DR.ALTAF AHMEDConsultant Microbiologist & Director Lab Services,

The Indus Hospital, KarachiPresident, Infectious Diseases Society of Pakistan

Rational use of antibiotics

PROBLEMS RELATED TO TREATMENT OF INFECTIOUS DISEASES

• 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• ______________________________________________________• 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?

Increasing Numbers & Clinical significance of ESBL

ProducersExtended spectrum beta

lactamases

GRAM NEGATIVE BACTERIA

SOMEWHERE IN KARACHIPlease Vote

• In your experience, the prevalence of ESBLs in your Intensive Care Unit(s) is __________?a. Growing

b. Declining

c. Staying the same

d. 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 Speciesin which ESBLs are Found

• Klebsiella• Escherichia coli• Enterobacter• Proteus• Salmonella• Citrobacter• Pseudomonas• Acinetobacter• and others!!!

Bradford PA. Bradford PA. Clin MicrobiolClin Microbiol Rev.Rev. 2001;14:933 2001;14:933

Numbers are increasing every week

Risk Factors for ESBL Infection

• 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 PA. Clin Microbiol Rev. 2001;14:933-951.2Peña C, et al. J Hosp Infect. 1997;35:9-16.

Overuse of Cephalosporins Leads to Resistance

Reprinted with permission from Bernstein JM, et al. Chest. 1999;115(suppl):1S-2S.

Klebsiella spp.E. coli

with ESBL

Enterococcus spp.

Acinetobacter spp. VREFungi, yeast

Overuse

Resistance No coverage

Overgrowth Selection

Imipenem/cilastatinImipenem/cilastatin VancomycinVancomycin

Third-generation cephalosporinsThird-generation cephalosporins

Impact of Inadequate Initial Therapy on Mortality in ESBL Infections

0

2

4

6

8

10

12

14

16

18

<24 <48 <72 <96 <120 >120

P<0.001 (Χ2, Trend)

Association between delay in initiation of adequate initial antimicrobial

therapy and mortality

Time to institution of effective antimicrobial therapy (hours)

aOnly patients with non urinary ESBL-producing E. coli and Klebsiella spp. infections had a significantly elevated risk of death.

% M

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Sites of infection with ESBLs

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Urinar

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Blood

Wound

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Klebsiella spp.E. coli

Reprinted with permission from Hyle EP, et al. Arch Intern Med. 2005;165:1375-1380.

SST, skin and soft tissue.

Trends in Gram-Positive Resistance:Trends in Gram-Positive Resistance: US US

Thronsberry C. NNIS. 38th ICAAC.1998; San Diego, Calif; Abstract E22;Thronsberry C. NNIS. 38th ICAAC.1998; San Diego, Calif; Abstract E22;1 1 Edmond M. Edmond M. CID 1999, MMWR Morb Mortal Wkly Rep. 1997;46:624-636.CID 1999, MMWR Morb Mortal Wkly Rep. 1997;46:624-636.22

Thronsberry C. NNIS. 38th ICAAC.1998; San Diego, Calif; Abstract E22;Thronsberry C. NNIS. 38th ICAAC.1998; San Diego, Calif; Abstract E22;1 1 Edmond M. Edmond M. CID 1999, MMWR Morb Mortal Wkly Rep. 1997;46:624-636.CID 1999, MMWR Morb Mortal Wkly Rep. 1997;46:624-636.22

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1975 1980 1985 1990 1995 2000

MRSEMRSE

MRSAMRSA

VREVRE

DRSPDRSP

VISAVISA

1997

1980 to 1980 to 19991999

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

Prevalence of MRSA in Asia Pacific Region 2003/2004

0

10

20

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40

50

60

70

80

90

100Taiw

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a

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STAPHYLOCOCCUS SPP

MRSA STUDY• 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%.

• 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 patientsa year in England•100000 cases of hospital acquired infection inEngland 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 fluoroquinolonesPakistan – 176 brands of CiprofloxacinIn 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

• 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.• Gakuu LN. East Afr Med J 1997; 74: 198-202 • Thevanesam V et all. J Hosp Infect 1994; 26: 123-127. • 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.

.

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

46%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jan-

06

month

perc

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ge

Process Analysis. Hand Washing Compliance.

Compliance By Health Care Workers Type. Liaquat National Hospital – Medical ICU

Hand Washing Compliance. Compliance By Health Care Workers Type. Liaquat National Hospital – Medical ICU - January 2006

64%

35%23%

0%10%

20%30%

40%50%60%

70%80%

90%100%

Physicians Nurses Anc Staff

Professional

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ge

Break the Chain of Infection

Portal of Entry

Mucos Membrane GI TractRespiratory Broken Skin

Infectious Agents

Bacteria FungiViruses Protozoa

Susceptible Host

ImmunosuppressionDiabetes Surgery Burns

Cardiopulmonarys

Means Of Transmission

Direct Contact FomaitesIngestion Airborne

Portal Of Exit

Excretions SecretionsSkin Droplets

Reservoirs

People Equipment

WaterHand washing

Sterilization

Isolation

Food Handling

Air flow control

COCKROACHES• Frequency of different species of cockroaches in tertiary care

hospital and their role in transmission of bacterial pathogensPakistan 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

• Culture not send properly

• Culture not performed properly

• Pathogen not identified

• Unreliable sensitivity test

• Typing errors

• 40% bhatta culture?

CONSULTANT

RMO

RESIDENTNURSE

WARDBOY

SWEEPER

LABORATORY?

patient

•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?

?

SWEDEN

Zulfiqar A. Bhutta, AKUH

Zulfiqar A. Bhutta, AKUH

Antibiotics are not the solution for every illness

Institutional Strategies to Control Antibiotic resistance

• 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. 1. Meyer KS et al. Ann Intern MedAnn Intern Med. 1993:119:353 . 1993:119:353 2. Patterson JE et al. 2. Patterson JE et al. Infect Control Hosp EpidemiolInfect Control Hosp Epidemiol. 2000;21:455. 2000;21:455

3. Peña C et al. 3. Peña C et al. Antimicrob Agents ChemotherAntimicrob Agents Chemother. 1998;42:53. 1998;42:534. Rice LB et al. 4. Rice LB et al. Clin Infect DisClin Infect Dis. 1996;23:118. 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