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
Purpose of
this presentation
•
•
to give an overview on the antimicrobial
resistance
to present suggested policies and strategies
Background to
this presentation
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•
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•
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 RESISTANCE
DEVELOPMENT
Antibiotic
Discovered Introduced Resistance
into 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
Presentation Outline
Factors and
Actions
Situation
Policies and
Strategies
Drug-resistant organisms
include viruses, bacteria,
fungii and parasites
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)
Methicillin-Resistant
Staphylococcus Aureus spread
Antimicrobials are misused / overused. E.g.
methicillin-resistant Staphylococcus aureus
(MRSA) spread

from health facilities

to communities and

other countries
Methicillin-resistant
Staphylococcus aureus (MRSA)
•
•
•
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)
declined in USA (CDC)
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
Multidrug-resistant
Tuberculosis (MDR – TB)
•
•
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 (XDRTB) has been reported in 64 countries
John Conly, former Chairman of the
Board for the Canadian Committee on
Antibiotic Resistance (2010)
•
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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
In Europe
•
•
In EU, more than 25 000 people die each year
from infections caused by antibiotic resistant
bacteria (WHO Europe, 2011)
Resistance is increasing in Europe for Gramnegative bacteria such as Escherichia
coli or Klebsiella pneumoniae, where new
resistant mechanisms are emerging and new
drugs are not in sight.
Food-borne induced
microbial resistance
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 antibioticresistant 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
(WHO Europe, 2011)
(WHO Europe, 2011)
Resistance to chloroquine and
sulfadoxine-pyrimethamine
(WHO)
•
Resistance to chloroquine and sulfadoxinepyrimethamine is in most malaria-endemic countries
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–
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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)
chemistdirect.co.uk
Presentation Outline
Factors and
Actions
Situation
Policies and
Strategies
Factors contributing to AMR
(WHO, 2012)
•
National commitment and coordination is
deficient,
•
Communities are insufficiently engaged
•
Surveillance and monitoring is weak / absent
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inadequate systems to ensure quality and
uninterrupted supply of medicines
Factors contributing to AMR
(continued)
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•
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
Interagency cooperation
for food-borne resistance
•
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
WHO Surveillance Effort
•
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)
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Antimicrobial resistance surveillance guidelines
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Surveillance of resistance
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Developed Software for surveillance resistance
Surveillance on 52 communicable
diseases in EU countries
coordinated by the European Centre for Disease
Prevention and Control, collects annual data on
infections with resistant bacteria such as:
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Streptococcus pneumoniae
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Staphylococcus aureus
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Escherichia coli
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Enterococcus faecalis
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Enterococcus faecium
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Klebsiella pneumoniae
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Pseudomonas auruginosa
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Clostridium difficile
Surveillance in USA on
additional 11 other AMR
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Acinetobacter baumannii
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Mycobacterium tuberculosis
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Neisseria gonorrhoeae and meningitidis
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HIV
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Plasmodium falciparum
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Haemophilus influenzae
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Helicobacter pylori
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Trichomonas vaginalis
Presentation Outline
Factors and
Actions
Situation
Policies and
Strategies
Global and National
Coordination is necessary
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•
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:•
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Education of physicians and other health care
providers for rational use of antibiotics and early
detection
regulation of over-the-counter selling of antibiotics
Reducing the incidence of
nosocomial infections in
hospital and healthcare (AAM)
■ 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)
The World Health Organization’s
policy package to combat
antimicrobial resistance
(Emily Leung et al, 2011)
• 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
WHO policies
(continued)
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Regulate and promote rational use of
medicines, including in animal husbandry, and
ensure proper patient care
Enhance infection prevention and control
Foster innovations and research and
development for new tools
no action today, no cure tomorrow
7.April world day of AMR
USA Interagency Task Force
on Antimicrobial Resistance
(Interagency Task Force on Antimicrobial Resistance , USA,2010)
1. Surveillance
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Goal 1: Improve the detection, monitoring,
and characterization of drug-resistant
infections in humans and animals.
Goal 2: Better define, characterize, and
measure the impact of antimicrobial drug use
in humans and animals in the United States.
2.Prevention and Control
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Goal 3: Develop, implement, and evaluate
strategies to prevent the emergence,
transmission, and persistence of drug-resistant
microorganisms.
Goal 4: Develop, implement, and evaluate
strategies to improve appropriate antimicrobial
use.
3. Research
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Goal 5: Facilitate basic research on antimicrobial
resistance.
Goal 6: Practical applications of findings for the
prevention, diagnosis and treatment of resistant
infections.
Goal 7: Facilitate clinical research to improve the
treatment and prevention of antimicrobial drug
resistant infections.
Goal 8: Conduct and support epidemiological
studies to identify key drivers of the emergence and
spread of AR in various populations.
4. Product Development
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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.
Next steps
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Surveillance in hospitals for early detection of
antibiotic resistance
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Report to central authorities
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Networking of information
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Centrally controlled actions and measures
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standardized nomenclature and laboratory
procedures
References
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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