Antibiotic Resistance in Texas Jennifer A. Shuford, MD, MPH - PowerPoint PPT Presentation

Texas Department of State Health Services Antibiotic Resistance in Texas Jennifer A. Shuford, MD, MPH Infectious Disease Medical Officer Department of State Health Services

Texas Department of State Health Services Overview of Antibiotic Resistance 3/6/2018 2

Antibiotic Resistance Timeline T IC RESISTAN CE ANTIB I OT IC INDENTIFI ED INTRODUCE D 1940 5taphyloeocw, penicillln-R 1943 penici lli n 19 50 to tracycllne 19 53 er yth romycln 1959 tetracycllne- iUh/qef/o 1960 methldllln 1962 methicillln-R 5taphyloeocw, 1965 penicillin R pneunococrus 196 7 gentamlcln 1968 erythromycm-R srreprowccu, 19 7 2 vancom)'Cln 1979 gentam i cin -R Enterococcu; 1985 lmlpeMm and ceftazldlme 1987 cefta zidi mc A EntcrobactN laccac Cnte roeocw, 1988 vancomycin-R 1996 19 9 6 levofioxacl n [pyc,floxarin-R prlPl.mo<O f nJI 1998 lmipcnc -m A En tcrobactcriaccae 2000 llne z olld 2 000 XOR l ul>e1w l usi1 2001 llnezolld-R Staphylococcus 2 002 vancomycin-R Stoph~'lococcu; 2003 ciaptomyc i~ DR - Aclrerooacterand P5eudomonai 2 004 /5 P 2 009 ~e rt riaxo11e -R M! l »erlu gv,,or,/,o,,r,e 2010 ceftaroll n<> PnR -FntPmbartorlar ASe Available at: https://www.cdc.gov/drugresistance/about.html 3/6/2018 3 Accessed: January 8, 2018.

Antibiotic Use • Antibiotics have saved countless lives since sulfa was introduced in the 1930s • Overuse of antibiotics is now common • ~30-50% of antibiotic use is unnecessary or inappropriate Available at: https://www.cdc.gov/antibiotic- 3/6/2018 4 use/healthcare/index.html. Accessed January 8, 2018.

~ Development of Resistance Health and Human Services Texas Department of State Health S•rvices How Antibiotic Resistance Happens 2. 1. Lots of germs. Antib iotics kill The drug -resistant Some bacteria give A few are drug res istant. bacteria causing the illness, bacteria are now allowed to their drug-resistance to as well as good bacteria grow and take over. other bacteria. causing .. , prot@Cting the body from more problems. infection. ' , ' ' I X X X '., '' .X X l( JC ' X X , x / Available at: 3/6/2018 https://www.cdc.gov/drugresistance/about.html. Accessed 5 January 8, 2018.

Development of Resistance Texas Department of State Health Services • Many organisms are now resistant to multiple different antibiotics - These are termed MDROs, also known as “nightmare bacteria” • Organisms may become resistant to all antibiotics - Sometimes called “pan - resistant” • Threaten to return us to a time without any antibiotics • Use of antibiotics is the most important factor in rising prevalence of resistant organisms around the world Available at: www.cdc.gov/drugresistance/threat-report- 3/6/2018 6 2013/pdf/ar-threats-2013-508.pdf#page=11. Accessed January 9, 2018.

~ ~ ~ ~ ~ A~m~ Spread of Resistance Health and Human Services Texas Department of State Health S•rvices 1w Antibiotic Resistance Spreads : , I ll I] Geor9e gets antibiotics and - ---1 e ..._ ,nt ibioti cs and develop resistant • ..,. develops resistant bacteria in th•ir gut> . bacteria in his gut. Drug-resistant George stays at ~ remain on me;at '- di home and in the - bacteria can _,~ general conmunity. \. from anima~. Spreads resistant When not handled { bacteria. George gets ure at a °' cooted properly, ho,pital, nursing home or the bacteria can I other inpatient care facility. spread to humans. t ,, • Fertilizer or water Kesi,tant gern15 >pread containing animal fecu directly to other patient> or I ft l J and drug-resist,nt bacteria indirectly on unclean hands is used on food crops. \ ', of healthcare Frovidtrs. I Re sistant ba cte ria sprea d to other DNg rcsisi.nt boctcrio patients from in the animal feces car Pat1ents go home , ' ' surfaces within the remain on cr ops and b-e healthcare laci l ity. eaten. Tnese bacteria " c an rem.ain in the human gut. Simply using antibiotics creates resistance. T hese drugs should only be used to treat infections. Available at: 3/6/2018 https://www.cdc.gov/drugresistance/about.html. Accessed 7 January 8, 2018.

Cost of Resistance Available at: https://www.cdc.gov/drugresistance/pdf/3- 3/6/2018 8 2013-508.pdf. Accessed January 9, 2018.

Progression of Antibiotic Treatment Start Health and Human Services Patient with Obtain broad- Texas Department of State Health S•rvices sepsis Cultures spectrum antibiotic If no If resistance Final culture response, suspected, results add/change start antibiotics carbapenem Culture- based antibiotic plan 3/6/2018 9

Antibiotic Resistance- ~ Susceptibility Profile Texas Department of State Health S•rvices PSEUOOMONAS AERUGINOSA Organi3m 1 >=100,000 CFO/ML ESBL+ ESCHERICHIA COLI Organism 2 25,000 - 50,000 CFO/ML INSTITUTE CONTACT PRECAUTIONS FOR IBIS 0 ECOLIESBL PS AERUG MIC Intexp Interp MIC ------ ------ ------ ------ R >16 AMEICILLIN <•8/4 R AMP/SULBACTAM B R s <=2 CEFEPIME R >16 CE FAZ OLIN >32 R CEFTRIAXONE s R >2 <""''.:. CI PROFLOXACIN s <--4 s <='i GENTAMICIN s <=0.5 ERTAPEl'lE.M s >4 R <=2 i.EVOFLOXACI.N s <= 32 NITROFORANTOI-N <=16 R 3 PIP/TAZO- GNR <=-6 s s < <='i TOBRAMYCIN >2/38 R ~Rl11/ SULFA ESB~+ ESC~ERICRIA COL: : MIC GRA11 NEGATIVE ~iOT E: PRODUCTION 0 :1" AN EXTE!iDED SPEC:'Rm-f 3ETA LACTAMASE (ESSL) RAS 3EEN CONFIRMEt FOR :HIS ORGANISM. 3/6/2018 10

Antibiotic Resistance- KPC-producing K. pneumoniae Antibiotic Interpret. Antibiotic Interpret. Amikacin I Ciprofloxicin R Amox/clav R Ertapenem R Ampicillin R Gentamicin R Aztreonam R Imipenem R Cefazolin R Meropenem R Cefotaxime R Pip/tazo R Cefotetan R Tobramycin R Cefoxitin R Trimeth/Sulfa R Ceftazidime R Polymixin B MIC >4mg/l Ceftriaxone R Colistin MIC >4mg/l Cefepime R Tigecycline S Chloramphenicol R 3/6/2018 11

Cost of Resistance • Antibiotic-resistant infections are complex • Longer hospital stays 1 • Increased mortality 1 • Increased hospital costs 2 • Est costs of antibiotic-resistant infections 3 • $20 billion per yr in excess direct healthcare costs • $35 billion per yr in additional societal costs 1. Raymond DP , et al. 2003. Crit Care Med. 2. Dicks KV, et al. 2017. Infect Control Hosp Epidemiol. 3. CDC. 2013. Available at: https://www.cdc.gov/drugresistance/threat-report-2013/pdf/ar- 3/6/2018 12 threats-2013-508.pdf#page=11. Accessed January 9, 2018.

Texas Department of State Health Services Interventions to Decrease Antibiotic Resistance 3/6/2018 13

Fighting Antibiotic Resistance BACK AGAINST ANTIBIOTIC RESISTANCE Four Core Actions to Prevent Antibiotic Resistance PRMHTING INFIC110NS, PREVENTING THE SPREAD OF IIESiSTllNCE .~ Avoldlfl!l lnfecllons In the n11t pt.Ka reouc0 the amount ct antlblotb that ha\/0 to tie uSQd and reduces t~ tnl!llhood th1t rMtance will develop dlJrlng therapy. Thtre are inany ft'lys that drug.c~l.'lnt lnfoctlons c.:in I» P<Q\enl~: lmmuilzatlon. safe food J>fep.mtlon, handwasbtng, and using antibiotics M directed and onlY ·imen necessary. In addition. p,-event1119 lnfect1ons also prevtnts the spread d resistant bacteri.1. 2 TRACKING CDC gathers d.11.'1 on antibiotic-resistant lnfe<tions, cauws of lnfllCtfons aad whOUlQr tl\o!'Q ar11 partkular rDllOOS (rtSk ractors) that c~USQCI some ~plt to tel I reslswit infection. Wlth that lnformtlon, experts can tievetop spectnc strateq!M to preve!nt those infoctions and prvvent tlle resistant bacteria fror.i ~preading. lMPROVING ANTIBIOTIC PRISCPJBING/STIWARDSHIP 3 PQrtups th! slnglR most Important action neodod to grMlt/ slow down ~ 6evelopment and spread of antiblotk-mlstant lnftdtons ts to cllange tne way anttblOtks are~- Up to 11.tlf or ant1ntot1c use In humans and much of antibiotic use In animals Is unnece-ssary and 1napprol)fla:e and mates e,e~ne iess saf(I. Stolll>!nt.l ewn some of tilt frop~roprute an:S unnec:C!SSllry use of antibiotics in pvopll! arid .mlm.m would help greatly In i.low1ng down the spread of rosktJnt bactQrla. This commttmonl to llt..-Jys use a!ltlblot1cs appropmtel:, 100 wfety-only are needed to t.JNt fthen they disease, and to choose tM right antibiotics and to administer thtm In the right way In e.eiy as.-ls kllOMI as anttblotic ste-1rardshlp. DEVllOPING NEW DRUGS AND DIAGNOSTIC IlSTS 4 Bocauw antibiotic ~lsbnct occurs as part of a natural process In i whkh bacteo. evolve, it can be i.lowed but not stopped. llNnfore, WC! will alwa115 need ntN antibiotics to kl!fp up with resktmt bacteria as Yl°i!I as new diagnostk Les~ to track the clevi'lop;nent of roshuncQ. Available at: https://www.cdc.gov/drugresistance/threat-report- 3/6/2018 14 2013/pdf/ar-threats-2013-508.pdf#page=11. Accessed January 9, 2018.

Texas Response- Surveillance Texas Department of State Health Services • Mandatory reporting of certain resistant bacteria • Carbapenem-resistant Enterobacteriaceae • Multidrug-resistant Acinetobacter spp. • Voluntary reporting/submission of additional resistant bacteria • Submitted to ARLN labs • Including carbapenem-resistant P. aeruginosa , carbapenemase- producing Acinetobacter baumanii , and ESBL-producing organisms 3/6/2018 15

Texas Department of State Health Services Antibiotic Resistance Testing Grace Kubin, Ph.D. Laboratory Services Section Director Department of State Health Services 3/6/2018 16