Title: -Track 2-5- Antibiotics resistance : opportunities

& challenges ;

Grand Challenges – Antimicrobial Resistance

The prevalence of Carbapenem Resistant Gram Negative Bacteria

(CRGNB) and

Methicillin Resistant Staphylococcus aureus (MRSA)

in a central referral hospital, Durban,

South Africa between 2010-2014.

Dr Khine Swe Swe-Han FC Path (Micro) SA

MMed (Micro) SA

DTMH (Wits univer) SA; PDIC( Stellenbosch univ) SA

MB,BS (Yangon Myanmar)

Consultant/Senior Pathologist, Lecturer,

Medical Microbiology Department

IALCH Academic complex, NHLS/UKZN

Contents of presentation

• Introduction - Antimicrobial resistance

• Developing resistance

• How resistance happened

• How to spread

• What are the risk factors

• Economic burdens of Antimicrobial resistance

• Dead Attributable

• Global /CDC/WHO

• SA- GERMS , SASCM

• Local data – prevalence study

• Antimicrobial resistance– challenging –WHAT CAN WE DO ?

Antimicrobial Resistance

Firstly Remember !!

Antibiotics, antivirals, and other antimicrobials have saved millions of lives

worldwide,

• but these drugs are losing their effectiveness because of antimicrobial

resistance.

• Intrinsic

• Acquired

• over-prescription and improper use of antimicrobials plays a big

role.

Ref: Thomas Frieden ; Antibiotic Resistance and the Threat to Public Health , House Committee on Energy and Commerce, Subcommittee on Health April 28, 2010

Antibiotic Resistance and the Threat to Public Health

•

• The emergence of Gram negative Enterobacteriaceae resistant to

carbapenem due to

• New Delhi metallo – ß –lactamase 1 (NDM-1)

• has been identified as a major global health problem.

(Kumarasamy et al, 2010). (CRE)

• The emergence and rapid spread of carbapenemase producing

gram-negatives such as

• Extensively drug-resistant/ Pan-resistant Acinetobacter

spp . ( CRNE)

Patients with few or no antimicrobial options.

Ref ; Huttner et al. Antimicrobial Resistance and Infection Control 2013, 2:31

ANTIBIOTIC RESISTANCE THREATS in the United States, 2013

Bacterial Resistance

• Antimicrobial resistance (AMR) is now a global threat.

• Its emergence rests on

• antimicrobial overuse in humans

• food-producing animals;

• globalization and suboptimal infection control

facilitate its spread.

• Antimicrobial conservation/stewardship programs have seen some

measure of success in reducing antimicrobial overuse in humans, but

their reach is limited to acute-care settings in high-income countries.

Ref ; Huttner et al. Antimicrobial Resistance and Infection Control 2013, 2:31

• Resistance rates for many isolates are rising but are highly

variable. For example,

• The proportion of isolates of Staphylcoccus aureus resistant to

methicillin increased from close to zero 10–15 years ago to

approximately 70% in Japan and the Republic of Korea, 40%

in Belgium, 30% in the United Kingdom, and 28% in the USA

by 1998 (1).

Thank you to all participating patients, laboratory, clinical and

administrative staff for submitting case reports and isolates

NICD

CED: Elias Khomane, Florah Mnyameni, Husna Ismail, Jack Kekana, Mimmy

Ngomane, Mzikazi Dickmolo, Rosah Mabokachaba, Tshegofatso Ntshabele, Mandile

Thobela, Munyadziwa Muvhali, Nomsa Tau, Portia Mogale, Emily Dloboyi

COTHI: Boniwe Makwakwa, Crystal Viljoen, Florah Motsai, Gloria Molaba, Thoko

Zulu, Mabatho Moerani, Nondumiso Sithole, Notsikelelo Matiwane, Rubeina Badat,

Naseema Bulbulia, Ruth Mohlabeng, Serisha Naicker, Tsidiso Maphanga, Mbali

Dube, Sydney Mogokotleng.

CRDM: Dineo Mogale, Fahima Moosa, Happy Skosana, Karistha Ganesh,

Kedibone Ndlangisa,, Maimuna Carrim, Malefu Moleleke, Mignon du Plessis, Nicole

Wolter, Noluthando Duma, Olga Hattingh, Prabha Naidoo, Thabo Mohale, Judith

Tshabalala, Thembi Mthembu.

CTB: Tiisetso Lebaka, Lebogang Matlou.

DPHSR: Emily Sikanyika, Tsakane Nkuna.

Surveillance Officers: Sandisiwe Joyi, Siyabonga Mboxwana, Badikazi Matiwana (EC); Khasiane Mawasha, Thandeka Kosana (FS); Anna Motsi, Dikeledi Leshaba, Fiona

Timber, Hazel Mzolo, Molly Morapeli, Nthabiseng Motati, Ophtia Kaoho, Phindile Ngema, Rachel Nare, Thandi Mdima, Venesa Kok, Vusi Ndlovu, Zodwa Kgaphola (GA);

Indran Naidoo, Nkosinathi Mbhele, Nokuthula Nzuza, Thobeka Simelani (KZN); Tebogo Modiba (LP); Sunnieboy Njikho, Ennica Ntlemao (MP); Matsheko Siyaka (NC);

Bekiwe Ncwana, Joyce Tsotsotso, Louisa Phalatse, Sibongile Rasmeni-Quariva (NW); Cheryl Mentor, Elizabeth Jerome, Nazila Shalabi, Priscilla Mouton, Catherine Bishop

(WC).

GERMS-SA: Carel Haummann, Patricia Hanise, Sandeep Vasaikar, John Black, Vanessa Pearce (EC); Anwar Hoosen, Vicky Kleinhans (FS); Alan Karstaedt, Caroline

Maluleka, Charl Verwey, Charles Feldman, David Moore, David Spencer, Gary Reubenson, Khine Swe Swe Han, Jeannette Wadula, Jeremy Nel, Kathy Lindeque,

Maphoshane Nchabeleng, Nicolette du Plessis, Norma Bosman, Ranmini Kularatne, Ruth Lekalakala, Sharona Seetharam, Theunis Avenant, Trusha Nana, Vindana Chibabhai

(GA); Adhil Maharj, Asmeeta Burra, Fathima Naby, Halima Dawood, Koleka Mlisana, Lisha Sookan, Praksha Ramjathan, Prasha Mahabeer, Romola Naidoo, Sumayya

Haffejee, Yacoob Coovadia (KZN); Ken Hamese, Ngoaka Sibiya (LP); Greta Hoyland, Jacob Lebudi (MP); Riezaah Abrahams, Pieter Jooste, Sindiswa Makate (NC);

Ebrahim Variava, Erna du Plessis (NW); Andrew Whitelaw, Mark Nicol, Preneshni Naicker, Shareef Abrahams (WC); Adrian Brink, Elizabeth Prentice, Inge Zietsman, Maria

Botha, Peter Smith, Xoliswa Poswa (AMPATH); Chetna Govind, Keshree Pillay, Suzy Budavari (LANCET); Catherine Samuel, Marthinus Senekal (PathCare); Cynthia

Whitney (CDC); Keith Klugman (Emory); Ananta Nanoo, Andries Dreyer, Anne von Gottberg, Anthony Smith, Arvinda Sooka, Cecilia Miller, Charlotte Sriruttan, Cheryl

Cohen, Chikwe Ihekweazu, Claire von Mollendorf, Frans Radebe, Genevie Ntshoe, Gillian Hunt, Karen Keddy, Linda de Gouveia, Linda Erasmus, Marshagne Smith, Martha

Bodiba, Mbhekiseni Khumalo, Motshabi Modise, Nazir Ismail, Nelesh Govender, Nicola Page, Olga Perovic, Oliver Murangandi, Penny Crowther-Gibson, Portia Mutevedzi,

Riyadh Manesen, Ruth Mpembe, Samantha Iyaloo, Sarona Lengana, Shabir Madhi, Sibongile Walaza, Sonwabo Lindani, Susan Meiring, Thejane Motladiile, Vanessa Quan,

Verushka Chetty (NICD).

This work has been supported by NICD/NHLS and the President’s Emergency Plan for AIDS Relief (PEPFAR) through the Centers for Disease Control and Prevention (CDC) under the

terms of [5U2GPS001328]. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NICD/NHLS or CDC.

The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

The prevalence of Carbapenem Resistant Gram Negative Bacteria (CRGNB) and

Methicillin Resistant Staphylococcus aureus (MRSA)

in a central referral hospital, Durban, South Africa

between 2010-2014.

Introduction:

• Antibiotic resistance poses a serious challenge to public health

worldwide, including South Africa.

• This problem has been exacerbated by the emergence of

• carbapenem resistant Gram-negative bacteria

• belonging to the Enterobacteriaceae, Acinetobacter and

Pseudomonas aeruginosa (CRE/CRNE),

• methicillin resistant Staphylococcus aureus (MRSA).

• This study was conducted to determine the prevalence of

CRE/CRNE and MRSA at a central referral hospital within a 5

year period.

Methods:

• The laboratory data and hospital admission data were reviewed

between 2010 and 2014.

• The identification and drug susceptibility test results were

interpreted by using

• the automatic system (Vitek 2) and

• the clinical ,laboratory standards institute (CLSI) guidelines.

• The prevalence of the patients infected with MRSA/CRE/CRNE

was determined.

Results: • The prevalence of the patients with MRSA decreased;

• from 47%(421/889) to 22%(172/770) from 2010 to 2014.

• This was probably due to implementation of strict infection control

measures .

• CRNE was fluctuated

• between 39%(368/941) to 48%(331/689) during the same

period, with A.baumannii being the predominant organism

among the CRNE.

• However, the prevalence of the CRE (K.pneumoniae and E.coli)

increased

• from 0% (0/1110) to 2% (20/1265) during the study period.

Results [central referral hospital, Durban , SA]

0

5

10

15

20

25

30

35

40

45

50

421/889(47) 263/615(43) 231/666(35) 233/649(36) 172/770(22)

2010 2011 2012 2013 2014

%

MRSA(%) [2010-2014]

MRSA(%)

Prevalence of CRNE & CRE [ 2010-2014]

YEAR CRNE CRNE% CRE CRE %

2010 495/1060(47) 47 0/1110(0) 0

2011 422/946(45) 45 3/1109(0.3) 0.3

2012 368/941(39) 39 7/1339(0.5) 0.5

2013 331/689(48) 48 7/1196(0.6) 0.6

2014 317/680(47) 47 20/1265(2.0) 2

Results[central referral hospital, Durban , SA]

Results [central referral hospital , Durban , SA]

32

No. CPEs by organism and resistance genes since

October 2012 to Feb 2015 (608 referral isolates)

100%

Conclusion:

• Although the prevalence of MRSA was significantly reduced, the

challenge remains for the total elimination of these resistant

pathogens, as well as the highly prevalent CRNE and the newly

emerging CRE before this spirals out of control.

• Additional resources, antibiotic stewardship and aggressive

infection control programs are urgently needed to prevent and

control the spread of these resistant organisms in the hospital

setting.

Can we ever live in harmony ?

• Antibiotic use is a known

• saved millions of lives

• risk factor for the emergence of antibiotic resistance,

But

• demonstrating the causal link between antibiotic use and

resistance is challenging.

Ref: Vered Schechner,a Elizabeth Temkin, et al ; Epidemiological Interpretation of Studies Examining the Effect of

Antibiotic Usage on Resistance. April 2013 Volume 26 Number 2 Clinical Microbiology Reviews p. 289–307

Acknowledgement

• K SweSwe- Han1, 2,

• Co-authors : K. Mlisana1, 2 , M. Pillay2,

• Department of Medical Microbiology, National Health Laboratory

Service1 ,Medical Microbiology and Infection Control, School of

Laboratory Medicine & Medical science , College of Health Sciences,

University of KwaZulu-Natal 2 .

THANKS YOU ! FOR Your attention

15TH September 2015