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DR.ALTAF AHMED Consultant Microbiologist & Director Lab Services, The Indus Hospital, Karachi President, Infectious Diseases Society of Pakistan Rational.

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Presentation on theme: "DR.ALTAF AHMED Consultant Microbiologist & Director Lab Services, The Indus Hospital, Karachi President, Infectious Diseases Society of Pakistan Rational."— Presentation transcript:

1 DR.ALTAF AHMED Consultant Microbiologist & Director Lab Services, The Indus Hospital, Karachi President, Infectious Diseases Society of Pakistan Rational use of antibiotics




5 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?

6 Increasing Numbers & Clinical significance of ESBL Producers Extended spectrum beta lactamases GRAM NEGATIVE BACTERIA

7 SOMEWHERE IN KARACHI Please 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%

8 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

9 Some Species in which ESBLs are Found Klebsiella Escherichia coli Enterobacter Proteus Salmonella Citrobacter Pseudomonas Acinetobacter and others!!! Bradford PA. Clin Microbiol Rev. 2001;14:933 Numbers are increasing every week


11 Risk Factors for ESBL Infection Length of hospital stay 1 Severity of illness 1 Time in the ICU 1 Intubation and mechanical ventilation 1,2 Urinary catheterization 1,2 Arterial catheterization 1,2 Previous exposure to antibiotics 1 1 Bradford PA. Clin Microbiol Rev. 2001;14:933-951. 2 Peña C, et al. J Hosp Infect. 1997;35:9-16.

12 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 ResistanceNo coverage OvergrowthSelection Imipenem/cilastatinVancomycin Third-generation cephalosporins

13 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 (Χ 2, Trend) Association between delay in initiation of adequate initial antimicrobial therapy and mortality Time to institution of effective antimicrobial therapy (hours) a Only patients with non urinary ESBL-producing E. coli and Klebsiella spp. infections had a significantly elevated risk of death. % Mortality Sites of infection with ESBLs Total Number 0 20 40 60 80 100 120 Urinary a Respiratory Blood Wound Abdominal SST Other Klebsiella spp. E. coli Reprinted with permission from Hyle EP, et al. Arch Intern Med. 2005;165:1375-1380. SST, skin and soft tissue.


15 Trends in Gram-Positive Resistance: US Thronsberry C. NNIS. 38th ICAAC.1998; San Diego, Calif; Abstract E22; 1 Edmond M. CID 1999, MMWR Morb Mortal Wkly Rep. 1997;46:624-636. 2 Percent of Pathogens Resistant to Antibiotics 0 10 20 30 40 50 60 70 80 90 100 197519801985199019952000 MRSE MRSA VRE DRSP VISA 1997 1980 to 1999

16 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


18 Prevalence of MRSA in Asia Pacific Region 2003/2004


20 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**
















36 Hospital acquired infections kill 5000 patients a year in England 100000 cases of hospital acquired infection in England each year BMJ 2000; 321:1370 In USA - Hospital infections, kills about 90,000 people a year HOW MANY IN PAKISTAN?


38 QUALITY AND POTENCY OF ANTIMICROBIAL DRUGS ? Drugs are produced locally in India, Veitnam, and Pakistan etc. India - 80 different brands of fluoroquinolones Pakistan – 176 brands of Ciprofloxacin In 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

39 Prevention is better than cure!


41 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.

42 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


44 Process Analysis. Hand washing Compliance. Global Monthly Compliance. Liaquat National Hospital – Medical ICU

45 Process Analysis. Hand Washing Compliance. Compliance By Health Care Workers Type. Liaquat National Hospital – Medical ICU

46 Break the Chain of Infection Portal of Entry Mucos Membrane GI Tract Respiratory Broken Skin Infectious Agents Bacteria Fungi Viruses Protozoa Susceptible Host Immunosuppression Diabetes Surgery Burns Cardiopulmonarys Means Of Transmission Direct Contact Fomaites IngestionAirborne Portal Of Exit Excretions Secretions SkinDroplets Reservoirs People Equipment Water Hand washing Sterilization Isolation Food Handling Air flow control

47 COCKROACHES Frequency of different species of cockroaches in tertiary care hospital and their role in transmission of bacterial pathogens Pakistan J Med Res Dec 2005;44(4):143-8. Army Medical College, Rawalpindi Pakistan J Med Res 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.

48 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.

49 Infection control is



52 Please Remember Infection control is everyone’s job and responsibility The effectiveness of program depends on everyone’s commitment

53 UNRELIABLE LAB REPORTS Culture not send properly Culture not performed properly Pathogen not identified Unreliable sensitivity test Typing errors 40% bhatta culture?


55 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?

56 ?



59 Zulfiqar A. Bhutta, AKUH


61 Antibiotics are not the solution for every illness



64 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. Ann Intern Med. 1993:119:353 2. Patterson JE et al. Infect Control Hosp Epidemiol. 2000;21:455 3. Peña C et al. Antimicrob Agents Chemother. 1998;42:53 4. Rice LB et al. Clin Infect Dis. 1996;23:118




68 My message to all Guidelines does not work unless they are implemented! Implementation does not work unless there is local comittment and educational outreach!


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