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Antibiotic resistance among in- and outpatients attending Lashkar-Gah hospital, Afghanistan.

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Presentation on theme: "Antibiotic resistance among in- and outpatients attending Lashkar-Gah hospital, Afghanistan."— Presentation transcript:

1 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 Cf. study Sahar Bajis: “Antimicrobial use in a district hospital in Kabul, Afghanistan – are we too high?“ Ahmad Shah Baba hospital (Kabul):

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 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 Methods

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

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

13 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 How to become an AMR specialist? Interpretation of resistance in a population of species

14 E. coli: Penicillins & ß-lactamase inhibitors R I S RS RS I R S I R S RS

15 R S C2 E. coli & Cephalosporins I R S I R S I S R C3 C4 IS R SR Cephamycines

16 Ciprofloxacine Levofloxacine Moxifloxacine Ofloxacine RIS E. coli & Quinolones

17 Gentamicine Tobramycine Netilmicine Amikacine RIS E.coli & Aminoglycosides

18 E. coli & Penems RIS RIS Imipenem Meropenem

19 E. coli & other antibiotics RIS RS Chloramphenicol Tigecycline

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 A wake-up call to MSF: our protocols and standard treatment guidelines risk to be outdated Discussion ?

22 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 Discussion

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

24 Special thanks Health promotion: Caroline Zahndt Abdul Bashir And all their wonderful TEAM! Management: Catherine Van Overloop Gabriele Rossi (« SuperMedco ») Gbane (« huge support for end phase ») 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, … Lab: Dr Wardak Bismillah Sher Agah Baryalai Sorry for anyone I would have forgotten !!!! MSF-Supply Diana & Sonia


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