Anti- Microbial Resistancebsmedicine.org/congress/2012/Dr._Quazi_Tarikul_Islam.pdf · 2018. 3....

Anti- Microbial Resistance: Are We LOOSING THE BATTLE!

Prof. Quazi Tarikul Islam FCPS, FACP (USA), FRCP(Glasg), FRCP(Edin)

Professor of Medicine

WHERE ARE WE?

World Health Day 7th April, 2011

ANTIMICROBIALS AND ITS’ RESISTANCE

The magic bullet • Antibiotics revolutionised medicine

• The first antibiotic, penicillin, was discovered by Alexander Fleming in 1929

• It was later isolated by Florey and Chain

• It was not extensively used until the World War II when it was used to treat war wounds

• After World War II many more antibiotics were developed

• Today about 150 types are used

• Most are inhibitors of the protein synthesis, blocking the 70S ribosome, which is characteristic of prokaryotes

© 2008 Paul Billiet ODWS

http://www.saburchill.com/IBbiology/bio_hp.html

Antibiotic time line:

• 1910 - Arsphenamine aka Salvarsan • 1912 - Neosalvarsan • 1935 - Prontosil (an oral precursor to

sulfanilimide) • 1936 - Sulfanilimide • 1938 - Sulfapyridine (M&B 693) • 1939 - sulfacetamide • 1940 - sulfamethizole • 1942 - benzylpenicillin • 1942 - gramicidin S • 1942 - sulfadimidine • 1943 - sulfamerazine • 1944 - streptomycin • 1947 - sulfadiazine • 1948 - chlortetracycline • 1949 - chloramphenicol • 1949 - neomycin • 1950 - oxytetracycline

• 1950 - penicillin G procaine • 1952 - erythromycin • 1954 - benzathine penicillin • 1955 - spiramycin • 1955 - tetracycline • 1955 - thiamphenicol • 1955 - vancomycin • 1956 - phenoxymethylpenicillin • 1958 - colistin • 1958 - demeclocycline • 1959 - virginiamycin • 1960 - methicillin • 1960 - metronidazole • 1961 - ampicillin • 1961 - spectinomycin • 1961 - sulfamethoxazole


• 1961 - trimethoprim • 1962 - cloxacillin • 1962 - fusidic acid • 1963 - fusafungine • 1963 - lymecycline • 1964 - gentamicin • 1966 - doxacycline • 1967 - carbenicillin • 1967 - rifampicin • 1968 - clindamycin • 1970 - cefalexin • 1971 - cefazolin • 1971 - pivampicillin • 1971 - tinidazole • 1972 - amoxicillin • 1972 - cefradine • 1972 - minocycline • 1972 - pristinamycin

• 1973 - fosfomycin • 1974 - talampicillin • 1975 - tobramycin • 1975 - bacampicillin • 1975 - ticarcillin • 1976 - amikacin • 1977 - azlocillin • 1977 - cefadroxil • 1977 - cefamandole • 1977 - cefoxitin • 1977 - cefuroxime • 1977 - mezlocillin • 1977 - pivmecillinam • 1979 - cefaclor • 1980 - cefmetazole


• 1980 - cefotaxime • 1980 - cefsulodin • 1980 - piperacillin • 1981 - amoxicillin/clavulanic acid (co-

amoxiclav) • 1981 - cefperazone • 1981 - cefotiam • 1981 - cefsulodin • 1981 - latamoxef • 1981 - netelmicin • 1982 - apalcillin • 1982 - ceftriaxone • 1982 - micronomicin • 1983 - cefmenoxime • 1983 - ceftazidime • 1983 - ceftiroxime • 1983 - norfloxacin • 1984 - cefonicid

• 1984 - cefotetan • 1984 - temocillin • 1985 - cefpiramide • 1985 - imipenem/cilastatin • 1985 - ofloxacin • 1986 - mupirocin • 1986 - aztreonam • 1986 - cefoperazone/sulbactam • 1986 - ticarcillin/clavulanic acid • 1987 - ampicillin/sulbactam • 1987 - cefixime • 1987 - roxithromycin • 1987 - sultamicillin • 1987 - ciprofloxacin • 1987 - rifaximin • 1988 - azithromycin


• 1988 - flomoxef • 1988 - isepamycin • 1988 - midecamycin • 1988 - rifapentine • 1988 - teicoplanin • 1989 - cefpodoxime • 1989 - enrofloxacin • 1989 - lomefloxacin • 1990 - arbekacin • 1990 - cefozidime • 1990 - clarithromycin • 1991 - cefdinir • 1992 - cefetamet • 1992 - cefpirome • 1992 - cefprozil • 1992 - ceftibufen • 1992 - fleroxacin • 1992 - loracarbef

• 1992 - piperacillin/tazobactam • 1992 - rufloxacin • 1993 - brodimoprim • 1993 - dirithromycin • 1993 - levofloxacin • 1993 - nadifloxacin • 1993 - panipenem/betamipron • 1993 - sparfloxacin • 1994 - cefepime • 1999 - quinupristin/dalfopristin • 2000 - linezolid • 2001 - telithromycin • 2003 - daptomycin • 2005 - tigecycline • 2005 - doripenem • 2009 - telavancin

Resistance

• It took less than 20 years for, bacteria to show signs of resistance

• Staphylococcus aureus, which causes blood poisoning and pneumonia, started to show resistance in the 1950s

• Today there are different strains of S. aureus resistant to every form of antibiotic in use



Bugs vs. Humans?

Staphylococcus aureus Sir Alexander Fleming

1925

Penicillin discovered

1928 1944

Penicillin clinical use

1950 1975 2000

Bugs vs. Humans?


1925

1950 1956


1928 1944


50% SA Penicillin resistant

1950 1975 2000

Bugs vs. Humans?


1925

1950 1956


1928 1944



1950 Vancomycin

1975 2000

Bugs vs. Humans?


1925

1950 1956


1928 1944



1960

Methicillin

1950 Vancomycin

1975 2000

Bugs vs. Humans?


1925

1950 1956


1928 1944



1960

Methicillin

1950 Vancomycin

1975 Methicillin Resistance 2000

Bugs vs. Humans?


1925

1950 1956


1928 1944



1960

Methicillin

1950 Vancomycin

1975 Methicillin Resistance

2% Methicillin- resistant

2000

Bugs vs. Humans?


1925

1950 1956


1928 1944



1960

Methicillin

1950 Vancomycin


1996



2000

Bugs vs. Humans?


1925

1950 1956


1928 1944



1960

Methicillin

1950 Vancomycin


1996



2000

Intermediate Resistance to Vancomycin

Bugs vs. Humans?


1925

1950 1956


1928 1944



1960

Methicillin

1950 Vancomycin


2003 1996



Vancomycin- resistance

2000

Intermediate Resistance to Vancomycin

Mechanism of developing resistance in a bacteria

Mechanisms of Antibiotic Resistance Method Examples

Inactivation: enzymatic inhibition

β-lactamase

Target site modification Penicillin binding protein (β lactams), Ribosomal proteins (Aminoglycosides, Macrolides), Cell wall peptidoglycan (glycopeptide resistant enterococci)

Cell wall permeability Reduced permeability (Gram –ve bacteria), Blocked influx (Imipenem resistant pseudomonas), Reduced uptake (Tetracyclines)

Active expulsion Tetracyclines in enterobacter

Metabolic Development of alternative target (Sulfonamide & Trimethoprim resistant), Alternative Pathway (MRSA)

Multiple resistance • It seems that some resistance was already naturally present in

bacterial populations

• The presence of antibiotics in their environment in higher concentrations increased the pressure by natural selection

• Resistant bacteria that survived, rapidly multiplied

• They passed their resistant genes on to other bacteria (both disease causing pathogens and non-pathogens)



Transposons & Integrons • Resistance genes are often associated with transposons, genes that

easily move from one bacterium to another

• Many bacteria also possess integrons, pieces of DNA that accumulate new genes

• Gradually a strain of a bacterium can build up a whole range of resistance genes

• This is multiple resistance

• These may then be passed on in a group to other strains or other species



Mechanism of Transferring the resistance to other bacteria

Antibiotics promote resistance • If a patient taking a course of antibiotic treatment does not

complete it

• Or forgets to take the doses regularly,

• Then resistant strains get a chance to build up

• The antibiotics also kill innocent bystanders bacteria which are non-pathogens

• This reduces the competition for the resistant pathogens

• The use of antibiotics also promotes antibiotic resistance in non-pathogens too

• These non-pathogens may later pass their resistance genes on to pathogens



Resistance gets around

• When antibiotics are used on a person, the numbers of antibiotic resistant bacteria increase in other members of the family

• In places where antibiotics are used extensively e.g. hospitals and farms antibiotic resistant strains increase in numbers



WHAT DRIVES ANTIMICROBIAL

RESISTANCE?

What drives antimicrobial resistance?

• Inappropriate and irrational use of medicines

• Patients not taking the full course of a prescribed antimicrobial

• When poor quality antimicrobials are used, resistant microorganisms can emerge and spread.

Underlying factors that drive AMR include: • Inadequate national commitment

• Ill-defined accountability

• Insufficient engagement of communities;

• Weak or absent surveillance and monitoring systems;

• Inadequate systems to ensure quality and uninterrupted supply of medicines

Underlying factors that drive AMR include: • Inappropriate and irrational use of medicines in animal

husbandry:

• Poor infection prevention and control practices;

• Depleted arsenals of diagnostics, medicines and vaccines as well as insufficient research and development on new products.

WHY ARE WE CONCERNED?

Why is antimicrobial resistance a global concern?

• AMR kills

Infections caused by resistant microorganisms often fail to respond to the standard treatment, resulting in prolonged illness and greater risk of death.

• AMR hampers the control of infectious diseases

AMR reduces the effectiveness of treatment because patients remain infectious for longer, thus potentially spreading resistant microorganisms to others.

Why is antimicrobial resistance a global concern?

• AMR threatens a return to the pre-antibiotic era

Many infectious diseases risk becoming uncontrollable and could derail the progress made towards reaching the targets of the health-related United Nations Millennium Development Goals set for 2015.

• AMR increases the costs of health care

When infections become resistant to first-line medicines, more expensive therapies must be used. The longer duration of illness and treatment, often in hospitals, increases health-care costs and the financial burden to families and societies.

Why is antimicrobial resistance a global concern? • AMR jeopardizes health-care gains to society

The achievements of modern medicine are put at risk by AMR. Without effective antimicrobials for care and prevention of infections, the success of treatments such as organ transplantation, cancer chemotherapy and major surgery would be compromised.

• AMR threatens health security, and damages trade and economies

The growth of global trade and travel allows resistant microorganisms to be spread rapidly to distant countries and continents.

WHAT IS GLOBAL SITUATION?

• Antimicrobial resistance is both a natural phenomenon and a man made major global threat to public health

• Through replication and conjugation by “jumping”

plasmids

• Observed soon after introduction of penicillin

Global trends: Infectious diseases (SEAR)

• Streptococcus pneumoniae is the most common causative agent of pneumonias in children and adults in Asia.

• Till the1980s, almost all isolates of this organism used to be susceptible to penicillin.

• In 2006, almost 69 percent isolates of this bacterium were found to be penicillin resistant.


• Typhoid and paratyphoid fever continue to be important causes of illness and death, particularly among children and adolescents in the SEA Region.

• Shortly after the emergence of multidrug-resistant S. Typhi in this Region, case fatality rates approaching 10 per cent (close to 12.8% recorded in pre-antibiotic era) were reported.


• More than 50 percent isolates of Staphylococcus aureus in hospital settings are now methicillin resistant.

• 48 per cent patients with bacteraemia due to resistant S. aureus died. Methicillin-resistant S. aureus (MRSA) is a major problem in hospital-associated infections in almost all countries in the SEA Region.


• Multiresistant klebsiellae, Pseudomonas and Acinetobacter species have given new dimensions to the problem of hospital-associated infections.

• A. baumannii has become an important pathogen in intensive care units. In a study done , mortality in admitted patients due to imipenem-resistant

• A. baumannii was 52 per cent as compared to 19 per cent in those who were infected with the sensitive variant.

Regional trends: Health implications

• Multidrug resistance is commonly found

• Need to “underpin” treatment choice with laboratory tests

• Need for time-series to determine trends

Antimicrobial resistance is increasing in the Region

Wide availability of antimicrobials

Widespread use of new generation antimicrobials

Global trends: Infectious diseases

• Acute respiratory infections 3.5 million killed globally

• Influenza and pneumonia

• Diarrhoea 2.2 million killed globally

• E. coli, shigellosis, cholera

• Lack of testing for antibiotic sensitivity during outbreaks

Infectious diseases still account for 45% of deaths in low-income countries

Global trends: Infectious diseases

• HIV/AIDS

• Resistance to multidrug therapy • Malaria

• Chloroquine no longer effective in 81 of 92 countries • Tuberculosis

• ? 20% of resistant new tuberculosis cases are multidrug resistant

• Cost implications

Global trends: Nosocomial infections

• Intensity of use of antimicrobials in hospitals

• Increasing resistance of highly virulent strains (Staphylococcus aureus)

• Hospital acquired infections (mainly drug resistant microbes) account for significant death rates and numbers

• 40 000 deaths/year in USA

Global trends: Food production

• About half of all antibiotics produced are used for farming

• Reports indicate that 50% of human antimicrobial resistance is caused by growth promoters in livestock

• Where growth promoters are phased out, antimicrobial resistance in livestock drops dramatically (Denmark)

Medicines: (Ir) rational use !

• 25%–75% of antibiotic prescriptions inappropriate

• Empirical treatment, lack of diagnostic services

• Lack of targeted education

• 50%–90% bought privately from community pharmacy;

• half for 1-day treatment

• Only half of 102 countries surveyed regulate drug promotion

Medicines: Access

30

35

40

45

50

55

60

65

1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997

0

5

10

15

20

25

30

35

40

R&D expenditure

(US$ billions) New products

(number) Multitude of problems:

Drug “pipeline”

Between 1975 and 1997 1223 new compounds launched only 11 for tropical diseases

Medicines: Quality

not all countries in the

Region have well-

functioning drug regulatory

systems

10%–20% of drugs fail

quality testing

substandard and counterfeit

drugs continue to kill

Quality and safety standards exist, enforcement varies greatly:

Medicines: Quality

Incorrect

amount

17%

No active

ingredient

60%

Other errors

7%

Incorrect

ingredient

16%

not all countries in the

Region have well-

functioning drug regulatory

systems

10%–20% of drugs fail

quality testing

substandard and counterfeit

drugs continue to kill

Quality and safety standards exist, enforcement varies greatly:

Regional trends: Health implications

• Similarity between the Member States in terms of scope and magnitude of the problem

• Link between antimicrobial resistance and irrational use of medicines is established in various studies

• High levels of drug resistance are found throughout the region for medicines used in common infectious diseases

• Tuberculosis, acute respiratory infections, urinary tract infections, malaria, etc.

Regional trends: Economic implications Cost of ARI, diarrhoea, tuberculosis and malaria treatment

Total morbidity

First line

Second line

Third line

Total cost of

treatment

First line

Second line

Third line

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Global problem of antimicrobial resistance

• Malaria • choroquine resistance in 81/92 countries

• Tuberculosis • 0-17 % primary multi-drug resistance

• HIV/AIDS • 0-25 % primary resistance to at least one anti-retroviral

• Gonorrhoea • 5-98 % penicillin resistance in N. gonorrhoeae

• Pneumonia and bacterial meningitis • 0-70 % penicillin resistance in S. pneumoniae

• Diarrhoea: shigellosis • 10-90% ampicillin resistance, 5-95% cotrimoxazole resistance

• Hospital infections • 0-70% S. Aureus resistance to all penicillins & cephalosporins

Source: WHO country data 2000-3

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0

5

10

15

20

25

30

35

FR GR LU PT IT BE SK HR PL IS IE ES FI BG CZ SI SE HU NO UK DK DE LV AT EE NL

DD

D p

er 1

000

inh

. per

day

Variation in outpatient antibiotic use in 26 European countries in 2002

Source: Goosens et al, Lancet, 2005; 365: 579-587; ESAC project.

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Total antibiotic use (DDD/1000 population/day)

40 30 20 10 0

Pe

nic

illin

-re

sist

ant

S. p

neu

mo

nia

e (%

)

60

50

40

30

20

10

0

USA

UK

Sweden

Spain

Portugal

Norway Netherlands

Luxemburg

Italy

Ireland

Iceland

Greece

Germany

France

Finland

Denmark

Canada

Belgium Austria

Australia

Albrich, Monnet and Harbarth,

Emerg Infect Dis.; 2004; 10(3):514-7

Taiwan

World Health Organization Essential Medicines and Pharmaceutical Policy

% patients treated according to clinical guidelines source: WHO/EMP drug use database 2009

0

10

20

30

40

50

60

70

80

90

100

1982-1994 1995-2000 2001-2006

Sub-Saharan Africa (n=29,48,29) Latin America & Caribbean (n=13,10,5)

Middle East & Central Asia (n=4,8,5) East Asia & Pacific (n=7,11,7)

South Asia (n=12,11,6)


Inappropriate antibiotic prescribing over time source: WHO/EMP drug use database 2009

0

10

20

30

40

50

60

70

80

90

100

1982-1994 1995-2000 2001-2006

Pe

rce

nta

ge

% Antibiotics prescribed in underdosage (n=6,14,8)

% Patients prescribed antibiotics inappropriately (n=97,103,121)


Inappropriate antibiotic prescribing by region source: WHO/EMP drug use database 2009

010

2030

4050

6070

8090

100

% Antibiotics prescribed in

underdosage

% Patients prescribed antibiotics

inappropriately

Pe

rce

nta

ge

Sub-Saharan Africa (n=11,104) Latin America & Caribbean (n=4,67)

Middle East & Central Asia (n=3,39) East Asia & Pacific (n=4,64)

South Asia (n=6,47)

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Varying intervention impact in developing countries source: WHO/EMP database 2009

Intervention type No.

studies

Largest %

change in any

study outcome

Median % change

across all study

outcomes

Printed materials 5 8% 5%

Community education 3 26% 2%

Provider education 24 18% 7%

Provider+Community ed. 12 18% 9%

Provider supervision 25 22% 13%

Provider group process 8 37% 13%

Essential drug program 5 27% 15%

Community case mgt. 5 28% 29%

Provider & Community

education + supervision

7 40% 24%

BANGLADESH SITUATIONS

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Publications on AMR in Bangladesh

• In various national and international journals, a total of 171 papers have been published till 2009,

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Bangladesh antibiotic use • General lack of information:

• No consumption analysis possible due to manual inventory control systems throughout the health system

• 47% of EDCL sales was on antibiotics, waiting for data from CMSD.

• Dhaka Medical College Hospital • Pharmacist estimates 30% of the budget is spent on antibiotics

• Quick OPD survey showed 74% of patients received an antibiotic and that 31% had to purchase medicines outside

• No prescription audit – 1 study in literature review: • Inappropriate use of antibiotics in children <5 years pre-IMCI in 2000

was 48-72% & post-IMCI in 2005 was 9% (Arifeen et al, WHO Bull. 2005)

• Role of Pharmaceutical companies:

BIRDEM Hospital: October 2008 to March

2009 (total 6month period).

• Study design: Prospective, descriptive study.

ORGANISMS BLOOD RESP SEC URINE OTHERS TOTAL (% of total isolates)

Pseudomonas 25 22 5 2 54 (23.3%)

Acinetobacter 4 45 2 1 52 (22.51%)

Esch coli 7 5 10 0 22 (9.52%)

Klebsiella 1 11 1 0 13 (5.62%)

Proteus 0 1 0 0 1 (0.43%)

Citrobacter 0 0 1 0 1 (0.43%)

Enterobacter 0 0 1 0 1 (0.43%)

Staph aureus 7 8 2 4 21 (9.09%)

Staph epidermidis

3 2 0 0 5 (2.16%)

Enterococci 0 0 9 1 10 (4.32%)

Candida 2 9 39 1 51 (22.07%)

Fig: No. of Organisms isolated from samples

Resistance Pattern (%) of Common Gram Negative

Antibiotics Acinatobacter Klebsiella E.coli Pseudomonas

Amikacin 46/52 (88.4%)

5/13 (38.4%)

10/22 (45.4%) 49/54 (90.7%)

Gentamicin 39/44 (88.6%)

4/12 (33.3%)

9/21 (42.8%) 43/48 (89.5%)

Netilmicin 35/52 (67.3%)

4/13 (30.7%)

7/22 (31.8%) 40/53 (75.4%)

Ciprofloxacin 48/52 (92.3%)

9/11 (81.8%)

22/22 (100%) 30/53 (56.6%)

Cefixime 37/37 (100%)

8/8 (100%) 9/9 (100%) 5/5 (100%)

Ceftriaxone 52/52 (100%)

11/12 (91.6%)

22/22 (100%) 42/45 (93.3%)

Resistance Pattern (%) of Common Gram Negative


Ceftazidime 49/52 (94.2%)

12/12 (100%)

22/22 (100%)

34/54 (62.9%)

Cefepime 27/30 (90%)

9/10 (90%) - 10/10 (100%)

Imipenem 37/50 (74%)

2/12 (16.6%)

0/22 (0%) 35/53 (66.03%)

Piperacillin 5/5 (100%) - - 26/50 (52%)

Resistance Pattern (%) of Common Gram Positives

Antibiotics S.aureus Enterococci

Penicillin 10/10 (100%) 7/10 (70%)

Ampicillin 8/8 (100%) 7/10 (70%)

Oxacillin 9/18 (50%) 1/1 (100%)

Cephalexin 10/20 (50%) -

Amikacin 9/18 (50%) 10/10 (100%)

Erythromycin 13/13 (100%) 1/1 (100%)

Cotrimoxazole 12/19 (63.1%) 9/10 (90%)

Vancomycin 0/12 (0%) 2/8 (25%)

Rifampicin 5/14 (35.7%) 1/1 (100%)

BIRDEM General Hospital ICU : January 2011 to October

2011

• Study design: Prospective, descriptive study

Res. Sec. Blood Urine Total (% of all isolates)

Acineto 288 26 4 318

Pseudo 95 47 5 147

Klebsiella 47 14 7 68

Esch coli 14 6 8 28

Proteus 3 - 1 4

Flavobacterium 3 1 - 4

Citrobacter 2 - 1 3

Enterobacter 1 - - 1

Staph Aureus 19 1 - 20

Staph Epi. - - 1 1

Str. Pneumoniae - 2 - 2

Enterococci - - 2 2

Non-enterococci - 2 5 7

Candida 19 5 55 79

Sensitivity Pattern (%) of Common Gram Negatives


Amikacin 2/318 (0.62%)

28/58 (48.2%)

15/27 (55.5%) 42/147 (28.57%)


7/55 (12.7%)

10/27 (37.03%)

18/147 (12.24%)

Netilmicin 37/309 (11.97%)

17/60 (28.3%)

14/28 (50%) 38/147 (25.8%)

Ciprofloxacin 1/318(0.31%)

3/61 (4.9%) 1/28 (3.57%) 48/146 (32.87%)

Ceftriaxone 1/318(0.31%)

3/61 (4.9%) 0/19 (0%) 43/147 (29.25%)


4/59 (6.7%) 0/27 (0%) 20/47 (42.55%)

Sensitivity Pattern (%) of Common Gram Negatives


Cefotaxime 2/289 (0.69%)

6/56 (10.7%)

1/27 (3.7%) 17/147 (11.56%)

Cotrimoxazole 12/316 (3.79%)

4/10 (40%) 18/27 (66.6%)

22/147 (14.97%)

Imipenem 15/318 (4.71%)

28/62 (45.1%)

5/14 (35.7%)

104/135 (77.03%)

Piperacillin + Tazobactam

12/307 (3.9%)

8/37 (21.6%)

7/9 (77.7%) 54/77 (70.12%)

Colistin 332/338 (98.22%)

32/32 (100%)

6/6 (100%) 17/147 (11.56%)

ANTIBIOTIC STAPH AUREUS (n=20) *†

Oxacillin 5/18 (27.7%)

Cephradine 0/20 (0%)

Erythromycin 1/19 (5.26%)

Cotrimoxazole 12/20 (60%)

Amikacin 10/19 (52.6%)


Netilmicin 16/20 (80%)

Vancomycin 18/18 (100%)

Rifampicin 7/14 (50%)

Sensitivity Pattern (%) of Common Gram Positive

Data from Square Hospital (ICU and General Ward)

Site / Source of Positive Samples

Square Hospital, Dhaka

Specimens No %

Urine 2168 46

Blood 777 16.5

Tracheal aspirate 426 9

Sputum 371 7.9

Wound swab 294 6.2

Pus 256 5.4

Asceitic fluid 30 0.6

Liver abscess 19 0.4

Bronchial lavage 17 0.4

CV line 17 0.4

Sensitivity Pattern (%) of Common Gram Negative rods

Antibiotics E.coli Klebsiella Enterobac

ter Proteus Citobacter Serratia

Acinetobact

er

Pseudomin

us

Burkholderi

a

Steno

trophomon

as

Imipenem 99.2 96.9 100 98.7 100 100 33.3 61.7 - -

Amikacin 88 90 86.4 86.7 100 100 25.7 57.3 - -

Gentamycin 71 60.8 63.6 69.3 85.7 87.5 21.7 50.9 - -

Ceftriaxone 41,9 38.8 54.5 70.7 57.1 87.5 - - - -

Cefixime 40.3 36.6 45.5 66.7 57.1 75.0 - - - -

Ceftazidime - - - - - - 25.4 55.1 92.0 -

Cefuroxime 39.1 35.2 4.5 56.0 42.9 37.5 - - -

Cepepime 42.9 39.0 59.1 76 57.1 87.5 19.8 53.3 - 14.3

Sensitivity Pattern (%) of Common Gram Negative rods

Antibiotics E.coli Klebsiella Enterobac

ter Proteus Citobacter Serratia

Acinetobact

er

Pseudomin

us

Burkholderi

a

Steno

trophomon

as

Ciprofloxaci

n

31.5 42.1 60.6 56 42.9 100 23.5 52.6 83.2 81

Cotrimoxaz

ol

39.6 40.4 59.1 37.3 42.9 87.5 22.2 - 73.9 95.2

Tetracycline 29.9 47 25 6.7 - - 28 - - -

Co

Amoxiclav 23.9 28 0 45.1 14.3 0 - - - -

Amoxicillin 12,3 1.9 0 25.3 14.3 0 - - - -

Nitrofuranto

in

(In Urine)

87,5 36.2 34.8 15.2 33.3 0 - - - -

Piperacillin

–

Tazobactum

25 50 - - - - 29.7 75.3 - -

Tobramycin - - - - - - 22 50.4 - -

ESBL

Positive 54.8 55.9 36.4 22.6 42.8 - - 5.6 - -

Sensitivity Pattern (%) of Common Gram Positive Cocci

Antibiotics Staph aureus CoNS

(Co Neg Staph) Enterococci Gr D Non Enterococci

Penicillin 9 9 73.6 100

Oxacillin 77.9 40.2 - -

Amoxicillin 11.2 12.1 80.2 100

Cefuroxime 76.2 40.6 - -

Vancomycin 100 100 98.9 100

Gentamycin 89.5 49.6 67.9 100

Nitrofurantoin 100 95.7 95.5 93.3

Tetracycline 67.4 54.3 37.7 -

Cotrimoxazole 85.3 51.2 - -

Ciprofloxacin 48.3 28.9 23.9 44.4

Rifampicin 96.5 91.1 56.6 100

Linezolid 100 100 99.4 100

Erythromycin 42.9 18.4 33.3 33.3

Climdamycin 61.7 55.6 - -

Sensitivity Pattern (%) of

Salmonella typhi & S. paratyphi A

Antibiotics S. typhi S. paratyphi A

Imipenem 100 100

Ceftriaxone 100 100

Cefepime 100 100

Cefixime 99.7 100

Ciprofloxacin 83.6 96.3

Cotriamoxazole 78.8 100

Ampicillin 64.8 99.3

Total Sample (n=100)

Sample Number

Urine c/s 68

Blood c/s 26

Tracheal Aspirate c/s 02

Wound Swab 04

Total 100

Organism Isolated

Organisms Percentage

E.coli 45 %

Klebshiella 04 %

Pseudomonas 07 %

Strept.pneum 04 %

S.typhie 08 %

S.p.typhie 08 %

Others 24 %

Total 100 %

Sensitivity Pattern (%) of Common Gram Negative

Antibiotics E.coli Klebsiella Pseudomonas S.typhie S.p.typhie

Amikacin 49/45 (90.7%)

4/4 (100%)

3/7 (42.8%) 4/8 (50%) 4/8 (50%)


4/4 (100%)

2/7 (28.5%) 6/8 (75%) 6/8 (75%)

Netilmicin 39/45 (86.6%)

4/4 (100%)

2/7 (28.5%) 6/8 (75%) 6/8 (75%)

Cephradine 7/45 (15.6%)

4/4 (100%)

0/7 (0%) 0/8 (0%) 0/8 (0%)

Cefixime 8/45 (15.6%)

4/4 (100%)

0/7 (0%) 8/8 (100%) 8/8 (100%)

Amoxycillin 1/45 (2.2%)

1/4 (25%)

0/7 (0%)

0/8 (0%) 0/8 (0%)



Ceftriaxone 9/45 (20%)

4/4 (100%)

1/7 (14.3%)

8/8 (100%)

8/8 (100%)


4/4 (100%)

2/7 (28.5%)

8/8 (100%)

8/8 (100%)

Cefepime 12/45 (26.6%)

4/4 (100%)

2/7 (28.5%)

8/8 (100%)

8/8 (100%)

Imipenem 45/45 (100%)

4/4 (100%)

7/7 (100%)

8/8 (100%)

8/8 (100%)

Meropenem 45/45 (100%)

4/4 (100%)

7/7 (100%)

8/8 (100%)

8/8 (100%)

Erythromycin - - - 2/8 (25%) 2/8 (25%)



Azactum 9/45 (20%)

4/4 (100%)

2/7 (28.5%)

8/8 (100%) 8/8 (100%)

Nalidixic Acid 3/45 (6.6%)

3/4 (75%)

0/7 (0%) 8/8 (100%) 8/8 (100%)

Ciprofloxacin 6/45 (13.3%)

4/4 (100%)

2/7 (28.5%)

8/8 (100%) 8/8 (100%)

Levofloxacin 7/45 (15.5%)

4/4 (100%)

2/7 (28.5%)

8/8 (100%) 8/8 (100%)

Tetracycline 10/45 (22.2%)

3/4 (75%)

0/7 (0%) 0/8 (0%) 0/8 (0%)

Doxycycline 12/45 (26.6%)

3/4 (75%)

0/7 (0%) 0/8 (0%) 0/8 (0%)

Nitrofurantoin

40/45 (88.8%)

4/4 (100%)

0/7 (0%) 0/8 (0%) 0/8 (0%)

Sensitivity Pattern (%) of Common Gram Positives and others

Antibiotics S.pneumon Other

Amikacin 1/4 (25%) 12/24 (50%)

Gentamicin 1/4 (25%) 18/24 (75%)

Netilmicin 1/4 (25%) 18/24 (75%)

Cephradine 1/4 (25%) 20/24 (60%)

Cefixime 2/4 (50%) 24/24 (100%)

Amoxycillin 1/4 (25%) 18/24 (75%)



Ceftriaxone 2/4 (50%) 24/24 (100%)

Ceftazidime 2/4 (50%) 24/24 (100%)

Cefepime 2/4 (50%) 24/24 (100%)

Imipenem 4/4 (100%) 24/24 (100%)

Meropenem 4/4 (100%) 24/24 (100%)

Erythromycin 1/4 (25%) 18/24 (75%)



Azactum 4/4 (100%) 8/8 (100%)

Nalidixic Acid 3/4 (75%) 18/24 (75%)

Ciprofloxacin 3/4 (75%) 18/24 (75%)

Levofloxacin 2/4 (50%) 18/24 (75%)

Tetracycline 0/4 (0%) 12/24 (50%)

Doxycycline 0/4 (0%) 12/24 (50%)

Nitrofurantoin 2/4 (50%) 12/24 (50%)

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BANGLADESH: WHAT COULD WE DO?

• Restrict some antibiotics to prescription-only

• Not to allow drug representatives in govt. health facilities

• Expand role of Drug Selection Committee to Drug and Therapeutics committee overseeing regular program of drug use evaluation in each district, or specialty

• Start Drug Information Centre & Drug Bulletin

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BANGLADESH: WHAT COULD WE DO?

• Introduce prescription audit of antibiotic use & AMR containment measures in UG and PG curricula

• Decrease crowding to improve consultation time

• Use health promotion units to inform communities & patients about not needing antibiotics for cough-colds, etc

• Lobby for special unit in MOH to oversee/monitor drug use

• Develop a national strategy for containment of AMR

Recommendations

For Member States in the South-East Asia Region Member States should:

1. Establish a national alliance against antimicrobial resistance with all key stakeholders as its members. The implementation of national efforts to prevent and contain antimicrobial resistance should be through a multisectorial national steering committee headed by the senior-most health executive and facilitated through advisory/ expert groups.

2. Designate a national focal point for antimicrobial resistance in the Ministry of Health.

For Member States in the South-East Asia Region 3. Institute appropriate surveillance mechanisms in the health

and veterinary sectors to generate reliable and actionable epidemiological information including baseline data and trends on antimicrobial resistance, utilization of antimicrobial agents and impact on the economy and health through designated national and regional reference centers.

4. Discourage non-therapeutic use of antimicrobial agents in veterinary, agriculture and fishery practices as growth-promoting agents.

For Member States in the South-East Asia Region 5. Develop national standard treatment and infection control

guidelines and ensure their application at all levels of health care and veterinary services through training, continuous educational activities and establishment of functional drugs and therapeutic committees and hospital infection control committees in health facilities (with the focus on proven, cost-effective intervention such as isolation, hand washing etc).

6. Undertake operational research for better understanding of the technical and behavioural aspects of prevention and control of antimicrobial resistance and utilize the outcomes of these research studies/interventions in policy and programme development/ improvement in the national context

For Member States in the South-East Asia Region 7. Launch educational and awareness programmes for

communities and different categories of health care professionals.

8. Strengthen communicable diseases control programmes to reduce disease burden and accord priority to the discipline of infectious diseases in medical education and health services.

For the World Health Organization

• WHO should:

1. Undertake advocacy with national authorities to establish national alliances against antimicrobial resistance;

2. Develop and disseminate generic protocols to facilitate generation of comparable epidemiological data on antimicrobial resistance and utilization of antimicrobials;

3. Facilitate cooperation between various players (government agencies, professionals, academia, NGOs, INGOs etc) to enhance synergy between their actions and to obviate duplication of efforts;

4. Develop generic IEC material to create awareness amongst communities and obtain their active participation in the fight against AMR;

For the World Health Organization

5. Through its WHO Collaborating Centre on AMR, collate and share global data and regional experiences on all aspects of antimicrobial resistance; The WHO CC should be supported to act as a Regional Clearing Centre and to coordinate multicentric studies in the Region;

6. Document and disseminate experiences gained within the Region and lessons learnt in combating AMR;

7. Support operational research on various aspects of antimicrobial resistance;

and

8. Organize regional meetings on a regular basis for exchange of experiences within the Region.

Take home MESSAGE……. • Antimicrobial resistance control is not an option, it is a must

for Health and economic incentive

• Implementation of comprehensive, integrated strategies involving all key partners will:

• Lead to control of antimicrobial resistance development

• Improve the quality of health services; antimicrobial resistance control as a “proxy indicator” for an effective essential drugs program.

Acknowledgement……

• Dr. Areef Ahsan.

• Dr. Kaniz Fatema.

• Dr. Quazi Tamjidul Islam.

• Dr. ARM Nooruzzaman.

• Dr. Farhana

• Ms. Sufia Islam.

05.03.2012

Anti- Microbial Resistancebsmedicine.org/congress/2012/Dr._Quazi_Tarikul_Islam.pdf · 2018. 3....

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