Emerging Diseases

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Emerging Diseases Antimicrobial Resistance Shahid
Beheshti University of medical sciences
2008 By Hatami H. MD. MPH
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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

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But over the last decade
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Introduction
But over the last decade

• Antimicrobial resistance has increased
• The pace of development for new and replacement
  antimicrobials
• have decreased

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The increasing threat of antimicrobial resistance
Penicillin

• Penicillin was once 100 successful
• for curing gonorrhea
• Now it is virtually useless against
• gonorrhea in all of the world

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The increasing threat of antimicrobial resistance

• Streptomycin was once the most
• effective drug we had to cure TB
• It is no longer effective in many
• European countries

Streptomycin
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The increasing threat of antimicrobial resistance
Chloroquine

• Chloroquine and sulfadoxine
• pyrimethamine could once stop
• malaria
• Now they can not

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The increasing threat of antimicrobial resistance
Lamivudine

• Lamivudine , recently developed to treat
  hepatitis B
• Has quickly become ineffective in
• percent of patients

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How resistance develops and spreads (1)
Microbiology (Natural selection) The Poverty
Paradigm Misdiagnosis and Resistance
Counterfeit Drugs Dubious Pay-offs and
High- priced Prescriptions
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How resistance develops and spreads (2)0
Advertising for Resistance Lack of
Education Resistance and Hospitals
Antimicrobial Resistance and Food
Globalization and Resistance
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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

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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

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Dubious Pay-offs andHigh-priced prescriptions

• Unethical pharmaceutical companies pay a
  commission for
• recommending more expensive
• broader-spectrum medications
• This troubling development accelerates the
  natural process
• of resistance

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Advertising for Resistance

• Patient demand for antimicrobials
• sometimes the result of
• TV
• Magazine
• Internet
• Newspaper
• Spouse the development of
• resistance

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Resistance and Hospitals

• Between 40 and 91 of antibiotics prescribed
  in 10 studies
• were inappropriate
• Health care workers of ten disregarded basic
  hygiene practices
• Hand washing
• Changing gloves
• Inadequately cleaned equipment

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Antimicrobial Resistance and food

• 50 of antibiotics are used to
• 1- Treat sick animals
• 2- As growth promoters
• 3- rid cultivated
• foodstuffs
• Development of resistance

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Resistance traits spread
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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

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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

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Mortality Morbidity Cost Limited
solutions
Consequences ofAntimicrobial Resistance
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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

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Major infectious killers Pneumonia
Diarrhoeal Diseases AIDS Tuberculosis
Malaria Viral Hepatitis Hospital-Acquired
Infections Leishmaniasis Gonorrhoea
Common worms
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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
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CDC 12 Steps to Prevent Antimicrobial Resistance
Among Hospitalized Adults to Prevent Infection(A
campaign to educate Doctors)
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12 Steps to Prevent Antimicrobial Resistance
Hospitalized Adults
Use Antimicrobials Wisely
1. Vaccinate 2. Get the catheters
out 3. Target the pathogen 4. Access the
experts
Prevent Infection
5. Practice antimicrobial control 6. Use local
data 7. Treat infection, not contamination 8. Trea
t 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 Transmission
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Prevent Infection Step 1 Vaccinate
FactPredischarge influenza and pneumococcal
vaccination of at-risk hospital patients AND
influenza vaccination of healthcare personnel
will prevent infections.
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Prevent Infection Step 1 Vaccinate
Fact Predischarge influenza and pneumococcal
vaccination of at-risk hospital patients and
influenza vaccination of healthcare personnel
will prevent infections.

• Actions
• give influenza/S. pneumonia vaccine to at-risk
  patients before discharge
• get influenza vaccine annually

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

• Fact Catheters and other invasive devices are
  the 1 exogenous cause of hospital-acquired
  infections.
• Actions
• use catheters only when essential
• use the correct catheter
• use proper insertion and catheter-care protocols
• remove catheters when not essential

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

• Fact Appropriate antimicrobial therapy saves
  lives.
• Actions
• culture the patient
• target empiric therapy to likely pathogens and
  local antibiogram
• target definitive therapy to known pathogens and
  antimicrobial susceptibility test results

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Diagnose and Treat Infection Effectively Step 4
Access the experts
Fact Infectious diseases expert input
improves the outcome of serious infections.
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Infectious Diseases Expert Resources
Infectious Diseases Specialists
Healthcare Epidemiologists
Infection Control Professionals
Optimal Patient Care
ClinicalPharmacists
Clinical Pharmacologists
Clinical Microbiologists
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Surgical Infection Experts
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Diagnose and Treat Infection Effectively Step 4
Access the experts

• Fact Infectious diseases expert input improves
  the
• outcome of serious infections.
• Action
• consult infectious diseases experts about
  patients with serious infections

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Use Antimicrobials Wisely Step 5 Practice
antimicrobial control

• Fact
• Programs to improve antimicrobial use are
  effective.

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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

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Use Antimicrobials WiselyStep 5 Practice
antimicrobial control

• Fact Programs to improve antimicrobial use are
  effective.
• Action
• engage in local antimicrobial use quality
  improvement efforts

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

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Interpreting a Positive Blood Culture
True Bacteremia Unlikely
Uncertain Likely

• S. aureus
• S. pneumoniae
• Enterobacteriaceae
• P. aeruginosa
• Candida albicans

• Corynebacterium spp.
• Non-anthracis Bacillus spp.
• Propionibacterium acnes

• Coagulase-negative
• staphylococci

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Use Antimicrobials Wisely Step 7 Treat
infection, not contamination
Fact A major cause of antimicrobial overuse
is treatment of contaminated cultures.
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Use Antimicrobials Wisely Step 8 Treat
infection, not colonization
Fact A major cause of antimicrobial overuse
is treatment of colonization.
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Use Antimicrobials WiselyStep 8 Treat
infection, not colonization

• Fact A major cause of antimicrobial overuse is
  treatment of colonization.
• Actions
• treat pneumonia, not the tracheal aspirate
• treat bacteremia, not the catheter tip or hub
• treat urinary tract infection, not the indwelling
  catheter

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Use Antimicrobials Wisely Step 9 Know when to
say no to vanco
Fact Vancomycin overuse promotes emergence,
selection, and spread of resistant pathogens.
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Evolution of Drug Resistance in S. aureus
Penicillin
Penicillin-resistant
S. aureus
1950s
S. aureus
Vancomycin- resistant S. aureus
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Use Antimicrobials WiselyStep 9 Know when to
say no to vanco

• Fact Vancomycin overuse promotes emergence,
  selection, and spread of resistant pathogens.
• Actions
• treat infection, not contaminants or colonization
  
• fever in a patient with an intravenous catheter
  is not a routine indication for vancomycin

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

• Fact Failure to stop unnecessary antimicrobial
  treatment contributes to overuse and resistance.
  
• Actions
• when infection is cured
• when cultures are negative and infection is
  unlikely
• when infection is not diagnosed

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

• Fact Patient-to-patient spread of pathogens can
  be prevented.
• Actions
• use standard infection control precautions
• contain infectious body fluids (use approved
  airborne/droplet/contact isolation precautions)
• when in doubt, consult infection control experts

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Prevent Transmission Step 12 Contain your
contagion

Fact Healthcare personnel can spread
antimicrobial-resistant pathogens from patient to
patient.
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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
• contain your contagion
• keep your hands clean
• set an example!

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12 Steps to Prevent Antimicrobial Resistance
Hospitalized Adults
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Antimicrobial Resistance Key Prevention
Strategies
Susceptible Pathogen
Pathogen
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Hand washing
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Source

• CDC, Internet cite
• WHO, Internet cite

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