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Jason Gale Editor-at-large – Global Health Bloomberg News/Sydney

Are prostate needle biopsy patients at risk of ciprofloxacin-resistant gut commensals? Learn about new approaches to mitigate this risk, especially for travelers, healthcare workers, and repeat biopsy patients.

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Jason Gale Editor-at-large – Global Health Bloomberg News/Sydney

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  1. Jason GaleEditor-at-large – Global HealthBloomberg News/Sydney Tel. +61-2-9777-8660E-mail: j.gale@bloomberg.net Twitter: @jwgale

  2. Transrectal ultrasound-guided PROSTATE BIOPSIES • Prostate needle biopsy patients = sentinels for ciprofloxacin-resistant (?MDR) in gut commensals? • Small BUT growing risk Nam, Loeb, Williamson, Patel et al • Travelers, health-care workers (and their household members), veterinarians, repeat Bx patients, recent antibiotic-users among those at highest risk • New approaches to mitigating risk needed Source: Michael Liss, University of California, San Diego

  3. microbial SOUVENIRS • Travelers return with MDR gut commensals • Cipro resistance 3.9% pre-travel 33% post-travel • ESBL+ve 2% pre-travel 22% post-travel North America 30% Europe 24% China, Hong Kong, Taiwan, Korea 69% Japan 0% Middle East/Africa 75% India/Nepal/ Sri Lanka 79% Southeast Asia/Pacific 52% South America/ Mexico 60% Source: Kennedy et al, European Journal of Clinical Microbiology & Infectious Diseases, 2010

  4. microbial SEX

  5. NEXUS The Superbug, Biopsy, Sepsis • Global problem • Getting worse • Challenging clinical practice • Affecting outcomes

  6. gut Colonization • E. coli strains are shared among household members, including the family dog Johnson et al, Journal of Clinical Microbiology December 2008 • Multidrug-resistant E. coli may colonize the GI tract for 1 year or more Nordmann et al, Journal of Antimicrobial Chemotherapy, 2011

  7. Extended Spectrum Beta Lactamase • Enzymes that open the beta-lactam ring, inactivating the antibiotic • Confer resistance to most beta-lactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam • First plasmid-mediated beta lactamase in Gram-negative bacteria was discovered in Greece in the 1960s • Now worldwide • CTX-M-15, probably from India • CTX-M-14, probably from China • First line options for UTIs are lost: Trimethoprim • Trimethoprim/sulfamethoxazole • Gentamicin • Ceftriaxone • Ticarcillin/clavulanate • Piperacillin/tazobactam • Ciprofloxacin

  8. Why? • Nature of Gram-negative bacteria • accumulate resistance mechanisms • gut colonization • combining with virulencemechanisms • Antibiotic use • in people • in animals • Global travel • global trotting grandpas • medical tourism

  9. % Fluoroquinolone Resistance in E. coli/ K. pneumoniae Isolates* • Greece – 24 / 71 • Bulgaria – 33 / 52 • Cyprus – 43 / 39 • Hungary – 37 / 43 • Italy – 39 / 39 • Czech Republic – 23 / 55 • Latvia – 14 / 52 • Poland – 26 / 33 • Portugal – 27 / 31 • Malta – 34 / 16 • Spain – 33 / 14 * Bacteraemias in (mostly) elderly and not necessarily reflective of gut carriage

  10. resistance RESERVOIRS? • ESBL genes in 80% of raw chicken meat sold at retail • Predominant ESBL genes in chicken meat and human rectal swab specimens were identical Source: Overdevest et al, Emerging Infectious Diseases, July 2011

  11. Jason GaleEditor-at-large – Global HealthBloomberg News/Sydney Tel. +61-2-9777-8660E-mail: j.gale@bloomberg.net Twitter: @jwgale

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