Widespread MultiAntimicrobialResistant Shigella in Asia: What Does It Mean

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Widespread Multi-Antimicrobial-Resistant Shigella
in Asia What Does It Mean?
Chiang Mai, Thailand March 30 April 2, 2004
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of Medicines

• Okumura J1), Osaka K2), Okabe N2)
• University of Tokyo
• National Institute of Infectious Diseases, Japan

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Background

• Despite immense efforts to contain antimicrobial
  resistance (AMR), development of resistant
  microbes has been accelerated.
• For example, Shigella sonnei, spread by
  travelers, illustrates the problems caused by
  resistant microbes and the urgency of its
  containment.

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Objectives

• To understand the trend of development and
  distribution of resistant S. sonnei in Asia.
• To identify factors by which the world has been
  failing to contain AMR, in spite of holding a
  number of expert meetings and a mountain of
  documents on the agenda.
• To seek effective and practical measures to halt
  the spread of AMR before it reaches at critical
  level.

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Methods (1)

• Design Retrospective, time series
• Samples
• Imported S. sonnei which were isolated from
  travelers at quarantine stations in Japan
• 120, 87 and 159 samples each year during the
  period of 1997 1999

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Methods (2)

• Checked AMR of the isolated S. sonnei by
  measuring Minimum Inhibitory Concentration (MIC)
• By using E-test (AB Biodisk) on agar media
• Antimicrobials are Ampicillin (ABPC),
• Chloramphenicol (CP), Cefotaxime (CTX),
• Fosfomycin (FOM), Levofloxacin (LVFX),
• Norfloxacin (NFLX), Tetracycline (TC),
  Sulfamethoxazole-Trimethoprim (ST)
• Referred the National Committee for
• Clinical Laboratory Standards

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Overall trend of AMR
n 120
n 159
n 87
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Trend and level of AMR in 3 countries
n43
n26
n72
n7
n18
n38
n14
n17
n17
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Resistance by Antimicrobials in Indonesia

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Resistance by Antimicrobials Expenditure for
Antimicrobials for Human in Thailand
Million Bhats

FOM Resistant Strain
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Resistance to 2nd or 3rd line antimicrobials
Multiple Resistance and Susceptibility to FOM

(Unit Strain)
Odds Ratio 10.4 (95 CI 4.0 27.2) Plt0.001

• All the S. sonnei developed resistance to NFLX
  also attained resistance to more than three
  antimicrobials (Plt0.001).

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Lessons learned

• In spite of immense efforts to contain AMR during
  the last century, the problem has been unsolved
  and AMR strains become easily transmitted in the
  current highly mobile world.
• e.g.1, The World Health Assembly (WHA) Resolution
  of 1988 urged member states to take actions to
  contain AMR.
• e.g.2, The current efficacy of Antimicrobial
  Resistance Information Bank (A-R Info Bank) is
  questionable.
• The velocity of AMR development has been
  accelerated hence no effective antimicrobials may
  exist in the near future.
• There might be accumulated data on AMR in each
  country, which are however least likely used for
  the purpose of AMR containment.

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Implications

• Establishment of monitoring and information
  sharing systems is urgently needed, which cover
  sensitivity of antimicrobials, its consumption
  and usage.
• The system should be reciprocal one, which can be
  accessed by Internet. If Internet access is
  difficult, at least quarterly reports should be
  distributed.
• Strong political commitment and a sense of
  urgency of each stakeholder, are needed to
  establish and maintain the reciprocal system,
  such as smallpox eradication programme.

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Research Agenda

• For the monitoring system, key microbes should be
  determined with considering test cost, required
  skill, severity of problems. Also, targeted
  antimicrobials should be determined.
• The efficacy of the reciprocal monitoring system
  should be carefully monitored and evaluated
• Baseline data analysis
• Regular submission and utilization of relevant
  data
• Changes in antimicrobial consumption and AMR
  development among key microbes

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Conclusions

• Before establishing the system, a certain period
  is needed for the preparation. However, by
  utilizing the existing platform (e.g., national
  data on AMR and Antimicrobial consumption in
  several countries), it can be initiated shortly
  in some regions.
• Each country should be responsible for their
  antimicrobial use and understand we live in
  highly mobile world.

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