Antimicrobial resistance

and susceptibility testing

 History
Nobel Lecture, December 11, 1945
Sir Alexander Fleming
The Nobel Prize in Physiology or Medicine 1945

“It is not difficult to make microbes resistant to

penicillin in the laboratory by exposing them to
concentrations not sufficient to kill them, and the
same thing has occasionally happened in the body…
…and by exposing his microbes to non-lethal
quantities of the drug make them resistant.”
 Objectives
• What is antimicrobial resistance
• Why antibacterial resistance is a concern
• How anti-bacterials work
• Mechanisms of resistance to antibacterials
• Indian scenario
• Strategies to contain resistance
• Summary
 Antibiotic Resistance

Defined as micro-organisms that are not inhibited

by usually achievable systemic concentration of
an antimicrobial agent with normal dosage
schedule and / or fall in the minimum inhibitory
concentration (MIC) range.

Antibiotic Resistance (DR)

= MIC / MCC > Toxic Plasma Concentration
 Antibiotic Resistance

Some microorganisms may ‘born’ resistant,

some ‘achieve’ resistance by mutation or some

have resistance ‘thrust upon them’ by plasmids

Some are born great, some achieve greatness

or some have greatness thrust upon them
 Resistance in microbes is a natural
phenomenon
• Resistance is unresponsiveness to
antimicrobial agents in standard doses
• A natural biological unstoppable
phenomenon
• Resistance is generally slow to reverse or
irreversible
• All antimicrobial agents have the potential
to select drug-resistant subpopulations of
microorganisms
 Myths of Antibiotic Resistance
1. Drugs (antibiotics) cause organisms
antibiotic resistant.

2. Antibiotic resistant organisms are

more virulent
 Truth
• Antibiotics select out the resistant strain
• Faulty use of antibiotics or widespread use of
antibiotics increases the probability of such
selection.
• Antibiotic resistant strains appear to be more
virulent because we cannot kill them or stop
their growth.
Timeline of Antibiotic Resistance
Why resistance is a concern
Treatment failure

Increased mortality

Community spread

Increased burden on
health system

Huge economic impact

Burden on healthcare costs

 Determinants
of Antimicrobial resistance
 Factors of Antibiotic Resistance
Drug Related
Environmental Factors
Factors Patient Related
Factors

Antibiotic
Resistance Healthcare
professional
Related Factors
Policy related
factors
 1. Environmental Factors
• Widespread use of antibiotics in animal husbandry
and agriculture and as medicated cleansing products
• Huge populations and overcrowding
• Rapid spread by better transport facility
• Poor sanitation
• Increases community acquired resistance Awareness
• Ineffective infection control program about
hygiene and
sanitation
 2. Drug Related
• Over the counter availability of antimicrobials

• Counterfeit and substandard drug causing sub-

optimal blood concentration

• Irrational fixed dose combination of

antimicrobials
Policy
• Soaring use of antibiotics Decision at
Higher level
 3. Patient Related

• Poor adherence of dosage Regimens

• Poverty
• Lack of sanitation concept
• Lack of education
Patient
• Self-medication
Counseling,
• Misconception Awareness
Program
 4. Health-care professional Related

• Poor clinical practice: Inappropriate use of

available drugs
• Increased empiric poly-antimicrobial use
• Overuse of antimicrobials
• Inadequate dosing
• Lack of current knowledge and training
 4. Policy Related
• In India, around 5% of GDP is spent on health out
of which public health sector contributes to 0.9%
and a major portion of the remaining is by the
private health sector.

• Around 80% share of private health sector

contribution comes from out of pocket
expenditure mostly for medicines.

• In private sector, many of the doctors are poorly

trained or unlicensed.
Public/Private Spending on Healthcare
 Strategy of Containment
Antibiotic Resistance

Evolutionary Faulty Use of

Process Antibiotics

Hospital Acquired Hospital Environmental

Antibiotic Resistance Community Acquired
Antibiotic Resistance

Empirical Use Definitive Use

Use of antimicrobials before
pathogen responsible for a particular
illness or the susceptibility to a
particular antimicrobial is known
 Possible solutions
• Discover new drugs faster than emergence of
resistance

• Rationalize the use of available antimicrobial

agents

• Prevent emergence of resistance by reducing

selection pressure by appropriate control
measures

• Promote discovery, development and

dissemination of new antimicrobial agents
 New Antibiotic Development
• Only 15 antibiotics of 167 under development had a new
mechanism of action with the potential to combat of
multidrug resistance.

• Lack of incentive for

companies to develop
antibiotics.
 Hope is not exhausted….yet
• Phage therapy
• Use of the lytic enzymes found in mucus and saliva
• Agents that target type IIA topoisomerases
• Antimicrobial peptides (AMPs), lipopeptides
(AMLPs)  target bacterial membranes, making
it nearly impossible to develop resistance (bacteria
would have to totally change their membrane
composition).
• Synergistic therapy with herbal drugs and
antibiotics
 Possible solutions
• Discover new drugs faster than emergence of
resistance

• Rationalize the use of available antimicrobial

agents

• Prevent emergence of resistance by reducing

selection pressure by appropriate control measures

• Promote discovery, development and dissemination of

new antimicrobial agents
 Judicious Use of Antibiotics
• Can only contain antibiotic resistance
• Cannot eliminate the possibility of
antibiotic development as resistance is
an evolutionary process
• Weak surveillance and regulatory system is also an
important determinant of antimicrobial resistance.
Samples are generally tested only when patients fail
to respond to common treatments.

• Paucity of data at national level makes it difficult to

understand the magnitude of the problem and
various factors responsible for emergence of
antimicrobial resistance.
 Who’s Work?

Microbiologist
Bacterial
sensitivity test
and find out
the possible
causes of Physician
development
Treat Infection
 Who’s Work?

Microbiologist

Advise the proper

and adequate
antibiotics with
Physician
balancing the
economy of
hospital Pharmacologist
Indian scenario
Price trends for selected antibiotics
Sale of Antibiotic in India
Antibiotic sales in India by states
Prescribing determinants of antibiotics
• Meta analyses of the drug susceptibility results of various
laboratories in India reveal an increasing trend of development of
resistance to commonly used antimicrobials in pathogens like
• Salmonella,
• Shigella,
• Vibrio cholerae,
• Staphylococcus aureus,
• Neisseria gonorrhoeae,
• N. meningitidis,
• Klebsiella,
• Mycobacterium tuberculosis
• Metallo- β- lactamases (MBL) are the enzymes that mediate resistance to
carbapenems. MBL producing P. aeruginosa are emerging as important
causes of nosocomial infection. Prevalence of MBL producing organisms
ranges from 7-65% in India

• A recent study in Sikkim, India found that MRSA was seen in 111out of 291
clinical specimens (38.14%) of S. aureus and 41 out of 196 carrier screening
nasal samples (20.92%) of S. aureus and overall a total of 152 isolates of S.
aureus from 487 specimens (31.21%) were found to be methicillin resistant
(Tsering et al 2011)

• Methicillin Resistant Staphylococci constituted 4.16% of the S. aureus strains

in a study conducted among children in an urban community in Nagpur,
India. (Chande et al., 2009)

• Studies carried out in Delhi and Vellore, with support from World Health
Organization during 2003-2005 suggested a very high use of
flouroquinolones in the community as compared to other antimicrobials.
• Multi-resistant enterobacteriaceae due to the production of extended
spectrum β-lactamases (ESBL) have become very common in India.

• Various studies in South India highlighted the drug resistance pattern like
Multidrug resistant Extended-Spectrum β-Lactamase Producing Klebsiella
pneumoniae, Ciprofloxacin resistant Salmonella enteric serovar Typhi,

 Emergence of vancomycin-intermediate staphylococci

 Fluoroquinolone resistance among Salmonella enteric serovar Paratyphi A

 Pseudomonas aeruginosa and Acinetobacter baumannii resistant to

ceftazidime, cefepime and ciprofloxacin
• The resistance spectrum of pathogens varies in different regions.

• Therefore local resistance patterns have to be known for appropriate

antimicrobial use.

• there is no national database on surveillance of use of antimicrobials in

the community
 Major activities

Governance Establishment of national alliances against AMR

Designation of national focal points in MoH

Constitution of multisectoral National Steering Committee

Regulatory Development and application of standard treatment

guidelines
in health and veterinary sectors
Discourage non-therapeutic use of drugs in animals
Restrictions on over-the-counter sale of antimicrobial agents

Capacity Surveillance of antimicrobial use and resistance

Training prescribers for rational use of antimicrobials
building
Reducing disease burden and infection control
Undertaking operational research

Community Educating for adherence to recommended regimens

Discouraging self-prescription
participation
Challenges
 Lack of veterinary capacity
• Only 34,500 veterinarians are employed for field services
against the required 67,000, based on animal population
and geographic coverage.

• Only 3,050 veterinary scientists are available for teaching

and research, compared to proposed requirement of 7,
500.

• The biggest dearth is in the realm of veterinary technicians

and support staff, where the 52,000 actively employed
meets less than 20 percent of the need
(Planning Commission of India 2013).
• Strengthening of Surveillance Data
• Standard Operating Guidelines
• Improvement in antibiotic prescription practices
• Over the counter sale of antibiotics
• Poor sanitation, endemic infections, malnutrition
• Limited public awareness and government commitment
• Lack of coordination and fragmentation of effort
• Perverse incentives.
Possible reasons for Antibiotic overuse
• Lack of microbiology facilities
• Doctors prescribing antibiotics to any patients with a
fever, taking it as a sign of bacterial infection
• Patient expectations
• Desire of pharmacists and some doctors to make a
profit from drug sales
• The public’s lack of knowledge about the
(in)appropriate use of antibiotics
 Antibiotic Use in Animal Husbandry
• little is known about the use of antibiotics in animal
husbandry in India

• Antibiotics are also added to feed to promote growth

• No government regulations exist to control antibiotic

use in domestic animals in India.

• precise impact of agricultural antibiotic use on

resistance levels in the general population is not known
• Suresh and colleagues (2006) tested the prevalence and antibiotic-
resistance patterns of Salmonella in eggs in South India (Suresh et
al.2006). Salmonella bacteria were found in 7.7 percentof 492 eggs
tested. The bacteria were thentested for susceptibility to 10
common antibiotics, and 100 percent of strains were found to be
resis- tant to four different antimicrobials: ampicillin, neomycin,
polymyxin-B, and tetracycline.

• Singh and colleagues (2007) examined Salmonella isolates from

horses, donkeys, and mules kept either on equine farms or by low-
income individuals (Singh et al. 2007). Nearly all isolates were
resistant to three or more antibiotics, with 91 percent resistant to
sulfamethoxazole, 71 percent to tetracycline, and 68 percent to
doxycycline.
• Singh and colleagues (2009) examined 111 isolates from
equids and found that all were resistant to at least one
antibiotic, and 89 percent were multidrug resistant (Singh et
al. 2007). High levels of resistance were even found to
antibiotics not used for the horse family.
• Singh (2009) examined antibiotic resistance among 267 strains
of enterococci isolated from horses (and related animals) in
North India (Singh 2009). Vancomycin resistance was found in
80.2 percent of strains, and 99.3 percent were esistantto five
or more antimicrobials.
• Levels of resistance to individual antibiotics were
extremely high: cefdinir(96.5 percent), oxacillin
(90.6 percent), cefotaxime (89.1 percent),
ampicillin (88.4 percent), cloxacillin (88.4
percent), and cotrimazine (87.3percent).
• Antibiotic resistance to E. coli serogroup O157 in
cattle stool in West Bengal was also examined
(Manna et al. 2006). Ten of the 14 strains tested
were resistant to at least one antimicrobial, and
eight strains were multidrug resistant. E. coli
resistance was high to the most frequently used
antibiotics in the region: oxytetracycline,
gentamicin, co-trimoxazole, and ampicillin.
Recent developments
Approaches that are applicable in India
Increased use of vaccines that reduce disease and,
therefore, the demand for antibiotics

Improved infection control, by hygiene and sanitation

drive

Education and public awareness campaigns for providers

and consumers

Increasing the number and use of good-quality

diagnostics to better target antibiotic use

Addressing supply chain constraints and failures to

improve the quality of drugs on the market,
1) Track rates of veterinary antibiotic use,
resistance, and residues through a nationwide
surveillance and monitoring system
2) Change incentives to discourage unnecessary
antibiotic use in animals
3) Educate farmers, veterinarians, and consumers
on the dangers of antibiotic resistance
4) Phase out the sub-therapeutic use of antibiotics
in animals
 Surveillance System for monitoring
antibiotic resistance
• Identification of pathogens/diseases of public
health importance
• Creation of network of Antibiotic
Susceptibility Testing (AST) or methodology for
microbial identification and AST
• The laboratories will perform AST using
standardized methods Strengthen Quality
Systems in the network laboratories
• Invasive Bacterial Infection Surveillancewas funded by the United States Agency for
International Development (USAID) through the Indian Clinical Epidemiology Network
(IndiaCLEN) (IBIS) projectIndia Clen (Indian Clinical Epidemiology Network) quality data on
AMR in pathogens like pneumococcus, H.influenzae across the country

• IIMAR (Indian Initiative for Management of Antibiotic Resistance) launched in March 2008,
with WHO support, by a consortium of NGOs to promote prudent use of antimicrobials

• INSAR (Indian Network for Surveillance of Antimicrobial Resistance) a network of 20

laboratories in the private as well as public sector across the country to generate quality data
on AMR

• National policy for containment of antimicrobial resistance 2011 is the recent development
and welcome step by Ministry of Health and Family Welfare, Government of India which
address the intervention strategies required and the steps for formulation and
implementation of a standard antibiotic policy.

• Integrated Disease Surveillance Project The Ministry of Health and Family Welfare initiated the Integrated
Disease Surveillance Project (IDSP) in 1998 with funding from the World Bank.
 Chennai Declaration—A Roadmap to Tackle the
Challenge of Antimicrobial Resistance-2012
1) to evaluate the extent of antibiotic usage in the veterinary practice and
the indications of use (prophylaxis,treatment, or growth promoter)
2) to regulate antibiotic usage in the veterinary practice
3) to ascertain and monitor the prevalence of resistant bacteria, especially
important zoonotic food-borne bacteria in animals and food of animal
origin to quantify the rate of transfer of medically relevant resistance
genes and resistant bacteria from animals to humans.
4) to regulate monitoring of residues of antibiotics in food of animal origin
and study the role of antibiotic residues in food towards development
of resistance
5) to formulate/implement proper regulations for observance of
withholding or withdrawal periods between the use of antibiotics and
animal slaughter or milking to avoid residues of antibiotics in milk and
meat.
 Take Home Message
• Target definitive therapy to known pathogen
• Treat infection, not contamination
• Treat infection, not colonization
• Know when to say “no” to Vancomycin,
Carbepenems and Cephalosporin IV Generation
• Isolate Pathogen
• Break the chain of contagion – Keep your hands
clean.
• Start simple bed side test: Gram stain,
microscopy