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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 – PowerPoint PPT presentation

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Title: Prevention, Surveillance and Statistics of Resistance to Antibiotics


1
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

2
Purpose of this presentation
  • to give an overview on the antimicrobial
    resistance
  • to present suggested policies and strategies

3
Background to this 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

4
(WHO Europe, 2011)
5
ANTIBIOTIC DISCOVERY AND RESISTANCE DEVELOPMENT
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
6
Presentation Outline
Policies and Strategies
Factors and Actions
Situation
7
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)

8
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

9
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10
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)

11
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

12
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

13
(No Transcript)
14
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

15
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

16
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

17
(WHO Europe, 2011)
18
(WHO Europe, 2011)
19
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)

20
chemistdirect.co.uk
21
Presentation Outline
Policies and Strategies
Factors and Actions
Situation
22
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

23
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

24
Interagency cooperation for 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

25
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

26
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

27
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

28
Presentation Outline
Policies and Strategies
Factors and Actions
Situation
29
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

30
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)

31
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

32
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

33
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

34
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


35
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

36
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
37
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
38
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
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