ANTIMICROBIAL RESISTANCE

AMONG OTHER BACTERIAL

PATHOGENS OF PUBLIC HEALTH
IMPORTANCE

Ma. Charmian M. Hufano, M.D., F.P.C.P.

Medical Specialist II
Antimicrobial Resistance Surveillance Program
g
Research Institute for Tropical Medicine
Once upon a time…
when
h

Alexander Fleming in
1928 accidentally
di
discovers PENICILLIN

www.nobelprize.org
http//ccat.sas.upenn.edu/goldenage/state/state.htm
Timeline of Antibiotic Deployment and the
Evolution of Antibiotic Resistance

Clatworthy AE, Pierson E & Hung DT. Nature Chemical Biology 2007;3: 541 - 548.
A i i bi l R
Antimicrobial Resistance
i
• Antimicrobial resistance occurs when
bacteria changes in ways that
reduces/eliminates the effectiveness
off th
the d
drug ddesigned
i d tto cure/prevent
/ t
tthe
e infection
ect o

http://www.cdc.gov/getsmart/antibiotic-use/anitbiotic-resistance-faqs.html
“S i l off the
“Survival h Fi
Fittest””

http://www.defra.gov.uk/foodfarm/farmanimal/diseases/vetsurveillance/antimicrobial-res-fig.htm
A i i bi l R
Antimicrobial Resistance
i

National Institute of Allergy and

I f ti
Infectious Diseases
Di
http://www.usc.edu
Antimicrobial Resistance: The Bugs Fight Back
Consequences of Antimicrobial Resistance
• Mortality

• Morbidity- prolonged illness, greater chance of resist

organisms to spread to others

• Cost- increase cost of care, newer and more expensive

antibiotics
•
• Limited
Li it d O
Options-
ti f
few new drugs
d on the
th horizon
h i
Antimicrobial Resistance Surveillance Program
(ARSP)

• World Health Organization (WHO) Working Group on the

Regional Information Network on Antimicrobial Resistance
(1987)

• Department Order No. 339J- Department of Health

Created the Antimicrobial Resistance Surveillance
Committee (December 1 1, 1988)

• Objective: To provide critical inputs to the DOH’s

DOH s effort to
promote rational drug use by determining the current
status and developing trends on antimicrobial resistance
off selected bacteria to specific
f antimicrobials.
 Antimicrobial Resistance Surveillance Program
(ARSP)
1988: Philippine General Hospital (PGH)
(PGH), National Kidney Institute (NKI)
(NKI), Lung Center of the
Philippines (LCP), Research Institute for Tropical Medicine (RITM), San Lazaro Hospital (SLH),
Bureau of Research Laboratory (BRL), Far Eastern University (FEU) and Jose Reyes Memorial
Medical Center (JRMMC)

1994: Rizal Medical Center (RMC), Governor Celestino Gallares Memorial Medical Center
(GMH) and Zamboanga medical Center (ZMC)

1998: Eastern Visayas Regional Medical Center (EVR), Corazon Locsin Montelibano Memorial
Medical Center (MMH), Vicente Sotto Memorial Medical Center (VSM) and Davao Medical
Center (DMC)

p
2000- Cotabato General Hospital and Medical Center ((CMC),) Baguio
g General Hospital
p and
Medical Center (BGH) , Bicol Regional Teaching and Training Hospital; Gonorrhea
Surveillance- Pangasinan Provincial Hospital (PPH), Zamboanga del Norte Provincial Hospital
(ZPH), Dr. Rafael S. Tumbokon Memorial Hospital (RTH) and Bicol Regional Teaching and
Training Hospital (BRT)

2008- Mariano Marcos Memorial Hospital (MAR)and Medical Center and Batangas Regional
Hospital (BRH)

2009- Cagayan Valley Medical (CVM)

2009 (CVM), Jose B
B. Lingad Memorial General Hospital (JBL) and
Northern Mindanao Medical Center (NMC)
Antimicrobial Resistance Surveillance Program
(ARSP)
Pathogens of Public Health Importance
Covered by this Presentation
• Diarrheal Diseases • Urinary Tract Infections
Salmonella species Escherichia coli
Shigella species
Vibrio cholerae • Skin/Lung/Bloodstream
Skin/Lung/Bloodstream 
Infections
• Respiratory Tract Infections
p y Staphylococcus aureus
Streptococcus pneumoniae
• Hospital Acquired 
• Sexually Transmitted  Infections
Infections Klebsiella spp.
Neisseria gonorrhoeae Pseudomonas aeruginosa
g
ANTIMICROBIAL RESISTANCE
SURVEILLANCE PROGRAM
2009 REPORT
Trends in Antimicrobial Resistance among
Neisseria gonorrhoeae Isolates 1995-2009 ARSP
E
Enteric
i PPathogens
h
• Diarrhea remains once of the top 5 causes of morbidity
and mortality amongst Filipino children < 5 years old

• Key Bacterial Causes of Diarrhea:

1. Vibrio
Vib i cholera
h l
2. Salmonella sp.
3. Shigella
Shi ll sp.

World Health Statistics 2010

Trends in Antimicrobial Resistance among
Vibrio cholera Isolates 1988-2009 ARSP
S l
Salmonella
ll IInfections
f i

Salmonella Infections

Diarrhea-
Typhoid Fever-
Nontyphoidal
S l
Salmonella
ll T
Typhi
hi
Salmonella
Trends in Antimicrobial Resistance among
Salmonella Typhi Isolates 1988-2009 ARSP
Trends in Antimicrobial Resistance among
Non-typhoidal Salmonellae 1988-2009 ARSP

YEAR
Trends in Antimicrobial Resistance among
Shigella spp. Isolates 1988-2009 ARSP
Burden and Epidemiology of Pneumonia
• Pneumonia is the leading killer of children under 5 years
of age worldwide.

• Although bacterial infections account for no more than

50% of cases of pneumonia
pneumonia, they cause nearly 70% of
deaths due to pneumonia.

WHO report by the Secretariat. Treatment and

prevention of pneumonia. March 25, 2010.
WHO Statistics 2009.
Burden and Epidemiology of Pneumonia
• Streptococcus pneumoniae and Haemophilus influenzae
are the most common bacteria causing pneumonia and
these two organisms account for more than half of all
deaths due to pneumonia in children under five years of
age.
g

• Penicillin
e c nonsusceptible
o suscep b e SS. pneumoniae
p eu o ae ((PNSP)
S ) was
as
initially detected in the 1970s, but resistance to the
antimicrobial has since spread worldwide.

WHO report by the Secretariat. Treatment and prevention of

pneumonia. March 25, 2010.
Lynch etal. Curr Opin Pulm Med. 2010
Trends in Antimicrobial Resistance among
g
Streptococcus pneumoniae Isolates 1988-2009
ARSP
E h i hi coli
Escherichia li
• Most common cause of UTIs

• Other infections: neonatal meningitis, hospital acquired

pneumonia, gallbladder and biliary tract infections, skin,
b
bone and
d jjoint
i t iinfections
f ti and
d bl
bloodstream
d t iinfections
f ti
Resistance Rates of Escherichia coli
All Sites 1988-2009
SuperBugs and Hospital-acquired Infections
Staphylococcus aureus,
aureus Klebsiella spp.
spp and Pseudomonas
aeruginosa

Hospital bugs are exposed to wide range of antibiotics

H
Hospital
it l b
bugs are more resistant
i t t

-higher mortality rates

-longer length of hospital stay
-higher
g cost

Cosgrove SE. CID 2006

Zoleta etal. Phil J Microbio lnfect Dis 2004
Presumptive Nosocomial Infections
ARSP 2009 Data from All Sites
# of Isolates 2009 with # of Isolates from % of Isolated
Date of Admission Data Specimens Submitted Presumed to Be of
48 Hours Admission Nosocomial Origin
13776 4995 36%
Presumptive Nosocomial Infections (N= 4995)
O
Organism # off Isolates % off Presumed
Nosocomial
Infections
Klebsiella spp. 1142 23
Escherichia coli 850 17
Pseudomonas aeruginosa 789 16
Enterobacter spp 662 13
Staphylococcus aureus 320 6
Others 683 14
MRSA (Methicillin-Resistant Staphylococcus aureus)
Skin and soft tissue
infections, bone
infections, pneumonia,
catheter-related
infections, bloodstream
infections
MRSA (Oxacillin) Trends
All ARSP Sites 1998-2009
 MRSA: 2009 ARSP and the ANSORP
Surveillance

MRSA Rates ARSP ANSORP

2009 2004-2006
Over-all 45% 53%

ANSORP (Asian Network for Surveillance of Resistant Pathogens) Countries

participating: Korea, Taiwan, Hong Kong, Thailand, Philippines, Vietnam, India
and Sri Lanka.

Song J etal. , J Antimicrob Chemother. 2011

S. Aureus Oxacillin Resistance Rates
All Sites 2009 ARSP
Community-acquired
Community acquired MRSA

• Skin infections
• Younger population
• No hospital exposure
• No previous antibiotic
treatment
• No
N risk
i k ffactors off
underlying disease
 Distribution of MRSA Isolates Among
g Admitted
Patients with Date of Admission
All ARSP Sites 2009

Admitted Patients with Information on

Date of Admission
MRSA % MRSA
Community
C it Acquired
A i d 99 57
Presumptive 74 46
Nosocomial Infection *

* Presumptive Nosocomial Infection- “specimen date” was 48 hours

after “date
date of admission”
admission
Gram negative Superbugs and Hospital-
Gram-negative Hospital
Acquired Infections
• Gram-negative bacteria are highly efficient in developing
mechanisms
h i off antimicrobial
ti i bi l resistance
i t

• Absence
Ab off new d
drug d
development
l t with
ith activity
ti it against
i t
drug-resistant gram-negative bacteria

• Klebsiella spp. and Pseudomonas aeruginosa –

representative of gram-negative hospital pathogens

WHO: Surveillance Standards for Antimicrobial Resistance

Kl b i ll spp.
Klebsiella
Trends in Resistance of Klebsiella spp.
spp
1992-2009 ARSP
 Trends in Resistance of Pseudomonas
aeruginosa 1988-2009 ARSP
100
90
80 Ciprofloxacin Ceftazidime Imipenem
70
60
50
40
30
20
10
0
AND THE STORY GOES
ON…
ON
Antibiotic resistance now has been universally identified
as public
bli health
h lth priority
i it and
d necessary plan
l off action
ti tto
combat resistance should be developed.
ANTIMICROBIAL RESISTANCE
SURVEILLANCE PROGRAM
ARSP A
Achievements
hi
T assure the
To th quality
lit off our data:
d t

The ARSRL participate regularly in International External

Quality Assurance Programs for the ARSRL

Sentinel sites’ microbiology laboratories perform culture

and susceptibility tests according to international standards
and
d refer
f data
d to the
h centrall coordinating
di i laboratory
l b off the
h
program

Regular feedback with alert reports for possible outbreaks

p
are reported to the sentinel sites
ARSP annual reports from 1988-2009
1988 2009
distributed to relevant stakeholders
Philippine CAP and UTI Guidelines
Philippine National Drug Formulary

 reassessingg the national formulary

y
 assuring that drug supplies are appropriate for needs
ARSP PUBLICATIONS, LOCAL AND INTERNATIONAL

PSMID JJournall CID JJournall

 ARSP Achievements
Relevant researches and publications by Dr. Celia C. Carlos and ARSP
staff:
• The clinical and molecular epidemiology of an outbreak of multi-drug
resistant typhoid fever in Metro Manila. Abstracts of the 34th ICAAC
Conference, Orlando, Florida, 1994.
• Carriage of antibiotic-resistant pneumococci among Asian children: a
multinational surveillance by the Asian Network for Surveillance of
Resistant of Resistant Pathogens (ANSORP), CID 2001: 32 (15 May):
1463-1469.
• Clinical
C outcomes off pneumococcal pneumonia caused by antibiotic-
resistant strains in Asian countries: a study by the Asian Network for
Surveillance of Resistant Pathogens, CID 2004: 39 (1 June): 1570-8.
• Epidemiology and clinical outcomes of community-acquired pneumonia in
adult patients in Asian countries: a prospective study by the Asian Network
for Surveillance of Resistant Pathogens.
Pathogens International Journal of
Antimicrobial Agents 31(2):107-114, 2008 (February).
 ARSP Achievements
Relevant researches and publications by Dr. Celia C. Carlos
and ARSP staff:

• Antimicrobial susceptibility of Shigella isolates in eight Asian

countries, 2001-2004. Journal of Microbiology, Immunology
and Infection 41(2):107-111, 2008 (April).
• Surveillance
S ill off antimicrobial
i i bi l resistance
i off Salmonella
S l ll enterica
t i
serotype Typhi in seven Asian countries. Epidemiology and
Infection 12:1
12:1-4,
4, 2008 (May).
• Layman’s Guide to Food and Water-borne disease Outbreak
Response. FCA Printhouse, Manila, Philippines, 2010.
• Clinical impact of methicillin resistance on outcome of patients
with Staphylococcus aureus infections: a stratified analysis
according to underlying diseases and site of infection in a
large prospective cohort, J of Infection (2010) 61: 299-306.
 ARSP Achievements
Relevant researches and publications by Dr. Celia C. Carlos and
ARSP staff:
• Spread of methicilin-resistant Staphylococcus aureus between the
community and the hospitals in Asian countries: an ANSORP study.
J Antimicrob Chemother (Feb 20, 20 2011).
2011)
• Hospital-based Surveillance to Estimate the Economic Burden of
Rotavirus Gastroenteritis in Children Under 5 yyears of age g in the
Philippines
• A prospective multinational surveillance of hospital-acquired
pneumonia (HAP) and ventilator-associated
ventilator associated pneumoniae (VAP) in
adults in Asian countries: etiology, clinical outcome, and impact of
antimicrobial resistance
• Prospective,
P ti hospital-based,
h it l b d multinational
lti ti l surveillance
ill on
antimicrobial resistance and serotypes of Streptococcus
pneumoniae and disease burden of pneumococcal infections in
Asian countries in the era of pneumococcal conjugate vaccine
ACKNOWLEDGEMENTS
THE END