DR.ALTAF AHMED
Consultant Microbiologist & Director Lab Services,
The Indus Hospital, Karachi
President, Infectious Diseases Society of Pakistan
Rational use of antibiotics
PROBLEMS RELATED TO TREATMENT OF
INFECTIOUS DISEASES
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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
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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?
GRAM NEGATIVE BACTERIA
Increasing Numbers & Clinical
significance of ESBL
Producers
Extended spectrum beta
lactamases
SOMEWHERE IN KARACHI
Please Vote
• In your experience, the prevalence of
ESBLs in your Intensive Care Unit(s) is
__________?
a.
b.
c.
d.
Growing
Declining
Staying the same
Don’t know – 90%
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
Some Species
in which ESBLs are Found
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Klebsiella
Escherichia coli
Enterobacter
Proteus
Salmonella
Citrobacter
Pseudomonas
Acinetobacter
and others!!!
Numbers are increasing every week
Bradford PA. Clin Microbiol Rev. 2001;14:933
Risk Factors for ESBL Infection
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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
2Peña
PA. Clin Microbiol Rev. 2001;14:933-951.
C, et al. J Hosp Infect. 1997;35:9-16.
Overuse of Cephalosporins Leads to Resistance
Third-generation cephalosporins
Overuse
Klebsiella spp.
E. coli
with ESBL
Enterococcus spp.
Resistance
Imipenem/cilastatin
No coverage
Vancomycin
Overgrowth
Acinetobacter spp.
Fungi, yeast
Reprinted with permission from Bernstein JM, et al. Chest. 1999;115(suppl):1S-2S.
Selection
VRE
Impact of Inadequate Initial Therapy on Mortality in
ESBL Infections
Association between delay in initiation
of adequate initial antimicrobial
therapy and mortality
18
P<0.001 (Χ2, Trend)
16
Sites of infection with ESBLs
120
80
60
40
14
% Mortality
Total Number
100
Klebsiella spp.
E. coli
12
10
8
6
4
20
0
2
0
<24
<48
<72
<96 <120 >120
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. 2005;165:1375-1380.
Trends in Gram-Positive Resistance: US
1980 to
1999
100
90
80
70
MRSE
60
MRSA
50
40
DRSP
30
VRE
20
10
0
1975
VISA
1980
1985
1990
1995
2000
1997
Thronsberry C. NNIS. 38th ICAAC.1998; San Diego, Calif; Abstract E22;1 Edmond M.
CID 1999, MMWR Morb Mortal Wkly Rep. 1997;46:624-636.2
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
0
Hongkong
India
Australia
Malaysia
Thailand
Pakistan
Singapore
Japan
Korea
China
Taiwan
Prevalence of MRSA in Asia Pacific Region
2003/2004
100
90
80
70
60
50
40
30
20
10
STAPHYLOCOCCUS SPP
MRSA STUDY
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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%.
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Authors:
Khalil Ahmed*, Abid Mahmood**, Muhammad Khurram
Ahmad***, Khurram Hussain*, Mehreen Ali Khan**
• DON’T WORRY DR.ALTAF, WE WILL
GET NEW ANTIBIOTICS
•Hospital acquired infections kill 5000 patients
a year in England
•100000 cases of hospital acquired infection in
England each year
BMJ 2000; 321:1370
•In USA - Hospital infections, kills about 90,000 people a year
HOW MANY IN PAKISTAN?
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 1998;317:647-650
Prevention is better than cure!
Nosocomial infection in developing countries
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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.
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Gakuu LN. East Afr Med J 1997; 74: 198-202
Thevanesam V et all. J Hosp Infect 1994; 26: 123-127.
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Ben Hassen A et al. Bull Soc Pathol Exot 1995; 88: 257-259.
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.
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J Hosp Infect. 2004 Jul;57(3):223-7
Process Analysis.
Hand washing Compliance.
Global Monthly Compliance.
Liaquat National Hospital – Medical ICU
Hand washing Compliance. Global Monthly Compliance.
Liaquat National Hospital – Medical ICU
100%
90%
80%
60%
50%
40%
30%
20%
46%
10%
0%
Ja
n06
percentage
70%
month
Process Analysis.
Hand Washing Compliance.
Compliance By Health Care Workers Type.
Liaquat National Hospital – Medical ICU
percentage
Hand Washing Compliance. Compliance By Health Care Workers Type.
Liaquat National Hospital – Medical ICU - January 2006
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
64%
35%
Physicians
23%
Nurses
Professional
Anc Staff
Break the Chain of Infection
Infectious Agents
Bacteria
Viruses
Fungi
Protozoa
Susceptible Host
Reservoirs
Immunosuppression
Diabetes Surgery Burns
Cardiopulmonarys
Portal of Entry
Mucos Membrane
Respiratory
People
Water
Equipment
Hand washing
Isolation
Air flow control
Sterilization
Food Handling
GI Tract
Broken Skin
Portal Of Exit
Excretions
Skin
Means Of Transmission
Direct Contact
Ingestion
Fomaites
Airborne
Secretions
Droplets
COCKROACHES
• Frequency of different species of cockroaches in tertiary care
hospital and their role in transmission of bacterial pathogens
Pakistan J Med Res Dec 2005;44(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.
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.
Infection control is
WE NEED MORE INCINERATORS
Please Remember
• Infection control is everyone’s job and
responsibility
• The effectiveness of program depends on
everyone’s commitment
UNRELIABLE LAB REPORTS
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Culture not send properly
Culture not performed properly
Pathogen not identified
Unreliable sensitivity test
Typing errors
40% bhatta culture?
LABORATORY?
CONSULTANT
SWEEPER
patient
RMO
WARDBOY
NURSE
RESIDENT
•POOR QUALITY SPECIMENS GENERATE USELESS RESULTS!
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
• Doctor’s fee,medicine,x-ray/ultrasound etc.
A dilemma-what is your suggestion?
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SWEDEN
Zulfiqar A. Bhutta, AKUH
Zulfiqar A. Bhutta, AKUH
Antibiotics are not the solution for
every illness
Institutional Strategies
to Control Antibiotic resistance
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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. 1993:119:353
2. Patterson JE et al. Infect Control Hosp Epidemiol. 2000;21:455
3. Peña C et al. Antimicrob Agents Chemother. 1998;42:53
4. Rice LB et al. Clin Infect Dis. 1996;23:118
My message to all
• Guidelines does not work unless they are
implemented!
• Implementation does not work unless
there is local comittment and educational
outreach!
THANK YOU &
www.idspak.org
altafvirus@yahoo.com