Transcript 11.00 Pleanary - Robin Howe

11th October 2011
Antimicrobial Resistance:
from Global to Local
Robin
A Howe
Antimicrobial
use in Primary Care
World Health Day
2011
AMR: a major challenge
• Tuberculosis (TB): 440,000 new multidrug resistance (MDR) TB
cases annually; extensively drug resistance (XDR) TB cases
reported in 64 countries so far
• Malaria: Emergence of Artemisin resistance linked to ongoing use
of monotherapies
• HIV: With expanded use of antiretrovirals (ARVs), resistance is a
concern
• Methicillin-resistant Staphylococcus aureus: lethal infections in
hospital settings becoming increasingly frequent
• Multi-drug resistant E.coli, K.pneumoniae and Enterobacter sp.:
infections are on the rise and a new beta-lactamase, NDM-1, is
causing alarm
• Neisseria gonorrheae and Shigella: becoming increasingly
resistant to drugs
3
7 April 2011
|
World Health Day
No action today, no cure tomorrow
AMR: a major challenge
• Tuberculosis (TB): 440,000 new multidrug resistance (MDR) TB
cases annually; extensively drug resistance (XDR) TB cases
reported in 64 countries so far
• Malaria: Emergence of Artemisin resistance linked to ongoing use
of monotherapies
• HIV: With expanded use of antiretrovirals (ARVs), resistance is a
concern
• Methicillin-resistant Staphylococcus aureus: lethal infections in
hospital settings becoming increasingly frequent
• Multi-drug resistant E.coli, K.pneumoniae and Enterobacter sp.:
infections are on the rise and a new beta-lactamase, NDM-1, is
causing alarm
• Neisseria gonorrheae and Shigella: becoming increasingly
resistant to drugs
4
7 April 2011
|
World Health Day
No action today, no cure tomorrow
A global epidemic of
“ESBLs” 2001 - 2009
• Extended spectrum beta-lactamases
– Seen in coliforms (eg E. coli)
– Confer resistance to 3rd generation
cephalosporins (eg cefotaxime)
– Associated resistance to many other
classes of antibiotics
– Not identified until late 1980s
– TEM/SHV/CTX-M
E. coli resistance to
Cefotaxime rates from HPA
ECDC/EMEA JOINT TECHNICAL REPORT
(2009). The bacterial challenge: time to react
ECDC/EMEA JOINT TECHNICAL REPORT
(2009). The bacterial challenge: time to react
Development and spread of Antimicrobial
Resistance is Multifactorial
• Antibiotic use
– Evolutionary
pressure
– (effective treatment
reduces disease
burden)
• Infection control
– Community –
sanitation etc
– Hospital
• Immunisation
• Globalisation
• Bacterial factors
– Strain virulence
– Genetic linkage of
resistance with resistance
– Genetic linkage of
resistance with other
resistance
– Genetic mobility of
resistance genes
–Sub-lethal concentrations of Ciprofloxacin induce the SOS response
–Ciprofloxacin
–recA:GFP fusion
–Amikacin
tetracycline
–A. Couce and Jesus Blazquez 2009 FEMS Microbiol Rev 531-538
All-Wales antimicrobial resistance rates for
coliforms from community urines(2005-10)
• Odds ratio for revisiting GP
within next 30 days:
–
–
–
British Journal of General Practice; 2006; 56: 686–692
1.47 (95% CI = 1.10 - 1.95) if R to
any antibiotic
1.49 (95% CI = 1.11 - 2.00) for
ampicillin resistance
2.48 (95% CI = 1.70 - 3.59) for
trimethoprim resistance.
“~30% antimicrobial use inappropriate”
“~30%
antimicrobial
use
inappropriate”
Good practice promoted via
Antimicrobial Stewardship Forum
Good practice promoted via
Antimicrobial Stewardship Forum
Project to develop all-Wales guidance for
infection management and antimicrobial
usage
Work package
Detail
Review and adapt HPA guidance for primary care
A
Infection Management
guidance for Primary Care
B
Antimicrobial formulary
C
Antimicrobial usage
guidance/standards
D
Infection management
guidance
Implement Guidance
Maintain Guidance
Develop restrictive formulary with availability of agents
categorised, for example, as
 Freely available across primary and secondary care
 Restricted to initiation in secondary care
 Restricted to particular indications or areas
 Restricted (requiring agreement of microbiologist or
deputy)
Maintain formulary
Develop standards for antimicrobial use for primary care (e.g.
telephone prescribing, delayed prescribing) and secondary
care (e.g. Duration must be specified)
Maintain standards
Develop guidance for infection management as above
Maintain guidance
Stakeholders
PHW, AWMSG, DTC,
MSSAG, ASF, Health Boards,
Primary Care, NWIS (PSU)
PHW, AWMSG, DTC,
MSSAG, ASF, Health Boards,
Primary Care, NWIS (PSU)
PHW, AWMSG, DTC,
MSSAG, ASF, Health Boards,
Primary Care, NWIS (PSU)
PHW, AWMSG, DTC,
MSSAG, ASF, Health Boards,
Primary Care, NWIS (PSU),
Clinical specialty groups
E
Tools to support infection
management and
antimicrobial usage
guidance
Develop tools as above
PHW, AWMSG, DTC,
MSSAG, ASF, Health Boards,
Primary Care, NWIS (PSU)
F
IT support
Develop IT solution to support formulary and guidance
PHW, AWMSG, ASF, Health
Boards, Primary Care, NWIS
(PSU)
Carbapenemases/
metallo-beta-lactamases
• Carbapenems (imipenem, meropenem)
are v.broad spectrum agents
– (Gram positive, Gram negative, aerobes,
anaerobes)
• Carbapenemases
– breakdown carbapenems (and all betalactams) conferring resistance
– associated with resistance to many
(all) alternative agents
Antimicrobial Resistance & Usage
Location of Mobile MBL- Containing Organisms
IMP
VIM
SPM-1
GIM-1
AIM-1
SIM-1
NDM-1
DIM-1
TMB-1
KHM-1
DIM-1 – Poirel and Nordmann (unpublished data)
TMB-1 – El Salabi, Toleman and Walsh (unpublished data)
Location of Mobile MBL- Containing Organisms
IMP
VIM
SPM-1
GIM-1
AIM-1
SIM-1
NDM-1
DIM-1
TMB-1
KHM-1
DIM-1 – Poirel and Nordmann (unpublished data)
TMB-1 – El Salabi, Toleman and Walsh (unpublished data)
Carbapenemase +ve Enterobacteria
referred to ARMRL, 2003-May 2011
HPR June 17th 2001
Kumarasamy et al (2010) TLID (online Aug 11 2010)
Carbapenemases in Wales
• 2008:
– VIM-2 in P. aeruginosa from 2 patients (Cardiff)
– GES in 1 isolate of A. baumanii (Newport)
• 2009:
– VIM-2 in P. aeruginosa (Newport)
• 2010:
– VIM-1 in K. pneumoniae from 2 patients (Wrexham)
– VIM-1 in 1 isolate K. Pneumoniae (Rhyl)
• 2011:
–
–
–
–
OXA-48 in 1 isolate of K. pneumoniae (Swansea)
NDM in multiple isolates of A. baumanii (Swansea)
NDM in 1 isolate of E. cloacae from (Newport)
VIM-2 in 1 isolate of P. aeruginosa (Abergavenny)
Conclusions
• Antimicrobial resistance is a global public
health issue
• Development and spread of resistance is
multifactorial
• Global resistance will become a local issue
• Local “good practice” can influence spread
(and treat patients optimally)
• Post-Antimicrobial age is getting closer