Antimicrobial resistance global amr 7

Dr.Sherin Elsherbiny
MD, Clinical Pathology and Microbiology Infection Control Specialist
RRT-Member ,Meeqat General Hospital. Madinah

1. MDRO as a Growing Global Health Threat Dr.Sherin Elsherbiny MD, Clinical Pathology and Microbiology Infection Control Specialist RRT-Member

2. Expectations Antibiotic resistance is a growing crisis worldwide. New resistance mechanisms are emerging and spreading globally, threatening our ability to treat common infectious diseases By 2050, 10 million people may die from causes attributable to AMR with a loss of up to $100 trillion (£64 trillion) to the global economy Dr Marie- Paule Kieny , WHO's Assistant General Director- for Health Systems and Innovation said . "Antibiotic resistance is growing, and we are fast running out of treatment options. If we leave it to market forces alone. The new antibiotics we most urgently need, are not going to be developed o n time”

3. Common Causes of antibiotic resistance Over-prescribing of antibiotics Patients not taking antibiotics as prescribed Unnecessary antibiotics used in agriculture Poor infection control in hospitals and clinics Poor hygiene and sanitation practices Lack of rapid laboratory tests

4. Role of WHO A global action plan on antimicrobial resistance, including antibiotic resistance, was endorsed at the World Health Assembly in May 2015

5. Global Antimicrobial Resistance Surveillance System (GLASS) GLASS promotes and supports a standardized approach to the collection, analysis and sharing of AMR data at a global level by encouraging and facilitating the establishment of national AMR surveillance systems that are capable of monitoring AMR trends and producing reliable and comparable data. GLASS objectives Foster national surveillance systems and harmonized global standards; Estimate the extent and burden of AMR globally by selected indicators; Analyze and report global data on AMR on A regular basis; Detect emerging resistance and its international spread; Inform implementation of targeted prevention and control programs; and Assess the impact of interventions .

6. To date, 52 countries (25 high-income, 20 middle-income and 7 low-income countries) are enrolled in WHO’s Global Antimicrobial Surveillance System . For the first report, 40 countries provided information about their national surveillance systems and 22 countries also provided data on levels of antibiotic resistance.

7. (GLASS) Reveals WHO’s new Global Antimicrobial Surveillance System (GLASS) reveals widespread occurrence of antibiotic resistance among 500.000 people with suspected bacterial infections across 22 countries. The most commonly reported resistant bacteria were  Escherichia coli ,  Klebsiella pneumoniae ,  Staphylococcus aureus , and  Streptococcus pneumoniae , followed by  Salmonella  spp . The system does not include data on resistance of  Mycobacterium tuberculosis , which causes tuberculosis (TB), as WHO has been tracking it since 1994 and providing annual updates in the  Global tuberculosis report . .

8. Among patients with suspected bloodstream infection, the proportion that had bacteria resistant to at least one of the most commonly used antibiotics ranged widely between different countries from zero to 82%. Resistance to penicillin –to treat pneumonia – ranged from zero to 51% among reporting countries. And Between 8% to 65% of  E. coli  associated with urinary tract infections presented resistance to ciprofloxacin, an antibiotic commonly used to treat this condition

9. WHO list for R&D of new antibiotics 27 FEBRUARY 2017 | GENEVA - WHO today published its first ever list of antibiotic-resistant "priority pathogens" – a catalogue of 12 families of bacteria that pose the greatest threat to human health. This list is a new tool to ensure R&D responds to urgent public health needs. The WHO list is divided into three categories according to the urgency of need for new antibiotics: critical, high and medium priority.

10. WHO priority pathogens list for R&D of new antibiotics   Priority 1: CRITICAL •Acinetobacter baumannii, carbapenem-resistant •Pseudomonas aeruginosa, carbapenem-resistant • Enterobacteriaceae ( carbapenem-resistant, ESBL-producing) Priority 2: HIGH •Enterococcus faecium, vancomycin-resistant •Staphylococcus aureus, methicillin-resistant, vancomycin-intermediate and resistant •Helicobacter pylori, clarithromycin-resistant •Campylobacter spp., fluoroquinolone-resistant •Salmonellae, fluoroquinolone-resistant •Neisseria gonorrhoeae, cephalosporin-resistant, fluoroquinolone-resistant Priority 3: MEDIUM •Streptococcus pneumoniae, penicillin-non-susceptible •Haemophilus influenzae, ampicillin-resistant •Shigella spp., fluoroquinolone-resistant

11. MDRO prevalence tended to be higher in low- and middle-income countries A conducted a laboratory-based period-prevalence survey of AMR through 420 laboratories in 67 countries for S. aureus, Enterococci and Gram-negative bacilli respectively. Enterobacteriaceae were the most common organisms BUT had the lowest proportion of MDRO ESBL- representing 13.9% from blood and 10.2% from urine CRE representing 2.3 % and 1.0% S. aureus was the most frequent organism from blood with 38.1%

12. CDC CDC published a report outlining the top 18 drug-resistant threats to the United States. These threats were categorized based on level of concern: urgent, serious, and concerning . Regardless of category based on threat-specific , CDC activities are tailored to meet the epidemiology of the infectious agent and to address any gaps in the ability to detect resistance and to protect against infections

13. Role of Pharmacopeias Around the world, governments and stakeholders are implementing approaches to minimize AMR induced by falsified and substandard medicines , Medicines can be substandard (not meeting quality, labeling, or other requirements) for a variety of reasons, including product degradation due to weak supply chains; or improper practices or missteps occurring during manufacturing. Falsified medicines contain the wrong amount or no active ingredient. C oordinated actions across governments, sectors, and agencies is critical to reduce the size of this market and reduce its harmful effects on public health

14. Pharmacopeias working through strengthening the supply chain and ensuring access to medicines of assured quality. This includes 1.Compliance with Quality Standards Pharmacopeia quality standards (e.g., those of USP and other pharmacopeias) cover the entire lifecycle of medicines, from production to consumption, 2. Quality Assurance Programs, Regulatory System Strengthening, and Surveillance

15. USP USP is an independent public health organization established in 1820. USP develops transparent standards of quality for medicines, dietary supplements and foods, working with a network of independent experts . USP’s standards are enforceable by the U.S. FDA , and have been used in more than 140 countries globally. Such standards also assist industry in the development, manufacturing, and testing of medicines . USP focuses on reducing the threat of resistance posed by substandard medicines (one important cause) and advances quality pharmaceutical products and stewardship practices .

16. KSA National antibiotic guideline Prepared by the Antimicrobial Stewardship Subcommittee of the National Antimicrobial Resistance Committee and the General Administration of Pharmaceutical Care at Ministry of Health

17. Drug restriction list Definition Restricted antimicrobial agent is an agent which requires -prior to dispensing- authorization by the infectious Diseases (ID) physicians, other authorized personnel such as antimicrobial stewardship clinical pharmacist, or approved protocol by the antimicrobial stewardship committee. Depending on the hospital’s policy, the first few doses may be allowed to be dispensed without authorization

18. Antibacterial agents Antiviral Antiprotozoal Antifungal drugs 1. Amikacin 2. Ceftazidime 3. Cefepime 4. Colistin 5. Daptomycin 6. Doxycycline IV 7. Linezolid 8. Imipenem 9. Meropenem 10. Mupirocin 11. Rifampicin 12. Sulfadiazine 13. Tigecycline 14. Tobramycin 15. Ethionamide 1. HIV medicines 2. Cidofovir 3. Ganciclovir 4. Foscarnet 5. Oseltamivir 6. Ribivarin 1. Artesunate 2. Atovaquone proguanil 3. Pyrimethamin 4. Pentamidine (systemic and inhalation) 5. Quinidine 1. Liposomal Amphotericin B 2. Anidulafungin 3. Caspofungin 4. Posaconazole 5. Voriconazole

19. Antibiograms   Gram Negative   Gram Positive Antibiotic Tested Escherichia coli Klebsiella pneumoniae Proteus mirabilis Pseudomonas aeruginosa   Staphylococcus aureus nonMRSA | MRSA † Staphylococcus coag . Neg Enterococcus sp # of Isolates‡ 165 75 39 33   10* 35 18 68 Oral or Oral Equivalent   Oral or Oral Equivalent Ampicillin 46% 0% 62%     50% 0% 50% 96% Amox / Clav 77% 96% 100%             Cefazolin 70% 93% 88%     100% 0% 50%   Cefoxitin 82% 100% 100%             Ceftriaxone 85% 79% 92%             Ciprofloxacin 58% 79% 62% 56%     0% 0% 47% Levofloxacin 59% 79% 62% 57%   33% 20% 0% 64% Nitrofurantoin 100% 0% 0%     100% 100% 100% 100% TMP / SMX 64% 79% 54%     67% 100% 100%   Tetracycline 64% 60% 0%     100% 100% 80% 38% Oxacillin           100% 0% 50%   Clindamycin           50% 50% 100%   Erythromycin           50% 0% 0%   Linezolid           100% 100%   100% IV Only   IV Only Pip / Taz 98% 96% 100% 100%           Cefepime 89% 95% 92% 91%           Ceftazidime       91%           Gentamicin 85% 83% 92% 91%   100% 100% 67%   Imipenem 100% 100% 100% 71%           Vancomycin           100% 100% 100% 100% Antibiotic Tested Escherichia coli # of Isolates 165 Ciprofloxacin 58%

20. WI cumulative statewide antibiogram for 2008 28 Indicates a ≥10% decrease in susceptibility as compared to 2006 Indicates a ≥10% increase in susceptibility as compared to 2006

21. HOME MESSAGE Antibiotic resistance can affect anyone, of any age, in any country. Antibiotic resistance occurs naturally, but misuse of antibiotics in humans and animals is accelerating the process . The world urgently needs to change the way it prescribes and uses antibiotics. Even if new medicines are developed, without behavior change, antibiotic resistance will remain a major threat . Behavior changes must also include actions to reduce the spread of infections through vaccination, hand washing and good food hygiene . Without urgent action, we are heading for a post-antibiotic era, in which common infections and minor injuries can once again kill . Antibiotic resistance is one of the biggest threats to global health, food security, and development today.

22. References GLASS REPORT Early implementation 2016-17.WHO Worldwide country situation analysis response to antimicrobial resistance Summary April WHO/HSE/PED/AIP/2015.1 World Health Organization period prevalence survey on multidrug-resistant microorganisms in healthcare 23 April 2017, 13:42 - 13:47 EP0409 27 TH ECCMID USP Global Public Policy Position Combatting Antimicrobial Resistance 2017 International Activities to Combat AR | Antibiotic/Antimicrobial ... – CDC 2.17