Transcript Is AMR a public health crisis?

ANTIBIOTICS UPDATE
2016 Pork Management Conference
Clearwater, FL
June 15, 2016
Steven Solomon, MD, FACP, FIDSA
Global Public Health Consulting, LLC
Atlanta, GA
Presentation Outline
A brief, high-level overview of the public
health approach to the antibiotic &
antimicrobial resistance (AMR) problem
• Is AMR a public health crisis?
• What is the framework for a successful
response?
• How do we implement successful
strategies to address the AMR problem?
Is AMR a public health crisis?
• Yes,
in context. A crisis can be defined as:
1.
a difficult or dangerous situation that needs
serious attention;
2.
a situation that has reached a critical phase;
3.
an unstable or crucial time or state of affairs
in which a decisive change is impending
• AMR
can fit that description but in a way
that is different from other infectious
diseases
What is the response
framework?
• Acknowledge
complexity
• Improve
coordination
• Commit
to collaboration
• Focus
on communication
• Accelerate
computation
Antibiotic Use
• Antibiotics
are the principal driver of
antibiotic resistance
• All
antibiotic use, in every setting, adds
to the burden of antibiotic resistance,
including human infections
• Antibiotics
• Antibiotics
are overused in all settings
disrupt the human
microbiome, contributing to disease
The microbiome
• The “ecological community
of …microorganisms that
literally share our body
space”
• 90% of all the cells
associated with the human
body; the other 10% are
human cells
• Disruption of the microbiome
leads to:
• Short-term and long-term
adverse events, including
C. difficile disease
• Greater likelihood of
resistant infection
Grice, E. A. and J. A. Segre (2012). "The human
microbiome: our second genome." Annu Rev
Genomics Hum Genet 13: 151-170.
6
The Black Box of AMR Dynamics
Antibiotics
People
Bacteria
Animals
Plants
Soil
Water
Air
AMR-The “Resistome”
Many Action Plans and Reports
Coordination
National Action Plan Outcomes
Goals
Significant Outcomes
Objectives
Sub-objectives
Milestones
Sub-milestones
5
21
22
33
232
36
https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for
_combating_antibotic-resistant_bacteria.pdf
National Action Plan Metrics: 2020 Targets
AMR Bacteria
Microorganism
Reduce by
Compared to
CRE
Hospital-acquired infections
60%
estimates
MDR Pseudomonas
Hospital-acquired infections
35%
2011 estimates
MRSA
Bloodstream infections
50%
2011 cases
Salmonella non-Typhi
Infections
25%
2010-2012 estimates
M. tuberculosis
MDR infections
15%
2011 cases
S. pneumoniae
Rate of invasive disease among
65 year olds
≥25%
2008 estimates
N. gonorrheae
prevalence of ceftriaxoneresistance
Maintain < 2%
2013 estimates
Reduce by
Compared to
Adverse drug events
Microorganism
C. difficile
Infections
50%
2011 estimates
Collaboration
Ambitious prevention and reduction
targets are achievable with collaboration
• CRE
• Success in Israel
• MRSA
• “Search and destroy” in the Netherlands
• Invasive MRSA reduction in the US
• C. difficile
• Success in England
National Intervention to Contain the Spread of
Carbapenem-Resistant Enterobacteriaceae, Israel 2005-2008
CRE incidence per
105 patient-days.
Schwaber . Clin Infect Dis. 2014;58:697-703
One Health
•The One Health concept is a worldwide
strategy for expanding interdisciplinary
collaborations and communications in
all aspects of health care for humans,
animals and the environment
http://www.onehealthinitiative.com/about.php
Collaboration
One Health and Antibiotic Use
Comparing
antibiotic use in
humans and
animals in the
European Union:
corrected by
biomass
http://ecdc.europa.eu/en/public
ations/_layouts/forms/Publicatio
n_DispForm.aspx?List=4f55ad514aed-4d32-b960af70113dbb90&ID=1249
14
Impact of various sources of antibiotic
use on resistant infections in humans
Sector 1
Sector 6
Sector 2
Sector 7
Sector 3
Sector 8
Sector 4
Sector 9
Sector 5
• Human
• Outpatient use
• Inpatient use
• Hospitals
• Nursing homes
• Other
• Animal
• Companion animals
• Livestock
• Crops
• Environment
• Wastewater
• Manufacturing
The “color code” is unknown.
Communication
The Need for Integrated Actions
Coordination, collaboration,
communication, computation
must be integrated in all aspects
of activities to address the AMR
problem
Antibiotic overuse in human medicine:
Variations in prescribing demonstrates overuse
Antibiotic prescribing per 1000 persons, US, 2011
Hicks. Clin Infect Dis. 2015;60:1308
State and
national AMR
data
http://gis.cdc.gov/grasp/PSA/index.html;
http://wwwn.cdc.gov/narmsnow/
Current infection control is inadequate:
Infected and colonized patients move widely and easily
between healthcare settings
CRE patients
Won S Y et al. Clin Infect Dis. 2011;53:532-540
Stewardship
http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html;
http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
Summary
• We know a great deal and we need to learn a lot more about the
complexity of AMR, but we know enough to implement measures to
improve antibiotic use and prevent the spread of resistance
• We need to coordinate our actions as much as possible; agreeing on a
core set of short & medium term objectives would be a good first step
• We need to collaborate and ask each sector to accept its own role and
take additional steps before looking elsewhere for changes
• We need much better data, more rapid feedback, more integrated
information systems, better (esp. genetic) laboratory capacity to
compute and monitor risks and evaluate interventions
• We need to communicate in an entirely different way about AMR,
specifically addressing misinformation and confusion and focusing on
changing the culture of antibiotic use in all settings.
Thank you.
[email protected]
Global Public Health Consulting, LLC