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

• to give an overview on the antimicrobial resistance

• to present suggested policies and strategies

Purpose ofthis presentation

• 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

(WHO Europe, 2011)

ANTIBIOTIC DISCOVERY AND RESISTANCEDEVELOPMENT

Antibiotic Discovered

Introduced

Resistanceinto 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

Policies andStrategies

Policies andStrategies

Factors andActions

Factors andActions

Situation

Presentation Outline

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)

Drug-resistant organisms include viruses, bacteria, fungii and parasites

Antimicrobials are misused / overused. E.g. methicillin-resistant Staphylococcus aureus (MRSA) spread

from health facilities

to communities and

other countries

Methicillin-Resistant Staphylococcus Aureus spread

• 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)

Methicillin-resistant Staphylococcus aureus (MRSA)

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

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

• 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

Multidrug-resistant Tuberculosis (MDR – TB)

• NDM1 (New Delhi metallo-β-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

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

In Europe

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-resistant 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

Food-borne induced microbial resistance

(WHO Europe, 2011)

(WHO Europe, 2011)

• Resistance to chloroquine and sulfadoxine-pyrimethamine 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)

Resistance to chloroquine and sulfadoxine-pyrimethamine (WHO)

chemistdirect.co.uk

Policies andStrategies

Policies andStrategies

Factors andActions

Situation

Presentation Outline

• 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

Factors contributing to AMR (WHO, 2012)

• 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

Factors contributing to AMR(continued)

• 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

Interagency cooperationfor food-borne resistance

• 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

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

Surveillance on 52 communicable diseases in EU countries

• Acinetobacter baumannii

• Mycobacterium tuberculosis

• Neisseria gonorrhoeae and meningitidis

• HIV

• Plasmodium falciparum

• Haemophilus influenzae

• Helicobacter pylori

• Trichomonas vaginalis

Surveillance in USA on additional 11 other AMR

Policies andStrategies

Factors andActions

Factors andActions

Situation

Presentation Outline

• 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

Global and National Coordination is necessary

■ 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)

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

• 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

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

WHO policies (continued)

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

2.Prevention and Control

3. Research

• 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.

4. Product Development

• 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

Next steps

• 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 2011;89:390–392 | doi:10.2471/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

References