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Are our options running out?

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Presentation on theme: "Are our options running out?"— Presentation transcript:

1 Are our options running out?
Antibiotic resistance among in- and outpatients attending Lashkar-Gah hospital, Afghanistan

2 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

3 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

4 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

5 MSF-Afghanistan context: Poor therapeutic outcomes…
In Lashkar-Gah hospital (Helmand): Unexplained high paediatric mortality rates Lashkar Gah Hospital (Helmand)

6 MSF-Afghanistan context: Overuse of antibiotics…
Over-prescriptions of antimicrobial drugs among all outpatient consultations Ahmad Shah Baba hospital (Kabul): Cf. study Sahar Bajis: “Antimicrobial use in a district hospital in Kabul, Afghanistan – are we too high?“

7 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

8 Methods 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

9 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


11 Bacterial species isolation
Screening of normal flora: Participants recruited IPD / OPD Adult / Paediatric 2077 Stool samples 692 Nasopharyngeal swabs 1762 482 E. coli isolates 173 S. pneumoniae isolates 447 Enterococcus species isolates 115 H. influenzae isolates 259 S. aureus isolates

12 Levels of AMR E. coli as indicator species: proportion of patients with a resistant organism (N=114) ß-Lactamins Aminoglycos. Quinol. Others. ESBL Chloramphenicol Nitrofurantoin Nitrofurantoin Amikacine Netilmicine Tigecycline Amoxi / Clav Pipera / Tazo Cefoxitin Imipenem Meropenem

13 How to become an AMR specialist
How to become an AMR specialist? Interpretation of resistance in a population of species 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 disappeared Most of the strains are on the left 0% R 8% R 80% R

14 E. coli: Penicillins & ß-lactamase inhibitors

15 E. coli & Cephalosporins
Cephamycines C4 I S R

16 E. coli & Quinolones R I S Ofloxacine Ciprofloxacine Levofloxacine

17 E.coli & Aminoglycosides
Gentamicine R I S E.coli & Aminoglycosides Tobramycine Netilmicine Amikacine

18 Imipenem E. coli & Penems R I S Meropenem R I S q

19 E. coli & other antibiotics
Chloramphenicol E. coli & other antibiotics R S Tigecycline R I S

20 Resistance in S. pneumoniae (N=64)
Screening by oxacilline shows a decreased susceptibility to penicillin MICs to Penicillin could be tested: 16 strains were oxa-R…. MIC values are <= 2 mg/l Thus: decreased susceptibility, but no high level of resistance

21 Discussion A wake-up call to MSF: our protocols and standard treatment guidelines risk to be outdated ?

22 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

23 Thanks to everybody ! Lashkar Gah team July 2013 In MSF-compound
It has been a incredible challenge not possible without a huge involvement of everyone ! Boost Hospital Lashkar Gah

24 Special thanks Health promotion: Management: Caroline Zahndt
Abdul Bashir And all their wonderful TEAM! Management: Catherine Van Overloop Gabriele Rossi (« SuperMedco ») Gbane (« huge support for end phase ») Lab: Dr Wardak Bismillah Sher Agah Baryalai LuxOR: Rafael Van den Bergh Rony Zachariah And all the TEAM! OCB-Medical Depatment: Michel Van Herp Pascale Chaillet Logistics / Supply: Ann, Ben, Ryan, Antoine, Bazir, … MSF-Supply Diana & Sonia Sorry for anyone I would have forgotten !!!!

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