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ANTIBIOTICS UPDATE 2016 Pork Management Conference Clearwater, FL June 15, 2016 Steven Solomon, MD, FACP, FIDSA Global Public Health Consulting, LLC Atlanta, GA Presentation Outline A brief, high-level overview of the public health approach to the antibiotic & antimicrobial resistance (AMR) problem • Is AMR a public health crisis? • What is the framework for a successful response? • How do we implement successful strategies to address the AMR problem? Is AMR a public health crisis? • Yes, in context. A crisis can be defined as: 1. a difficult or dangerous situation that needs serious attention; 2. a situation that has reached a critical phase; 3. an unstable or crucial time or state of affairs in which a decisive change is impending • AMR can fit that description but in a way that is different from other infectious diseases What is the response framework? • Acknowledge complexity • Improve coordination • Commit to collaboration • Focus on communication • Accelerate computation Antibiotic Use • Antibiotics are the principal driver of antibiotic resistance • All antibiotic use, in every setting, adds to the burden of antibiotic resistance, including human infections • Antibiotics • Antibiotics are overused in all settings disrupt the human microbiome, contributing to disease The microbiome • The “ecological community of …microorganisms that literally share our body space” • 90% of all the cells associated with the human body; the other 10% are human cells • Disruption of the microbiome leads to: • Short-term and long-term adverse events, including C. difficile disease • Greater likelihood of resistant infection Grice, E. A. and J. A. Segre (2012). "The human microbiome: our second genome." Annu Rev Genomics Hum Genet 13: 151-170. 6 The Black Box of AMR Dynamics Antibiotics People Bacteria Animals Plants Soil Water Air AMR-The “Resistome” Many Action Plans and Reports Coordination National Action Plan Outcomes Goals Significant Outcomes Objectives Sub-objectives Milestones Sub-milestones 5 21 22 33 232 36 https://www.whitehouse.gov/sites/default/files/docs/national_action_plan_for _combating_antibotic-resistant_bacteria.pdf National Action Plan Metrics: 2020 Targets AMR Bacteria Microorganism Reduce by Compared to CRE Hospital-acquired infections 60% estimates MDR Pseudomonas Hospital-acquired infections 35% 2011 estimates MRSA Bloodstream infections 50% 2011 cases Salmonella non-Typhi Infections 25% 2010-2012 estimates M. tuberculosis MDR infections 15% 2011 cases S. pneumoniae Rate of invasive disease among 65 year olds ≥25% 2008 estimates N. gonorrheae prevalence of ceftriaxoneresistance Maintain < 2% 2013 estimates Reduce by Compared to Adverse drug events Microorganism C. difficile Infections 50% 2011 estimates Collaboration Ambitious prevention and reduction targets are achievable with collaboration • CRE • Success in Israel • MRSA • “Search and destroy” in the Netherlands • Invasive MRSA reduction in the US • C. difficile • Success in England National Intervention to Contain the Spread of Carbapenem-Resistant Enterobacteriaceae, Israel 2005-2008 CRE incidence per 105 patient-days. Schwaber . Clin Infect Dis. 2014;58:697-703 One Health •The One Health concept is a worldwide strategy for expanding interdisciplinary collaborations and communications in all aspects of health care for humans, animals and the environment http://www.onehealthinitiative.com/about.php Collaboration One Health and Antibiotic Use Comparing antibiotic use in humans and animals in the European Union: corrected by biomass http://ecdc.europa.eu/en/public ations/_layouts/forms/Publicatio n_DispForm.aspx?List=4f55ad514aed-4d32-b960af70113dbb90&ID=1249 14 Impact of various sources of antibiotic use on resistant infections in humans Sector 1 Sector 6 Sector 2 Sector 7 Sector 3 Sector 8 Sector 4 Sector 9 Sector 5 • Human • Outpatient use • Inpatient use • Hospitals • Nursing homes • Other • Animal • Companion animals • Livestock • Crops • Environment • Wastewater • Manufacturing The “color code” is unknown. Communication The Need for Integrated Actions Coordination, collaboration, communication, computation must be integrated in all aspects of activities to address the AMR problem Antibiotic overuse in human medicine: Variations in prescribing demonstrates overuse Antibiotic prescribing per 1000 persons, US, 2011 Hicks. Clin Infect Dis. 2015;60:1308 State and national AMR data http://gis.cdc.gov/grasp/PSA/index.html; http://wwwn.cdc.gov/narmsnow/ Current infection control is inadequate: Infected and colonized patients move widely and easily between healthcare settings CRE patients Won S Y et al. Clin Infect Dis. 2011;53:532-540 Stewardship http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html; http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf Summary • We know a great deal and we need to learn a lot more about the complexity of AMR, but we know enough to implement measures to improve antibiotic use and prevent the spread of resistance • We need to coordinate our actions as much as possible; agreeing on a core set of short & medium term objectives would be a good first step • We need to collaborate and ask each sector to accept its own role and take additional steps before looking elsewhere for changes • We need much better data, more rapid feedback, more integrated information systems, better (esp. genetic) laboratory capacity to compute and monitor risks and evaluate interventions • We need to communicate in an entirely different way about AMR, specifically addressing misinformation and confusion and focusing on changing the culture of antibiotic use in all settings. Thank you. [email protected] Global Public Health Consulting, LLC