Download increasing prevalence rate of macrolide resistant streptococcus

INCREASING PREVALENCE RATE OF
MACROLIDE RESISTANT
STREPTOCOCCUS PYOGENES IN
THAILAND: A DECADE REVIEW
Nattapong Jitrungruengnij1,2 , Tanittha Chatsuwan3 , Rachaneekorn Nadsasarn2,
Suvaporn Anulgulruengkit1,2, Thanyawee Puthanakit1,2, Chitsanu Pancharoen1,2
1 Department
2 Research
of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Unit in Pediatric Infectious Diseases and Vaccine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
3 Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
Streptococcus pyogenes
(GAS) infection
Clinical: Pyogenic, Exotoxin, Invasive GAS, Immune process
Treatment: First-line: Penicillin
Allergic to penicillin: Macrolide Clindamycin
Duration: 10 days
Drug susceptibility:
Some area of the world have strain resistant to macrolides.
In Redbook 2015
Prevalence of Erythromycin resistant GAS
USA , 1990-2010
Korea, 2001
Serbia, 2009
5%
19%
China, 2004-2011
41%
98 %
Italy , 2013
9%
Japan, 2011-2013
62%
Mexico , 1990-2010
5%
Israel , 2011
<1%
Thailand
??? %
Limited publication
Laos, 2004-2013
8%
Brazil , 2008-2012
15%
Objectives
• Primary: to study the prevalence of drug
resistance of GAS in KCMH, particularly
macrolides
• Secondary: to study antibiotics prescription
and duration for GAS infections in KCMH
Methodology: Retrospective descriptive study
Population
• Age < 18 years old
• Duration: year 2006- 2015
Inclusion Criteria
•
•
Data
Culture positive for S. pyogenes
Clinical Diagnosis of S. pyogenes infection (ICD-10)
•
•
Antibiotic susceptibility was determined by disk diffusion
method and MIC strip & breakpoint as per CLSI
Method
Sensitivity
Intermediate
resistant
Penicillin
MIC
< 0.12
-
-
Erythromycin
Disk (15mcg)
> 21 mm
16-20 mm
< 15 mm
Clindamycin
Disk (2mcg)
> 19 mm
16-18 mm
< 15 mm
Clinical Data: age, sex, underlying disease, diagnosis, treatment
Results: Patient data
• Sex: Male 64%(77)
• Age: Median 6.9 years, IQR 2 Months-18 years
Clinical syndromes
No. of
case
30
Scarlet fever
Skin infections
Skin
25
2 1
3 2
Scarlet
20
9
Otitis media
15
Bacteremia
10
Pneumonia
5
(n=121)
0
Necrotizing
fasciitis
0-1
1-2
2-5
5-10
>10
47
Pharyngitis
0-1
1-2
2-5
5-10
>10
57
Year(s)
(age)
Jan-Feb
Mar-Apr
May-Jun
July-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
July-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
July-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
July-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
July-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
July-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
July-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
July-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
July-Aug
Sep-Oct
Nov-Dec
Jan-Feb
Mar-Apr
May-Jun
Case number
Clinical syndromes distribution
18
17
16
15
14
septicemia
13
12
NF
11
10
pneumonia
9
8
7
pharyngitis
6
5
otitis media
4
3
Scarlet
2
1
Skin infection
0
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Year
Microbiologic data: source of specimen
ET-tube suction 1 Sterile site 3
Sputum 1
Blood 3
Ear swab 9
Throat swab 49
Total 121
Non sterile site 118
Pus Swab 58
GAS: Antibiotics resistant rate
% resistance
50
46.5
45
40
35
31
Erythromycin
29.6
Clindamycin
30
25
20
15
10
5
0
Erythromycin and
clindamycin
14.3
14.3
Penicillin
8.6
4.3
0
4.8
0
2006-2009
0
2010-2012
0
2013-2015
Year
The rate of resistance is increasing rapidly
GAS: Antibiotics prescription
60
other
Number of cases
50
clindamycin
macrolides
40
Cephalosporins
cephalosporins
30
Amoxicillin
20
Cloxacillin
10
0
pneumonia otitis media
skin
infections
scarlet
pharyngitis invasive GAS
cloxacillin
amoxicillin
Duration of Antibiotics
skin infection
scarlet fever
Mean
treatment
Incomplete
treatment*
7.6 days
9.9 days
20%
15%
*incomplete treatment: skin infection is <7 days, Scarlet fever <10 days.
Discussions
• S. pyogenes is 100% susceptible to Penicillin
but less susceptible to Erythromycin and
Clindamycin especially in Asia.
Country
Year
no
% resistance
Penicillin
Erythromycin
Clindamycin
5.2%
41.3%
98.4%
N/A
34.8%
98.4%
61.9%
46.5%
12%
31%
USA1
Korea2
1999-2010 174
1998
92
0%
0%
China3
2004-2011 125
2011-2013 142
0%
0%
71
0%
Japan4
Thailand* 2013-2015
% resistance
1. Villaseñor-Sierra A., et al., Int J Infect Dis. 2012 Mar;16(3):e178-81
2. Cha S., et al., J Infect Chemother. 2001 Jun;7(2):81-6.
3. Zhou W., et al., Indian J Med Microbiol. 2014 Jul-Sep;32(3):290-3
4. Sakata H.,J Infect Chemother. 2015 May;21(5):398-401.
Discussions
% Erythromycin resistant
Macrolide use/1000children-years
• In Serbia, the increase in macrolide resistant GAS
significantly correlated with consumption of macrolide.*
• In Italy, the reduction of OPD macrolides prescription
significantly correlated with the decrease of
erythromycin resistant gas.+
year
*Mijac V, et al., Epidemiol Infect. 2015 Feb;143(3):648-52.
+Gagliotti C, et al. Acta Paediatr. 2015 Sep;104(9):e422-4
year
Conclusions
• The prevalence of macrolide resistant GAS has
been rising from 10 to 50% in the last 3 years
but none in penicillin.
• Amoxicillin remains a drug of choice for scarlet
fever and pharyngitis caused by GAS.
Acknowledgement