DR.ALTAF AHMED Consultant Microbiologist

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DR.ALTAF AHMEDConsultant Microbiologist
Director Lab Services, The Indus Hospital,
KarachiPresident, Infectious Diseases Society of
Pakistan

• Rational use of antibiotics

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PROBLEMS RELATED TO TREATMENT OF INFECTIOUS
DISEASES

• Increasing number of ESBL-producing Gram negative
  bacteria (ESBL)
• Increasing frequency of infections due to
  Resistant Gram positive bacteria
  (MRSA,VRE,CAMRSA)
• Emergence of new pathogens-Pan resistance bugs
• Quinolone resistant Salmonella typhi
• MDR TB
• Penicillin resistant Strep.pneumoniae
• __________________________________________________
  ____
• Quality of available drugs ?
• Do we need antibiotic policy?
• How important is infection control?
• Is there a need for hospital waste disposal?
• Do we need to improve house keeping?
• Quality and quantity of nursing staff?
• Surveillance/data collection?

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Increasing Numbers Clinical significance of
ESBLProducers
GRAM NEGATIVE BACTERIA

• Extended spectrum beta lactamases

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SOMEWHERE IN KARACHIPlease Vote

• In your experience, the prevalence of ESBLs in
  your Intensive Care Unit(s) is __________?
• Growing
• Declining
• Staying the same
• Dont know 90

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Extended Spectrum Beta- Lactamase(ESBL) producing
Nosocomial GNRs

• 50 AKU, Karachi Jabeen K, Zafar A, Hasan R
• JPMA 2005
• 37 PIMS, Islamabad Shah A, Hasan F, Ahmed S.
• Pak J Med Science. 2003
• 45 AMC, Rawalpindi Rafi A, Qureshi AH.
• JAMC2003

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Some Speciesin which ESBLs are Found

• Klebsiella
• Escherichia coli
• Enterobacter
• Proteus
• Salmonella
• Citrobacter
• Pseudomonas
• Acinetobacter
• and others!!!

Numbers are increasing every week
Bradford PA. Clin Microbiol Rev. 200114933
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Risk Factors for ESBL Infection

• Length of hospital stay1
• Severity of illness1
• Time in the ICU1
• Intubation and mechanical ventilation1,2
• Urinary catheterization1,2
• Arterial catheterization1,2
• Previous exposure to antibiotics1

1Bradford PA. Clin Microbiol Rev.
200114933-951. 2Peña C, et al. J Hosp Infect.
1997359-16.
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Overuse of Cephalosporins Leads to Resistance
Third-generation cephalosporins
Overuse
Klebsiella spp. E. coli with ESBL
Enterococcus spp.
Resistance
No coverage
Imipenem/cilastatin
Vancomycin
Overgrowth
Selection
Acinetobacter spp.
VRE
Fungi, yeast
Reprinted with permission from Bernstein JM, et
al. Chest. 1999115(suppl)1S-2S.
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Impact of Inadequate Initial Therapy on Mortality
in ESBL Infections
Association between delay in initiation of
adequate initial antimicrobial therapy and
mortality
Sites of infection with ESBLs
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120
Plt0.001 (?2, Trend)
Klebsiella spp.
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E. coli
100
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12
80
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Mortality
Total Number

60
8
6
40
4
20
2
0
0
lt24
lt48
lt72
lt96
lt120
gt120
SST
Other
Blood
Urinarya
Wound
Abdominal
Respiratory
Time to institution of effective antimicrobial
therapy (hours)
SST, skin and soft tissue.
aOnly patients with non urinary ESBL-producing E.
coli and Klebsiella spp. infections had a
significantly elevated risk of death.
Reprinted with permission from Hyle EP, et al.
Arch Intern Med. 20051651375-1380.
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Trends in Gram-Positive Resistance US
1980 to 1999
100
90
80
70
MRSE
60
MRSA
50
Percent of Pathogens Resistant to Antibiotics
40
DRSP
30
VRE
20
10
VISA
0
1975
1980
1985
1990
1995
2000
1997
Thronsberry C. NNIS. 38th ICAAC.1998 San Diego,
Calif Abstract E221 Edmond M. CID 1999, MMWR
Morb Mortal Wkly Rep. 199746624-636.2
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Gram Positive Infections

• Most prominent nosocomial pathogens,
• especially in the ICU
• Contribute to significant mortality morbidity
• With increasing antibiotic resistance, few
• therapeutic choices remain
• Substantial costs incurred with the use of more
• expensive drugs prolonged hospital stay

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Prevalence of MRSA in Asia Pacific Region
2003/2004
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STAPHYLOCOCCUS SPP
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MRSA STUDY

• Patients and methods
• departments of surgery, dermatology and
  pathology, Combined Military Hospital, Gujranwala
  Cantt to know the prevalence of MRSA amongst
  community vs. hospital acquired skin and soft
  tissue infections (SSTIs).
• A total of 216 community acquired and 48 hospital
  acquired SSTIs were included in the study. The
  pus swabs/pus specimens collected from all the
  cases were processed for routine cultures.
  Results
• Staphylococcus aureus was isolated in 64.35 of
  the community acquired and 72.91 of the hospital
  acquired SSTIs.
• Prevalence of MRSA amongst community acquired
  SSTIs was 26.6 while in the hospital acquired
  SSTIs was 68.57.
• Authors Khalil Ahmed, Abid Mahmood, Muhammad
  Khurram Ahmad, Khurram Hussain, Mehreen Ali
  Khan

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• DONT WORRY DR.ALTAF, WE WILL GET NEW ANTIBIOTICS

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• Hospital acquired infections kill 5000 patients
• a year in England
• 100000 cases of hospital acquired infection in
• England each year
• BMJ 2000 3211370
• In USA - Hospital infections, kills about 90,000
  people a year
• HOW MANY IN PAKISTAN?

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QUALITY AND POTENCY OF ANTIMICROBIAL DRUGS
? Drugs are produced locally in India , Veitnam,
and Pakistan etc. India - 80 different brands of
fluoroquinolones Pakistan 176 brands of
Ciprofloxacin In Vietnam - Locally acquired 500
mg capsule of Ciprofloxacin cost 400 dong (2
pence). The average weight of the capsule is 405
mg with a potency equivalent to 20mg of pure
Ciprofloxacin. Antimicrobial resistance in
developing countries C A Hart, professor, a
S Kariuki. BMJ 1998317647-650
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Prevention is better than cure!
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Nosocomial infection in developing countries

• The most important factors associated with its
  spread were found to be
• poor hospital hygiene.
• Overcrowding.
• lack of resources for infection control.
• lack of personnel trained in controlling
  infections in hospital.
• Gakuu LN. East Afr Med J 1997 74 198-202
• Thevanesam V et all. J Hosp Infect 1994 26
  123-127.
• Ben Hassen A et al. Bull Soc Pathol Exot 1995
  88 257-259.

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Reducing ventilator-associated pneumonia rates
through a staff education programme.

• VAP infection rates reduced by 51, from a mean
  of 13.2/-1.2 in the pre-intervention period to
  6.5/-1.5/1000 device days in the
  post-intervention period (mean difference 6.7
  95 CI 2.9-10.4, P 0.02).
• A multidisciplinary educational programme geared
  towards intensive care unit staff can
  successfully reduce the incidence rates of
  VAP..

J Hosp Infect. 2004 Jul57(3)223-7
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Process Analysis. Hand washing Compliance.
Global Monthly Compliance. Liaquat National
Hospital Medical ICU
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Process Analysis. Hand Washing Compliance.
Compliance By Health Care Workers Type. Liaquat
National Hospital Medical ICU
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Break the Chain of Infection
Infectious Agents Bacteria FungiViruses
Protozoa
Susceptible Host ImmunosuppressionDiabetes
Surgery BurnsCardiopulmonarys
Reservoirs People EquipmentWater
Hand washing
Isolation
Air flow control
Portal of Entry Mucos Membrane GI
TractRespiratory Broken Skin
Portal Of Exit Excretions SecretionsSkin Droplet
s
Food Handling
Sterilization
Means Of Transmission Direct Contact
FomaitesIngestion Airborne
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COCKROACHES

• Frequency of different species of cockroaches in
  tertiary care hospital and their role in
  transmission of bacterial pathogensPakistan J
  Med Res Dec 200544(4)143-8.Army Medical
  College, Rawalpindi
• Aims To identify different species of
  cockroaches in tertiary care hospital of
  Rawalpindi and evaluate their role in the
  transmission of bacterial pathogens as carrier
  agents.
• Design and setting Three species of cockroaches
  namely Periplaneta Americana (American
  cockroach), Blatta orientalis (Oriental
  cockroach) and Blattella germanica (German
  cockroach) were identified.
• They were collected from nine sites of the
  hospital viz. Medical ward-16, Medical ward-2,
  Medical ward-10. Children medical ward,
  Gynecology and Obstetrics ward, Children surgical
  ward, Female surgical ward, Skin ward and Cook
  house.

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COCKROACHES

• Results A total of 100 cockroaches were
  collected from various sites of a tertiary care
  Hospital from Oct-Dec 2004. American cockroaches
  were the most common in all the sites accounting
  for 73 followed by Oriental cockroaches 18 and
  German cockroaches 9.
• Thirteen types of bacteria were isolated which
  included Enterococcus spp 13.4, Proteus spp
  11.5, Citrobacter spp 11.3, Klebsiella
  pneumoniae 12.8, Escherichia coli 9.7,
  Enterobacter spp 8.0, Pseudomonas spp 8.0,
  Bacillus spp 6.9, Pseudomonas aeruginosa 5.7,
  Serratia marcescens 4.7, Providencia spp 3.4,
  Staphylococcus spp 2.3 and Klebsiella oxytoca
  1.8. The prevalence of Periplaneta americana was
  highly significant and Enterococcus spp was the
  most common bacterial isolate in the hospital
  environment.
• Conclusions Cockroaches appear to be potential
  source of spread of infection in the hospitals.
  Effective measures need to be taken to tackle
  this issue.

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Infection control is
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WE NEED MORE INCINERATORS
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Please Remember

• Infection control is everyones job and
  responsibility
• The effectiveness of program depends on
  everyones commitment

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UNRELIABLE LAB REPORTS

• Culture not send properly
• Culture not performed properly
• Pathogen not identified
• Unreliable sensitivity test
• Typing errors
• 40 bhatta culture?

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LABORATORY?
CONSULTANT
SWEEPER
patient
RMO
WARDBOY
RESIDENT
NURSE

• POOR QUALITY SPECIMENS GENERATE USELESS RESULTS!

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LNH--------------------AKUH

• 465---- blood culture-----750
• 85---------urine d/r---------150
• 300------------cbc----------420
• 700---------typhidot-------860
• 200-------------widal-------470
• 550----------mpICT--------490
• Rs.2300----------Total--------Rs.3140
• Doctors fee,medicine,x-ray/ultrasound etc.

A dilemma-what is your suggestion?
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?
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SWEDEN
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Zulfiqar A. Bhutta, AKUH
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Zulfiqar A. Bhutta, AKUH
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Antibiotics are not the solution for every illness
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Institutional Strategies to Control Antibiotic
resistance

• Physician education 2,4
• Rigorous infection control 1,3
• Accurate laboratory reporting 1,2,3,4
• Antibiotic control 1,2,3,4

1. Meyer KS et al. Ann Intern Med. 1993119353
2. Patterson JE et al. Infect Control Hosp
Epidemiol. 200021455 3. Peña C et al.
Antimicrob Agents Chemother. 19984253 4. Rice
LB et al. Clin Infect Dis. 199623118
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My message to all

• Guidelines does not work unless they are
  implemented!
• Implementation does not work unless there is
  local comittment and educational outreach!

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• THANK YOU

www.idspak.org
altafvirus_at_yahoo.com