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Antimicrobial Resistance: What Can We Do? - Dr. Terry Dwelle, State Health Officer, North Dakota Department of Health, from the 2013 NIAA Symposium Bridging the Gap Between Animal Health and Human Health, November 12-14, 2013, Kansas City, MO, USA. More presentations at http://www.trufflemedia.com/agmedia/conference/2013-niaa-antibiotics-bridging-the-gap-animal-health-human-health
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ANTIMICROBIAL RESISTANCE WHAT CAN WE
DO?Terry L Dwelle MD MPHTM FAAP CPH
State Health OfficerNorth Dakota Department of Health
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Antibiotic Era
Antibiotics first employed in the 1940’s Antibiotics + Vaccination + Sanitation =
Marked decline in deaths from ID’s Antimicrobial resistance is a major ID
threat to PH Much attention given to nosocomial
infections – ie VRE Community acquired resistance is rising –
St Pneu., E Coli, Salmonella, etc. Is an evolving problem – spans all health
care settings.
Major antibiotic categories Aminoglycosides Beta lactams – penicillins, cephalosporins, carbapenems,
monbactams Flouroquinolones Glycopeptides Ketolides Lincosamides Macrolides Oxazolidinones Streptogramins Sulfonamides Tetracyclines Levomycetinums Ionophores Bambermycins Polypeptide s
Why we use antibiotics?
Treat infections – animals and humans Prevent infections
Humans - surgical wounds, dental prophylaxis for endocarditis, neutropenia
Animals – prevent disease when animals are susceptible
Promote growth – cattle, poultry and swine
World Hunger
Developed Countries; 19; 2%
NE and N Africa; 37; 4%
Latin Am and Carribean; 53;
6%
SS Africa; 239; 26%
Asia and Pacific; 578; 62%
925 million hungrypeople in 2010, 13.7 % ofthe 6.8 billion peoplein the world
Children at risk
160 days of illness per year ½ of the 10.9 million deaths per year Magnifies the effect of diseases like
measles and malaria
Antibiotics and Animal growth
Swine – 3-9% improved weight gain, 3-7% improved feed efficiency.
Greatest benefit when feed composition, management practices and health status of animals is not optimal.
Action Eliminate bacteria that steal essential nutrients Reduce competition with beneficial bacteria that
produce essential nutrients for the animal. Control growth of bacteria that cause low-grade
infections or produce toxins – decreasing nutrient absorption.
Antibiotics used for animal growth
Human and Animal Tetracyclines Sulfonamides Penicillins Macrolides Fluoroquinolones Cephalosporins Aminoglycosides Chloramphenicols Streptogramins Polypeptides
Animal only Ionophores Bambermycins
Resistance
Strep. Pneumoniae Moraxella Catarrhalis Hem Influenza Type B Strep Pyogenes E. Coli Neis. Meningitidis Campylobacter Salmonella Shigella Staph Aureus Enterococcus Mycobacterium Tuberculosis Pertussis
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Reasons
Inappropriate antimicrobial prescribing – most important Overuse – 30-60% prescriptions are
inappropriate Inappropriate dosing Use of broad spectrum AB’s as first line Rx
Animal applications (food)
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Prescriptions - 1992Adults Prescribing Rates
Colds 51%
URI 52%
Bronchitis 66%
Children
Colds 44%
URI 46%
Bronchitis 75%
Gonzales R et al JAMA 1997:278:901-904. Nyquist AC et al JAMA 1998;279:875-77
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Broad Spectrum Antibiotic Use
• 46% of patients with common cold or non-specific URI’s received antibiotics
• Broad spectrum antibiotics used; 54% general, 51% colds, 53% sinusitis, 62% acute bronchitis, 65% OM
• Lower BS use – blacks, lack of insurance, HMO membership
• Greater use of BS- Northeast and South
JAMA 2003;289:719-725
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Patient Pressure
12% recently taken antibiotics 27% believed taking antibiotics during a
cold made them better 32% believed taking antibiotics during a
cold prevented more serious illness 48% expected antibiotics when seeking
medical care with a cold 58% not aware of the health risks of
antibiotics
Emerg Inf Dis: 9;9, pp 1128-1134 – JD Eng, et al
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Veterinary Usage
Human health hazards Antibiotic resistance particularly with low
dosing (ie Salmonella) Glycopeptide resistant E faecium of animal
origin – find in stools for 14 + days after ingestion of meat
Cross resistance ie Virginimycin and Quinupristin-dalfopristin
in enterococci
Sorensen TL, NEJM 2001;3435:1161-6, Welton LA et al AntiAgChem 1998;42:705-8
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Veterinary Usage Continued
Human Health Hazards Salmonella enterica (flouroquinolone resistant)
spread from swine to humans in meat
Chiu CH NEJM 2002;346:413-9
Association of Animal Antibiotic use and Antibiotic resistance in
humans Europe – 1990’s – Avoparin use
associated with vancomycin resistance in humans
US – 1990’s – Campylobacter resistance to fluoroquinolones
What can be done?
Use antibiotics only when indicated Least broad spectrum antibiotics first Least time exposure possible Use adequate therapeutic doses Use non-human antibiotics when possible With crossover drugs use those where
potential resistance will have the least impact on humans
Appropriately monitor cultures and sensitivities
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Resistance Reversal - Iceland
PRSP rose from 0% (1988) to 20% (1993) Information campaign – physicians Regulatory change – patients paid for
prescription drugs PRSP declined to 15% (1995)
Stephenson J, JAMA 1996;275-175, Gunnlaugsson A, AntiAgChem Conf, 1999, Abstract 1026
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Resistance Reversal - Finland
Macrolide use tripled in the 1980’s Erythromycin resistance for Gp A strep
rose sharply (17%) in the early 1990’s National campaign for physicians Resistance declined to 9% from 1992 to
1996
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Resistance Reversal - Med Center One
1980’s Appropriate use of advanced spectrum
antibiotics – 65% All advanced spectrum antibiotic orders
received a form to be completed within 24 hours (justification of usage)
No adequate response – consult or could result in loss of privileges
Appropriate use increased to > 95%
Resistance Reversal – Animal Antibiotic usage
Europe – Vancomycin resistance Denmark – reduction in resistance in E
Faecium in broiler chickens (from 60-80% to 5-35%) WHO Internation Panel Ruling, Nov, 2002)
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Tactics
Public Information Campaigns Intensive Information Campaigns for
Physicians Proactive Hospital Antibiotic Usage
Programs Collaborative task force – Veterinarians,
Physicians, and Public Health
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