Global response to antibiotic access and resistance: Stuart B. Levy, M.D. Tufts University School of Medicine Alliance for Prudent Use of Antibiotics

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1 Global response to antibiotic access and resistance: Stuart B. Levy, M.D. Tufts University School of Medicine Alliance for Prudent Use of Antibiotics

2 Established in 1981 APUA s Mission To improve control of infectious diseases worldwide through appropriate access to, and use of, antimicrobials and containment of antimicrobial resistance Build local capacity/advocacy: country chapters Form strategic partnerships among chapters and public health organizations Synthesize & disseminate the latest scientific information on antimicrobial resistance Conduct studies and activities to preserve the power of antibiotics

3 APUA Global Chapter Network Central & South America Costa Rica Cuba Dominican Republic El Salvador Guatemala Honduras Mexico Nicaragua Panama Argentina Bolivia Brazil Chile Colombia Ecuador Paraguay Peru Uruguay Venezuela Europe Austria Azerbaijan Belarus Bulgaria Croatia Georgia Greece Italy Kazakhstan Kyrgyzstan Lebanon Moldova Poland Romania Russia Serbia Montenegro Spain Sweden Turkey Ukraine United Kingdom Africa Ethiopia Gambia Kenya Mozambique Namibia Nigeria Senegal South Africa Tanzania Uganda Zambia Asia Bangladesh China Fiji Islands India Indonesia Nepal Pakistan Philippines South Korea Taiwan Vietnam Australia

4 Small Grants Program for Chapter Research To investigate the local impact of antibiotic usage and resistance, and the effects of local interventions on a country s s health Country Uruguay Bulgaria Russia India Belarus Moldova Guatemala Poland Brazil Nepal Project Cost of S.aureus hospital infections Survey of Antimicrobial Resistance in Bulgaria Inventory of Antibiotics in Home Medicine Cabinets Sensitivity Patterns and Cost Effectiveness of Newer Antibiotics A Study to Correlate the Use of Antibiotics for Acute Intestinal Infections Survey of Pediatricians Prescribing Practices Risk Factors for Antibiotic Resistance of S.pneumoniae among Guatemalan Children Cost-effectiveness of Antibiotic Resistance in Primary Care Hospitals Epidemiology and Treatment of Persistent Diarrhea in Northeastern of Brazil Development of National Antibiotic Guidelines

5 Annual Training on Antibiotics and Diagnosis of Antibiotic Resistance. Buenos Aires, Argentina.

6 The government of Venezuela declared AMR a public health issue and enacted a law that restricts the sale and dispensing of several antibiotic classes without a prescription: Macrolides Fluoroquinolones 3 rd. Generation Cephalosporins Rifampin

7 CHILE NATIONAL PRESS LATEST NEWS Pharmacies will require prescriptions to sell antibiotics

8 Sale of Antibiotics - Chile Years 1999 and 2000 (Units of Sale) 18,000,000 16,000,000 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000, ,376,139 10,609,

9 Antimicrobial Resistance in Africa Download at

10 Training Guide for Journalists Reporting on Antimicrobial Resistance Issues Download at

11 Global Partnerships

12 GAARD Alert 2005 SHADOW EPIDEMIC The Growing Menace of Antimicrobial Resistance STD s STDs PNEUMONIA AIDS MRSA TB MALARIA Morbidity & Mortality

13 Lessons Learned in Developing Countries (1) Government expenditure on healthcare is rarely 2-5% 2 of total budget; There is serious concern about drug quality and counterfeits; Sale and dispensing of antibiotics is often available without a prescription; Child mortality from ARI and diarrheal disease is high, but it is often overshadowed by HIV, TB and malaria;

14 Lessons Learned in Developing Countries (2) There is often a divorce between the government and professional organizations; Recognized key opinion leaders are often interested in leading efforts; Chapters often seek the involvement of WHO Country Offices; ; usually non monetary; Ongoing technical assistance is critical.

15 Short Term & Long Term Goals Make AMR a public health issue with government ownership and financial support; Engage legislators and the media for public education, support and visibility; Engage NGOs, CBOs, FBOs and consumer protection agencies for advocacy mobilization; Draw a national picture of AMR priority issues in the community and hospital settings Design a funding strategy to begin and sustain efforts;

16 Short Term & Long Term Goals Design a work plan with doable goals addressing one or two priority issues Seek mentorship with neighboring countries with similar public health issues; Publicize findings and achievements no matter how small there are; Engage WHO country offices for logistical and advocacy support.

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19 Sequential antibiotic therapy for acne promotes the carriage of resistant staphylococci on the skin of contacts Yvonne W. Miller, E. Anne Eady, Richard W. Lacey, Jonathan J. Cove, Derrick N. Joanes and William J. Cunliffe J. Antimicrob. Chemother :

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21 Ecologic Impact of the Use of Antibiotics in Food Animals: The Flow of Antibiotic Resistant Bacteria Prophylaxis Growth Promotion ANTIBIOTICS Therapeutic Use Feces and Manure Spreading Farm Dwellers Meat and Dairy Products Wildlife Soil Wells/Rivers/Streams Aquaculture Fruits and Vegetables Fish Products Domestic Pets PEOPLE

22 Plant agriculture therapy prophylaxis Animals therapy prophylaxis growth promotion Antibiotic Human: Hospital therapy prophylaxis Human: Community therapy prophylaxis

23 During use After use IMPACT ON ANTIBIOTIC RESISTANCE

24 NIAID/APUA ROAR Scientific Network The Reservoirs of Antibiotic Resistance (ROAR) project: Scientific/clinical collaboration to investigate the role of commensal bacteria in resistance. Outputs include research findings; and a public database. APUA was project coordinator for 12 university based ROAR research sub-grants.

25 Global Antibiotic Resistance Surveillance APUA chapters in India, South Korea, Turkey, Georgia, Uganda, Chile, Bangladesh. Search for new resistance determinants Collect and analyze soil, water and veterinary commensal organisms. Specimens verified by Tufts Laboratory. Phenotype and genotypic data in APUA ROAR database.

26 Should there be a separate drug class for antimicrobials?

27 Antibiotics should be given their own drug category Recognizes that antibiotics are like no other prescription drug category Emphasizes the consequences that individual misuse has on society at large Allows special considerations for these drugs in terms of: Incentives to industry to develop new drugs e.g. extended patent life Post-marketing surveillance to curb resistance e.g. tax reliefs Preservation of their efficacy through combined efforts of producers and consumers

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