2. بسم الله الرحمن الرحيم Emerging Diseases Antimicrobial Resistance Shahid Beheshti University of medical sciences 2008 2008 By: Hatami H. MD. MPH

3. Introduction Antimicrobial resistance is not a new or surprising phenomenon All micro-organisms have the ability to evolve various ways of protecting themselves from attack But over the last decade 1

4. Introduction Antimicrobial resistance has increased The pace of development for new and replacement antimicrobials have decreased have decreased :But over the last decade 2

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6. The increasing threat of antimicrobial resistance Penicillin was once 100% successful for curing gonorrhea Now it is virtually useless against gonorrhea in all of the world 4

7. Streptomycin was once the most effective drug we had to cure TB It is no longer effective in many European countries The increasing threat of antimicrobial resistance 5

8. Chloroquine and sulfadoxine pyrimethamine could once stop malaria Now they can not The increasing threat of antimicrobial resistance 6

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10. Lamivudine, recently developed to treat hepatitis B Has quickly become ineffective in percent of patients percent of patients The increasing threat of antimicrobial resistance 8

11. How resistance develops and spreads (1) * Microbiology (Natural selection) * Microbiology (Natural selection) * The Poverty Paradigm * The Poverty Paradigm * Misdiagnosis and Resistance * Misdiagnosis and Resistance * Counterfeit Drugs * Counterfeit Drugs * Dubious Pay-offs and High- priced Prescriptions * Dubious Pay-offs and High- priced Prescriptions 9

12. * Advertising for Resistance * Advertising for Resistance * Lack of Education * Lack of Education * Resistance and Hospitals * Resistance and Hospitals * Antimicrobial Resistance and Food * Antimicrobial Resistance and Food * Globalization and Resistance * Globalization and Resistance How resistance develops and spreads (2)0 and spreads (2)0 10

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14. Misdiagnosis and Resistance In Viet Nam more than 70% inadequate and 25% unnecessary In China 63% the wrong choice In Bangladesh 50% inappropriate In the North America 50% over prescribe 12

15. Counterfeit Drugs About 51% of counterfeiting cases uncovered by WHO revealed that forged drugs carried No active ingredient Wrong ingredient 17% Weaker concentration 11% The same quality and quantity 4% 13

16. Dubious Pay-offs and High-priced prescriptions Unethical pharmaceutical companies pay a commission for recommending more expensive broader-spectrum medications This troubling development accelerates the natural process of resistance Unethical pharmaceutical companies pay a commission for recommending more expensive broader-spectrum medications This troubling development accelerates the natural process of resistance 14

17. Advertising for Resistance Patient demand for antimicrobials sometimes the result of TVMagazineInternetNewspaper Spouse the development of resistance Patient demand for antimicrobials sometimes the result of TVMagazineInternetNewspaper Spouse the development of resistance 15

18. Resistance and Hospitals Between 40% and 91% of antibiotics prescribed in 10 studies Between 40% and 91% of antibiotics prescribed in 10 studies were inappropriate Health care workers of ten disregarded basic hygiene practices Health care workers of ten disregarded basic hygiene practices Hand washing Hand washing Changing gloves Inadequately cleaned equipment * * 16

19. Antimicrobial Resistance and food 50% of antibiotics are used to : 1- Treat sick animals 2- As growth promoters 3- rid cultivated foodstuffs foodstuffs Development of resistance 17

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21. Resistance traits spread 19191919

22. Animal resistance and food Vancomycin-resistant enterococcus faecium (VRE) is one particularly ominous example of a resistant bacterium appearing in animals that may have jumped into more vulnerable segments of the human population 20

23. Impact of globalization In the Middle Ages deadly plagues were shipped from one continent to another ( flea - rat )0 Today they travel by plane from one corner of the earth to another in a matter of hours 21212121

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29. * Mortality * Morbidity * Cost * Limited solutions Consequences of Antimicrobial Resistance 27272727

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31. Resistance means that People can not be effectively treated People are ill for longer People are at greater risk of dying Epidemics are prolonged Others are at greater risk of infection 2929

32. Major infectious killers Major infectious killers * Pneumonia * Pneumonia * Diarrhoeal Diseases * Diarrhoeal Diseases * AIDS * AIDS * Tuberculosis * Tuberculosis * Malaria * Malaria * Viral Hepatitis * Viral Hepatitis * Hospital-Acquired Infections * Hospital-Acquired Infections * Leishmaniasis * Leishmaniasis * Gonorrhoea * Gonorrhoea * Common worms * Common worms 39

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44. WHO's Recommendations 1. Adopt WHO Strategies and Policies 2. Educate Health Workers and the Public on the Use of Medicines 3. Contain Resistance in the Hospital 4. Reduce the Use of Antimicrobials in Livestock 5. Increase Research for new Drugs and Vaccines 6. Build Alliances and Partnerships to Increase Access to Antimicrobials 7. Increase Availability of Essential Drugs 8. Make Effective Medicines Available to Poor People 42

45. CDC: 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults to Prevent Infection (A campaign to educate Doctors) 43

46. 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults 1.Vaccinate 2.Get the catheters out 3.Target the pathogen 4.Access the experts 5.Practice antimicrobial control 6.Use local data 7.Treat infection, not contamination 8.Treat infection, not colonization 9.Know when to say “no” to vanco 10.Stop treatment when infection is cured or unlikely 11.Isolate the pathogen 12. Contain the contagion Diagnose and Treat Infection Effectively Prevent Infection Use Antimicrobials Wisely Prevent Transmission 44

47. Fact: Predischarge influenza and pneumococcal vaccination of at- risk hospital patients AND influenza vaccination of healthcare personnel will prevent infections. Prevent Infection Step 1: Vaccinate 45

48. Actions: give influenza/S. pneumonia vaccine to at-risk patients before discharge give influenza/S. pneumonia vaccine to at-risk patients before discharge get influenza vaccine annually get influenza vaccine annually Prevent Infection Step 1: Vaccinate Fact: Predischarge influenza and pneumococcal vaccination of at-risk hospital patients and influenza vaccination of of at-risk hospital patients and influenza vaccination of healthcare personnel will prevent infections. healthcare personnel will prevent infections. 46

49. Fact: Catheters and other invasive devices are the #1 exogenous cause of hospital- acquired infections. Prevent Infection Step 2: Get the catheters out 47

50. Fact: Catheters and other invasive devices are the #1 exogenous cause of hospital-acquired infections. Actions: use catheters only when essential use catheters only when essential use the correct catheter use the correct catheter use proper insertion and catheter-care protocols use proper insertion and catheter-care protocols remove catheters when not essential remove catheters when not essential Prevent Infection Step 2: Get the catheters out 48

51. Fact: Appropriate antimicrobial therapy (correct regimen, timing, dosage, route, and duration) saves lives. Diagnose and Treat Infection Effectively Step 3: Target the pathogen 49

52. Fact: Appropriate antimicrobial therapy saves lives. Actions: culture the patient culture the patient target empiric therapy to likely pathogens and local antibiogram target empiric therapy to likely pathogens and local antibiogram target definitive therapy to known pathogens and antimicrobial susceptibility test results target definitive therapy to known pathogens and antimicrobial susceptibility test results Diagnose and Treat Infection Effectively Step 3: Target the pathogen 50

53. Fact: Infectious diseases expert input improves the outcome of serious infections. Infectious diseases expert input improves the outcome of serious infections. Diagnose and Treat Infection Effectively Step 4: Access the experts 51

54. Infectious Diseases Expert Resources Infectious Diseases Specialists Optimal Patient Care Optimal Infection Control Professionals HealthcareEpidemiologists Clinical Pharmacists ClinicalPharmacologists Surgical Infection Experts Clinical Microbiologis ts 52

55. Fact: Infectious diseases expert input improves the outcome of serious infections. outcome of serious infections. Action: consult infectious diseases experts about patients with serious infections consult infectious diseases experts about patients with serious infections Diagnose and Treat Infection Effectively Step 4: Access the experts 53

56. Fact: Programs to improve antimicrobial use are effective. Use Antimicrobials Wisely Step 5: Practice antimicrobial control 54

57. Methods to Improve Antimicrobial Use  Passive prescriber education  Standardized antimicrobial order forms  Formulary restrictions  Prior approval to start/continue  Pharmacy substitution or switch  Multidisciplinary drug utilization evaluation (DUE)  Interactive prescriber education  Provider/unit performance feedback  Computerized decision support/online ordering 55

58. Use Antimicrobials Wisely Step 5: Practice antimicrobial control Fact: Programs to improve antimicrobial use are effective. Action: engage in local antimicrobial use quality improvement efforts engage in local antimicrobial use quality improvement efforts 56

59. Fact: The prevalence of resistance can vary by time, locale, patient population, hospital unit, and length of stay. Use Antimicrobials Wisely Step 6: Use local data 57

60. Use Antimicrobials Wisely Step 6: Use local data Fact: The prevalence of resistance can vary by locale, patient population, hospital unit, and length of stay. Actions: know your local antibiogram know your local antibiogram know your patient population know your patient population 58

61. Interpreting a “Positive” Blood Culture True Bacteremia: Unlikely Uncertain Likely S. aureusS. aureus S. pneumoniaeS. pneumoniae EnterobacteriaceaeEnterobacteriaceae P. aeruginosaP. aeruginosa Candida albicansCandida albicans Corynebacterium spp.Corynebacterium spp. Non-anthracis Bacillus spp.Non-anthracis Bacillus spp. Propionibacterium acnesPropionibacterium acnes Coagulase-negativeCoagulase-negative staphylococci staphylococci Pre-test probability patient risk factors prosthetic devices clinical evidence Post-test probability # positive/# cultures compare antibiograms compare genotypes 59

62. Fact: A major cause of antimicrobial overuse is “treatment” of contaminated cultures. Use Antimicrobials Wisely Step 7: Treat infection, not contamination 60

63. Fact: A major cause of antimicrobial overuse is “treatment” of colonization. Use Antimicrobials Wisely Step 8: Treat infection, not colonization 61

64. Use Antimicrobials Wisely Step 8: Treat infection, not colonization Fact: A major cause of antimicrobial overuse is treatment of colonization. Actions: treat pneumonia, not the tracheal aspirate treat pneumonia, not the tracheal aspirate treat bacteremia, not the catheter tip or hub treat bacteremia, not the catheter tip or hub treat urinary tract infection, not the indwelling catheter treat urinary tract infection, not the indwelling catheter 62

65. Fact: Vancomycin overuse promotes emergence, selection, and spread of resistant pathogens. Use Antimicrobials Wisely Step 9: Know when to say “no” to vanco 63

66. S. aureus Penicillin [1950s] Penicillin-resistant Evolution of Drug Resistance in S. aureus in S. aureus Methicillin [1970s] Methicillin- resistant S. aureus (MRSA) Vancomycin-resistant enterococci (VRE) Vancomycin [1990s] [1997]Vancomycin intermediate- resistant S. aureus (VISA) (VISA) Vancomycin-resistant S. aureus 64

67. Use Antimicrobials Wisely Step 9: Know when to say “no” to vanco “no” to vanco Fact: Vancomycin overuse promotes emergence, selection, and spread of resistant pathogens. Actions: treat infection, not contaminants or colonization treat infection, not contaminants or colonization fever in a patient with an intravenous catheter is not a routine indication for vancomycin fever in a patient with an intravenous catheter is not a routine indication for vancomycin 65

68. Fact: Failure to stop unnecessary antimicrobial treatment contributes to overuse and resistance. Use Antimicrobials Wisely Step 10: Stop treatment when infection is cured or unlikely 66

69. Fact: Failure to stop unnecessary antimicrobial treatment contributes to overuse and resistance. Actions: when infection is cured when infection is cured when cultures are negative and infection is unlikely when cultures are negative and infection is unlikely when infection is not diagnosed when infection is not diagnosed Use Antimicrobials Wisely Step 10: Stop antimicrobial treatment 67

70. Fact: Patient-to-patient spread of pathogens can be prevented. Prevent Transmission Step 11: Isolate the pathogen 68

71. Prevent Transmission Step 11: Isolate the pathogen Fact: Patient-to-patient spread of pathogens can be prevented. Actions: use standard infection control precautions use standard infection control precautions contain infectious body fluids (use approved airborne/droplet/contact isolation precautions) contain infectious body fluids (use approved airborne/droplet/contact isolation precautions) when in doubt, consult infection control experts when in doubt, consult infection control experts 69

72. Fact: Healthcare personnel can spread antimicrobial-resistant pathogens from patient to patient. Prevent Transmission Step 12: Contain your contagion 70

73. Prevent Transmission Step 12: Break the chain of contagion Fact: Healthcare personnel can spread antimicrobial- resistant pathogens from patient to patient. Actions: stay home when you are sick stay home when you are sick contain your contagion contain your contagion keep your hands clean keep your hands clean set an example! set an example! 71

74. 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults 12 Contain your contagion 12 Contain your contagion 11 Isolate the pathogen 11 Isolate the pathogen 10 Stop treatment when cured 10 Stop treatment when cured 9 Know when to say “no” to vanco 9 Know when to say “no” to vanco 8 Treat infection, not colonization 8 Treat infection, not colonization 7 Treat infection, not contamination 7 Treat infection, not contamination 6 Use local data 6 Use local data 5 Practice antimicrobial control 5 Practice antimicrobial control 4 Access the experts 4 Access the experts 3 Target the pathogen 2 Get the catheters out 2 Get the catheters out 1 Vaccinate 1 Vaccinate Prevent Transmission Prevent Transmission Use Antimicrobials Wisely Use Antimicrobials Wisely Diagnose and Treat Effectively Diagnose and Treat Effectively Prevent Infection Prevent Infection 72

75. Antimicrobial Resistance: Key Prevention Strategies Optimize Use Prevent Transmission PreventInfection EffectiveDiagnosis and Treatment Pathogen Antimicrobial-Resistant Pathogen Antimicrobial Resistance Antimicrobial Use Infection Susceptible Pathogen 73

76. Hand washing 74

77. Source : CDC, Internet citeCDC, Internet cite WHO, Internet citeWHO, Internet cite 75