findings from amr surveillance in bangladesh
TRANSCRIPT
Findings from AMR surveillance in Bangladesh
Dr. Zakir Hossain HabibPrincipal Scientific Officer (Associate Professor)
Department of Microbiology
Member Secretary
AMR Surveillance Coordination Sub-Committee
Institute of Epidemiology, Disease control & Research
(IEDCR)
Antimicrobials are probably one
of the most successful forms of
treatment in the history of
medicine
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3
Alexander
Fleming.
Gerhard
Domagk
411/26/2019
Prevention and Containment of Antimicrobial ResistancePrevention and Containment of Antimicrobial Resistance
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Any use of antimicrobials, howeverappropriate and conservative, contributes tothe development of resistance,
but
widespread unnecessary and excessiveuse makes it worse
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Pathway of antibiotics for human and veterinary use in the environment.
9
As things stand, AMR is projected to cause more deaths than cancer by 2050. Image courtesy of Jim O'Neill, Chairman of the Review on Antimicrobial Resistance.
Deaths attributable to AMR every year compared to other major causes of death
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The world is running out of antibiotics
10
Only 15 new antibiotics have been
approved since 2000, compared to the 63
put to clinical use between 1980 and
2000 .
Out of these new drugs, only 4 of them
represent new classes of antibiotics
Timeline of antibiotic production
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Antimicrobial Resistance Surveillance in Bangladesh(2016-2020)
1111/26/2019
Objectives:
General Objective
To establish a surveillance system to find out the status of Antimicrobial Resistance among common pathogens in Bangladesh
1211/26/2019
Specific Objectives
1. To strengthen selected Microbiology laboratories for performing standard techniques of bacterial culture & sensitivity testing.
2. To isolate, identify & perform Antimicrobial Sensitivity testing (AST) of the selected pathogens using uniform laboratory protocol.
3. To develop antibiogram periodically according to the observed sensitivity pattern.
1311/26/2019
s
Ten Priority pathogens
1. Escherichia coli
2. Klebsiella pneumoniae
3. Enterococcus species
4. Vibrio cholerae
5. Shigella species
6. Streptococcus pneumoniae
7. Staphylococcus aureus
8. Salmonella spp.
9. Pseudomonas aeruginosa
10.Acinetobacter spp.
14
Five Cases
5 different cases of infectious diseases are enrolled by case definition:
1. UTI
2. Diarrhoeal diseases
3. Wound infection
4. Pneumonia
5. Septicaemia
15
Six Type Samples
1. Urine
2. Stool
3. Wound swab or Pus
4. Sputum
5. Blood
6. Endotracheal aspirate
16
Findings of AMR Surveillance2017-2019
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Distribution of samples (N=14669)
Distribution of patients
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Distribution of patients according to sex
69537716
Female Male
(53%) (47%)
N=14669
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Distribution of patients according to age group
1596
1947
3219
2355
1998
1712
1199
453
190
11
%
13
%
22
%
16
%
14
%
12
%
8%
3%
1%
0
500
1000
1500
2000
2500
3000
3500
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 >81
N=14669
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Growth vs no growth of cultured bacteria
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Distribution of growth in cultured specimens (N=14669)
80.3%
50.3%
72.7%
90.6%
80.8%
43.1%
19.7%
49.7%
27.3%
9.4%
19.2%
56.9%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Blood
Endotracheal aspirate
Sputum
Stool
Urine
Wound swab
No growth Growth
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Bacterial growth in different specimens (N=3766)
1068
724647
402
189 179 159 136 89 89 39 39 6
28%
19%17%
11%
5% 5% 4% 4%2% 2%
1% 1%0%
0
200
400
600
800
1000
1200
Distribution of different bacterial growth in Urine (N=1302)
780
218
91 79 75 59
60%
17%
7% 6% 6% 5%
0
100
200
300
400
500
600
700
800
900
Escherichia coli Klebsiella
pneumoniae
Staphylococcus
aureus
Others Enterococcus
species
Pseudomonas
aeruginosa
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Distribution of different bacterial growth in Stool (N=190)
89
39 39
23
47%
21% 21%
12%
0
10
20
30
40
50
60
70
80
90
100
Vibrio cholerae Shigella spp. Nontyphoidal Salmonella Others
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Distribution of bacterial growth in blood (N=321)
187
4630 23 17 9 6 3
58%
14%
9%7%
5%3% 2% 1%
0
20
40
60
80
100
120
140
160
180
200
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Distribution of different bacterial growth in sputum (N=365)
176
118
69
2
48%
32%
19%
1%0
20
40
60
80
100
120
140
160
180
200
Klebsiella pneumoniae Others Staphylococcus aureus Streptococcus pneumoniae
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Distribution of different bacterial growth in Wound Swab (N=1226)
534
243186
159104
44%
20%
15%13%
8%
0
100
200
300
400
500
600
Pseudomonas
aeruginosa
Others Staphylococcus
aureus
Escherichia coli Klebsiella
pneumoniae
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Distribution of different bacterial growth in ETA (N=362)
126
8770
3224 22
1
35%
24%
19%
9%7% 6%
0%0
20
40
60
80
100
120
140
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Antibiotic Sensitivity
90%
80% 77%70%
45% 43% 41% 41% 39% 39% 37%34% 31%
26% 24% 21%
10%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Imip
en
em
Am
ika
cin
Nitro
fura
nto
in
Ge
nta
micin
Ce
fep
ime
No
rflox
acin
Trim
ethoprim
-…
Te
tracy
cline
Ce
ftazid
ime
Cip
roflo
xa
cin
Ce
ftriax
on
e
Aztre
on
am
Ce
furo
xim
e
Ce
ph
ale
xin
Am
ox
icillin-C
lav
ula
na
te
Pip
era
cillin
Am
picillin
E.coli(1068)
11/26/2019 32
75%
63%60%
50%45%
39% 38% 36%32% 29% 29% 28% 27%
20%17% 17%
3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Imip
en
em
Am
ika
cin
Ge
nta
micin
No
rflox
acin
Nitro
fura
nto
in
Ce
fep
ime
Cip
roflo
xa
cin
Te
tracy
cline
Trim
ethoprim
-…
Ce
ftriax
on
e
Aztre
on
am
Ce
ftazid
ime
Ce
furo
xim
e
Ce
ph
ale
xin
Pip
era
cillin
Am
ox
icillin-C
lav
ula
na
te
Am
picillin
K.pneumoniae(647)
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73%70%
54%50%
33%
25%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Ce
fixim
e
Ce
ftriax
on
e
Trim
eth
op
rim-
sulfa
me
tho
xa
zole
Cip
roflo
xa
cin
Azith
rom
ycin
Am
picillin
Nontyphoidal Salmonella(39)
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69
%
43
%
41
%
35
%
32
%
29
%
26
%
26
%
24
%
23
%
19
%
18
%
15
%
13
%
11
%
8%
6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Imip
en
em
Nitro
fura
nto
in
Am
ika
cin
Ge
nta
micin
Ce
fep
ime
Aztre
on
am
Ce
ftriax
on
e
Cip
roflo
xa
cin
No
rflox
acin
Pip
era
cillin
Ce
ftazid
ime
Trim
ethoprim
-…
Ce
furo
xim
e
Te
tracy
cline
Am
ox
icillin-C
lav
ula
na
te
Ce
ph
ale
xin
Am
picillin
Proteus spp. (179)
11/26/2019 35
52
%
34
%
32
%
29
%
27
%
24
%
24
%
19
%
18
%
15
%
0%
10%
20%
30%
40%
50%
60%
Imip
en
em
Am
ika
cin
Pip
era
cillin-T
azo
ba
ctam
Pip
era
cillin
Ge
nta
micin
Cip
roflo
xa
cin
Ce
fep
ime
Ce
ftazid
ime
Aztre
on
am
No
rflox
acin
P.aeruginosa(724)
11/26/2019 36
25%24% 24%
19%17%
12% 11% 11%
8% 7%
3%
0%
5%
10%
15%
20%
25%
30%
Do
xy
cyclin
e
Imip
en
em
Am
ika
cin
Ge
nta
micin
Trim
eth
op
rim-
sulfa
me
tho
xa
zole
Cip
roflo
xa
cin
Ce
fep
ime
Pip
era
cillin-T
azo
ba
ctam
Ce
ftriax
on
e
Ce
ftazid
ime
Pip
era
cillin
Acb Complex(159)
11/26/2019 37
99
%
99
%
98
%
98
%
98
%
97
%
95
%
94
%
94
%
86
%
86
%
84
%
83
%
75
%
71
%
8%
0%
20%
40%
60%
80%
100%
120%
Imip
en
em
Ce
fep
ime
Am
ika
cin
Ce
ftazid
ime
Ge
nta
micin
Ce
ftriax
on
e
Ce
furo
xim
e
Aztre
on
am
Ce
ph
ale
xin
Te
tracy
cline
Am
ox
icillin-C
lav
ula
na
te
No
rflox
acin
Trim
eth
op
rim-
sulfa
me
tho
xa
zole
Am
picillin
Pip
era
cillin
Cip
roflo
xa
cin
Salmonella spp.(189)
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89
%
56
%
50
%
37
%
32
%
19
%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ce
ftriax
on
e
Me
cillina
m
Azith
rom
ycin
Trim
eth
op
rim-
sulfa
me
tho
xa
zole
Am
picillin
Cip
roflo
xa
cin
Shigella spp.(39)
11/26/2019 39
81
%
80
%
48
%
5%
3%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Cip
roflo
xa
cin
Azith
rom
ycin
Te
tracy
cline
Ery
thro
my
cin
Trim
eth
op
rim-
sulfa
me
tho
xa
zole
Vibrio cholerae (89)
11/26/2019 40
76
%
75
%
58
%
56
%
42
%
39
%
36
%
25
%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Lin
ezo
lid
Nitro
fura
nto
in
Am
picillin
Va
nco
my
cin
Cip
roflo
xa
cin
Ge
nta
micin
Pe
ncillin
-G
Te
tracy
cline
Enterococcus spp.(89)
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Sample wise Antibiotic Sensitivity
Antibiogram of Urine sample
E.coli (780) K. pneumoniae(218)Enterococcus species(75)
Staph. aureus(91) P. aeruginosa(59)
Sensitivity % Sensitivity % Sensitivity % Sensitivity % Sensitivity %
Amikacin 85% 82% - - 69%
Amoxicillin-Clavulanate 27% 31% - - -
Ampicillin 12% 5% 58% - -
Azithromycin - - - 8% -
Aztreonam 39% 52% - - 35%
Cefepime 51% 63% - - 51%
Cefoxitin - - - 20% -
Ceftazidime 45% 53% - - 41%
Ceftriaxone 45% 57% - - -
Cefuroxime 35% 45% - - -
Cephalexin 29% 36% - - -
Ciprofloxacin 45% 60% 45% 42% 51%
Clindamycin - - - 46% -
Doxycycline - - - 67% -
Gentamicin 78% 77% 45% 73% 74%
Imipenem 94% 92% - - 75%
Linezolid - - 80% 85% -
Nitrofurantoin 80% 51% 75% - -
Norfloxacin 46% 60% - -
Pencillin-G - - 34% 22% -
Piperacillin 23% 30% - - 49%
Tetracycline 43% 46% 25% - -
Trimethoprim-sulfamethoxazole 46% 46% - 51% -
E.Coli (159) K. pneumoniae (104) Staph. aureus (186) P. aeruginosa (534)
Sensitivity % Sensitivity % Sensitivity % Sensitivity %
Amikacin 58% 35% - 27%
Amoxicillin-Clavulanate 6% 4% - -
Ampicillin 1% 0% - -
Azithromycin - - 17% -
Aztreonam 10% 11% - 15%
Cefepime 24% 13% - 20%
Cefoxitin - - 56% -
Ceftazidime 20% 5% - 14%
Ceftriaxone 7% 7% - -
Cefuroxime 6% 5% - -
Cephalexin 9% 6% - -
Ciprofloxacin 21% 14% 24% 20%
Clindamycin - - 48% -
Doxycycline - - 64% -
Gentamicin 45% 32% 66% 20%
Imipenem 72% 72% - 50%
Linezolid - - 75% -
Norfloxacin 26% 15% - 10%
Oxacillin - - 30% -
Pencillin-G - - 8% -
Piperacillin 10% 9% - 29%
Piperacillin-Tazobactam - - - 28%
Tetracycline 17% 24% - -
Trimethoprim-sulfamethoxazole 23% 14% 53% -
Antibiogram of wound swab culture isolates
K. pneumoniae(176) Staph. aureus(69)
Sensitivity % Sensitivity %
Amikacin 81% -
Amoxicillin-Clavulanate 8% -
Ampicillin 2% -
Azithromycin - 13%
Aztreonam 26% -
Cefepime 46% -
Cefoxitin - 8%
Ceftazidime 25% -
Ceftriaxone 30% -
Cefuroxime 23% -
Cephalexin 14% -
Ciprofloxacin 46% 29%
Clindamycin - 32%
Doxycycline - 62%
Gentamicin 75% 66%
Imipenem 84% -
Linezolid - 58%
Norfloxacin 61% -
Oxacillin - 13%
Pencillin-G - 7%
Piperacillin 12% -
Tetracycline 39% -
Trimethoprim-sulfamethoxazole
35% 35%
Antibiogram of sputum culture isolates
Antibiogram of ETA culture isolates
Klebsiella pneumoniae (126)
Pseudomonas aeruginosa (70)
Acb complex(87)
Sensitivity % Sensitivity % Sensitivity %
Amikacin 28% 24% 15%
Amoxicillin-Clavulanate 6% - -
Ampicillin 0% - -
Aztreonam 2% 8% -
Cefepime 8% 7% 2%
Ceftazidime 4% 6% 3%
Ceftriaxone 3% - 6%
Cefuroxime 1% - -
Ciprofloxacin 10% 11% 5%
Doxycycline - - 31%
Gentamicin 27% 13% 9%
Imipenem 34% 26% 14%
Oxacillin - - -
Piperacillin 2% 8% 3%
Piperacillin-Tazobactam - 9% 5%
Tetracycline 16% - -
Trimethoprim-sulfamethoxazole
11% - 13%
Antibiogram of blood culture isolates
E.Coli (46) Salmonella spp.(187)
Sensitivity % Sensitivity %
Amikacin 70 98%
Amoxicillin-Clavulanate 24 86%
Ampicillin 6% 76%
Aztreonam 26% 94%
Cefepime 99%
Ceftazidime 33% 98%
Ceftriaxone 19% 97%
Cefuroxime 18% 95%
Cephalexin 19% 94%
Ciprofloxacin 27% 8%
Gentamicin 54% 98%
Imipenem 88% 99%
Norfloxacin 87%
Piperacillin 71%
Tetracycline 87%
Trimethoprim-sulfamethoxazole
21% 83%
Antibiogram of stool culture isolates
NontyphoidalSalmonella(39)
Shigella spp.(39)Vibrio
cholerae(89)
Sensitivity % Sensitivity % Sensitivity %
Ampicillin 25 32 -
Azithromycin 33 50 80
Cefixime 73 - -
Ceftriaxone 70 89 -
Ciprofloxacin 50 19 81
Erythromycin - - 5
Mecillinam - 56 -
Tetracycline - - 48
Trimethoprim-sulfamethoxazole 54 37 3
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The isolate is non-susceptible to at least 1 agentin ≥3 antimicrobial categories
The isolate is non-susceptible to at least 1 agent in all but 2 or fewer antimicrobial categories
Non-susceptibilityto all agents in allantimicrobial categoriesfor each bacterium
MDR
XDR
PDR
56%21%
14%
9%
Percentage of MDR, XDR, PDR Pseudomonas aeruginosa (n=724)
MDR(n=403)
XDR(n=149)
PDR(n=98)
Other thanMDR,XDR,PDR (n=74)
33%
43%
26%
8%
Percentage of MDR, XDR & PDR Proteus spp. (n=179)
MDR (n=62)
XDR (n=76)
PDR (n=26)
Other thanMDR,XDR,PDR (n=15)
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53%
23%
13%
11%
Percentage of MDR, XDR & PDR Klebsiella pneumoniae (n=647)
MDR (n=347)
XDR (n=147)
PDR (n=82)
Other thanMDR,XDR,PDR (n=71)
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73%
13%
3%
11%
Percentage of MDR,XDR & PDR in E. coli (n=1068)
MDR (n=778)
XDR (n=138)
PDR (n=31)
Other thanMDR,XDR,PDR (n=121)
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Percentage of MDR, XDR and PDR Acinetobacter spp.(N=159)
7043%
5937%
2214%
85%
XDR
PDR
MDR
Non - MDR, XDR, PDR
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Percentage of MDR, XDR and PDR Enterococcus spp.(N=89)
11%
3337%
5562%
XDR
PDR
MDR
Non - MDR, XDR, PDR
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Distribution of Pan drug-resistant bacteria (PDR) bacteria
Organism ICU Medicine Surgery Others Total
E. coli 8 8 6 9 31
P. aeruginosa 9 2 5 82 98
K. pneumoniae 36 29 11 13 89
Acinetobacter spp. 46 4 2 7 59
Enterococcus spp. 1 0 0 0 1
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Antibiotic
consumption
37%
9% 9% 8% 8% 7%5%
2% 2% 2%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Antibiotics used for patients in all sites (n=7486)
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23%22%
12%11% 11%
6%
3%2%
1% 1%
0%
5%
10%
15%
20%
25%
Antibiotic used in UTI (n=921)patients in all sites
11/26/2019 59
20%
9% 9%8%
3%2% 2%
1%
0%
5%
10%
15%
20%
25%
Antibiotic used in UTI (n=558) patients of (OPD) Outpatient
department
11/26/2019 60
20%
6%
3%2% 2% 2%
1%
0%
5%
10%
15%
20%
25%
Antibiotic used in UTI (n=365) patients from (IPD)Inpatient
Department
11/26/2019 61
42%
22%
12%
5% 4% 3% 2% 2% 2% 2%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Antibiotic used for patients with Wound infection
(n=2303)
11/26/2019 62
44%
33%
11%
5% 4%2%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Cip
rofl
oxa
cin
(n=
34
0)
Azi
thro
myc
in(n
=2
52
)
Cef
tria
xon
e(n
=84
)
Do
xycy
clin
(n=
36
)
Met
ron
idaz
ole
(n=2
9)
Cef
ixim
e(n
=1
8)
Antibiotic used for Diarrhoea patients (n=766)
11/26/2019 63
47%
15%
4% 4% 3% 3% 2% 2% 2% 2%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Antibiotic used in Septicaemia patients (n=2106)
11/26/2019 64
29%
16%
5%3% 3% 3% 2% 2% 2% 1%
0%
5%
10%
15%
20%
25%
30%
35%
Antibiotic used for pneumonia patients (n=1535)
11/26/2019 65
46%
25%
4% 3% 3% 3% 3% 3% 3% 2%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Antibiotic used in ICU patients with septicaemia (n=1786)
Percentage of antibiotic usage in…
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Access
Which indicates the antibiotic of choice for each of the 25 most common infections. These antibiotics should be available at all times, affordable and quality-assured.
Watch
Which includes most of the “highest-priority critically important antimicrobials” for human medicine and veterinary use.
These antibiotics are recommended only for specific, limited indications
Reserve
Antibiotics that should only be used as a last resort when all other antibiotics have failed.
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Access, Watch and Reserve Antibiotics in the WHO Essential Medicines List
• Access group:
This group includes antibiotics that have activity against a wide range of commonly encountered susceptible pathogens while also showing lower resistance potential than antibiotics in the other groups. Selected Access group antibiotics are recommended as essential first or second choice empiric treatment options.
• Watch group:
This group includes antibiotic classes that have higher resistance potential and includes most of the highest priority agents among the Critically Important Antimicrobials for Human Medicine and/or antibiotics that are at relatively high risk of selection of bacterial resistance.
• Some ACCESS antibiotics, such as ceftriaxone or azithromycin, are also part of the WATCH group.
• Reserve group:
• This group includes antibiotics and antibiotic classes that should be reserved for treatment
of confirmed or suspected infections due to multi-drug-resistant organisms. Reserve group
antibiotics should be treated as “last resort” options.
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7211/26/2019
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The overall goal is to reduce the use of Watch
Group and Reserve Group antibiotics (the
antibiotics most crucial for human medicine
and at higher risk of resistance), and to
increase the use of Access antibiotics where
availability is low.
97%
3%
Percentage of Reserve Drugs used overall (among total
7486 Antibiotics)
Other Antibiotic (n=7274) Reserve Drugs (n=212)
11/26/2019 74
49%
23%
20%
8%
Percentage of Reserved Drugs used
Cefepime(n=104,49%) Linezolid(n=49,23%)
Tigecyclin(n=42,20%) Colistin(n=17,8%)
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24
%
4%
2%
0%
32
%
46
%
0%
0%
41
%
22
%
95
%
24
%
0%
28
%
3%
76
%
3%
0%
0%
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cefepime(n=104) Linezolid(n=49) Tigecyclin(n=42) Colistin(n=17)
‘Reserve Drugs’
Medicine dept. Surgery dept. ICU Burn Others
11/26/2019 76
7711/26/2019
11/26/2019 78