1

2
 3

http://www.independent.co.uk/news, 2013
4
5
6
Why is AMR a global concern

•
•
•
•

WHO factsheet, 2015

•

•
8
•
•

9
significant association between carbapenem resistance and 10
mortality risk in P. aeruginosa infection (adjusted OR = 2.38
 11
Kwon, et al., Impact of imipenem resistance on mortality, J Antimicrob Chemother. 2007.
12
 Results: Mortality
10
P=0.05
9
8
7 8.1%
% Mortality

6
5
4
3
2
1.4%
1
0
Infection-Related Mortality
FQ-susceptible (n=70) FQ-Resistant (n=123)
Lautenbach, SHEA, 132002
•

CDC, 2013

14
Geographic Spread Of ESBLs

Area C3 Area B2
> 100 miles 10-20 miles
Rate - 5% Rate- 23%

Area B1
0-10 miles
Rate- 37%

Area C2 Area C1
80-100 miles 20-80 miles Hospital A
Rate - 3% Rate-9% Rate- 58%

15

Monnet, et al. Infect. Control Hosp Epidemiol. 1997;18:492-8.

How AMR Happens

16
 Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Emergence of Antimicrobial Resistance

Susceptible Bacteria

Resistant Bacteria

Resistance Gene Transfer

New Resistant Bacteria
 Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Selection for Antimicrobial-Resistant Strains

Resistant Strains
Rare
Antimicrobial
Exposure

Resistant Strains
Dominant
 Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Antimicrobial Resistance:
Key Prevention Strategies
Susceptible Pathogen
Antimicrobial-Resistant
Pathogen Pathogen
Prevent Prevent
Transmission Infection

Antimicrobial Infection
Resistance
Effective
Optimize Diagnosis
Use and Treatment

Antimicrobial Use
 Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Key Prevention Strategies

 Prevent infection
 Diagnose and treat
infection effectively
 Use antimicrobials wisely

 Prevent transmission

Clinicians hold the solution!

Cause of AMR

21
 Superbugs* are visible manifestations of our prolonged failure to preserve antibiotics

Known but neglected.

Need immediate action

Known but
inevitable

** Methicillin resistant Staph aureus, MDR-and XDR Mycobacteria, ESBL producing Gram negative bacteria and NDM-1 producing
enterobacteriaceae bacteria are few examples of superbugs because these fail to respond to large number of commonly used antibiotics
•
How much
misuse?
•

*WHO factsheet, 2012

$CDC 2013
23
•

24
25
 Introduction of
Resistance to
one antibiotic
?
new antibiotic
by
pharmaceutical
companies

26
27
•
•

28
29
 ‫راه حل‬
‫افزایش مقاومت‬
‫میکروبی (مصرف‬
‫نادرست)‬

‫مصرف‬
‫منطقی آنتی‬
‫بیوتیکها‬
‫کاهش سرعت‬
‫کشف آنتی‬
‫بیوتیکهای جدید‬
‫‪30‬‬
•
•
•

31
•

32
 33

Antimicrobial Resistance in Gram-negative…, Arch. Razi Ins, 2003.

Resistance of leading Gram negative bacterial isolates

34

ETIOLOGY AND ANTIBACTERIAL RESISTANCE …, Acta Medica Iranica, 2007.

 •

35

ETIOLOGY AND ANTIBACTERIAL RESISTANCE …, Acta Medica Iranica, 2007.

36
 DDD(defined daily dose) per 1000/day

120
100 100 101 101

100

80

60

40

20

0
85 86 87 88 37
Total outpatient antibiotic use in Europe 2005 and 2006 expressed in DDD per 1000
inhabitants per day. Data from the European Surveillance of Antimicrobial Consumption38
(ESAC) project’s 2006 year book
39
•
•
•

40
 •
•

Wise R, Hart T, Cars O, et al. Antimicrobial Resistance is a major threat to public health.
41
BMJ 1998;317:609-10.
•
42
43
•
•

•
•
•
•
44
Lautenbach, Arch Intern Med 2003;163:601
 No Infection
(n=27)
33%

Other Agent First

Line (n=43) Insufficient
53% Information
(n=11)
14%

45
•
•
•
•
•
•
•
•
Lautenbach, Arch Intern Med 2003;163:601
46
•
•
•
•
•
•
•
•
•
•
47
Switzer GE, J Gen Intern Med 2003;18:816
 Used guideline Not at all
(20%) familiar (21%)

Read guideline Have seen

(30%) guideline (29%)

48
 Good antimicrobial stewardship is a practice that ensures the optimal
selection, dose, and duration of an antimicrobial therapy that leads
to:
 best clinical outcome for the treatment or prevention of infection
 producing the fewest toxic effects and the lowest risk for subsequent
resistance

49
Gerding, 2001
•
•
•
•
•
•
•

50
•
•

51
•
•

52
•

53
 Antibiotics are
a precious
resource

We need to preserve this

resource by working
together

Combating antimicrobial
resistance: No action
today, no cure tomorrow

54 | World Health Day 2011: Antimicrobial Resistance

55
56
 Reasons for Antibiotic Overuse :
Conclusions from 8 Focus Groups
Patient Concerns Physician Concerns
• Want clear explanation • Patient expects antibiotic
• Green nasal discharge • Diagnostic uncertainty
• Need to return to work • Time pressure

Antibiotic Prescription
Barden L.S. Clin Pediatr 1998;37:665
 Antibiotic Use Leads to
Antibiotic Resistance
• Resistant bacteria or their
genetic determinates are
selected when colonizing or
infecting bacteria are exposed
to antibiotics
• Resistant bacteria can then be
transmitted between patients
• Highest risk patients:
– Immunocompromised
– Hospitalized
– Invasive devices
(central venous catheters)
 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

12 Steps to Prevent Antimicrobial Resistance:

Hospitalized Adults
Use Antimicrobials Wisely
Prevent Infection 5. Practice antimicrobial control
1. Vaccinate 6. Use local data
2. Get the catheters out 7. Treat infection, not contamination
8. Treat infection, not colonization
9. Know when to say “no” to vanco
Diagnose and Treat 10. Stop treatment when infection is
Infection Effectively cured or unlikely
3. Target the pathogen
4. Access the experts Prevent Transmission
11. Isolate the pathogen
12. Contain the contagion