-meri-penem they're almost the same but it just is easier if people standardize on one or the other let's look at that here imipenem let me show that in the table let me go to imipenem alright here they are so they tested imipenem 14 times they tested meri-meri-penem 118 times so they were very rarely test imipenem and it was 0% resistant they usually test meri-penem and it's 1.7% resistant there's really no need to be testing like we in my house but we do test both because it's on the panel there are slight differences for example for proteas imipenem is usually resistant it's an intrinsic issue so there are small differences between them but for most practical purposes for almost everything imipenem meri-penem are basically identical you just choose one or the other you really don't need both you see that in the graph imipenem is very rarely tested meri-penem is tested very often so again we're trying to decrease sometimes people say we run out of discs but one problem they run out of discs is they order discs that they don't need it's just better to focus your money on the discs that are that are needed imication genomycin tested about half the time to vermycin Nalodexic acid I'm surprised I'm sorry Nalodexic acid a lot of people do not test it's a very useful drug for finding quinolone resistance but it's not usually used clinically so it's appropriate Nalodexic acid is not it's an appropriate drug but a lot of people don't test it because they usually just use a fluorine Nalodexic acid is a quinolone but it's not a fluorine quinolone and let me look at the resistance for Nalodexic acid good as you can see it's 85% resistant so it's 85% resistant it's really not a good use of your money to be testing it because it's just usually not going to work so one thing I'm trying to do is decrease the number of antibiotics to come up with something to allow you to have more complete testing on the drugs we care about why are we testing a drug that's 85% resistant you know it's not at the best use of money especially when resources are an issue the test Cipro the test SXT that's great ACM is not tested that's inappropriate that you're referring to in the test usually that would probably be the urine's continue any questions on what we have seen there the final thing I want to do is to show you with the national database in Ethiopia the different patterns between the different laboratories before I do that any other questions okay so I'm going to go to analysis type to do this analysis I don't want to do the detailed report I want to do the summary report so let me do the summary report first okay therefore is an E. coli that's fine begin analysis okay well let me just do the same way I just want to show you what let me do the same way that I showed you already so I'm just doing the detailed report and so that's no different but I do want to change the data file instead of choosing that first file you sent me I'm going to choose the other ones where are they a yd those two nrl tas h and those are those are the four files that you sent to me from the four different laboratories I'm gonna click on okay and begin analysis so everything we focused on so far is what's tested at EPHI but now when I look at the whole country I see there are 270 isolates if I click on number of tested you can see very clear here there are one well there are only three drugs so we have 270 isolates let me find out the number tested so these three drugs are almost always tested which is which is good for those three drugs staff or is erythromycin SXT and clindamycin all great drugs and then we jump down to the second tier the benicillin and the suffoxidin and I will ignore the oxicillin for the reasons that we discussed it's just a copy of the suffoxidin and then we jump down further to Cipro and then we jump down further and then we jump down to rarely tested drugs so these three drugs in the graph SXT clindy and erythro I'm happy with because they're tested very often I'm happy but not very happy with the penicillin the suffoxidin and the Cipro because they should be tested more and the genomycin and the chloramphenicol and tetracycline have some data they don't have a lot of data I'm going to copy this table to excel copy copy data this is the first example let me do the second example here I'm going to delete the columns that I don't really care about right now delete delete I don't need the break points I don't need this I don't need the I don't need those I don't need human core national set okay so now that I see what you are testing and let me just save this as more options save a browse and put this on the desktop and Ethiopia antibiotics tested so first of all all of these drugs at the bottom are very rarely tested it's either a mistake or it's either mistake in the lab or it's a mistake in data entry I'm going to here yes maybe or no so let me say in terms of the core national set no no why because the because he PHA is very really testing them I'm gonna make some exceptions later so okay I'm looking at the real numbers let me call the supplemental testing okay okay good I'm just looking at the names of drugs here yeah okay Venka my son and Leneza lead I would say yes for supplemental testing but not for routine testing same thing for depth of my son where are we now is it for my son so you're not usually testing it now but you're testing a rhythm so erythromycin and azithromycin are very similar so I would say no for azithromycin and I would say yes for erythromycin because it is what you're usually testing it yes for this yes for this yes for penicillin suffoxidin yes proxy that's class reporting sip growth yes tetracycline yes gentamycin may I maybe yes maybe no maybe chloramphenicol and you can discuss some of these things with your pharmacy people maybe yes on azithromycin I'm not really sure if there's a big difference between them so if I'm gonna I'm gonna turn on my filter core national set I'm gonna say yes so here what we have are seven drugs that have a lot of data across the country across those four facilities I'm very happy with these three these three yeah they could be better tetracycline I mean it's debatable I mean it is a valuable drug so but you're only testing it less than half the time but this would be a good reasonable core set for you to discuss with your pharmacy people I'm gonna put here maybe you know gentamycin chloramphenicol that's just an internal national discussion and then I'm gonna say here no you know they may disagree so but this is a reasonable set like like dachi cycline there's nothing wrong with dachi cycline but it's very similar to tetracycline you don't really need both same thing minocycline it says very similar drug so this is for this one is for steph aureus let me just rename this is steph aureus let me know the next one do E. coli so it's good of reference labs test a lot of antibiotics but for routine labs you want to come up with a minimum set that the clinicians need to make treatment decisions so why do we aren't do antibiotic testing one reason is for clinical therapy another reason is for research and epidemiology and trends so you so a lot of the routine labs don't have to the focus their focus is what's gonna be used clinically like for example a certain drug like amicacea maybe they don't have maybe they don't have access to it they don't have access to it they don't really have to test it but it might be useful epidemiologically but that's more of a research lab you know to kind of do the general trends whether or not the drug is actually available okay what am I gonna do now that's right I was just gonna click on continue to do the E. coli the E. coli the gram negatives are usually more complicated than the gram positives because there are many more choices imipenem or meropenin cipro or levo septraxin or sephotexin on the gram positives side there are not a lot of choices let me sort this by number so I see my common antibiotics at the top of this list let me copy that over and I paste it here let me delete the antibiotics that I the columns I don't care about right now and okay core antibiotics so we see the biggest number here is 433 which is a little bit ironic because meropenin is usually a very expensive reservation it's usually not the most common drug you test because I hope it's not the most common drug they use that would be bad but it's so these three definitely are tested routinely that's over 400 but ampicillin it's only it's only 300 times and you can see it's usually resistant it's 92% resistant so this is microbiologically it's a valuable drug except in your situation it's very resistant so I would say yes because it's a very important drug for epidemiology in comparison with other countries it's just unfortunate how high how much resistance there is for you sephapine yes or no it's sort of a reserve agent tobermysin usually people do gentemysin and not tobermysin just the door handle okay so yes so personally I would do gentemysin instead of tobermysin you can see it's very similar tobermysin 289 gentemysin 277 so if you have to make a choice I personally would go with gentemysin but my choice doesn't really matter it's what your pharmacist and your clinicians want maybe for this one amicacin epidemiological it's valuable it's very effective you see gentemysin is 21% resistant amicacin is 1% resistant so it's a great drug either as first line or second line testing amoxicillin you see amoxicillin probably on the gas at the augmentant it's better than ampicillin ampicillin was 92% resistant augmentin is 59 it's still not a great drug but it is better than a ampicillin by itself seftraxone yes metropharentine yes for the urines again yes urine peptazone yes seftazidine so the list gets so long that you really have to start making choices maybe no maybe yes maybe no so for units you here we have seftraxone sorry I picked on the wrong thing seftraxone and seftraxone you don't need to test both the two drugs are basically identical seftraxone was 67% resistant seftraxone was 72% resistant so the results are always very similar so you don't need both of those perpacillin no chloramphenicol my personal view is probably no but your people may say different no 75% resistant phenelodixic acid so this list goes on and on and on but it's only 17 times 16 times seven times so and obviously penicillin is completely inappropriate for an E coli no no no I won't finish it but so here it's a lot so the gram negatives on the gram positive side there are fewer options on the gram negative side there are more options so but you there only so many antibiotics you can fit on a plate on a small plate you can comfortably fit six antibiotics on a small plate you can put six antibiotics on a large plate you can put 12 antibiotics so the question is how many drugs can they reasonably do so even here with what I put for yes just the pure yeses that's already 11 so we're starting to run out of space on the discs and I will tell you everybody has their own opinion as to what they should be testing but you need to come to some national agreement what the minimum corset is then of course if a hospital wants to do more than that they can do more than the basic minimum other questions like that we're almost finished where I'm looking at the hour 923 so so basically you have a large number of antibiotics I suggest decrease the number of antibiotics but increase the systematicness what I would love to see here is 433 Maripenems and 433 everything's just so that you have nice complete statistics for the clinician medical decisions for your epidemiology for your trends if everything is tested in exactly the same way it's easier to focus on purchasing 12 drugs completely than 30 drugs that you test once in a while of course I don't have to deal with suppliers and running out of discs and the budget but at least if you had a minimum corset you could develop your planning around the corset purchase in bulk purchase all the laboratories at the same time but don't purchase 50 drugs just purchase the core drugs that are of greatest value the laboratory wants to do more of course they can do more the last thing I want to do here so it's good I hope you have a bit sense of that what you just saw these numbers you see in front of you are all four laboratories grouped together what I'd like to do now is repeat that as a summary I click on okay there are two kinds of summaries well I mean so first the summary this is a national summary so here you see my E. Coli and my Steph Horace is a national statistic I see by denominators here on the right so E. Coli there were 284 medications there was one azithromycin just to make this a bit simpler let me just change this to one organism Steph Horace let me get rid of the E. Coli okay good so here so I'm gonna copy this table over to Excel Steph Horace what you see here the numbers you see at the bottom are the same numbers you see at the top 270 azithromycin is 78.3% resistance. Azithromycin where is it oh this is sensitive sensitive here it is here we have 78.3 percent sensitive at the top we have seventy point three percent that sensitive at the bottom in other words we're having exactly the same statistics but we have simplified it instead of one big table for Steph Horace we just have one row for Steph Horace and I'm not showing you in this row the breakpoint percent R percent I I'm not writing out everything in full it's only the summary so this is simply so if I do this is the summary version is one row and if I do this as percent R I and S these numbers are exactly the same it's just that now you see a lot of extra detail but right now I don't want to see the detail right now I just want to see the nice little summary okay so this is our summary and this is the summary for the country I want to do a different summary I want to do the summary by laboratory okay begin analysis so now I'm going to copy this table to Excel and I will continue the discussion in Excel and let me get rid of stuff you don't need okay here you see the percent sensitive right now I'm not interested in the percent sensitive I'm interested in the testing patterns so for example the this is laboratory well this is this is laboratory zero one this is laboratory zero zero one I'm sorry I got the backwards I did that again okay this is lever oops this is this is laboratory zero one two three four so I can see not only what's happening at the national level in terms of the testing I can see that is different from hospital to hospital for example here we have number of isolates let me I'm just going to delete the zero zero one so we have 98 step or is from laboratory zero one from laboratory zero zero one we just have three but that was not real I'm just going to delete that row so here I can see that laboratory one is the biggest 98 isolates followed by laboratory two 69 isolates laboratory 357 isolates let me just make the numbers bigger and the smallest is laboratory four with 43 isolates and how many times did the test is a termicin laboratory one tested at 20 times 20 out of 98 but the other laboratories did not test it at all I'm except for one here so this is an antibiotic that only ephi is testing the other laboratories are not these two laboratories did not test it at all this laboratory tested at once azm you know azm hospital four is testing it for the other three laboratories aren't all of the laboratories I am glad are testing suffoxitin so so for laboratory one it's 79 out of 98 what is that 79 out of 98 so 80 percent of the time 81 percent of the time this test of foxy tin but laboratory two it's 16 divided by 69 so laboratory two is only testing suffoxitin 23 percent of the time or how about laboratory three is equal to 42 divided by 57 I'm just going to reformat this and the last laboratory 41 divided by 43 let me just reformat this in the form of a percentage now I'm looking at the time so let's see sure this so as you can see laboratory four is doing great they tested suffoxitin 95 percent of the time laboratory two only tested at 23 percent of the time laboratory one is testing at 81 percent of the time so what we would love is everybody to be testing 95 percent of the time so then I can see it's now 930 so I can see that I'm going to delete antibiotics I'm going to hide antibiotics like a zithromycin almost nobody tested zithromycin nobody tested for a fendicol two labs tested for my son very few doctors I think you very few lenezolid very few meri-pennum very few delete norefoxicin very few pippercilin very few Tobromycin vancomycin deptomycin so this is the core set of approximately what is that one two I don't know what it is that's about eight drugs so there are eight drugs that have some real data but you can see for example laboratory two does not test tetracycline you can see that laboratory four does not do the oxycylind proxy testing but laboratory three laboratory three oh no I have it backwards so laboratory two usually tested so far laboratory two usually test the five test oxycylind so laboratory two is a mistake laboratory two looks like they are testing oxycylind but they are not testing suffoxidin I'm just going to leave it at that because of the time but I hope this was useful to you can get and I can send you the excel file you can get a sense of what people are doing what should they be doing and we want to try to bring them together so they really are testing the recommended minimal set