Antibiotic resistance among in- and outpatients attending
Lashkar-Gah hospital, Afghanistan
Antimicrobial resistance
• Antimicrobial resistance (AMR) is defined as “resistance
of a microorganism to an antimicrobial drug that was
originally effective for treatment of infections caused by
it”
• It represents a considerable public health threat:
– Requires longer and more expensive treatment
– Negatively affects patient outcomes
– Erodes our armamentarium of drugs against microorganisms
Global context
• Poor availability of AMR data all over the world,
especially in developing country settings
• Suspicions that Asia has the highest level of AMR
• Current consensus about a clear correlation between
anarchic, unregulated use of antibiotics and levels of
AMR
Afghan context
• Unregulated market of antibiotics (subquality, selfmedication…)
• High pressure from patients to obtain antibiotics
from the prescriber (often IV drugs!)
• Over-prescription in hospitals AND private practice
• Suspected therapeutic failures in MSF-Hospital
MSF-Afghanistan context:
Poor therapeutic outcomes…
Lashkar Gah Hospital (Helmand)
In Lashkar-Gah
hospital
(Helmand):
Unexplained
high paediatric
mortality rates
MSF-Afghanistan context:
Overuse of antibiotics…
Over-prescriptions
of antimicrobial
drugs among all
outpatient
consultations
Cf. study Sahar Bajis:
“Antimicrobial use in a
district hospital in
Kabul, Afghanistan –
are we too high?“
Ahmad Shah Baba hospital (Kabul):
How to assess AMR reality?
How to collect data?
Option 1?
Install a bacteriology lab for routine bacteriology
and
… be patient 2-3 years to obtain aggregated data?
Option 2?
Collect enough bacteria from voluntary inhabitants
(such as in- and outpatients of an « MSF-hospital »)
and screen for resistance…
4 months
We’ve chosen Option 2
… for a first statement
Methods
• Study conducted in Lashkar-Gah hospital
(Helmand), Afghanistan
• Screening of normal flora was chosen
• Adult and paediatric in- and outpatients
requested to provide a stool and/or
nasopharyngeal swab sample
• Bacteria cultured from these samples and
tested for AMR
Screening of normal flora
- limitations
• Everyone of us is carrying thousands of millions of
bacteria. We are reservoirs.
• Sepsis is the most often due to an intrusion of one of
these bacteria in our bloodstream.
• The bacteria we “carry” can be used as indicators for
levels of AMR among pathogenic bacteria.
HOWEVER… this is not the same as resistance testing
of pathogens in a routine laboratory
RESULTS
Bacterial species isolation
• Screening of normal flora:
Participants recruited
IPD / OPD
Adult / Paediatric
2077
Stool samples
692
Nasopharyngeal swabs
1762
482 E. coli isolates
173 S. pneumoniae isolates
447 Enterococcus species isolates
115 H. influenzae isolates
259 S. aureus isolates
Levels of AMR
E. coli as indicator species: proportion of patients with
a resistant organism (N=114)
Tigecycline
Others.
Nitrofurantoin
Chloramphenicol
Netilmicine
Imipenem
Meropenem
Amikacine
Amino Quinol.
glycos.
Cefoxitin
Amoxi / Clav
E
S
B
L
Pipera / Tazo
ß-Lactamins
How to become an AMR specialist?
Interpretation of resistance in a population of species
ONLY SUSCEPTIBLE STRAINS
A nice bell curve taking place
on the right of the graph
0% R
A FEW RESISTANT STRAINS
8% R
Imperfect bell curve
+ shifting to the left
(diameters becoming smaller)
shift
MAINLY RESISTANT STRAINS
80% R
Bell curve has disappeared
Most of the strains are on the left
E. coli: Penicillins
& ß-lactamase inhibitors
R
R
S
S
R
R I
I
S
S
R
R
S
I
S
C2
E. coli &
Cephalosporins
S
R
C3
I
R
I
R
R
S
I
S
S
Cephamycines
R
S
C4
R
I
S
R
E. coli & Quinolones
Ofloxacine
Ciprofloxacine
Levofloxacine
Moxifloxacine
I
S
E.coli & Aminoglycosides
Gentamicine
Tobramycine
Netilmicine
Amikacine
R
I
S
E. coli & Penems
Imipenem
R
I
S
R
I
S
Meropenem
E. coli & other antibiotics
Chloramphenicol
R
S
Tigecycline
R
I
S
Resistance in S. pneumoniae (N=64)
Screening by oxacilline shows
a decreased susceptibility to penicillin
MICs to Penicillin could be tested:
16 strains were oxa-R….
MIC values are <= 2 mg/l
Thus: decreased susceptibility,
but no high level of resistance
Discussion
• A wake-up call to MSF: our protocols and
standard treatment guidelines risk to be
outdated
?
Discussion
• Diagnosis of AMR under field conditions is a
bottle-neck – study shows the feasibility of
laboratory screening of AMR in normal flora,
but not as matter of routine
=> Haemoculture as routine feasible?
• Holistic management of AMR (rational drug
use, infection control, improved diagnostics) is
required to avert public health disaster
Lashkar Gah team July 2013
In MSF-compound
Thanks to
everybody !
It has been
a incredible challenge
not possible without
a huge involvement of
everyone !
Boost Hospital
Lashkar Gah
Special thanks
Health promotion:
Caroline Zahndt
Abdul Bashir
And all their wonderful
TEAM!
Management:
Catherine Van Overloop
Gabriele Rossi (« SuperMedco »)
Gbane (« huge support for end phase »)
LuxOR:
Rafael Van den Bergh
Rony Zachariah
And all the TEAM!
OCB-Medical Depatment:
Michel Van Herp
Pascale Chaillet
MSF-Supply
Diana & Sonia
Lab:
Dr Wardak
Bismillah
Sher Agah
Baryalai
Logistics / Supply:
Ann, Ben, Ryan, Antoine, Bazir, …
Sorry for anyone I would have forgotten !!!!