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

10. RESULTS

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
Moxifloxacine

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 !!!!