Update on Antimicrobial Resistance Allison McGeer, MD, FRCPC Mount Sinai Hospital

“This inquiry has been an alarming experience which leaves us convinced that resistance to antibiotics... constitutes a major public health threat and ought to be recognized as such”. UK House of Lords White Paper, 1999

Antibiotic resistance in pneumococci, CBSN,

Antibiotic resistance in pneumococci in older adults, respiratory specimens, CBSN,

Number of Patients Colonized/Infected with MRSA, Ontario, LPTP Survey, 1996/97/ $25M

Risk of death from MRSA vs MSSA bacteremia l Meta-analysis, 2001 l 9 case control studies, l Pooled relative risk: 2.1 (1.7, 2.6) Whitby, MJA, 2001;175:264-7

Resistance in E. coli, Baycrest

MH, NH #1, March 2001 l Admitted to MSH with SOB, ?pneumonia l Sputum: E. coli AmpicillinR CotrimoxazoleR NitrofurantoinR CefazolinR CiprofloxacinR

G.D. 82yo Male ESRF on Hemodialysis-resident of RH l TO ER with fever, shortness of breath l T=38.0, WBC-N l Bibasilar Infiltrate-Rx IV Cefuroxime x24hrs l Deterioration: Resp Failure +Septic Shock l ETT suction-Gram-Mod Poly’s, many Gram neg rodst: culture; heavy MDR E.Coli l IV Azithro+Meropenem l Death due to septic shock + Refractory hypoxemia

Inappropriate antimicrobial therapy Impact on Mortality 42% mortality 17% mortality Rel risk % Ci 1.8,3.1) Kollef et al. Chest 1999;115:462

Conclusion l Antibiotic resistance is coming bad for patients expensive l The only good news is that we can choose to spend our money on prevention or on treatment

What can be done? l Surveillance l Prevention –Hand hygiene –Vaccine l Transmission control l Reduced/improved antibiotic use –Public expectations –Provider practice

Surveillance l Measure burden of illness – incidence, mortality, morbidity, cost l Identify opportunities for prevention l Evaluating/inform prevention programs –vaccine, appropriate AB, transmission prevention l Minimize treatment failures

WHO, 1997 Antimicrobial resistance has increased dramatically in the last decade, adversely affecting control of many important diseases. Antimicrobial resistance leads to prolonged morbidity, increased case fatality and lengthens duration of epidemics. Surveillance is necessary for national and international co-ordination.

Canada,1998 UK, influenza 5 tuberculosis 15 inv S. pneumoniae 18 inv H. influenzae 23 gonorrhea 24 invasive GAS 35 Campylobacteriosis 2 antibiotic resistance 4 nosocomial infections 5 tuberculosis 8 MRSA 9 salmonellosis 12 campylobacteriosis 14 C. difficile

Top ten (1,1) S. aureus (2,2) S. pneumoniae (3,4) M. tuberculosis (5,4) Enterococcus spp. (4,7) N. gonorrhoeae (8,5) E. coli (x,6) H. influenzae (7,8) Salmonella spp. (9,9) N. meningitidis (x,6) P. aeruginosa (10,10) Klebsiella spp

What can be done? l Surveillance l Prevention –Hand hygiene –Vaccine l Transmission control l Reduced/improved antibiotic use –Public expectations –Provider practice

Impact of hand hygiene on infections

Vaccines l Influenza (universal) l Pneumococcal –polysaccharide (pneumovax) for high risk children and adults –conjugate vaccine for children

Effect of influenza vaccine for staff and residents of long term care facilities Potter et al. JID 1997;175:1-6

Annual risk of influenza outbreaks by percentage of staff vaccinated

Impact of influenza vaccine on antibiotic use l Pediatrics (Belshe, NEJM, 1998) –30% reduction in acute otitis media l Healthy adults (Nichols, NEJM, 1995) –45% reduction in antibiotic prescriptions

Rate of invasive pneumococcal disease: Metro/Peel vs. Quebec

Cases of invasive disease by vaccine eligibility, Metro/Peel,

Pneumococcal vaccination rates, by risk group

What can be done? l Surveillance l Prevention –Hand hygiene –Vaccine l Transmission control l Reduced/improved antibiotic use –Public expectations –Provider practice

Number of Patients Colonized/Infected with MRSA, Ontario, QMP/LS Surveys,

Number of Patients Colonized/Infected with MRSA, Ontario, ?.

Number of Patients Colonized/Infected with VRE, Ontario, Number of Patients Colonized/Infected with VRE, Ontario, QMP-LS Surveys,

ALC - Risk Factors for Colonization

Public Health Role l Surveillance l Daycare, long term care l Communication l Co-ordination within regions l National, provincial, regional guidelines

What can be done? l Surveillance l Prevention –Hand hygiene –Vaccine l Transmission control l Reduced/improved antibiotic use –Public expectations –Provider practice

Improved antibiotic use Challenges l Dissemination from current programs in the community –Edmonton, Port Hope, Ottawa l Institutions