garp kathmandu jul2016
DESCRIPTION
http://www.cddep.org/sites/default/files/garp.kathmandu.jul2016.pdfTRANSCRIPT
The Global Challenge of Antimicrobial Resistance
Ramanan LaxminarayanGARP Regional Meeting, Kathmandu
Bacterialdiseasesarestillmajorkillersindevelopingcountriesbecauseoflackofaccesstoantibiotics
O’Brienetal,Lancet2009
Pneumococcalpneumoniadeathsavertablewithimprovedantibioticaccess
Laxminarayanetal,Lancet,2015
Whatareweaskingofantibiotics?
Substituteforimmunization,infectioncontrolandwater/sanitation
South Asia
Substituteforimmunization,infectioncontrolandwater/sanitation
Sub-Saharan Africa
Percentage of Staphylococcus aureus isolates that are methicillin resistant (MRSA) in selected countries, 1999–2014
Source: CDDEP 2015
Depending on the country, resistance to one or more of the following drugs may have been used to test for MRSA: Oxacillin, cefoxitin, flucloxacillin, cloxacillin, dicloxacillin, and methicillin. Intermediate-resistant isolates are included as resistant
CREratesinchildrengrewbetween2000and2012
Loganetal,EID,2015
15
ClonalspreadofS.pneumoniae 23F
Tennessee
Cleveland
Mexico
Colombia
Brazil
ArgentinaUruguay
Chile SouthAfrica
SingaporeMalaysia
ThailandPhilippines
HongKongTaiwan
SouthKoreaSpain
FranceBM42001978?
Finland
Slidecourtesy:KeithKlugman
ResistanceMapwebpage
Resistanceratesinvariouscountriesonglobalmap
Resistanceratescomparisonamongcountries
Wheredoestheburdenofresistancelie?
Neonatalsepsis– 421,000deathsglobally
Mortalityoutcomesareworseinneonateswithresistantinfections
Kayange M,Kamugisha E,MwizamholyaDL,JeremiahS,Mshana SE.2010.Predictorsofpositivebloodcultureanddeathsamongneonateswithsuspectedneonatalsepsisinatertiaryhospital,Mwanza- Tanzania.BMCPediatrics10:39.
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151
91
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Culture GramReaction ESBL MRSA
Death(%)
Parameter
Positive
Negative
NeonatalCasefatalityratesinIndia(InPress)
LaxminarayanetalLancet,2015
Typhoidandpara typhoid–400,000deaths,16millioncases
Resistanceisincreasingandassociatedwithworseoutcomes• InKenya,proportionofStyphi inKenyathataremultidrugresistantandresistanttonalidixic acidandwithdecreasedsusceptibilitytofluoroquinolones hadrisenfrom1%in2000tonearly25%in2008.
• FluoroquinoloneresistanceisincreasinginIndia(44%)andPakistan(58%).
• Casefatalityratesassociatedwithmultidrug-resistantStyphi insouthAsiaare10%(closetothe12·8%recordedinthepre-antibioticera)LancetInfectDis2005;5:481–93
Surgicalsiteinfections– over400,000deaths
Surgicalsiteinfections
• Thereare92millionsurgeriesinlow-incomecountrieseachyear• 5.5millionsurgicalsiteinfectionsorSSIs(6per100procedures)–aboutathirdofallhealthcareassociatedinfections
• SSIsaretheleadingcauseofinfectioninsettingswithlimitedresources
• MortalityratefromSSIRatesofmortalityfromsurgicalsiteinfectionsare3%intheUSandbetween8and20%inlow-incomecountries
• Between400,000andamilliondeathsfromSSIseachyearwithanincreasingnumbercausedbyresistantpathogens.
Maternaldeathscausedbysepsis– aboutatenthofallmaternaldeaths
Increasingratesofinstitutionaldeliveriesplaceagreaterburdenoninfectionstandardsinhealthcareinstitutions.
Absolute risk reduction (ARR) of infection with antibiotic prophylaxis in common surgical procedures and blood cancer chemotherapy in the USA
Teillant etal,LancetInfectDis,2015
Number of additional infections per year in the USA under a 30% decreased efficacy of antibiotic prophylaxis
Teillant etal,LancetInfectDis,2015
Malaria– 420,000deaths
Riskofmalariamortalityinchildrenunder10wentupbetweentwoandfive-foldinthreepopulationsinSenegalfollowingemergenceofchloroquine resistance.
Anticipatedimpactofdrugresistanceinthenearterm• Neonatalsepsis• Entericpathogens• Surgicalsiteinfections• Maternalmortalityassociatedwithobstetrics• Malaria• Tuberculosis• HIV
Population without access to improved sanitation, by MDG region 2012
Source: WHO/UNICEF 2014
Kyaw MH et al. N Engl J Med 2006;354:1455-1463.
VaccinescanbeeffectiveInvasivediseasecausedbyPneumococciinchildrenundertwodeclinedintheUSpostpneumovaccination
Kyaw MH et al. N Engl J Med 2006;354:1455-1463.
Invasivediseasecausedbynon-susceptiblePneumococci,US
EffectofPCV7introductiononantibioticprescriptionsandambulatorycarevisits
Zhou et al, Pediatrics 2008
EffectofPCV7introductiononantibioticprescriptionsandambulatorycarevisits
Zhou et al, Pediatrics 2008
Antibiotic prescriptions attributable to acute otitis media decreased from 1244 to 722 prescriptions per 1000 person-years – a 41.9% reduction.
LaxminarayanetalLancet,2015
Antibiotic consumption is increasing in developing countries...
Source: Based on data obtained under license from IMS Health MIDAS ™ (January 2005-December 2010); IMS Health Incorporated. All Rights Reserved.
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5000
10000
15000
20000
25000
BRAZIL, RETAIL INDIA, RETAIL VIETNAM, RETAIL NORWAY, RETAIL USA, RETAIL
Stan
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Uni
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r 100
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Per capita total antibiotic use, retail sector, 2005-2010
2005
2006
2007
2008
2009
2010
-50 – -30 -29 – -20 -19 – -10 -9 – 0 1 – 10 11 – 20 21 – 40 41 – 80 >80 No data
Percentage change in antibiotic consumption per capita 2000–2010*, by country
Source: Van Boeckel et al. 2015 (adapted; based on IMS MIDAS)
*Data for Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama were available only as a group classified as Central America. Similarly, data for Benin, Burkina Faso, Cameroon, Côte d’Ivoire, Gabon, Guinea, Mali, Republic of the Congo, Senegal, and Togo were grouped and classified as French West Africa. The data for these countries represent the estimates for the corresponding regional groupings they belong to. For countries that did not have data available for 2000, the values for the earliest years for which data were available after 2000 were used to calculate the percentage changes. These countries and initial years are Algeria (2002), Bangladesh (2007), Croatia (2005), Netherlands (2005), and Vietnam (2005).
Faropenem consumptionhasincreasedby154%sinceitwasapprovedforuseinIndiain2010
Gandra etal,Clin Inf Dis,2016
Carbapenem consumption in the hospital sector in selected European countries, 1997–2013
ESAC-Net 2015
Non-prescriptionuseofantimicrobialsiscommon
Morganetal,LancetID,2011
Globalavailabilityofcolistin
Wertheim et al, JGAR 2013
Antibioticuseforgrowthpromotionanddiseaseprevention
2/3rds ofthetonnageofantibioticssoldworldwideareusedinagriculture
Numbersofuniqueβ-lactamaseenzymesidentifiedsinceintroductionoffirstβ-lactamantibiotics
• TotalconsumptioninChina- 92700tonsin2013,
• 54000tonsof antibioticsexcretedbyhumanandanimals- muchofthisenteredintothereceivingenvironmentfollowingvariouswastewatertreatmentsinto58riverbasinsofChina
Zhangetal,Env Sci Tech,2015
High-capacityquantitativePCRarraysdetected149uniqueresistancegenesamongallofthefarmsamples,thetop63ARGsbeingenriched192-fold(median)upto28,000-fold(maximum)comparedwiththeirrespectiveantibiotic-freemanureorsoilcontrols.
IncreaseofantibioticresistancegenesamongsoilscollectedatfivesitesinTheNetherlandsfrom1940to2008.
KnappetalEnv Sci Tech,2010
Temporalassociationbetweencontaminationofretailchicken withceftiofur-resistantSalmonellaHeidelbergstrainsandincidenceofceftiofurresistantSalmonellaHeidelberginfectioninhumans
Dutil etal,EID,2010
Global antibiotic consumption in livestock (mg per 10 km2 pixels) 2010
Van Boeckel et al., PNAS, 2015
Log10 [(mg/pixel) + 1]
No data0 - 1 4 - 5 5 - 6 6 - 7 7 - 8 8 - 9 9 - 10 10 - 11
Global antibiotic consumption in livestock (mg per 10 km2 pixels) 2010
Van Boeckel et al., PNAS, 2015
Log10 [(mg/pixel) + 1]
No data0 - 1 4 - 5 5 - 6 6 - 7 7 - 8 8 - 9 9 - 10 10 - 11
Globalconsumptionofantimicrobialsinfoodanimalproduction• estimatedat63,151(±1,560)tonnes in2010• projectedtoriseby67%,to105,596(±3,605)tonnes by2030• hotspotslikeIndiawhereareasofhighconsumption(30kgperkm2)for
industrialpoultryproductionareexpectedtogrow312%by2030
ImageCourtesy ofShutterstock