Antibiotic resistance among in- and outpatients attending Lashkar-Gah hospital, Afghanistan
Antimicrobial resistance• Antimicrobial resistance (AMR) is defined as “resistance
of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it”
• It represents a considerable public health threat: – Requires longer and more expensive treatment– Negatively affects patient outcomes– Erodes our armamentarium of drugs against microorganisms
Global context
• Poor availability of AMR data all over the world, especially in developing country settings
• Suspicions that Asia has the highest level of AMR
• Current consensus about a clear correlation between anarchic, unregulated use of antibiotics and levels of AMR
Afghan context
• Unregulated market of antibiotics (subquality, self-medication…)
• High pressure from patients to obtain antibiotics from the prescriber (often IV drugs!)
• Over-prescription in hospitals AND private practice
• Suspected therapeutic failures in MSF-Hospital
MSF-Afghanistan context:Poor therapeutic outcomes…
In Lashkar-Gah hospital (Helmand):
Unexplained high paediatric mortality rates
Lashkar Gah Hospital (Helmand)
MSF-Afghanistan context:Overuse of antibiotics…
Over-prescriptions of antimicrobial drugs among all outpatient consultations
Cf. study Sahar Bajis: “Antimicrobial use in a district hospital in Kabul, Afghanistan – are we too high?“
Ahmad Shah Baba hospital (Kabul):
How to assess AMR reality?How to collect data?
Option 1? Install a bacteriology lab for routine bacteriology
and… be patient 2-3 years to obtain aggregated data?
Option 2?Collect enough bacteria from voluntary inhabitants (such as in- and outpatients of an « MSF-hospital »)
and screen for resistance… 4 months
We’ve chosen Option 2… for a first statement
• Study conducted in Lashkar-Gah hospital (Helmand), Afghanistan• Screening of normal flora was chosen• Adult and paediatric in- and outpatients requested to provide a stool and/or nasopharyngeal swab sample• Bacteria cultured from these samples and tested for AMR
Methods
Screening of normal flora- limitations
• Everyone of us is carrying thousands of millions of bacteria. We are reservoirs.
• Sepsis is the most often due to an intrusion of one of these bacteria in our bloodstream.
• The bacteria we “carry” can be used as indicators for levels of AMR among pathogenic bacteria.
HOWEVER… this is not the same as resistance testing of pathogens in a routine laboratory
RESULTS
• Screening of normal flora:
Bacterial species isolation
Participants recruited IPD / OPD
Adult / Paediatric2077
Stool samples692
Nasopharyngeal swabs1762
482 E. coli isolates 173 S. pneumoniae isolates
447 Enterococcus species isolates 115 H. influenzae isolates
259 S. aureus isolates
ß-Lactamins Aminoglycos.
E. coli as indicator species: proportion of patients with a resistant organism (N=114)
Quinol. Others.ESBL
Levels of AMR
A nice bell curve taking place on the right of the graph
Imperfect bell curve+ shifting to the left(diameters becoming smaller)
ONLY SUSCEPTIBLE STRAINS
A FEW RESISTANT STRAINS
shift
MAINLY RESISTANT STRAINS Bell curve has disappearedMost of the strains are on the left
0% R
8% R
80% R
How to become an AMR specialist?Interpretation of resistance in a population of species
E. coli: Penicillins & ß-lactamase inhibitors
R
I
S
R S R S
IR S IR S
R S
R S
C2E. coli &Cephalosporins
IR S
IR S
I SRC3
C4I SRSR
Cephamycines
Ciprofloxacine
Levofloxacine
Moxifloxacine
OfloxacineR I S
Gentamicine
Tobramycine
Netilmicine
Amikacine
R I S
R I S
R I S
Imipenem
Meropenem
R I S
R S
Chloramphenicol
Tigecycline
Resistance in S. pneumoniae (N=64)
Screening by oxacilline showsa decreased susceptibility to penicillin
MICs to Penicillin could be tested: 16 strains were oxa-R…. MIC values are <= 2 mg/lThus: decreased susceptibility, but no high level of resistance
• A wake-up call to MSF: our protocols and standard treatment guidelines risk to be outdated
Discussion
?
• Diagnosis of AMR under field conditions is a bottle-neck – study shows the feasibility of laboratory screening of AMR in normal flora, but not as matter of routine=> Haemoculture as routine feasible?
• Holistic management of AMR (rational drug use, infection control, improved diagnostics) is required to avert public health disaster
Discussion
Boost HospitalLashkar Gah
Lashkar Gah team July 2013In MSF-compound
Thanks to
everybody !
It has been a incredible challengenot possible without a huge involvement of
everyone !
Special thanksHealth promotion:Caroline ZahndtAbdul BashirAnd all their wonderfulTEAM!
Management:Catherine Van OverloopGabriele Rossi (« SuperMedco »)Gbane (« huge support for end phase »)
LuxOR:Rafael Van den BerghRony ZachariahAnd all the TEAM!
OCB-Medical Depatment:Michel Van HerpPascale Chaillet
Logistics / Supply:Ann, Ben, Ryan, Antoine, Bazir, …
Lab:Dr WardakBismillahSher AgahBaryalai
Sorry for anyone I would have forgotten !!!!MSF-SupplyDiana & Sonia
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