update on antimicrobial resistance
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Update on Antimicrobial Resistance. Allison McGeer, MD, FRCPC Mount Sinai Hospital [email protected] 416-586-3118 http://microbiology.mtsinai.on.ca. - PowerPoint PPT PresentationTRANSCRIPT
Update on Update on Antimicrobial ResistanceAntimicrobial Resistance
Allison McGeer, MD, FRCPC
Mount Sinai Hospital
416-586-3118
http://microbiology.mtsinai.on.ca
“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, Antibiotic resistance in pneumococci, CBSN, 1988-2000CBSN, 1988-2000
0
2
4
6
8
10
12
14
16
Year
Per
cen
t re
sist
ant
isol
ates
Pen(NS)
Cipro
Ery
TS
Antibiotic resistance in pneumococci in Antibiotic resistance in pneumococci in older adults, respiratory specimens, older adults, respiratory specimens,
CBSN, 1988-2001CBSN, 1988-2001
0
1
2
3
4
5
6
7
8
Year
Per
cen
t re
sist
ant
isol
ates
Cipro
Lev
Number of Patients Number of Patients Colonized/Infected with MRSA, Colonized/Infected with MRSA,
Ontario, 1992-2000Ontario, 1992-2000
0100020003000400050006000700080009000
10000
No.
of c
ases
of M
RS
A
1992 1993 1994 1995 1996 1997 1998 1999 2000
.
6866
471 475 566
1426
4212
LPTP Survey, 1996/97/98LPTP Survey, 1996/97/98
80168 252 9345 $25
M
Risk of death from MRSA vs Risk of death from MRSA vs MSSA bacteremiaMSSA bacteremia
Meta-analysis, 2001 9 case control studies, 1990-2000
Pooled relative risk:
2.1 (1.7, 2.6)
Whitby, MJA, 2001;175:264-7
Resistance in Resistance in E. coli, E. coli, Baycrest 1997-2002Baycrest 1997-2002
0
5
10
15
20
25
30
35
1997 1998 1999 2000 2001 2002
Per
cen
t o
f is
ola
tes
resi
stan
t
Amp
Cipro
TS
MH, NH #1, March 2001MH, NH #1, March 2001
Admitted to MSH with SOB, ?pneumonia Sputum: E. coli
Ampicillin R
Cotrimoxazole R
Nitrofurantoin R
Cefazolin R
Ciprofloxacin R
G.D. 82yo Male G.D. 82yo Male
ESRF on Hemodialysis-resident of RH TO ER with fever, shortness of breath T=38.0, WBC-N Bibasilar Infiltrate-Rx IV Cefuroxime x24hrs Deterioration: Resp Failure +Septic Shock ETT suction-Gram-Mod Poly’s, many Gram neg
rodst: culture; heavy MDR E.Coli IV Azithro+Meropenem Death due to septic shock + Refractory hypoxemia
Inappropriate antimicrobial therapyInappropriate antimicrobial therapyImpact on MortalityImpact on Mortality
0
100
200
300
400
500
600
Innapropriatetherapy
Appropriatetherapy
No
. in
fecte
d p
ati
en
ts
Deaths
Survivors
42% mortality
17% mortality
Rel risk 2.495% Ci 1.8,3.1)
Kollef et al. Chest 1999;115:462
ConclusionConclusion Antibiotic resistance is
coming
bad for patients
expensive
The only good news is that we can choose to spend our money on prevention or on treatment
What can be done?What can be done? Surveillance Prevention
– Hand hygiene– Vaccine
Transmission control Reduced/improved antibiotic use
– Public expectations– Provider practice
SurveillanceSurveillance
Measure burden of illness– incidence, mortality, morbidity, cost
Identify opportunities for prevention Evaluating/inform prevention programs
– vaccine, appropriate AB, transmission prevention
Minimize treatment failures
WHO, 1997WHO, 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 UKInternational considerations -
Incidence/severity Present burden ill health
General population impact Socioeconomic impact
Socioeconomic burden Socioeconomic impact
Preventability Health gain opportunity
Potential to drive policy -
Risk perception Public concern
Changing patterns Potential threat
- PHLS "added value"
Canada,1998 UK, 1997Canada,1998 UK, 1997
3 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 tenTop 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?What can be done? Surveillance Prevention
– Hand hygiene– Vaccine
Transmission control Reduced/improved antibiotic use
– Public expectations– Provider practice
Impact of hand hygiene on infectionsImpact of hand hygiene on infections
Year Author Setting Impact on infections
1982 Maki ICU Decreased
1984 Massanari ICU Decreased
1990 Simmons ICU No effect
1992 Doebbeling ICU Decreased
1994 Webster NICU MRSA eliminated
1995 Zafar Nursery MRSA eliminated
1999 Pittet Hospital MRSA decreased
2000 Hammond Schools Illness/absenteeism decreased
2000 Dyer Schools Illness/absenteeism decreased
2001 Ryan Army base URI decreased
VaccinesVaccines
Influenza (universal) Pneumococcal
– polysaccharide (pneumovax) for high risk children and adults
– conjugate vaccine for children
Effect of influenza vaccine for staff Effect of influenza vaccine for staff and residents of long term care and residents of long term care
facilitiesfacilitiesEffect of
vaccinatingHCW
Effect ofvaccinating
residentsMortality 0.56 (.40,.80) 1.2 (0.81,1.6)
Mortality frompneumonia
0.60 (0.37,.97) 0.83 (0.5,1.3)
LRTI 0.69 (0.40, 1.2)0.67 (0.39, 1.4)
Potter et al. JID 1997;175:1-6
Annual risk of influenza outbreaks by Annual risk of influenza outbreaks by percentage of staff vaccinatedpercentage of staff vaccinated
05
101520253035404550
Per
cent
of L
TC
Fs
repo
rtin
g in
flue
nza
outb
reak
<25% 25-50% 50-75% >75%
Percent of staff vaccinated
Impact of influenza vaccine on Impact of influenza vaccine on antibiotic useantibiotic use
Pediatrics (Belshe, NEJM, 1998)– 30% reduction in acute otitis media
Healthy adults (Nichols, NEJM, 1995)– 45% reduction in antibiotic prescriptions
Rate of invasive pneumococcal Rate of invasive pneumococcal disease:disease:
Metro/Peel vs. QuebecMetro/Peel vs. Quebec
02468
1012141618
Rat
e pe
r 10
0,00
0 po
pula
tion
1995 1996 1997 1998 1999 2000 2001
Year
Metro/Peel
Quebec
Cases of invasive disease by Cases of invasive disease by vaccine eligibility, Metro/Peel, vaccine eligibility, Metro/Peel,
1995-81995-8
0
50
100
150
200
250
300
350
Nu
mb
er o
f ca
ses
Ineligible Eligible
Vaccine eligibility
1995
1996
1997
1998
1999
2000
2001
Pneumococcal vaccination Pneumococcal vaccination rates, by risk grouprates, by risk group
0
10
20
30
40
50
60
70
<1996 1996 1997 1998 1999 2002Cum
ulat
ive
perc
ent o
f pop
ulat
ion
grou
p v
acci
nate
d
<65, ill
>64, well
>64, ill
What can be done?What can be done? Surveillance Prevention
– Hand hygiene– Vaccine
Transmission control Reduced/improved antibiotic use
– Public expectations– Provider practice
Number of Patients Number of Patients Colonized/Infected with MRSA, Colonized/Infected with MRSA,
Ontario, 1992-2001Ontario, 1992-2001
0100020003000400050006000700080009000
10000
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
No
. o
f ca
ses
of
MR
SA
.
6866
471 475 5661426
4212
QMP/LS Surveys, 1996-QMP/LS Surveys, 1996-20022002
80168252
9345
7684
Number of Patients Number of Patients Colonized/Infected with MRSA, Colonized/Infected with MRSA,
Ontario, 1993-2005?Ontario, 1993-2005?
0100020003000400050006000700080009000
10000
1 2 3 4 5 6 7 8 9 10 11 12
Nu
mb
er
of
pa
tie
nts
02468101214161820
MR
SA
as
% a
ll S
A
OntarioDenmark
.
Number of Patients Number of Patients Colonized/Infected with VRE, Colonized/Infected with VRE,
Ontario, 1992-2001Ontario, 1992-2001
0
100
200
300
400
500
600
700
800
1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
Year
Nu
mb
er o
f p
atie
nts
2 7
99
589
167
718 685
QMP-LS Surveys, 1996-2002QMP-LS Surveys, 1996-2002
445
230
ALC - Risk Factors for ALC - Risk Factors for ColonizationColonization
Risk Factor Odds Ratio (95% CI)
Tmp-smx, last 3mos 0.11 (.02,.59)
Cip/cef2, last 6mos 3.9 (1.0,15)First floor residence 0.37 (.16,.89)Bath on Sun/Mon 3.8 (1.2,12)3 positive BR mates 2.3 (1.0,5.3)
Public Health RolePublic Health Role
Surveillance Daycare, long term care Communication Co-ordination within regions National, provincial, regional
guidelines
What can be done?What can be done? Surveillance Prevention
– Hand hygiene– Vaccine
Transmission control Reduced/improved antibiotic use
– Public expectations– Provider practice
Improved antibiotic useImproved antibiotic useChallengesChallenges
Dissemination from current programs in the community– Edmonton, Port Hope, Ottawa
Institutions