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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 Presentation
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Update on Update on Antimicrobial ResistanceAntimicrobial Resistance
Allison McGeer, MD, FRCPCMount Sinai Hospital
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
02468
10121416
Year
Perc
ent r
esis
tant
isol
ates
Pen(NS)CiproEryTS
Antibiotic resistance in pneumococci in Antibiotic resistance in pneumococci in older adults, respiratory specimens, older adults, respiratory specimens,
CBSN, 1988-2001CBSN, 1988-2001
012345678
Year
Perc
ent r
esis
tant
isol
ates
CiproLev
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
RSA
1992 1993 1994 1995 1996 1997 1998 1999 2000
.
6866
471 475 5661426
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
Perc
ent o
f iso
late
s re
sist
ant
AmpCiproTS
MH, NH #1, March 2001MH, NH #1, March 2001
Admitted to MSH with SOB, ?pneumonia Sputum: E. coli
Ampicillin RCotrimoxazole RNitrofurantoin RCefazolin RCiprofloxacin 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.
infe
cted
pat
ient
s
DeathsSurvivors
42% mortality
17% mortality
Rel risk 2.495% Ci 1.8,3.1)
Kollef et al. Chest 1999;115:462
ConclusionConclusion Antibiotic resistance is
comingbad for patientsexpensive
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, 1997Antimicrobial 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 healthGeneral population impact Socioeconomic impactSocioeconomic burden Socioeconomic impactPreventability Health gain opportunityPotential to drive policy -Risk perception Public concernChanging patterns Potential threat- PHLS "added value"
Canada,1998 UK, 1997Canada,1998 UK, 1997 3 influenza 5 tuberculosis 15 inv S. pneumoniae18 inv H. influenzae23 gonorrhea24 invasive GAS35 Campylobacteriosis
2 antibiotic resistance4 nosocomial infections5 tuberculosis8 MRSA9 salmonellosis12 campylobacteriosis14 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 Decreased1984 Massanari ICU Decreased1990 Simmons ICU No effect1992 Doebbeling ICU Decreased1994 Webster NICU MRSA eliminated1995 Zafar Nursery MRSA eliminated1999 Pittet Hospital MRSA decreased2000 Hammond Schools Illness/absenteeism decreased2000 Dyer Schools Illness/absenteeism decreased2001 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
Perc
ent o
f LTC
Fs
repo
rtin
g in
fluen
za
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 100
,000
po
pula
tion
1995 1996 1997 1998 1999 2000 2001Year
Metro/PeelQuebec
Cases of invasive disease by Cases of invasive disease by vaccine eligibility, Metro/Peel, vaccine eligibility, Metro/Peel,
1995-81995-8
050
100150200250300350
Num
ber o
f cas
es
Ineligible EligibleVaccine eligibility
1995199619971998199920002001
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 cas
es o
f 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
Num
ber o
f pat
ient
s
02468101214161820
MRS
A as
% a
ll SA
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
Num
ber o
f pat
ient
s
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