Prevention, Surveillance and Statistics of Resistance to Antibiotics

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Prevention, Surveillance and Statistics of
Resistance to Antibiotics

• Salma B. Galal, M.D. Ph.D.
• Prof. Public Health and Medical Sociology
• Former WHO technical officer
• Egypt
• World Congress of Microbes 2012, Guangzhou, China
  

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Purpose ofthis presentation

• to give an overview on the antimicrobial
  resistance
• to present suggested policies and strategies

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Background tothis presentation
SG

• Antimicrobial resistance (AMR) is the resistance
  of a microorganism to an antimicrobial medicine
  to which it was previously sensitive. Standard
  treatments become ineffective and infections
  persist and may spread to others.(WHO, 2012)
• Since the 40s, antimicrobial resistance (AMR) has
  been spreading in
  - number - type -
  geographically
• It leads to prolonged morbidity, risk of death
  and higher cost
• AMR might set us back to the pre-antibiotic era

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(WHO Europe, 2011)
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ANTIBIOTIC DISCOVERY AND RESISTANCEDEVELOPMENT
Antibiotic Discovered Introduced Resistance into clinical use identified
Penicillin 1940 1943 1940 (Methicillin 1965)
Streptomycin 1944 1947 1947,1956
Tetracycline 1948 1952 1956
Erythromycin 1952 1955 1956
Vancomycin 1956 1972 1987
Gentamycin 1963 1967 1970
Source CIBA Foundation (14). Reproduced with the
permission according to Stuart B Levy
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Presentation Outline
Policies and Strategies
Factors and Actions
Situation
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Drug-resistant organisms include viruses,
bacteria, fungii and parasites

• Drug resistant organisms cause-
• serious hospital infections (staphylococci,
  enterococci, gram-negative bacilli, clostridium
  difficile)
• pneumonia and tuberculosis, sexually transmitted
  diseases (some strains of HIV, Neisseria
  gonorrhea, Candida)
• food-borne diseases (Salmonella, Campylobacter)
• parasitic manifestations (Plasmodium falciparum)

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Methicillin-Resistant Staphylococcus Aureus
spread

• Antimicrobials are misused / overused. E.g.
  methicillin-resistant Staphylococcus aureus
  (MRSA) spread
• from health facilities
• to communities and
• other countries

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Methicillin-resistant Staphylococcus aureus (MRSA)

• In USA (2005), from 478.000 hospitalized staph
  aureus infections 58 were MRSA.
  94,000 persons had life-threatening
  infections and nearly 19,000 deaths resulted from
  MRSA, accounting for more deaths than AIDS,
  etc.(CDC)
• SENTRY program in South East Asia showed MRSA
  prevalence rate of 23.8, 27.8, and 5 from
  Australia, China, and the Philippines
• The prevalence in Africa ranged from 5-45
  (Bustamante,2011)

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Methicillin-resistant Staphylococcus aureus
(MRSA) declined in USA (CDC)

• Due to strict hospital infection control
  measures
• in hospitals MRSA declined 28 from 2005 to 2008
  (MRSA Statistics)
• MRSA bloodstream infections in hospitalized
  patients fell 50 from 1997 to 2007 (National
  Healthcare safety Network)
• 17 drop of community onset MRSA infections

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Multidrug-resistant Tuberculosis (MDR TB)

• According to WHO (2011), about 440 000 new cases
  of multidrug-resistant tuberculosis appear
  yearly, causing at least 150 000 deaths.
• Extensively drug-resistant tuberculosis (XDR-TB)
  has been reported in 64 countries

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John Conly, former Chairman of the Board for the
Canadian Committee on Antibiotic Resistance
(2010)

• NDM1 (New Delhi metallo-ß-lactamase-1) superbug
  is an enzyme that confers resistance to one of
  the most potent classes of antibiotics, known as
  carbapenems
• 10 of these NDM1-containing strains appear to be
  pan-resistant,
• It is governed by a set of genes that can move
  easily from one bacterium to another
• NDM1 is found in E.coli infecting kidney and
  bladder
• Treated with colistin, this antibiotic causes
  toxic effects to the kidney in a third of the
  population

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In Europe

• In EU, more than 25 000 people die each year from
  infections caused by antibiotic resistant
  bacteria (WHO Europe, 2011)
• Resistance is increasing in Europe for
  Gram-negative bacteria such as Escherichia
  coli or Klebsiella pneumoniae, where new
  resistant mechanisms are emerging and new drugs
  are not in sight.
• SG

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Food-borne induced microbial resistance

• Antibiotics are used (WHO Europe, 2011)
• to treat food animals
• to prevent them from developing diseases
• to promote their growth
• it promotes the development of antibiotic-resistan
  t Salmonella and Campylobacter and resistance
  genes that can be passed on to people
• multiresistant Salmonella Typhimurium definitive
  phage type (DT)104 that exhibits quinolone
  resistance

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(WHO Europe, 2011)
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(WHO Europe, 2011)
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Resistance to chloroquine and sulfadoxine-pyrimeth
amine (WHO)

• Resistance to chloroquine and sulfadoxine-pyrimeth
  amine is in most malaria-endemic countries
• 1947, chloroquine was used for the prophylactic
  treatment of malaria (wiki)
• 1950s, P. falciparum resistant strains appeared
  in East / West Africa, South East Asia, and South
  America
• resistant to artemisinins are emerging in
  South-East Asia (WHO)
• Chloroquine is used as anti-rheumatic, anti-viral
  (HIV1) and anti-tumor which might widen the
  spread of resistance (Krafts et al, 2012)

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chemistdirect.co.uk
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Presentation Outline
Policies and Strategies
Factors and Actions
Situation
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Factors contributing to AMR (WHO, 2012)

• National commitment and coordination is
  deficient,
• Communities are insufficiently engaged
• Surveillance and monitoring is weak / absent
• inadequate systems to ensure quality and
  uninterrupted supply of medicines

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Factors contributing to AMR(continued)

• The use of medicines is inappropriate, also in
  animal husbandry
• infection prevention and control is poor
• research and development of new diagnostics
  medicines / vaccines is insufficient

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Interagency cooperationfor food-borne resistance

• Since 2005, World Health Organization (WHO), Food
  and Agricultural Organization (FAO) and the World
  Organization for Animal Health (OIE) work on
  food-borne resistance
• to assess the public health risk associated with
  the usage of antibiotics in animal husbandry
  (including aquaculture)
• to propose high-level management options to
  address the risks identified

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WHO Surveillance Effort SG

• In 2008, WHO established the Advisory Group on
  Integrated Surveillance of Antimicrobial
  Resistance to support its effort to minimize the
  adverse effect on public health of antibiotic
  resistance associated with antibiotic usage in
  food animals (WHO Europe, 2011)
• Antimicrobial resistance surveillance guidelines
• Surveillance of resistance
• Developed Software for surveillance resistance

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Surveillance on 52 communicable diseases in EU
countries

• coordinated by the European Centre for Disease
  Prevention and Control, collects annual data on
  infections with resistant bacteria such as
• Streptococcus pneumoniae
• Staphylococcus aureus
• Escherichia coli
• Enterococcus faecalis
• Enterococcus faecium
• Klebsiella pneumoniae
• Pseudomonas auruginosa
• Clostridium difficile

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Surveillance in USA on additional 11 other AMR

• Acinetobacter baumannii
• Mycobacterium tuberculosis
• Neisseria gonorrhoeae and meningitidis
• HIV
• Plasmodium falciparum
• Haemophilus influenzae
• Helicobacter pylori
• Trichomonas vaginalis

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Presentation Outline
Policies and Strategies
Factors and Actions
Situation
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Global and National Coordination is necessary

• Antibiotic resistance data are not available in
  all countries and often in some hospitals only
• Standardization of data and indicators is
  necessary to work on globally and nationally
• On national level in developing countries-
• Education of physicians and other health care
  providers for rational use of antibiotics and
  early detection
• regulation of over-the-counter selling of
  antibiotics

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Reducing the incidence of nosocomial infections
in hospital and healthcare (AAM)

• Hand hygiene
• Isolation of infectious patients
• Hospitals have to report infection rates to
  resistance mechanisms and to antibiotics used
• Withholding reimbursement for treating
  nosocomial infections
• Mandating the use of checklists for specific
  procedures to target transmission of pathogens
  from one patient to another
• In developing countries- access to basic
  healthcare equipment and resources (safe water)

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The World Health Organizations policy package to
combat antimicrobial resistance(Emily Leung et
al, 2011)

• Commit to a comprehensive, financed national
  plan with accountability and civil society
  engagement
• Strengthen surveillance and laboratory capacity
• Ensure uninterrupted access to essential
  medicines of assured quality

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WHO policies (continued)

• Regulate and promote rational use of medicines,
  including in animal husbandry, and ensure proper
  patient care
• Enhance infection prevention and control
  
• Foster innovations and research and development
  for new tools
• no action today, no cure tomorrow
• 7.April world day of AMR
  SG

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USA Interagency Task Force on Antimicrobial
Resistance (Interagency Task Force on
Antimicrobial Resistance , USA,2010)

• 1. Surveillance
• Goal 1 Improve the detection, monitoring, and
  characterization of drug-resistant infections in
  humans and animals.
• Goal 2 Better define, characterize, and measure
  the impact of antimicrobial drug use in humans
  and animals in the United States.
• SG

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2.Prevention and Control

• Goal 3 Develop, implement, and evaluate
  strategies to prevent the emergence,
  transmission, and persistence of drug-resistant
  microorganisms.
• Goal 4 Develop, implement, and evaluate
  strategies to improve appropriate antimicrobial
  use.
  
  
  
  
  
  
  SG
• 
  

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3. Research

• Goal 5 Facilitate basic research on
  antimicrobial resistance.
• Goal 6 Practical applications of findings for
  the prevention, diagnosis and treatment of
  resistant infections.
• Goal 7 Facilitate clinical research to improve
  the treatment and prevention of antimicrobial
  drug resistant infections.
• ? Goal 8 Conduct and support epidemiological
  studies to identify key drivers of the emergence
  and spread of AR in various populations.
  SG

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4. Product Development

• Goal 9 Provide information on the status of
  antibacterial drug product development and
  clarify recommended clinical trial designs for
  antibacterial products.
• Goal 10 Consider opportunities for international
  harmonization and means to update susceptibility
  testing information for human and animal use.
• Goal 11 Encourage development of rapid
  diagnostic tests and vaccines.

SG
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Next steps

• Surveillance in hospitals for early detection of
  antibiotic resistance
• Report to central authorities
• Networking of information
• Centrally controlled actions and measures
• standardized nomenclature and laboratory
  procedures

SG
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References

• American Academy of Microbiology (AAM),
  Antibiotic Resistance An Ecological Perspective
  on an Old Problem, 2009
• Interagency Task Force on Antimicrobial
  Resistance, co-chairs Centers for Disease Control
  and Prevention, Food and Drug Administration,
  National Institutes of Health others, A public
  health action plan to combat antimicrobial
  resistance, 2011 2007
• Emily Leung et al, The WHO policy package to
  combat antimicrobial resistance, Bull World
  Health Organ 201189390392 doi10.2471/BLT.11.
  088435
• WHO Regional Office Europe, Tackling antibiotic
  resistance from a food safety perspective in
  Europe, 2011
• Stuart B Levy, Introduction, WHO Antibiotic
  Resistance synthesis of recommendations by expert
  policy group, 2001
• See also references mentioned in slides /
  comments