THE STORY OF ANTIBIOTIC RESISTANCE IN LIBYA:

1970-2011

Prof. Khalifa Sifaw Ghenghesh

الرحيم الرحمن الله بسم

• Resistance to antimicrobial drugs is a major problem that inflicts the whole world.

• The problem is still worse in developing countries where lack of antimicrobial-resistance surveys and lack of control policies are the norm.

Antimicrobial resistance of Salmonella isolated from diarrheic fecal specimens in Libya

Antibiotic

% resistant1979-1980

Tripoli(n=244)

1979-1980Tripoli(n=238)

1992-1993Tripoli(n=21)

2000-2001Zliten(n=23)

2008Tripoli(n=19)

Ampicillin 89 29 52 100 47

Chloramphenicol 79 89 52 96 5

Gentamicin 17 14 43 78 NANalidixic acid 12 17 0.0 4 84Ciprofloxacin (or Norfloxacin)

NA* NA 0.0 0.0 63

Trimethoprim-sulphamehtoxazole

NA NA 48 4 21

*NA=Data not available

Escherichia coli from UTIs in Libya

Antibiotic

% resistant1981

Benghazi(n=38)1

1994-1995Tripoli

(n=534)2

1996Benghazi(n=148)3

2002-2005Sirte

(n=1265)4

2005-2006Tripoli(n=29)5

2006-2008Benghazi(n=105)6

Ampicillin 22 74 75 49 59 57Chloram- phenicol

NA 29 45 23 21 14

Gentamicin 0.0 7 18 9 10 7Nalidixic acid

0.0 11 10 28 28 23

Cipro- floxacin

NA NA NA 2 14 17

Nitrofuran- toin

0.0 25 7 7 NA 0.0

TMP-SMZ NA 45 81 36 24 31

1,3,4-6Outpatients.2Outpatients and inpatients.

Antimicrobial resistance of Gram-negative bacilli isolated from hospital and community cockroaches (2000-2002)

No. (%) resistantAntibiotic Hospital Community Total

cockroach cockroach (n=193) (n=246) (n=439)

------------------------------------------------------------------------------------------Ampicillin 141(73) 208(85) 349(80)Augmentin 85(44) 88(36) 173(39)Cephalothin 144(75) 145(59) 289(66)Chloramphenicol 51(26) 39(16) 90(21)Gentamicin 16(8) 0(0) 16(4)Norfloxacin 0(0) 1(0.4) 1(0.2)Tetracycline 59(31) 62(25) 121(28)TMP-SMZ 48(25) 16(7) 64(15)------------------------------------------------------------------------------------------

Resistance of different bacterial pathogens isolated from ice cream in Tripoli (2001-2002).

% resistantAntibiotic Gram-negative bacilli Gram-positive cocci

(n=48) (n=67)------------------------------------------------------------------------------------------Ampicillin 83 90

Amoxicillin- 40 45clavulanic acid

Cefuroxime 25 NTCiprofloxacin 0.0 6Gentamicin 0.0 12Tetracycline 19 24TMP-SMZ 12.5 25------------------------------------------------------------------------------------------

Extended Spectrum -lactamases in Escherichia coli and Klebsiella pneumoniae from Libya

City/Year SourceE. coli K. pneumoniae

No. Tested

% ESBL

No. Tested

% ESBL

Tripoli (2002-2003) Clinical specimens 383 8.6 209 15.3

Tripoli (2005-2006) Urine 48 4 - -

Benghazi (2006-2008) Urine 105 1.9 42 2.4

Libya (2009) Clinical specimens 104 6.7 40 32.5

Antimicrobial agentAcinetobacter

baumannii (n=4)Pseudomonas

aeruginosa (n=12)Enteric bacteria1

(n=9)Amikacin 25 8.3 0.0Gentamicin 100 50 88.9Ertapenem 100 100 11.1Imipenem 25 8.3 0.0Meropenem 25 8.3 0.0Cefuroxime 100 100 100Ceftazidime 25 50 100Cefotaxime 100 100 100Cefepime 25 33.3 100Aztreonam 100 50 100Piperacillin/tazobactam

25 25 22.2

Trimethoprim/sulfamethoxazole

100 100 88.9

Ciprofloxacin 100 58.3 66.7Colistin 25 0.0 NT3

1All (100%) isolates are ESBL producers.

Antibiotic Resistance of Gram-Negative Bacilli from Wounds of Combatants of the Libyan Uprising (2011)

Methicillin-resistance (MR) among Staphylococcus aureus (SA) from Libya

City/Year Source No Tested % MRSA

Tripoli (1995-1996) Foods samples 23 0.0

Tripoli (1995-1996) Clinical specimens 40 0.0

Tripoli (1998) Used bank notes 50 4

Tripoli (2004) DVDs 35 11

Tripoli (2005-2006) UTIs 24 21

Benghazi (2007) Clinical specimens 200 31

Tripoli (2007) Burn patients 120 54

Tripoli (2008) HCW 643 37

Tuberculosis• Mycobacterium tuberculosis• A serious health problem in Libya.

– Estimated incidence rate per 100,000 population (1990-2010) = 40

• First line drugs:– Isoniazid (INH), rifampicin (RIF), pyrazinamide (PZA) and ethambutol (EMB).

• Second line drugs:– Fluoroquinolones, aminoglycosides, ethionamide, D-cycloserine and peptides

(viomycin and capreomycin).

• Isoniazid and rifampicin – keystone drugs in the management of TB– Resistance to either isoniazid or rifampicin may be managed with other first-

line drugs

• Multidrug-resistant TB (MDR-TB): – Resistance to both isoniazid and rifampicin with or without resistance to other

drugs.

– MDR-TB demands treatment with second-line drugs that have limited sterilizing capacity, and are less effective and more toxic.

Primary, Acquired and Multidrug Resistance among TB Cases in Libya

Type of resistance

%1970-1980 1984-1986 2002-2007 2008 2011

Primary 13 (9-17) 11 (4-20) NA NA NAAcquired 28 (15-33) 22 (12-34) NA NA NAMDR-New TB cases1

NA NA 2.6 (0.4-14) 3 (0.0-8.0) 3.4 (1.9-5.0)

MDR-Retreatment cases1

NA NA 39 (10-77) 35 (0.0-75) 20 (14-25)

MDR-Total TB cases1

NA NA 3 (0.8-15) NA NA

1Estimated by WHO.

Resistance of Neisseria gonorrhoea isolated in Tripoli in 1988/1989 to antibiotics

Antibiotic % resistant

(n=42)

Penicillin 45.2Erythromycin 11.9Tetracycline 11.9Kanamycin 2.4Spectinomycin 2.4

• Lack of trained microbiologists.• Antibiotic Susceptibility testing:

– Standard methods are not used.– No control organisms.– Data reporting is not reliable.

• Medical doctors:– Lack of interest in infectious diseases. – Misuse of antimicrobial agents in the treatment of

infectious diseases.– Lack of interest in educating their patients regarding

proper use of antibiotics.•

In Libya

• The community:– Lack of knowledge of the proper use of antibiotics.– No knowledge of the antimicrobial resistance

problem.– Misuse and abuse of antimicrobial agents.

• The Government:– Lack of control over importation and quality of

antibiotics.– Lack of surveys of antibiotic resistance in the

country.– Lack of control of antibiotic use in animal

husbandry.– Infection prevention and control programs not

implemented– No support for research on antibiotic resistance.

THE PROBLEM

• The high prevalence of resistant bacteria in Libya seems to be related to antibiotic usage

– Easy availability without prescription at drug stores,

– Injudicious use in hospitals, and – Uncontrolled use in animal husbandry.

CONCLUSION

• The problem of antibiotic resistance is very serious in Libya, as it appears to be on the increase, particularly with the emergence of resistance to newer drugs that include the fluoroquinolones (e.g. ciprofloxacin) among the clinically important bacterial species.

RECOMMENDATIONS

• It is urgently required: – To ban the sale of antibiotics without prescription, – To use antibiotics more judiciously in hospitals by

intensive teaching of the principles of the use of antibiotics, and

– To establish better control measures of nosocomial infections.

• Regulation of antimicrobials for other than human use is also required.

• These issues are not easy to address and require the collective action of health authorities, the pharmaceutical community, health care providers, and consumers

e-mail: ghenghesh_micro@yahoo.com

ghenghesh@yahoo.com