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Dr. Terry Dwelle - Antimicrobial Resistance: What Can We Do?

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Antimicrobial Resistance: What Can We Do? - Dr. Terry Dwelle, State Health Officer, North Dakota Department of Health, from the 2013 NIAA Symposium Bridging the Gap Between Animal Health and Human Health, November 12-14, 2013, Kansas City, MO, USA.

More presentations at http://www.trufflemedia.com/agmedia/conference/2013-niaa-antibiotics-bridging-the-gap-animal-health-human-health

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Dr. Terry Dwelle - Antimicrobial Resistance: What Can We Do?

  1. 1. Terry L Dwelle MD MPHTM FAAP CPH State Health Officer North Dakota Department of Health
  2. 2.       Antibiotics first employed in the 1940’s Antibiotics + Vaccination + Sanitation = Marked decline in deaths from ID’s Antimicrobial resistance is a major ID threat to PH Much attention given to nosocomial infections – ie VRE Community acquired resistance is rising – St Pneu., E Coli, Salmonella, etc. Is an evolving problem – spans all health care settings. 2
  3. 3.                Aminoglycosides Beta lactams – penicillins, cephalosporins, carbapenems, monbactams Flouroquinolones Glycopeptides Ketolides Lincosamides Macrolides Oxazolidinones Streptogramins Sulfonamides Tetracyclines Levomycetinums Ionophores Bambermycins Polypeptide s
  4. 4.   Treat infections – animals and humans Prevent infections    Humans - surgical wounds, dental prophylaxis for endocarditis, neutropenia Animals – prevent disease when animals are susceptible Promote growth – cattle, poultry and swine
  5. 5. Developed Countries 19 2% NE and N Africa 37 4% Latin Am and Carribean 53 6% 925 million hungry people in 2010, 13.7 % of the 6.8 billion people in the world Asia and Pacific 578 62% SS Africa 239 26%
  6. 6.    160 days of illness per year ½ of the 10.9 million deaths per year Magnifies the effect of diseases like measles and malaria
  7. 7.    Swine – 3-9% improved weight gain, 3-7% improved feed efficiency. Greatest benefit when feed composition, management practices and health status of animals is not optimal. Action Eliminate bacteria that steal essential nutrients  Reduce competition with beneficial bacteria that produce essential nutrients for the animal.  Control growth of bacteria that cause low-grade infections or produce toxins – decreasing nutrient absorption. 
  8. 8.  Human and Animal Tetracyclines  Sulfonamides  Penicillins  Macrolides  Fluoroquinolones  Cephalosporins  Aminoglycosides  Chloramphenicols  Streptogramins  Polypeptides   Animal only   Ionophores Bambermycins
  9. 9.              Strep. Pneumoniae Moraxella Catarrhalis Hem Influenza Type B Strep Pyogenes E. Coli Neis. Meningitidis Campylobacter Salmonella Shigella Staph Aureus Enterococcus Mycobacterium Tuberculosis Pertussis
  10. 10.  Inappropriate antimicrobial prescribing – most important     Overuse – 30-60% prescriptions are inappropriate Inappropriate dosing Use of broad spectrum AB’s as first line Rx Animal applications (food) 10
  11. 11. Adults Colds URI Bronchitis Prescribing Rates 51% 52% 66% Children Colds URI Bronchitis 44% 46% 75% Gonzales R et al JAMA 1997:278:901-904. Nyquist AC et al JAMA 1998;279:875-77 11
  12. 12. • • • • 46% of patients with common cold or nonspecific URI’s received antibiotics Broad spectrum antibiotics used; 54% general, 51% colds, 53% sinusitis, 62% acute bronchitis, 65% OM Lower BS use – blacks, lack of insurance, HMO membership Greater use of BS- Northeast and South JAMA 2003;289:719-725 12
  13. 13.      12% recently taken antibiotics 27% believed taking antibiotics during a cold made them better 32% believed taking antibiotics during a cold prevented more serious illness 48% expected antibiotics when seeking medical care with a cold 58% not aware of the health risks of antibiotics Emerg Inf Dis: 9;9, pp 1128-1134 – JD Eng, et al 13
  14. 14.  Human health hazards Antibiotic resistance particularly with low dosing (ie Salmonella)  Glycopeptide resistant E faecium of animal origin – find in stools for 14 + days after ingestion of meat  Cross resistance   ie Virginimycin and Quinupristin-dalfopristin in enterococci Sorensen TL, NEJM 2001;3435:1161-6, Welton LA et al AntiAgChem 1998;42:705-8 14
  15. 15.  Human Health Hazards  Salmonella enterica (flouroquinolone resistant) spread from swine to humans in meat Chiu CH NEJM 2002;346:413-9 15
  16. 16.   Europe – 1990’s – Avoparin use associated with vancomycin resistance in humans US – 1990’s – Campylobacter resistance to fluoroquinolones
  17. 17.        Use antibiotics only when indicated Least broad spectrum antibiotics first Least time exposure possible Use adequate therapeutic doses Use non-human antibiotics when possible With crossover drugs use those where potential resistance will have the least impact on humans Appropriately monitor cultures and sensitivities
  18. 18.     PRSP rose from 0% (1988) to 20% (1993) Information campaign – physicians Regulatory change – patients paid for prescription drugs PRSP declined to 15% (1995) Stephenson J, JAMA 1996;275-175, Gunnlaugsson A, AntiAgChem Conf, 1999, Abstract 1026 18
  19. 19.     Macrolide use tripled in the 1980’s Erythromycin resistance for Gp A strep rose sharply (17%) in the early 1990’s National campaign for physicians Resistance declined to 9% from 1992 to 1996 19
  20. 20.      1980’s Appropriate use of advanced spectrum antibiotics – 65% All advanced spectrum antibiotic orders received a form to be completed within 24 hours (justification of usage) No adequate response – consult or could result in loss of privileges Appropriate use increased to > 95% 20
  21. 21.   Europe – Vancomycin resistance Denmark – reduction in resistance in E Faecium in broiler chickens (from 60-80% to 535%) WHO Internation Panel Ruling, Nov, 2002)
  22. 22.     Public Information Campaigns Intensive Information Campaigns for Physicians Proactive Hospital Antibiotic Usage Programs Collaborative task force – Veterinarians, Physicians, and Public Health 22

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