Antimicrobial Resistence Surveillence In Nepal For Rational Use of Antibiotics

1. Antimicrobial ResistenceSurveillence In NepalFor Rational Use of Antibiotics Dr. Geeta Shakya Director, NPHL, Teku World Health Day 7th April, 2011

2. Antimicrobial Resistance(AMR) One of the major challenges facing public health in this century a threat to current and future medical advances Bigger problem in developing countries like Nepal Spreading across countries and regions resulting increased cost of treatment increased morbidity and mortality

3. Constraints • Often, the use of practical guidelines in the management of key infectious diseases in the developing world is hampered by the lack of reliable antimicrobial surveillance data • When minimum requirements of AMR surveillance are met, data obtained from Antimicrobial Susceptibility Testing (AST) are of great importance to provide more effective therapy and minimize treatment failure

4. Resistance is accelerated through inappropriate use of antimicrobials • Standard treatment guidelines not provided to physicians or provided but not adhered to • Drugs available without prescription • Accessible but poor quality • Inadequate monitoring • Irrational self-administration or prescription Antimicrobial resistance

5. What is antimicrobial resistance ? • Unresponsiveness to antimicrobial agents in standard doses • A natural biological unstoppable phenomenon • May be inherent resistance or acquired resistance • Resistance is generally slow to reverse or irreversible • Resistance develops through: gene action (mutation) plasmid exchange between bacteria of the same species. • All antimicrobial agents have the potential to select drug-resistant subpopulations of microorganisms

6. Importance of AMR Surveillance • Antibiotics are valuable and most utilized therapeutic agents for life saving • Emergence of multi-drug resistance has limited therapeutic options • Need for the development of newer drugs frequently which is very costly • In vitro Antibiotic susceptibility testing (AST) is the mainstay for monitoring therapy and detecting resistance

7. Importance of AMR Surveillance contd.. • Reporting of AMR data is necessary for: • selection of empirical therapy at the local level • assessing the scale of the resistance problem at the local, national or international levels • monitoring changes in resistance rates • detecting the emergence and spread of new resistances types

8. Activities of AMR surveillance • Characterization of disease etiologies and resistance trends • Prompt identification and investigation of new threats in resistance • Guidance to policy makers in developing therapy recommendations • Guidance to public health authorities in responding to outbreaks • Evaluation of the impact of therapy and infection control interventions on infection rates and cure rates • Strengthening of laboratory capacity

9. AMR Surveillance in Nepal for selected bacterial pathogens Started in the year 1999 -technical assistance from ICDDR,B (Dhaka), NPHL as a national focal point • 1999-2003 Technical assistance - ICDDR,B (Dhaka) Financial support – USAID • 2004-2005 Technical assistance - NPHL Financial support –USAID • 2006 onward Technical assistance - NPHL Financial support –WHO

10. Currently Monitored Organisms For Diarrheal diseases: Vibriocholerae Shigellaspecies For Respiratory Infection: Streptococcus pneumoniae Haemophilusinfluenzae For MDR UTI: ESBL E coli (included since September 2009) For STI infection : Neisseria gonorrhoeae For Typhoid Fever MDR Salmonella species (included since 2002)

11. Participating laboratories Total 11 labs are included Central Region-(6) 1. National Public Health Laboratory (NPHL), Kathmandu 2. Bir Hospital Laboratory, Kathmandu 3. Patan Hospital Laboratory, Kathmandu 4. Kanti Children’s Hospital (KCH) Laboratory, Kathmandu 5. Tribhuvan University Teaching Hospital (TUTH) Laboratory, Kathmandu 6. Dhulikhel Hospital, Kavre Eastern Region-(1) 7. B. P. Koirala Institute of Health Sciences (BPKIHS) Laboratory, Dharan Western Region-(4) 8.Western Regional Hospital (WRH) Laboratory, Pokhara 9.Manipal Teaching Hospital (MTH) Laboratory , Pokhara 10. United Mission Hospital (UMN) Laboratory, Tansen 11. Lumbini Zonal Hospital (LZH) laboratory, Butwal

12. Status of Antimicrobial Resistance in Nepal Vibrio cholerae change in serovar; Ogawa-Inaba 2003, 2004-Ogawa, 2005, 2006- Inaba 2007- Ogawa+ Inaba and Hikojima 2008, 2009, 2010 - Ogawa Antibiotic susceptibility pattern; • Resistance : Cotrimoxazole (100%), Furazolidone (94%-100%), Nalidixic acid (100%) • Ampicillin sensitivity: 100% in 2005 declined to 17% by 2007 & increased from 44% in 2008 to 82% in 2010. • Tetracycline : sensitivity 100% up to 2009 and declined to 29% in 2010. • Ciprofloxacin : Sensitivity 96% -100% but in 2009 Sensitivity declined to 10% only • Ofloxacin: Sensitivity 98% - 100% and • Ceftriaxone : Sensitivity 1 00%-most effective

13. Status of Antimicrobial Resistance in Nepal Shigella species • Change of species S. dysenteriae and S. flexnerii • Antibiotic susceptibility pattern; Amoxycillin : Resistance 62% in 2005 to 100% in 2010 Nalidixic acid: Resistance 50% -100%, Cotrimoxazole: Resistance: 60% -100%, Mecillinam: Resistance:80% -100% Ciprofloxacin: Resistance 6.6% -33% Azithromycin: Resistance 0%- 50% in 2010 Ofloxacin :Sensitivity 50% -100% in 2010 Ceftriaxone: Sensitivity 80% - 100% in 2010

14. Status of Antimicrobial Resistance in Nepal S. pneumoniae: • Highest prevalence among children <15 yrs and old age groups • Antibiotic susceptibility pattern; Cotrimoxazole: Resistance 55-74% Amoxycillin : Resistance3% -13% in 2010, Penicillin: Resistance 0% -33% Erythromycin: Resistance 0 %- 14% Chloramphenicol: Resistance 0% -11% Ciprofloxacin: Resistance 0% - 14 % Ofloxacin: Sensitivity97% -100% Ceftriaxone: Sensitivity 94% -100%

15. Status of Antimicrobial Resistance in Nepal H. influenzae: • Antibiotic susceptibility pattern; Penicillin: Resistance 23% -100% by 2009 Cotrimaxazole: Resistance 16% -59% Ampicillin : Resistance 19% - 41% Azithromycin : Resistance 0% -13% Chloramphenicol : Resistance0%- 15 % Ciprofloxacin: Resistance0% -18% Ofloxacin : Resistance 0%- 19%

16. Status of Antimicrobial Resistance in Nepal Neiseria gonorrheae • Antibiotic susceptibility pattern; Nalidixic acid: Resistance75% Ciprofloxacin: Resistance 7% - 14% Ampicillin: Resistance 13% - 33% Penicillin: Sensitivity 29% -50% Tetracycline: Sensitivity 67% - 100% Azithromycin: Sensitivity 97 % - 100% Ceftriaxone: Sensitivity 100% • Neisesria gonorrheae is very fastidious organism, difficult to grow in comparison to other bacteria so it needs more emphasis to isolate this bacteria

17. Status of Antimicrobial Resistance in Nepal MDR Salmonella species: • Included in AMR surveillance since its outbreak in 2002 at Chitwan • MDR30% in 2002 • decreased to 2% in 2006 • increased to 7 % in 2009 and • further increased to 8% in 2010

18. Status of Antimicrobial Resistance in Nepal • MDR Salmonella species: • Antibiotic susceptibility pattern • Nalidixic acid: resistance pattern 60% -83% • Ciprofloxacin : Sensitivity 86% - 100% • Ceftriaxone :Sensitivity 99% - 100% • Azithromicin :Sensitivity 89% -100% • Ofloxacin :Sensitivity 97% -100% • Chloramphenicol: • sensitivity 41% in 2006 • increased to 96% in 2010 • Salmonella other than typhi and paratyphi A showed higher resistance rate during the outbreak

19. Status of Antimicrobial Resistance in Nepal ESBL E.coli • 13 isolates reported in 2009 and • 86 isolates in 2010 • Isolates were found resistant to most of the common antibiotics and 3rd generation cefalosporin as; Amoxicillin 100%, Furadantin 100%, Ciprofloxacin 97% - 100%, Ofloxacin 66% - 100%, Ceftriaxone 92%, Cefopodoxime 99% Ceftazidine 99%,Cefotaxime 100% Sensitive drugs: Cefopodoxime, Ceftazidine and Cefotaxime become sensitive once these are combined with Clavunic acid Imipenem Meropenem

20. Possible solutions Rationalize the use of available antimicrobial agents with support of Antimicrobial Susceptibility Testing (AST) for the prevention and containment of AMR

21. Thank You!