1. Update on Antimicrobial Resistance Allison McGeer, MD, FRCPC Mount Sinai Hospital amcgeer@mtsinai.on.ca 416-586-3118 http://microbiology.mtsinai.on.ca

2. “This inquiry has been an alarming experience which leaves us convinced that resistance to antibiotics... constitutes a major public health threat and ought to be recognized as such”. UK House of Lords White Paper, 1999

3. Antibiotic resistance in pneumococci, CBSN, 1988-2000

4. Antibiotic resistance in pneumococci in older adults, respiratory specimens, CBSN, 1988-2001

5. Number of Patients Colonized/Infected with MRSA, Ontario, 1992-2000 9345 8 252 $25M 8016 6866 4212 1426 . 566 471 475 LPTP Survey, 1996/97/98

6. Risk of death from MRSA vs MSSA bacteremia • Meta-analysis, 2001 • 9 case control studies, 1990-2000 • Pooled relative risk: 2.1 (1.7, 2.6) Whitby, MJA, 2001;175:264-7

7. Resistance in E. coli, Baycrest 1997-2002

8. MH, NH #1, March 2001 • Admitted to MSH with SOB, ?pneumonia • Sputum: E. coli Ampicillin R Cotrimoxazole R Nitrofurantoin R Cefazolin R Ciprofloxacin R

9. G.D. 82yo Male ESRF on Hemodialysis-resident of RH • TO ER with fever, shortness of breath • T=38.0, WBC-N • Bibasilar Infiltrate-Rx IV Cefuroxime x24hrs • Deterioration: Resp Failure +Septic Shock • ETT suction-Gram-Mod Poly’s, many Gram neg rodst: culture; heavy MDR E.Coli • IV Azithro+Meropenem • Death due to septic shock + Refractory hypoxemia

10. Inappropriate antimicrobial therapyImpact on Mortality 17% mortality Rel risk 2.4 95% Ci 1.8,3.1) 42% mortality Kollef et al. Chest 1999;115:462

11. Conclusion • Antibiotic resistance is coming bad for patients expensive • The only good news is that we can choose to spend our money on prevention or on treatment

12. What can be done? • Surveillance • Prevention • Hand hygiene • Vaccine • Transmission control • Reduced/improved antibiotic use • Public expectations • Provider practice

13. Surveillance • Measure burden of illness • incidence, mortality, morbidity, cost • Identify opportunities for prevention • Evaluating/inform prevention programs • vaccine, appropriate AB, transmission prevention • Minimize treatment failures

14. WHO, 1997 Antimicrobial resistance has increased dramatically in the last decade, adversely affecting control of many important diseases. Antimicrobial resistance leads to prolonged morbidity, increased case fatality and lengthens duration of epidemics. Surveillance is necessary for national and international co-ordination.

16. 3 influenza 5 tuberculosis 15 inv S. pneumoniae 18 inv H. influenzae 23 gonorrhea 24 invasive GAS 35 Campylobacteriosis 2 antibiotic resistance 4 nosocomial infections 5 tuberculosis 8 MRSA 9 salmonellosis 12 campylobacteriosis 14 C. difficile Canada,1998 UK, 1997

17. (1,1) S. aureus (2,2) S. pneumoniae (3,4) M. tuberculosis (5,4) Enterococcus spp. (4,7) N. gonorrhoeae (8,5) E. coli (x,6) H. influenzae (7,8) Salmonella spp. (9,9) N. meningitidis (x,6) P. aeruginosa Top ten (10,10) Klebsiella spp

18. What can be done? • Surveillance • Prevention • Hand hygiene • Vaccine • Transmission control • Reduced/improved antibiotic use • Public expectations • Provider practice

19. Impact of hand hygiene on infections

20. Vaccines • Influenza (universal) • Pneumococcal • polysaccharide (pneumovax) for high risk children and adults • conjugate vaccine for children

21. Effect of influenza vaccine for staff and residents of long term care facilities Potter et al. JID 1997;175:1-6

22. Annual risk of influenza outbreaks by percentage of staff vaccinated

23. Impact of influenza vaccine on antibiotic use • Pediatrics (Belshe, NEJM, 1998) • 30% reduction in acute otitis media • Healthy adults (Nichols, NEJM, 1995) • 45% reduction in antibiotic prescriptions

24. Rate of invasive pneumococcal disease:Metro/Peel vs. Quebec

25. Cases of invasive disease by vaccine eligibility, Metro/Peel, 1995-8

26. Pneumococcal vaccination rates, by risk group

27. What can be done? • Surveillance • Prevention • Hand hygiene • Vaccine • Transmission control • Reduced/improved antibiotic use • Public expectations • Provider practice

28. Number of Patients Colonized/Infected with MRSA, Ontario, 1992-2001 9345 8252 8016 7684 6866 4212 1426 . 566 471 475 QMP/LS Surveys, 1996-2002

29. Number of Patients Colonized/Infected with MRSA, Ontario, 1993-2005? .

30. Number of Patients Colonized/Infected with VRE, Ontario, 1992-2001 718 685 589 445 230 167 99 2 7 QMP-LS Surveys, 1996-2002

31. ALC - Risk Factors for Colonization

32. Public Health Role • Surveillance • Daycare, long term care • Communication • Co-ordination within regions • National, provincial, regional guidelines

33. What can be done? • Surveillance • Prevention • Hand hygiene • Vaccine • Transmission control • Reduced/improved antibiotic use • Public expectations • Provider practice

34. Improved antibiotic useChallenges • Dissemination from current programs in the community • Edmonton, Port Hope, Ottawa • Institutions