Dr.Sherin Elsherbiny MD, Clinical Pathology and Microbiology Infection Control Specialist RRT-Member ,Meeqat General Hospital. Madinah

1. MDRO AS A GROWING
GLOBAL HEALTH
THREAT
Dr.Sherin Elsherbiny
MD, Clinical Pathology and Microbiology
Infection Control Specialist
RRT-Member

2. Expectations
• Antibiotic resistance is a growing crisis worldwide. New resistance
mechanisms are emerging and spreading globally, threatening our ability
to treat common infectious diseases
• By 2050, 10 million people may die from causes attributable to AMR with
a loss of up to $100 trillion (£64 trillion) to the global economy
• Dr Marie-Paule Kieny, WHO's Assistant General Director- for Health
Systems and Innovation said .
• "Antibiotic resistance is growing, and we are fast running out of
treatment options. If we leave it to market forces alone. The new
antibiotics we most urgently need, are not going to be developed on time”

5. Common Causes of antibiotic resistance
1. Over-prescribing of antibiotics
2. Patients not taking antibiotics as prescribed
3. Unnecessary antibiotics used in agriculture
4. Poor infection control in hospitals and clinics
5. Poor hygiene and sanitation practices
6. Lack of rapid laboratory tests

7. Role of WHO
A global action plan on antimicrobial resistance, including antibiotic resistance,
was endorsed at the World Health Assembly in May 2015

9. Global Antimicrobial Resistance
Surveillance System (GLASS)
• GLASS promotes and supports a standardized approach to the collection, analysis and
sharing of AMR data at a global level by encouraging and facilitating the establishment of
national AMR surveillance systems that are capable of monitoring AMR trends and
producing reliable and comparable data.
• GLASS objectives
• Foster national surveillance systems and harmonized global standards;
• Estimate the extent and burden of AMR globally by selected indicators;
• Analyze and report global data on AMR on A regular basis;
• Detect emerging resistance and its international spread;
• Inform implementation of targeted prevention and control programs; and
• Assess the impact of interventions.

10. To date, 52 countries (25 high-income, 20 middle-income and 7 low-income countries)
are enrolled in WHO’s Global Antimicrobial Surveillance System.
For the first report, 40 countries provided information about their national surveillance
systems and 22 countries also provided data on levels of antibiotic resistance.

12. (GLASS) Reveals
• WHO’s new Global Antimicrobial Surveillance System (GLASS) reveals
widespread occurrence of antibiotic resistance among 500.000 people with
suspected bacterial infections across 22 countries.
• The most commonly reported resistant bacteria were Escherichia
coli, Klebsiella pneumoniae, Staphylococcus aureus, and Streptococcus
pneumoniae, followed by Salmonella spp.
• The system does not include data on resistance of Mycobacterium
tuberculosis, which causes tuberculosis (TB), as WHO has been tracking it
since 1994 and providing annual updates in the Global tuberculosis report.
• .

13. • Among patients with suspected bloodstream infection, the proportion
that had bacteria resistant to at least one of the most commonly used
antibiotics ranged widely between different countries from zero to
82%.
• Resistance to penicillin –to treat pneumonia – ranged from zero to
51% among reporting countries. And
• Between 8% to 65% of E. coli associated with urinary tract infections
presented resistance to ciprofloxacin, an antibiotic commonly used to
treat this condition

14. WHO list for R&D of new antibiotics
• 27 FEBRUARY 2017 | GENEVA - WHO today published its first ever
list of antibiotic-resistant "priority pathogens" – a catalogue of 12
families of bacteria that pose the greatest threat to human health.
• This list is a new tool to ensure R&D responds to urgent public health
needs.
• The WHO list is divided into three categories according to the urgency
of need for new antibiotics: critical, high and medium priority.

15. WHO priority pathogens list for R&D of new antibiotics
Priority 1: CRITICAL
•Acinetobacter baumannii, carbapenem-resistant
•Pseudomonas aeruginosa, carbapenem-resistant
•Enterobacteriaceae ( carbapenem-resistant, ESBL-producing)
Priority 2: HIGH
•Enterococcus faecium, vancomycin-resistant
•Staphylococcus aureus, methicillin-resistant, vancomycin-intermediate and resistant
•Helicobacter pylori, clarithromycin-resistant
•Campylobacter spp., fluoroquinolone-resistant
•Salmonellae, fluoroquinolone-resistant
•Neisseria gonorrhoeae, cephalosporin-resistant, fluoroquinolone-resistant
Priority 3: MEDIUM
•Streptococcus pneumoniae, penicillin-non-susceptible
•Haemophilus influenzae, ampicillin-resistant
•Shigella spp., fluoroquinolone-resistant

16. • MDRO prevalence tended to be higher in low- and middle-income countries
• A conducted a laboratory-based period-prevalence survey of AMR through
420 laboratories in 67 countries for S. aureus, Enterococci and Gram-
negative bacilli respectively.
• Enterobacteriaceae were the most common organisms BUT had the lowest
proportion of MDRO
• ESBL- representing 13.9% from blood and 10.2% from urine
• CRE representing 2.3% and 1.0%
• S. aureus was the most frequent organism from blood with 38.1%

17. CDC
CDC published a report outlining the top 18 drug-resistant threats to the
United States. These threats were categorized based on level of
concern: urgent, serious, and concerning.
Regardless of category based on threat-specific , CDC activities are
tailored to meet the epidemiology of the infectious agent and to address
any gaps in the ability to detect resistance and to protect against
infections

21. Role of Pharmacopeias
Around the world, governments and stakeholders are implementing
approaches to minimize AMR induced by falsified and substandard
medicines,
Medicines can be substandard (not meeting quality, labeling, or other
requirements) for a variety of reasons, including product degradation
due to weak supply chains; or improper practices or missteps occurring
during manufacturing.
Falsified medicines contain the wrong amount or no active ingredient.
Coordinated actions across governments, sectors, and agencies is
critical to reduce the size of this market and reduce its harmful effects
on public health

22. • Pharmacopeias working through strengthening the supply
chain and ensuring access to medicines of assured
quality. This includes
• 1.Compliance with Quality Standards
Pharmacopeia quality standards (e.g., those of USP and
other pharmacopeias) cover the entire lifecycle of
medicines, from production to consumption,
• 2. Quality Assurance Programs, Regulatory System
Strengthening, and Surveillance

23. USP
• USP is an independent public health organization established in
1820. USP develops transparent standards of quality for medicines,
dietary supplements and foods, working with a network of
independent experts.
• USP’s standards are enforceable by the U.S. FDA, and have been
used in more than 140 countries globally. Such standards also assist
industry in the development, manufacturing, and testing of medicines.
• USP focuses on reducing the threat of resistance posed by
substandard medicines (one important cause) and advances quality
pharmaceutical products and stewardship practices.

24. KSA National antibiotic guideline
Prepared by the Antimicrobial Stewardship Subcommittee of the National Antimicrobial
Resistance Committee and the General Administration of Pharmaceutical Care at Ministry of
Health

25. Drug restriction list
• Definition
• Restricted antimicrobial agent is an agent which requires -
prior to dispensing- authorization by the infectious
Diseases (ID) physicians, other authorized personnel
such as antimicrobial stewardship clinical pharmacist, or
approved protocol by the antimicrobial stewardship
committee. Depending on the hospital’s policy, the first
few doses may be allowed to be dispensed without
authorization

26. Antibacterial
agents
Antiviral Antiprotozoal Antifungal drugs
1. Amikacin
2. Ceftazidime
3. Cefepime
4. Colistin
5. Daptomycin
6. Doxycycline IV
7. Linezolid
8. Imipenem
9. Meropenem
10. Mupirocin
11. Rifampicin
12. Sulfadiazine
13. Tigecycline
14. Tobramycin
15. Ethionamide
1. HIV medicines
2. Cidofovir
3. Ganciclovir
4. Foscarnet
5. Oseltamivir
6. Ribivarin
1. Artesunate
2. Atovaquone
proguanil
3. Pyrimethamin
4. Pentamidine
(systemic and
inhalation)
5. Quinidine
1. Liposomal
Amphotericin B
2. Anidulafungin
3. Caspofungin
4. Posaconazole
5. Voriconazole

27. Antibiograms
Gram Negative Gram Positive
Antibiotic
Tested
Escherichia coli
Klebsiella
pneumoniae
Proteus
mirabilis
Pseudomonas
aeruginosa
Staphylococcus aureus
nonMRSA | MRSA †
Staphylococcus
coag. Neg
Enterococcus sp
# of Isolates‡ 165 75 39 33 10* 35 18 68
Oral or Oral Equivalent Oral or Oral Equivalent
Ampicillin 46% 0% 62% 50% 0% 50% 96%
Amox / Clav 77% 96% 100%
Cefazolin 70% 93% 88% 100% 0% 50%
Cefoxitin 82% 100% 100%
Ceftriaxone 85% 79% 92%
Ciprofloxacin 58% 79% 62% 56% 0% 0% 47%
Levofloxacin 59% 79% 62% 57% 33% 20% 0% 64%
Nitrofurantoin 100% 0% 0% 100% 100% 100% 100%
TMP / SMX 64% 79% 54% 67% 100% 100%
Tetracycline 64% 60% 0% 100% 100% 80% 38%
Oxacillin 100% 0% 50%
Clindamycin 50% 50% 100%
Erythromycin 50% 0% 0%
Linezolid 100% 100% 100%
IV Only IV Only
Pip / Taz 98% 96% 100% 100%
Cefepime 89% 95% 92% 91%
Ceftazidime 91%
Gentamicin 85% 83% 92% 91% 100% 100% 67%
Imipenem 100% 100% 100% 71%
Vancomycin 100% 100% 100% 100%
Antibiotic Tested Escherichia coli
# of Isolates 165
Ciprofloxacin 58%

28. WI cumulative statewide antibiogram for 2008
28
Indicates a ≥10% decrease in susceptibility as compared to 2006
Indicates a ≥10% increase in susceptibility as compared to 2006

29. HOME MESSAGE
1. Antibiotic resistance can affect anyone, of any age, in any country.
2. Antibiotic resistance occurs naturally, but misuse of antibiotics in
humans and animals is accelerating the process.
3. The world urgently needs to change the way it prescribes and uses
antibiotics. Even if new medicines are developed, without behavior
change, antibiotic resistance will remain a major threat.
4.
5. Behavior changes must also include actions to reduce the spread
of infections through vaccination, hand washing and good food
hygiene.
6. Without urgent action, we are heading for a post-antibiotic era, in
which common infections and minor injuries can once again kill.
7. Antibiotic resistance is one of the biggest threats to global health,
food security, and development today.

30. References
1. GLASS REPORT Early implementation 2016-17.WHO
2. Worldwide country situation analysis response to antimicrobial resistance Summary April
WHO/HSE/PED/AIP/2015.1
3. World Health Organization period prevalence survey on multidrug-resistant microorganisms in
healthcare 23 April 2017, 13:42 - 13:47 EP0409 27TH ECCMID
4. USP Global Public Policy Position Combatting Antimicrobial Resistance 2017
5. International Activities to Combat AR | Antibiotic/Antimicrobial ... – CDC 2.17