Prevention, Surveillance and Statistics of Resistance to Antibiotics

1. 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

2. Purpose ofthis presentation • to give an overview on the antimicrobial resistance • to present suggested policies and strategies

3. Background tothis presentation SG • 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

4. (WHO Europe, 2011)

5. ANTIBIOTIC DISCOVERY AND RESISTANCEDEVELOPMENT Source: CIBA Foundation (14). Reproduced with the permission according to Stuart B Levy

6. Presentation Outline Policies and Strategies Factors and Actions Situation

7. 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)

8. 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

10. 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)

11. 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

12. 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 (XDR-TB) has been reported in 64 countries

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

15. 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 Gram-negative bacteria such as Escherichia coli or Klebsiellapneumoniae, where new resistant mechanisms are emerging and new drugs are not in sight. SG

16. 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 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

17. (WHO Europe, 2011)

18. (WHO Europe, 2011)

19. Resistance to chloroquine and sulfadoxine-pyrimethamine (WHO) • 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. falciparumresistant 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)

20. chemistdirect.co.uk

21. Presentation Outline Policies and Strategies Factors and Actions Situation

22. Factors contributing to AMR (WHO, 2012) • 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

23. Factors contributing to AMR(continued) • 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

24. Interagency cooperationfor 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

25. WHO Surveillance Effort SG • 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

26. 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: • Streptococcus pneumoniae • Staphylococcus aureus • Escherichia coli • Enterococcus faecalis • Enterococcus faecium • Klebsiella pneumoniae • Pseudomonas auruginosa • Clostridium difficile

27. Surveillance in USA on additional 11 other AMR • Acinetobacter baumannii • Mycobacterium tuberculosis • Neisseria gonorrhoeae and meningitidis • HIV • Plasmodium falciparum • Haemophilus influenzae • Helicobacter pylori • Trichomonas vaginalis

28. Presentation Outline Policies and Strategies Factors and Actions Situation

29. Global and National Coordination is necessary • 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

30. 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)

31. 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

32. WHO policies (continued) • 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 SG

33. USA Interagency Task Force on Antimicrobial Resistance (Interagency Task Force on Antimicrobial Resistance , USA,2010) 1. Surveillance • 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. SG

34. 2.Prevention and Control • 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. SG

35. 3. Research • 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. SG

36. 4. Product Development • 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. SG

37. Next steps • 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 SG

38. References • 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