Escalating Problem on Pseudomonas and Acinobacter Resistance and MDRO Kuntaman Department of Medical Microbiology, Faculty of Medicine Airlangga University / Dr.Soetomo Hospital Surabaya 08113410352 kuntaman@mitra.net.id 1 Learning objectives 1. The antimicrobial resistance (AMR) and the development of AMR 2. Growing of Multi-drug Resistant Organism (MDRO) 3. Focus on P aeru, Acinetobacter plus ESBL 4. How to combat 2 The development of Antimicrobial Resistance (AMR) 3 1
First line of AMR Amox Co-trimox Increase up to 100% WHO Global Strategy for containment of antimicrobial Resietance. 2001 Clin Isolate Dr. Soetomo Hosp. 2012 E coli AML10 = 87% SXT = 52% Klebsiella spp AML10 = 92% SXT = 57% 4 Sec Line Increase up to Not efficient Cefotax Cefep Ciproflox Clin Isolate Dr. Soetomo Hosp. 2012 E coli Klebsiella spp CTX30 = 46% CTX30 = 70% FEP30 = 18% FEP30 = 32% CIP5 = 60% CIP5 = 47% 5 Dr Soetomo Hosp SBY 2012 ESBL ESBL Increase Clin Isolate Dr. Soetomo Hosp. 2012 E coli: 629 ESBL: 327(52%) Kleb pn:351 ESBL: 202(58%) Kleb ox:114 ESBL: 55(48%) 6 2
Hosp Microbes: Shifting to MDRO Commensal/Saphrophytes ESBL Producer: E coli, K. pneumo P aeruginosa Acinetobacter spp USA: 2 nd leading caused of mortality due to Gram Neg infection in Pts admitted to ICU (Wisplinghoff et al, 2004, Clin Infect Dis; 39:309-17) 7 Dr Soetomo Hospital SBY 2012 The big five Hosp. isolates Saphrophyte Commensal 2.499 Rank E coli Kleb spp Enterobct sp Acine baum Pseu aer N (%) 629 (25.2) 465 (18.6) 376 (15.1) 329 (13.2) 281 (11.3) 8 Overuse In mild infection Misuse Less supporting Facility A.B. Abuse AMR Underuse Less funding WHO Global Strategy for containment of antimicrobial Resietance. 2001 9 3
Overuse of 3rd GEN CEPH (in Hospital) ESBL Producing bacteria: - MDRO - Res 3rd Gen Cepha & Other gen - Co-res Cipro 10 Overuse of Very strong AB (in Hospital) Saphrophytic Microbes - P aeru - Acinetobacter - MDR, Pan Res 11 Rational Drug Use Dr. Soetomo Hospital: 33-65% Others: be similar 12 4
Growing of Multi-drug Resistant Organism (MDRO) 13 Growing of MDRO 1 2 Cumulative Selection Trans mission Plasmid Mediated Selection of New A.B. In which the Res to old A.B. Still present; Comb Thx Moving among Pts and HCW ONE Plasmid carry 2 Res gene or more 14 Multiple Selection in Combination Therapy AMR-1 AMR-2 AMR-3 AMR-1-2-3 Saphrophytic-Commensal 1. Pse aeru 2. Acineto spp 3. E coli 4. Kleb spp 15 5
Highly selected Microbes Commensal: E coli, K. pneumo Saphrophytic: P aeru, Acineto 16 Susceptibility (%) Pattern of Acine baum (329) and Pseu aer (281) AB Ac bau Pse aer AMI 39 70 SAM 58 - FEP 17 60 CAZ 14 52 CTR 11 11 CIP 19 47 GEN 19 53 AB Ac bau Pse aer IMI 44 70 MEM 56 75 TCC 62 - TIGE 62 - TOB 75 - SXT 47 25 17 Hence: key words ESBL MDRO COMMENSAL SAPHROPHYTIC 18 6
HOW TO COMBAT THE PROBLEM 19 Look for: New AB? Would be, Take time Use: the strongest AB? Would be Use: the AB in Comb? Would be Upgrade the Physician:? Would be, YES Strengthen the Micro Lab? Yes 20 AMR Surveillance? AB Cycling:? Yes Would be Strengthen the Pharmacist? Yes AB Surveillance? Yes - Quan - Qual 21 7
Thus Strengthen PPRA 22 Basic Concept to combat the Problem of MDRO 1. Prevent: AB Selection Pressure 2. Prevent: MDRO transmission 3. Provide the pattern of AMR for empiric therapy 4. Search and Destroy the MDRO Bocher at al. The search and destroy strategy prevents spread, Clin Microbiol Infect 2010; 16: 1427 1434 23 1. Prevent: AB Selection Pressure a) Increasing the prudent use of AB b) Hospital Policy on AB Use 2. Prevent: MDRO Transmission a) Increasing the compliance of UP/SP b) Increasing the compliance of Isolation Precaution 24 8
3. Provide the pattern of AMR for empiric therapy Multi Centre Study of ESBL, 2010 1. Surabaya (Kuntaman et al) 2. Semarang (Wahjono et al) 3. Malang (Santosa et al), MRPA etc 25 Species of ESBL producing Microbe --- TOTAL --- K. oxytoca 1.0% E. aerogenes 3.0% Others 2.0% E. cloacae 4.0% K. pneumoniae E. coli 42.7% TOTAL 300 47.3% K. pneumoniae E. coli E. cloacae E. aerogenes K. oxytoca Others Total Surabaya 71 61 4 0 1 3 140 Semarang 32 36 5 8 1 3 85 Malang 39 31 3 1 1 0 75 Total 142 128 12 9 3 6 300 Others : C. freundii, C. koseri, C. werkmanii, P. mirabilis, S. fonticola, S. marcescens 100% Sensitivity of ESBL producing ALL Microbe (300) 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 98.0% 87.7% 75.3% 63.0% ALL ESBL Meropenem Fosfomycin Meropenem Fosfomycin Amikacin Amikacin Cefoperazone /Sulbactam 29.7% Ciprofloxacin 2.0% Cefotaxime Ciprofloxacin Cefotaxime Sensitive 294 263 226 189 89 6 Intermediate 1 20 39 100 34 6 Resistance 5 17 35 11 177 288 Total 300 300 300 300 300 300 MEM FOS AMI SCF 9
4. Search and Destroy the MDRO Bocher at al. The search and destroy strategy prevents spread, Clin Microbiol Infect 2010; 16: 1427 1434 a) New Concept, Selected target b) Basic Principles: 1 Find the Important MDRO / MRSA 2 Clean the MDRO 3 Evaluate 28 SUMMARY 1. AMR to be a problem worldwide. How is our hospital, it would be 2. Are there MDRO in our hospital? Common, BUT need the surveillance 3. Why do MDROs develope? - More A.B. Expose - due to more irrationally A.B. Use - due to more quantity A.B. use 29 SUMMARY 4. How methods MDRO increase?? a. Selection pressure and Res gene movement b. Bacterial spread 5. What Microbes to be a problem?? a. Commensal/Saphrophytic b. E coli, Klebs spp and Pseud aeru/acineto 30 10
SUMMARY 6. Pseudo aer/acinetobacter a. more abundant in Environment b. more adaptive c. more intrisically res 31 SUMMARY 7 Combating MDRO 1 Increasing the Prudent use of AB AB Surveillance, Quan, Qual. Inf Dis Team 2 Increasing the compliance to UP/SP 3 Plan for Search and Destroy 8. Strengthen PPRA 32 Thank you for your kind attention May God bless us all 33 11