Antibiotic resistance: the rise of the superbugs

Transcription

1 Antibiotic resistance: the rise of the superbugs Allen Cheng Associate Professor of Infectious Diseases Epidemiology, Alfred Health; Monash University About me Specialist in infectious diseases Head, Infection Prevention and Healthcare Epidemiology Unit, Alfred Health Acting Director, Department of Infectious Diseases, Alfred Health Associate Professor of Infectious Diseases Epidemiology, Monash University Financial support: NHMRC, Alfred Health No funding from pharmaceutical companies 1

2 The Pre antibiotic era: Albert Alexander, 1941 Oxford policeman Scratched face with rose thorn Developed infection of face Infection spread to eyes, scalp over months Persisted despite surgery Howard Florey Australian pharmacologist Professor of Pathology at Oxford Developed methods to mass produce penicillin (Nobel Prize, 1945) Initially administered penicillin to rats Heard about Constable Alexander s case from wife 2

3 First use of penicillin Limited supplies of penicillin Given several doses Immediate improvement within 24 hours Re purified from urine Clinical response until day 5 The post antibiotic era: Alfred Hospital, 2012 Male, 30s Car accident in Thailand, multiple injuries, unconscious Admitted to intensive care in a Bangkok hospital Developed multiple infections wounds, pneumonia Transferred to The Alfred for further treatment Bloodstream infection resistant to all available antibiotics Treated with combination of 4 antibiotics died with active infection 3

4 Antibiotic resistance Use it and you will lose it evolution in action Superbugs : probably not a good term Colonisation vs infection Resistance danger Degrees of resistance Resistance associated with Patient morbidity and mortality Longer length of hospital stay Increased costs of treatment: Overall AR cost $50b in US; $25,000 per patient in 2009 RSA: TB $200; MDR: $6000 $10,000; XDR: $26,000 Perfect storm Increasing rates of resistance Decreasing development of new antibiotics New systemic antibacterial agents approved by the US FDA by 5 year period

5 Some examples MRSA VRE MDR gram negative bacteria Typhoid Malaria XDR Tuberculosis Gonorrhoea Areas impacted Hospital waiting lists and costs All surgical procedures Cardiac surgery Joint replacements Obstetrics Specialist services Intensive care Transplantation Cancer chemotherapy Patients with impaired immunity Travel related infections 5

6 Drivers of resistance Importation from overseas Antibiotic use humans, animals Cross transmission CDC Threat Report 2013 What can patients do? Prevent infection Don t use antibiotics for viral infections Take full course of antibiotics Stay away from hospitals! 6

7 What can we do in hospitals? Antibiotic stewardship quality use of antibiotics Reduce cross transmission cleaning, hand hygiene, good infrastructure Prevent infection Antibiotic use Not Colonized Colonized Infection Cross-transmission 7

8 Compliance with hand hygiene has increased from 43% in 2008 to 79% in 2014 The number of central line bloodstream infections in intensive care has decreased from 41 in 2008 to 2 in 2013 The number of Staph aureus bacteraemias has fallen from 198 in 2002 to 78 in 2013 The proportion of Staph aureus bacteraemias due to antibiotic resistant MRSA has fallen from 55% in 2002 to 22% in 2013 The proportion of Staph aureus bacteraemias acquired during hospitalisation has decreased from 46% in 2010 to 28% in 2013 The proportion of staff vaccinated against influenza has improved from <40% in 2004 to 78% in June, 2014 Antimicrobial stewardship DDD/1000OBD cephalosporins in Non-ICU month Observed Pre - intervention trend Post-intervention trend DDD/1000OBD glycopeptides in Non-ICU month Observed Pre - intervention trend Post-intervention trend Cairns MJA

9 What can we do in Australia? Co ordinated public policy humans/animals, community/hospitals Invest in infection prevention and research Track resistance rates Antibiotic stewardship and prevention of cross transmission as a standard Ensure access to new antibiotics A successful example Fluoroquinolone antibiotics particularly useful Not licensed in food producing animals Reserve antibiotic in treatment guidelines Restricted subsidy by PBS Proportion of E coli isolates resistant to quinolones.5.4 Malta Spain.3 Bulgaria Portugal Czech Republic Hungary Ireland Germany Greece Poland Austria.2 Luxembourg United Kingdom Slovenia France Belgium Latvia Lithuania Netherlands Denmark.1 Sweden Finland Norway Estonia Iceland Australia Usage (DDD/1000 population days) Italy Cyprus Cheng Emerg Infect Dis

10 National policy 1999 JETACAR report (Joint Expert Technical Advisory Committee on Antibiotic Resistance) Taskforce disbanded 2002 EAGAR (Expert Advisory Group of Antimicrobial Resistance) established by NHMRC AMRSC (Antimicrobial Resistance Subcommittee) established by Commonwealth CHO 2013 ACSQHC commissioned scoping studies 2014 Conclusions Antibiotic resistance due to antibiotic use Perfect storm of increasing resistance and declining antibiotic development Need to reduce unnecessary antibiotic use and cross transmission of resistant organisms Need for surveillance to inform co ordinated policy Interventions to reduce resistance need resources 10