CHOICE OF ANTIBIOTICS IN THE VIEW OF DEVELOPING ANTIBIOTIC RESISTANCE

1
CHOICE OF ANTIBIOTICS IN THE VIEW OF DEVELOPING
ANTIBIOTIC RESISTANCE

• Dr. Jolanta Miciuleviciene
• Vilnius City Clinical Hospital
• National Public Health Surveillance Laboratory

BARN 3rd Workshop "Prevention of Surgical Site
Infections" Visby, 2012
2


Discovery of Penicillin Changes
the History of Medicine

• In 1928 Sir Alexander Fleming, a Scottish
  bacteriologist, left a Petri dish with
  staphylococci uncovered. When he returned, he
  noticed that there was mold growing on it. Upon
  further examination, he saw that the area around
  the mold had no bacteria growing.
• Fleming concluded that the mold was releasing a
  substance that was inhibiting bacterial growth.
  He grew a pure culture of the mold and discovered
  that it was a Penicillium, now known to be
  Penicillium notatum.

3
(No Transcript)
4
Antimicrobial resistance

• Soon after the introduction of the penicillin
  into clinical practice, the fact that the
  development of antibiotic resistance would be a
  problem became apparent.
• Resistance to penicillin in some strains of
  Staphylococcus was recognized almost immediately
  after introduction of the drugs. Resistance to
  penicillin today occurs in as many as 90 of all
  strains of Staphylococcus aureus

5


Antimicrobial resistance

• Most commonly, this refers to infectious microbes
  that have acquired the ability to survive
  exposures to clinically relevant concentrations
  of antimicrobial drugs that would kill otherwise
  sensitive organisms of the same strain.

6

Resistant Nosocomial Pathogens

• S.aureus (MRSA, GISA),
• Enterococcus spp. (VRE),
• E.coli (ESBL),
• Klebsiella pneumoniae (ESBL, KPC),
• Enterobacteriaceae (MDR),
• Pseudomonas aeruginosa (MDR),
• Acinobacter baumannii (MDR).

7

European Antimicrobial
Resistance Surveillance Network (EARS Net)

Streptococcus pneumoniae, Staphylococcus
aureus, Enterococcus faecalis, Enterococcus
faecium Escherichia coli, Klebsiella
pneumoniae, Pseudomonas aeruginosa.
8

EARS Net participants in
Lithuania 10 laboratories of microbiology
37 hospitals

9
Number of blood-stream
infections, Lithuania, 2007 2011
10
Staphylococcus aureus trends
of invasive isolates resistant to meticillin
(MRSA),Lithuania, 2007-2011

2007m. - 241/22, 2008m. - 280/31, 2009m. -
255/29, 2010m. 257/36, 2011m. 263/16
11
Staphylococcus aureus
proportion () of invasive isolates resistant to
methicillin (MRSA), 2010

12
Klebsiella pneumoniae trends
of invasive isolates resistance to
third-generation cephalosporins, fluoroquinolones
and aminoglycosides, Lithuania, 2007-2011

13
Klebsiella pneumoniae
proportion () of invasive isolates with
resistance to third-generation cephalosporins,
2010

14
Klebsiella pneumoniae
proportion () of invasive isolates with
resistance to carbapenems, 2010

15
Number of K.pneumoniae blood
stream infections, Lithuania, 2007-2011.

16
Risk factors of developing bacterial resistance

• Inappropriate prescribing (overprescribing)
• Inappropriate selection of antimicrobial (broad
  spectrum cephalosporins, fluoroquinolones,
  carbapenems, glycopeptides)
• Prolonged administration of antimicrobial.

17
Evidence Based

• Evidence-based medicine is the process of
  systematically finding, appraising, and using
  research findings as the basis for clinical
  decisions.
• BMJ 19953101122-1126 (29 April)
• William Rosenberg, Anna Donald
• Evidence-based Medicine An Approach to Clinical
  Problem-solving

18
Evidence-based medicine

• Reference
• Cook PP, Catrou P, Gooch M, Holbert D. Effect
  of reduction in ciprofloxacin use on prevalence
  of methicillin-resistant Staphylococcus aureus
  rates within individual units of a tertiary care
  hospital. Journal of Hospital Infection. 2006
  64 348-351
• Setting
• 731-bed tertiary care teaching hospital,
  Greenville, NC, USA.

19
Evidence based medicine

• Intervention
• Reduction - Active monitoring of oral and IV
  ciprofloxacin use. 
• Impact
• Ciprofloxacin use decreased by 31.2
  (plt0.0001). MRSA rates decreased from 59.6 to
  54.2 (p0.112).  Correlation between
  ciprofloxacin use and MRSA rates (r0.70 95 CI
  -0.01-0.94 p0.053).

20
Evidence based medicine

• Reference
• Rahal JJ, Urban C, Horn D, Freeman K,
  Segal-Maurer S, Maurer J, Mariano N, Marks S,
  Burns JM, Dominick D, Lim M. Class restriction of
  cephalosporin use to control total cephalosporin
  resistance in nosocomial Klebsiella.  JAMA,
  1998280(14) 1233-1237
• Setting
• 500-bed university affiliated community
  hospital, Queens, NY, USA

21
Evidence based medicine

• Intervention
• Restriction - Hospital adopted antibiotic
  guidelines restricting routine cephalosporin use.
  
• Impact
• 80.1 reduction in hospital-wide
  cephalosporin use in 1996 compared to 1995.  44
  reduction in incidence of ceftazidime-resistant
  Klebsiella infection and colonization throughout
  medical center (plt0.01) and 70.9 reduction in
  all intensive care units (plt0.001).

22
Evidence based medicine

• Intervention
• Restriction - Hospital adopted antibiotic
  guidelines restricting routine cephalosporin use.
  
• Impact
• 80.1 reduction in hospital-wide
  cephalosporin use in 1996 compared to 1995.  44
  reduction in incidence of ceftazidime-resistant
  Klebsiella infection and colonization throughout
  medical center (plt0.01) and 70.9 reduction in
  all intensive care units (plt0.001).

23
Take home message

• Inappropriate selection and prolonged
  administration of antimicrobials

Fluoroquinolones Cephalosporins Carbapenems Glycopeptides. S.aureus (MRSA, GISA), Enterococcus spp. (VRE), E.coli (ESBL), Klebsiella pneumoniae (ESBL, KPC), Enterobacteriaceae (MDR), Pseudomonas aeruginosa (MDR), Acinobacter baumannii (MDR).
THANK YOU !