Update on Antimicrobial Resistance Allison Mc. Geer, MD, FRCPC Mount Sinai Hospital amcgeer@mtsinai. on. ca 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, CBSN, 1988 -2000
Antibiotic resistance in pneumococci in older adults, respiratory specimens, CBSN, 1988 -2001
Number of Patients Colonized/Infected with MRSA, Ontario, 1992 -2000 8 252 9345 $25 M 8016 6866 4212 . 1426 471 475 566 LPTP Survey, 1996/97/98
Risk of death from MRSA vs MSSA bacteremia Meta-analysis, 2001 l 9 case control studies, 1990 -2000 l l Pooled relative risk: 2. 1 (1. 7, 2. 6) Whitby, MJA, 2001; 175: 264 -7
Resistance in E. coli, Baycrest 1997 -2002
MH, NH #1, March 2001 l Admitted to MSH with SOB, ? pneumonia l Sputum: E. coli Ampicillin Cotrimoxazole Nitrofurantoin Cefazolin Ciprofloxacin R R R
G. D. 82 yo Male ESRF on Hemodialysis-resident of RH l TO ER with fever, shortness of breath l T=38. 0, WBC-N l Bibasilar Infiltrate-Rx IV Cefuroxime x 24 hrs l Deterioration: Resp Failure +Septic Shock l ETT suction-Gram-Mod Poly’s, many Gram neg rodst: culture; heavy MDR E. Coli l IV Azithro+Meropenem l Death due to septic shock + Refractory hypoxemia
Inappropriate antimicrobial therapy Impact on Mortality 17% mortality Rel risk 2. 4 95% Ci 1. 8, 3. 1) 42% mortality Kollef et al. Chest 1999; 115: 462
Conclusion l Antibiotic resistance is coming bad for patients expensive l The only good news is that we can choose to spend our money on prevention or on treatment
What can be done? Surveillance l Prevention l – Hand hygiene – Vaccine Transmission control l Reduced/improved antibiotic use l – Public expectations – Provider practice
Surveillance l Measure burden of illness – incidence, mortality, morbidity, cost Identify opportunities for prevention l Evaluating/inform prevention programs l – vaccine, appropriate AB, transmission prevention l Minimize treatment failures
WHO, 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, 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 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? Surveillance l Prevention l – Hand hygiene – Vaccine Transmission control l Reduced/improved antibiotic use l – Public expectations – Provider practice
Impact of hand hygiene on infections
Vaccines Influenza (universal) l Pneumococcal l – polysaccharide (pneumovax) for high risk children and adults – conjugate vaccine for children
Effect of influenza vaccine for staff and residents of long term care facilities Potter et al. JID 1997; 175: 1 -6
Annual risk of influenza outbreaks by percentage of staff vaccinated
Impact of influenza vaccine on antibiotic use l Pediatrics (Belshe, NEJM, 1998) – 30% reduction in acute otitis media l Healthy adults (Nichols, NEJM, 1995) – 45% reduction in antibiotic prescriptions
Rate of invasive pneumococcal disease: Metro/Peel vs. Quebec
Cases of invasive disease by vaccine eligibility, Metro/Peel, 1995 -8
Pneumococcal vaccination rates, by risk group
What can be done? Surveillance l Prevention l – Hand hygiene – Vaccine Transmission control l Reduced/improved antibiotic use l – Public expectations – Provider practice
Number of Patients Colonized/Infected with MRSA, Ontario, 1992 -2001 9345 8016 8252 7684 6866 4212. 471 475 566 1426 QMP/LS Surveys, 1996 -2002
Number of Patients Colonized/Infected with MRSA, Ontario, 1993 -2005? .
Number of Patients Colonized/Infected with VRE, Ontario, 1992 -2001 718 685 589 445 230 167 99 2 7 QMP-LS Surveys, 1996 -2002
ALC - Risk Factors for Colonization
Public Health Role Surveillance l Daycare, long term care l Communication l Co-ordination within regions l National, provincial, regional guidelines l
What can be done? Surveillance l Prevention l – Hand hygiene – Vaccine Transmission control l Reduced/improved antibiotic use l – Public expectations – Provider practice
Improved antibiotic use Challenges l Dissemination from current programs in the community – Edmonton, Port Hope, Ottawa l Institutions
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