Download Klebsiella pneumoniae

CHOICE OF ANTIBIOTICS IN THE VIEW OF
DEVELOPING ANTIBIOTIC RESISTANCE
Dr. Jolanta Miciulevičienė
Vilnius City Clinical Hospital
National Public Health Surveillance Laboratory
BARN 3rd Workshop ʺPrevention of Surgical Site Infectionsʺ
Visby, 2012
Discovery of Penicillin Changes the
History of Medicine
In 1928 Sir Alexander Fleming, a Scottish
bacteriologist, left a Petri dish with
staphylococci uncovered. When he
returned, he noticed that there was mold
growing on it. Upon further examination,
he saw that the area around the mold had
no bacteria growing.
Fleming concluded that the mold was
releasing a substance that was inhibiting
bacterial growth. He grew a pure culture of
the mold and discovered that it was a
Penicillium, now known to be Penicillium
notatum.
Antimicrobial resistance
• Soon after the introduction of the penicillin into clinical
practice, the fact that the development of antibiotic
resistance would be a problem became apparent.
• Resistance to penicillin in some strains of
Staphylococcus was recognized almost immediately
after introduction of the drugs. Resistance to penicillin
today occurs in as many as 90% of all strains of
Staphylococcus aureus
Antimicrobial resistance
Most commonly, this refers to infectious microbes that
have acquired the ability to survive exposures to
clinically relevant concentrations of antimicrobial drugs
that would kill otherwise sensitive organisms of the
same strain.
Resistant Nosocomial Pathogens
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•
•
•
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S.aureus (MRSA, GISA),
Enterococcus spp. (VRE),
E.coli (ESBL),
Klebsiella pneumoniae (ESBL, KPC),
Enterobacteriaceae (MDR),
Pseudomonas aeruginosa (MDR),
Acinobacter baumannii (MDR).
European Antimicrobial Resistance
Surveillance Network (EARS – Net)
Streptococcus pneumoniae,
Staphylococcus aureus,
Enterococcus faecalis,
Enterococcus faecium
Escherichia coli,
Klebsiella pneumoniae,
Pseudomonas aeruginosa.
EARS – Net participants in Lithuania:
10 laboratories of microbiology
37 hospitals
Number of blood-stream infections, Lithuania,
2007 – 2011
400
Number of BSi
350
300
Enterococcus spp.
E.coli
250
K.pneumoniae
200
P.aeruginosa
S.aureus
150
S.pneumoniae
100
50
0
2007
2008
2009
2010
2011
Staphylococcus aureus: trends of invasive isolates
resistant to meticillin (MRSA),Lithuania, 2007-2011
2007m. - 241/22, 2008m. - 280/31, 2009m. - 255/29, 2010m. – 257/36, 2011m. – 263/16
Staphylococcus aureus: proportion (%) of invasive isolates
resistant to methicillin (MRSA), 2010
Klebsiella pneumoniae: trends of invasive isolates
resistance to third-generation cephalosporins,
fluoroquinolones and aminoglycosides, Lithuania,
2007-2011
Klebsiella pneumoniae: proportion (%) of invasive isolates
with resistance to third-generation cephalosporins, 2010
Klebsiella pneumoniae: proportion (%) of invasive isolates
with resistance to carbapenems, 2010
Number of K.pneumoniae blood stream infections,
Lithuania, 2007-2011.
Risk factors of developing bacterial resistance
• Inappropriate prescribing (overprescribing);
• Inappropriate selection of antimicrobial (broad spectrum
cephalosporins, fluoroquinolones, carbapenems,
glycopeptides);
• Prolonged administration of antimicrobial.
Evidence Based
• “Evidence-based medicine is the process of
systematically finding, appraising, and using research
findings as the basis for clinical decisions.”
BMJ 1995;310:1122-1126 (29 April)
William Rosenberg, Anna Donald
Evidence-based Medicine: An Approach to Clinical Problem-solving
Evidence-based medicine
Reference:
Cook PP, Catrou P, Gooch M, Holbert D. Effect of
reduction in ciprofloxacin use on prevalence of
methicillin-resistant Staphylococcus aureus rates within
individual units of a tertiary care hospital. Journal of
Hospital Infection. 2006; 64: 348-351
Setting:
731-bed tertiary care teaching hospital, Greenville, NC,
USA.
Evidence based medicine
• Intervention
Reduction - Active monitoring of oral and IV ciprofloxacin use.
• Impact:
Ciprofloxacin use decreased by 31.2% (p<0.0001). MRSA rates
decreased from 59.6% to 54.2% (p=0.112). Correlation between
ciprofloxacin use and MRSA rates (r=0.70; 95% CI -0.01-0.94
p=0.053).
Evidence based medicine
• Reference:
Rahal JJ, Urban C, Horn D, Freeman K, Segal-Maurer S, Maurer J,
Mariano N, Marks S, Burns JM, Dominick D, Lim M. Class restriction
of cephalosporin use to control total cephalosporin resistance in
nosocomial Klebsiella. JAMA, 1998;280(14): 1233-1237
• Setting:
500-bed university affiliated community hospital, Queens, NY, USA
Evidence based medicine
• Intervention
Restriction - Hospital adopted antibiotic guidelines restricting routine
cephalosporin use.
• Impact:
80.1% reduction in hospital-wide cephalosporin use in 1996
compared to 1995. 44% reduction in incidence of ceftazidimeresistant Klebsiella infection and colonization throughout medical
center (p<0.01) and 70.9% reduction in all intensive care units
(p<0.001).
Evidence based medicine
• Intervention
Restriction - Hospital adopted antibiotic guidelines restricting routine
cephalosporin use.
• Impact:
80.1% reduction in hospital-wide cephalosporin use in 1996
compared to 1995. 44% reduction in incidence of ceftazidimeresistant Klebsiella infection and colonization throughout medical
center (p<0.01) and 70.9% reduction in all intensive care units
(p<0.001).
Take home message:
Inappropriate selection and prolonged administration of antimicrobials
Fluoroquinolones;
Cephalosporins;
Carbapenems;
Glycopeptides.
S.aureus (MRSA, GISA),
Enterococcus spp. (VRE),
E.coli (ESBL),
Klebsiella pneumoniae (ESBL, KPC),
Enterobacteriaceae (MDR),
Pseudomonas aeruginosa (MDR),
Acinobacter baumannii (MDR).
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