Antibiotic resistance among in- and outpatients attending Lashkar-Gah hospital, Afghanistan

Antimicrobial resistance• Antimicrobial resistance (AMR) is defined as “resistance

of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it”

• It represents a considerable public health threat: – Requires longer and more expensive treatment– Negatively affects patient outcomes– Erodes our armamentarium of drugs against microorganisms

Global context

• Poor availability of AMR data all over the world, especially in developing country settings

• Suspicions that Asia has the highest level of AMR

• Current consensus about a clear correlation between anarchic, unregulated use of antibiotics and levels of AMR

Afghan context

• Unregulated market of antibiotics (subquality, self-medication…)

• High pressure from patients to obtain antibiotics from the prescriber (often IV drugs!)

• Over-prescription in hospitals AND private practice

• Suspected therapeutic failures in MSF-Hospital

MSF-Afghanistan context:Poor therapeutic outcomes…

In Lashkar-Gah hospital (Helmand):

Unexplained high paediatric mortality rates

Lashkar Gah Hospital (Helmand)

MSF-Afghanistan context:Overuse of antibiotics…

Over-prescriptions of antimicrobial drugs among all outpatient consultations

Cf. study Sahar Bajis: “Antimicrobial use in a district hospital in Kabul, Afghanistan – are we too high?“

Ahmad Shah Baba hospital (Kabul):

How to assess AMR reality?How to collect data?

Option 1? Install a bacteriology lab for routine bacteriology

and… be patient 2-3 years to obtain aggregated data?

Option 2?Collect enough bacteria from voluntary inhabitants (such as in- and outpatients of an « MSF-hospital »)

and screen for resistance… 4 months

We’ve chosen Option 2… for a first statement

• Study conducted in Lashkar-Gah hospital (Helmand), Afghanistan• Screening of normal flora was chosen• Adult and paediatric in- and outpatients requested to provide a stool and/or nasopharyngeal swab sample• Bacteria cultured from these samples and tested for AMR

Methods

Screening of normal flora- limitations

• Everyone of us is carrying thousands of millions of bacteria. We are reservoirs.

• Sepsis is the most often due to an intrusion of one of these bacteria in our bloodstream.

• The bacteria we “carry” can be used as indicators for levels of AMR among pathogenic bacteria.

HOWEVER… this is not the same as resistance testing of pathogens in a routine laboratory

RESULTS

• Screening of normal flora:

Bacterial species isolation

Participants recruited IPD / OPD

Adult / Paediatric2077

Stool samples692

Nasopharyngeal swabs1762

482 E. coli isolates 173 S. pneumoniae isolates

447 Enterococcus species isolates 115 H. influenzae isolates

259 S. aureus isolates

ß-Lactamins Aminoglycos.

E. coli as indicator species: proportion of patients with a resistant organism (N=114)

Quinol. Others.ESBL

Levels of AMR

A nice bell curve taking place on the right of the graph

Imperfect bell curve+ shifting to the left(diameters becoming smaller)

ONLY SUSCEPTIBLE STRAINS

A FEW RESISTANT STRAINS

shift

MAINLY RESISTANT STRAINS Bell curve has disappearedMost of the strains are on the left

0% R

8% R

80% R

How to become an AMR specialist?Interpretation of resistance in a population of species

E. coli: Penicillins & ß-lactamase inhibitors

R

I

S

R S R S

IR S IR S

R S

R S

C2E. coli &Cephalosporins

IR S

IR S

I SRC3

C4I SRSR

Cephamycines

Ciprofloxacine

Levofloxacine

Moxifloxacine

OfloxacineR I S

Gentamicine

Tobramycine

Netilmicine

Amikacine

R I S

R I S

R I S

Imipenem

Meropenem

R I S

R S

Chloramphenicol

Tigecycline

Resistance in S. pneumoniae (N=64)

Screening by oxacilline showsa decreased susceptibility to penicillin

MICs to Penicillin could be tested: 16 strains were oxa-R…. MIC values are <= 2 mg/lThus: decreased susceptibility, but no high level of resistance

• A wake-up call to MSF: our protocols and standard treatment guidelines risk to be outdated

Discussion

?

• Diagnosis of AMR under field conditions is a bottle-neck – study shows the feasibility of laboratory screening of AMR in normal flora, but not as matter of routine=> Haemoculture as routine feasible?

• Holistic management of AMR (rational drug use, infection control, improved diagnostics) is required to avert public health disaster

Discussion

Boost HospitalLashkar Gah

Lashkar Gah team July 2013In MSF-compound

Thanks to

everybody !

It has been a incredible challengenot possible without a huge involvement of

everyone !

Special thanksHealth promotion:Caroline ZahndtAbdul BashirAnd all their wonderfulTEAM!

Management:Catherine Van OverloopGabriele Rossi (« SuperMedco »)Gbane (« huge support for end phase »)

LuxOR:Rafael Van den BerghRony ZachariahAnd all the TEAM!

OCB-Medical Depatment:Michel Van HerpPascale Chaillet

Logistics / Supply:Ann, Ben, Ryan, Antoine, Bazir, …

Lab:Dr WardakBismillahSher AgahBaryalai

Sorry for anyone I would have forgotten !!!!MSF-SupplyDiana & Sonia