Slide from WHO CME ITALIAN COURSE Antimicrobial resistance for clinicians Core competencies for antimicrobial prescribing: Understands the patient and the patient’s clinical needs Understands treatment options and how they support the patient’s clinical needs Works in partnership with the patient and other healthcare professionals to develop and implement a treatment plan Communicates the treatment plan and its rationale clearly to the patient and other health professionals Monitors and reviews the patient’s response to treatment

1. Antimicrobial resistance for clinicians

2. Course content
Courseroadmap
Basic concepts
Common infections
1

3. “The emergence and spread of drug-
resistant pathogens has accelerated.
The trends are clear and ominous. No
action today means no cure
tomorrow. At a time of multiple
calamities in the world, we cannot allow
the loss of essential medicines –
essential cures for many millions of
people – to become the next global
crisis.”
Dr. Margaret Chan
World Health Day
2011
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4. Core competencies for
antimicrobial prescribing
C1: Understands the patient and the patient’s clinical needs
C2: Understands treatment options and how they support the
patient’s clinical needs
C3: Works in partnership with the patient and other healthcare
professionals to develop and implement a treatment plan
C4: Communicates the treatment plan and its rationale clearly to
the patient and other health professionals
C5: Monitors and reviews the patient’s response to treatment
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Core Competencies

5. Objectives
• Highlight mechanisms by which microorganisms develop
antimicrobial resistance
• Illustrate the emergence and global spread of drug resistant
organisms
• Demonstrate the use of clinical guidelines in choosing empiric
antimicrobial therapy – one tool clinicians can use to combat
antimicrobial resistance
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6. 5

7. Antimicrobial resistance (AMR)
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8. 7
Antimicrobial
resistance
Therapeutic
options

9. Infections due to drug resistant organisms
• Longer illnesses
• Increased mortality
• Prolonged
hospitalizations
• Increased costs
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10. AMR jeopardizes all patients -
current and future.
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11. Mechanisms of resistance
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One common
multi-drug resistant
organism:
Neisseria gonorrhoeae
U.S. Centers for Disease Control and Prevention
– Medical Illustrator

12. Inappropriate use of antimicrobials can
have dire consequences.
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13. WHO/A. Kristensen
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ANTIMICROBIAL RESISTANCE:
THE BASICS
Core Competencies 1 & 2

14. Genetic variability
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Bacterial clone
harboring
antimicrobial
resistance
Population of bacteria

15. Selective pressure
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Population of bacteriaAntibiotics

16. Vertical transmission
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Time
Growing population of resistant bacteria

17. Horizontal transmission
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Foreign DNA can be packaged in:
• Plasmids
• Bacteriophages
• Other mobile genetic elements
Growing population of
resistant bacteria
Time

18. Major mechanisms of resistance
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Target modification
Decreased uptake Antibiotic inactivation
Increased efflux
Core Competencies 1 & 2

19. Neisseria gonorrhoeae
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WHO/S. Nahrgang
WHO estimated 78 million new
cases of N. gonorrhoeae
infections worldwide in people
ages 19 – 49 in 2012.
Major public health challenge in
part because of antimicrobial
resistance.

20. Gonococcal resistance to penicillin
19
Time
Minimuminhibitory
concentration(MIC)
-penicillin
• Resistance to
penicillin noted
immediately
• Over next decades,
MIC steadily
increased

21. Mechanisms of resistance
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Antibiotic inactivation
Increased efflux
Decreased uptake
Target modification
WHO/S. Nahrgang

22. 21
Target modification
Modified target of beta-
lactams: penicillin-
binding protein 2
(PBP2) encoded by
penA
Gonococcal resistance:
Primary mechanism of resistance to penicillin
WHO/S. Nahrgang

23. 22
Decreased uptake
Decreased outer
membrane porin
permeability
Increased efflux
Overexpression of
efflux pumps
Gonococcal resistance:
Lower intracellular concentrations of penicillin
WHO/S. Nahrgang

24. Gonococcal resistance:
Horizontal transmission
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Antibiotic inactivation
Acquired beta-lactamase
producing plasmids
Beta-lactamases hydrolyze
beta-lactam ring
WHO/S. Nahrgang

25. Resistance to tetracyclines
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Antibiotic inactivation
Increased effluxDecreased uptake
Target modification
U.S. Centers for Disease Control
and Prevention – Medical Illustrator

26. Increasing gonococcal resistance
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1943
Penicillin
first used
1986
Tetracyclines not
recommended
2007
Fluoroquinolones
not recommended
Azithromycin
not recommended

27. 26
PART 2:
A CLINICAL CASE
WHO/A. Kristensen

28. 28 year-old male with:
dysuria
Urethral discharge
sexual partner diagnosed with
gonococcal cervicitis
no allergies
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29. A clinical case
Subsequent evaluationInitial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
28
Core Competencies 1 & 2

30. A clinical case
Subsequent evaluationInitial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
29
Core Competencies 1 & 2

31. Diagnostic workup
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Depends upon resources
• Options:
• Gram stain +/- culture
• Nucleic acid amplification
tests (NAAT)
• NAAT can not provide
antimicrobial susceptibility
data
WHO/A. Kristensen
Core Competencies 1 & 2

32. Subsequent evaluationInitial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
Core Competencies 1 & 2

33. Subsequent evaluationInitial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessmentCeftriaxone 250 mg
intramuscular
OR
Cefixime* 400mg oral
PLUS
Azithromycin 1g oral
* CDC no longer recommends
Core Competencies 1 & 2

34. Subsequent evaluationInitial evaluation
Clinical
assessment
Diagnostic
work-up
Patient
education
Therapeutic
decisions
Modify
antimicrobials
Data
review
Clinical
re-assessment
Patient education critical!
• Screen for other sexually treated
infections (including HIV)
• Screen partners
• Safe sex practices
• Return to clinic if symptoms
persist – consider treatment
failure
Core Competencies 1 & 2

35. Review: Antimicrobial Resistance
Drug
Dose
Duration
Route
prescription
.............
.............
.............
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36. Review: Antimicrobial Resistance
Drug
Dose
Duration
Route
prescription
.............
.............
.............
• Prescribe antimicrobial
therapy according to
evidence-based guidelines

37. Review: Antimicrobial ResistanceReview: Antimicrobial Resistance
Drug
Dose
Duration
Route
prescription
.............
.............
.............
• Prescribe antimicrobial
therapy according to
evidence-based guidelines
• Prevention

38. Review: Antimicrobial Resistance
Drug
Dose
Duration
Route
prescription
.............
.............
.............
• Prescribe antimicrobial
therapy according to
evidence-based guidelines
• Prevention
• Patient education is critical
element of fight against
AMR

39. 38

40. Quiz time!
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proceed.