Presentation on antimicrobial resistance. A wake up call

Presentation by:AUGUSTINE MWAAWAARUANDMATTHEW FRIMPONG ANTWIFPRESBYTERIAN UNIVERSITY COLLEGE-GHANA

OBJECTIVES/SCOPE OF PRESENTATIONTo be able to define what antimicrobials are.To have a fair knowledge of the history of antibioticsFair knowledge of statistics concerning antimicrobials usage.Common resistant organismsHow microbes develop resistance.Factors contributing for resistanceSettings that Foster Drug ResistanceThe way forward as a nation

Abbreviations AMR: Antimicrobial ResistanceTB: Tuberculosis WHO: World Health OrganizationMRSA: Methicillin Resistant Staphylococcus Aureus LMIC: Low and Middle Income CountriesMDR: Multi Drug ResistanceARV: AntiretroviralNDM 1: New Delhi Metallo-Beta lactamase 1

TerminologiesMicroorganisms are microscopic living organism, which may be either single celled or multi-cellular; they include protozoa, virus, bacteria, fungiAntimicrobials are agents that kill microorganisms or inhibit their growth. They include: antifungal, antibacterial, antiviral Antibiotics, also known as antibacterial are a types of antimicrobial drugs, used in the treatment and prevention of bacteria infections by either slowing bacterial growth( bacteriostatic action) or killing bacteria (bactericidal action)

background

The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily under-dose himself and thereby exposing his microbes to non-lethal quantities of the drug, making them resistant.Alexander Flemings Nobel lecture - 1945

backgroundDiscovery of antibiotics in the 1940s ..Enormous medical gainsReduced morbidity and mortality due to microbial infectionsIncreased life expectancy

A requirement for modern health careLarger surgical interventionsTreatment of the immunosuppressed, including cancer patientsTransplantationsNeonatal care

Disturbing eventsIn the past 25 years no new class of antibiotics with novel mechanism of action has been developed. WHO (2012) increasing Cost of treatmentData shows that, AMR is more prevalent in the commonly used and affordable antibioticsIncreasing access to antimicrobials also leading to misuse of antimicrobials irrational use; blind treatmentResistant strains are not only in health facilities, but also found in the community.Resistance is not localized but has become a global health threat

AMR; A GLOBAL HEALTH THREAT ?

A Global Challenge Antimicrobials are losing their effectiveness at a pace that was unforeseen just 5-10 years ago

The drug development pipeline is virtually empty from antibiotics with a novel mechanism of action

AMR; a global concern?Antimicrobial resistance (AMR) kills

Challenges care and control of infectious diseases

Greatly increases care costs individual and society

Threatens a return to the pre-antimicrobial era

Jeopardizes healthcare gains for individuals and society

Lack of coherent approaches to prevention and containment

Hahahaha My paddi, me de3, I dey chop ma kingship here oooo. Make them overuse antibiotics

Did you know?Between 2000 and 2010, total global antibiotic consumption grew by more than 30 percent, from approximately 50 billion to 70 billion standard units, based on data from 71 countries, including most high- population countries (Van Boeckel et al. 2014). Per capita consumption is generally higher in high-income countries, but the greatest increase in antibiotic use between 2000 and 2010 was in LMICs, where use continues to rise

Did you know?Increasing prosperity and population growth drive an increasing demand for animal protein. To satisfy this need, many farmers are transitioning to intensive agriculture and often use antibiotics to optimize production.

Use in Agriculture:Sub therapeutic use in food animals.Transfer of resistance to humans through diet.70% of antibiotics produced are used in livestock in the (USA).51.1% - Campylobacter, 11.9% - Salmonella, 97.7% - E. coli & 82.6% - Enterococcus in chicken breasts. - NARMS (2006)20% MRSA infections from animal strain. CDC (USA).

Think of this gloomy statisticBy 2050 antimicrobial resistance (AMR) could lead to deaths of 4.15 million people in Africa every year. [1] The only continent that will overtake Africa is Asia, which could see 4.73 million people die from this canker over the same period.

WHO Reports

Tuberculosis (TB): 440,000 new multidrug resistance (MDR) TB cases annually; extensively drug resistance (XDR) TB cases reported in 64 countries so farMalaria: Emergence of Artemisinin resistance linked to ongoing use of monotherapiesHIV: With expanded use of antiretrovirals (ARVs), resistance is a concernMethicillin-resistant Staphylococcus aureus: lethal infections in hospital settings becoming increasingly frequentMulti-drug resistant E.coli, K.pneumoniae and Enterobacter sp.: infections are on the rise and a new beta-lactamase, NDM-1, is causing alarm Neisseria gonorrheae and Shigella: becoming increasingly resistant to drugs

Laboratory reports show increasing resistance among bacteria causing pneumonia, which kills about 1.8 million children annually.Resistance rates to anti-HIV drug regimens ranging from 10%20% have been reported in Europe and the USA.In Europe 512% of hospital patients acquire an infection during their stay. Each year, an estimated 400,000 present with a resistant strain, from whom 25,000 die, on average. Multidrug-resistant bacteria in the EU are estimated to cause an economic loss of more than 1.5 billion each year.

13.7% E. coli isolates from patients in Accra, were nalidixic acid-resistant. 52% of 2006 and 2007 isolates and 66.7% of 2008 isolates were also resistant to ciprofloxacin. All but one of the quinolone-resistant isolates were resistant to three or more other antimicrobial classes to sulphonamides, tetracycline and trimethoprim, streptomycin. Namboodiri, S.S. et. al. (2011)80.4% of the E. coli isolates from hospitals in Kumasi exhibited multiple drug resistance against gentamicin, ciprofloxacin, ceftriaxone and co-trimoxazole. Freeman et. al. (2012)Ghanaian currency notes in circulation are contaminated with microorganisms, most of which are resistant to the commonly used antibiotics.

Factors contributing for resistanceMisuse of antibioticsUse of antibiotics with no clinical indication (e.g, for viral infections)Use of sub-standard drugs-Use of broad spectrum antibiotics when not indicatedInappropriate choice of empiric antibiotics Overuse of antibioticsAddition of antibiotic to the feed of livestockFailure to follow infection control practices

This antimicrobial is sharp sharp it can cure all the diseases you have as well as your malnourishmentYou mean all my illnesses including the hernia?21

Settings that Foster Drug ResistanceIntensive care unitsOncology unitsDialysis unitsRehab unitsTransplant unitsBurn units

How does resistance occurBacterial strains that are resistant to an antibiotic can produce enzymes that inactivate the drug, are impermeable to it, actively export it from the cell or by-pass the cellular target

How does resistance occurNatural/ intrinsicAcquired: the presence of an enzyme that inactivates the antimicrobial agent the presence of an alternative enzyme for the enzyme that is inhibited by the antimicrobial agent, eg. NDM 1: New Delhi Metallo-Beta lactamase 1 a mutation in the antimicrobial agents target, which reduces the binding of the antimicrobial agent post-transcriptional or post-translational modification of the antimicrobialagents target, which reduces binding of the antimicrobial agentreduced uptake of the antimicrobial agentactive efflux of the antimicrobial agentoverproduction of the target of the antimicrobial agent

How does resistance occur

What is the way forward ?AMR is complex problem requiring a comprehensive response from all stakeholders:CommitmentAccountabilityFinancingInnovation

There is no one single approach to AMR containment

Preventing AMR is public good and requires collective responsibility

GloballyThe WHO publication on containment of AMR describes the five most important areas for the control of AMR: surveillance of antimicrobial use

rational use in humans

rational use in animals

infection prevention and control

innovations in practice and new antimicrobials

What can we also do in Ghana to curb this.

It is everyones business

Education

Teaching patients well on how to take their drugs, side effects, etcCreation of awareness on the dangers of irrational use of antimicrobialsTalks on health and the need to see a qualified practitioner for treatmentWorkshops in schools especially second cycle and tertiary on rational use of drugs especially antimicrobialsPublic education about medicines and their actionHealth promotion on living a healthy life-styleInvolving stake holders in the promotion of appropriate drug useDiscouraging self medications

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Encouraging a healthy life-style

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Policies Equipping A multi-disciplinary national body to regulate medicine use policy in the countryEnforcing regulations on drug-use policy (pharmacy act 489 and national drug policy)Punishing perpetrators who violate drug-use policies by selling un-prescribed antimicrobialsPromoting a good prescription policy in GhanaSufficient government support in ensuring availability of medical staffsPolicies on over the counter medical storesPolicies on no prescription, no drug on over the counter medical stores

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Health systemProvision of up to date clinical guidelines, eg. Standard treatment guidelines, bnf, etc, at health facilitiesProvision of up to date essential medicine list, based on the treatment of choiceDrugs and therapeutic committees in districts and hospitalsEncouraging good supervision, audit and feedbackEncouraging good doctor relationship and communications and trustPrescribers should treat underling causes of diseases.36

Involving stake holders

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Training and in-service trainingPromotion of problem based pharmacotherapy training in undergraduate schools

Promoting in-service medical education through seminars for medical staffs

Investing into training of practitioners through provision of journals and researched materials

Training of pharmacist and drug sellers

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Pharmaceutical companiesProvision of adequate information on drugs especially antimicrobialsAvoiding wrong means of advertising drugsSupporting the government and prescribers in educating the public on the effects of antimicrobial resistancePeriodic drug seminars for undergraduates and prescribers on new additions in the world of pharmacologyProvision of good formularies and therapeutic manuals on drugs.

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HELP IN THE FIGHT AGAINST AMR

References Zaidi, M. B., Zamora, E., Diaz, P., Tollefson, L., Fedorka-Cray, P. J., and Headrick,M. L. 2003. Risk factors for fecal quinolone-resistant Escherichia coli in Mexican children. Antimicrob. Agents Chemother. 47:19992001.Zhang, R., Eggleston, K., Rotimi, V., and Zeckhauser, R. J. 2006. Antibiotic resistance as a global threat: evidence from China, Kuwait and the United States. Global Health 2:6.

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