Presentations from NW Russian regions – gaps and challenges, opportunities and strengths: Arkhangelsk

1. Spread of antibiotic resistance in
Arkhangelsk: challenges,
opportunities and strengths
T.A.Bazhukova, A.S.Vorontsova, S.Yu Lepeshkin.

2. Arkhangelsk Region. General Information
• The Arkhangelsk region is the largest constituent
entity of the Russian Federation in the European
part of Russia
• The size of the Arkhangelsk region (589 913 km²)
exceeds the territory of such large European
countries as France (547 030 km²) and Spain
(504 782 km²)
• According to the Federal State Statistics Service,
the population of the region is 1,165,750
people. (2017).
• Population density — 1,98 people/km2 (2017)

4. The Arkhangelsk region comprises the following
geographical administrative divisions:
• 21 districts;
• 7 cities that have regional status (Arkhangelsk,
Koryazhma, Kotlas, Mirny, Novodvinsk, Onega,
Severodvinsk).

5. Microbiological service in the Region
• Fifteen laboratories at state-owned healthcare
facilities;
• Sixteen laboratories at national network’s state-
funded healthcare institutions (Hygiene and
Epidemiology Centers with affiliated branches and
state-owned healthcare facilities supervised by
national governing structures);
• The number of laboratories has not changed
compared with the previous year.

7. Laboratories performing PCR
1. Arkhangelsk City Hospital No1
2. STI Clinic (in November 2017 merged with AIDS
center)
3. Arkhangelsk TB Clinical Center
4. Arkhangelsk Blood Transfusion Center
5. Arkhangelsk Region Hygiene and Epidemiology
Center
6. Kotlas Central City Hospital
7. Severodvinsk City Hospital # №1
8. Arkhangelsk Central Regional Hospital

8. Laboratory facilities
Type of equipment Number Working lifespan is
more than 7 years
Automated bacteria analyzers for m/o
identification and and sensitivity testing
4 1
Analyzers for hemoculturing 4 1
Devices for anaerobic culturing 11 2
Automated media preparation system 1
Amplifiers for infectious diseases pathogens
identification by PCR in the "real time" mode
10 4
Automated nucleic acids extraction
WorkStations
1
Biosafety cabinets 37 17

9. Microbial landscape in the septic surgery unit , 2018, ratio in
percentage.
28,0%
11,7%
9,8%11,4%
7,8%
4,5%
2,2%
17,3%
7,3%
S.aureus
Klebsiella
Enterobacter
E.coli
Enterococcus
P.aeruginosa
Acinetobacter
Coagulase negative staphylococci
Others (saprophytes)

10. Composition of predominant microflora in the purulent surgery
unit, 2016 – 2018, ratio in percentage
30,3 30,6
28
17,8
16,7
21,5
17,9 18,1 17,3
14,0 13,5
11,4
6,8 7,1 7,8
4,3 5,1 4,5
1,5 1,8 2,2
0,0
5,0
10,0
15,0
20,0
25,0
30,0
35,0
2016 2017 2018
S. aureus, including MRSA
KES group ( Klebsiella,
Enterobacter, Serratia)
Coagulase negative staphylococci
E. сoli, other opportunistic
pathogenic enterobacteria
Enterococci
P. Аeruginosa
Acinetobacter

11. Microbial landscape in the abdominal surgery unit , 2018, ratio
in percentage.
3,6%
18,3%
14,5%
33,3%
8,5%
9,1%
12,7%
S.aureus
Klebsiella
Enterobacter
E.coli and other
enterobacteria
Enterococcus
P.aeruginosa
Coagulase negative
staphylococci

12. Composition of predominant microflora in the abdominal
surgery unit, 2016 - 2018, ratio in percentage
37,5
35,7
32,8
26,8
22,2
13,9
16,5
12,7
9,3
12,8
8,58,8
3,7 4,0 3,6
0,0
5,0
10,0
15,0
20,0
25,0
30,0
35,0
40,0
2016 2017 2018
KES group ( Klebsiella,
Enterobacter, Serratia)
E. сoli, other opportunistic
pathogenic bacteria
Coagulase negative staphylococci
enterococci
P. аeruginosa
S.aureus

13. Microbial landscape in the urology unit, 2018, ratio in
percentage.

14. Composition of predominant microflora in the urology
unit , 2016 – 2018, ratio in percentage
35,7
37,7
31,530,7
28,6
24,6
16,3
11,4
18,0
5,8
2,7
13,0
9,0
4,6
6,0
4,6
1,8 1,5
0,0
5,0
10,0
15,0
20,0
25,0
30,0
35,0
40,0
2016 2017 2018
E.coli
enterococci
KES group
P. аeruginosa
S.saprophyticus
Candida spp.
S.aureus

15. Microbial landscape in the ICU units, 2018, ratio in percentage.
10,0%
17,0%
11,0%
12,3%14,4%
3,7%
7,1%
16,0%
8,5%
S.aureus
Klebsiella
Enterobacter
E.coli
Enterococcus
P.aeruginosa
Acinetobacter
Coagulase negative staphylococci
others (saprophytes)

16. Composition of microflora isolated in the ICU units,
2016 -2018, ratio in percentage
31,8 31,5
28
16,5 15,6 1614,7
10,7
14,413,2 12,3
6,9 7,1
3,8
5,5
3,7
10
0
5
10
15
20
25
30
35
2016 2017 2018
KES ( Klebsiella, Enterobacter,
Serratia)
coagulase negative staphylococci
enterococci
E. сoli, otherpotentially
pathogenicentericbacteria
Acinetobacter
P. аeruginosa
S. aureus, MRSA included

17. Methicillin-resistant staphylococci identified in a
multidisciplinary inpatient hospital, 5 years trend
13,0%
10,0%
6,5%
10,0% 10,0%
27,6% 28,0% 27,4%
30,0%
28,7%
0,0%
5,0%
10,0%
15,0%
20,0%
25,0%
30,0%
35,0%
2014 2015 2016 2017 2018
S.aureus
coagulase negative
staphylococci

18. S. aureus sensitivity to antimicrobials
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
100%
92% 90% 92% 90%
52%
92%
2016
2017
2018

19. Klebsiella spp. sensitivity to antimicrobials
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
90%
70%
80%
50%
45%
30%
90%
55%
70%
50%
30%
25% 2015
2016
2017
2018

20. E. coli sensitivity to antimicrobials
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
100% 95% 98%
88%
65%
55%
87%
2016
2017
2018

21. Changes in gram-negative microorganisms sensitivity to
amoxiclav, 2007 - 2018
0,0%
10,0%
20,0%
30,0%
40,0%
50,0%
60,0%
70,0%
80,0%
90,0%
100,0%
E. coli KES
100,0%
70,0%
80,0%
50,0%
60,0%
20,0%
2007
2012
2017
2018

22. Changes in gram-negative microorganisms sensitivity to
cefoperazone-sulbactam, 2013 - 2018
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
E.coli Klebsiellа spp.
95%
80%
90%
60%
2013
2016
2018

23. P. aeruginosa sensitivity to antimicrobials
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
100%
75% 70%
60% 55%
70%
100%
70% 70% 70%
50%
65%
2015
2016
2017
2018

24. 70,0%
30,0%
P. aeruginosa
sensitive to carbapenems
resistant to carbapenems

25. Acinetobacter genus sensitivity to antimicrobials
0,0%
50,0%
100,0%
тигециклин
100,0% 100,0%
40,0%
30,0%
85,0%
70,0%
10,0% 5,0%
2015
2016
2017
2018
0,0%
50,0%
100,0%
100,0% 100,0%
40,0%
30,0%
85,0%
70,0%
10,0% 5,0%
2015
2016
2017
2018

26. 10,0%
90,0%
Acinetobacter spp.
sensitive to
carbapenems
resistent to
carbapenems

27. Unit
СТХ-М, % /n VIM, %/n MecA, % /n
E.aerogenes E.coli Klebsiella Proteus P.aeruginosa S.aureuus Coagulase
neg.
staphyl
Internal
medicine
unit
2 internal
medicine ward
6,25 /1 - 5,56 /3 - 6,67 /1 13,33/2 -
3 internal
medicine ward
- - 25,00/1 - - - -
4 internal
medicine ward
- - 25,00/1 - - - -
Surgery unit
1 surgery ward - - 9,09 /1 - - - -
2 surgery ward 15,38/4 5,79 /7 12,00/15 1,45 /1 7,69 /3 6,98 /9 2,53 /2
3 surgery ward - - 13,33/2 - - - -
5 surgery ward - - 33,33/1 - - - 33,33/1
Neurosurgery
ward
- 20,00/1 - - - - -
ICU
Critical care 7,41 /2 - 8,28 /14 - 12,50/2 8,33 /2 6,25 /1
Cardiac surgery - - 6,90 /2 - 28,57/2 - 6,67 /1
Urology unit - 1,55 /2 1,56 /1 12,50/1 - 12,50/1 -
Trauma unit 25,00/1 - 12,50/1 - 33,33/1 7,69/ 1 -
Neurology unit - - 3,23 /1 - - - -
Median prevalence for inpatient
dep., %
6,78 1,62 6,86 1,72 7,2 6,22 2,45

28. 4
1 1 1
27
2 1 1
16
2
4
2 11
3 2 2 12
11
1
3
1 1 1
0
5
10
15
20
25
30
СТХ-М
VIM
MecA
2int.ed.ward
3int.medward
4int.medward
1surgicalward
2surgicalward
3surgicalward
5surgicalward
Neurosurgicalward
Intensivecareunit
Cardiacsurgery
Urology
Trauma
Neurology

29. • Prevalence of P.aeruginosa strains containing MBL
genes of VIM group accounted for 7,2%, ESBL
producing enterobacteria (СТХ-М) accounted for
4,05%, MRSA – for 6,22%, and MRCNS - for 2,45%.
• Surgical unit and ICU are the most challenging
regarding resistant genes prevalence in the inpatient
department.
• Analyses of PSI pathogens antibiotic sensitivity
revealed a high level of multi-resistance in the carrier
strains of the genes under study.

30. CHALLENGES
• Growth of antibiotic-resistant strains of
challenging pathogens (CPE, ESBL, MRSA,
MRCNS, MDR-Pseud, MDR-Aci).
• No potential for sustainable identification of
antibiotic resistance genes.
• No awareness raising on AMR issues.
• The use of antibiotics is not hundred percent
efficient (a very long list of antimicrobials is in
use).
• Clinician lacks knowledge on state-of-the-art
information on AMR.

31. Opportunities
• Training in AMR and efficient use of
antimicrobials in medical residency
programs and at advance and upgrade
courses for clinicians.
• When reagents are available we detect, on a
periodic basis, AB resistant genes of
challenging pathogens.
• Equipment allowing determine AB resistance
genes is available.

32. KEY OBJECTIVES
• To enhance public awareness on
antimicrobials use and AMR problems.
• To continue training for specialists as part of
continued medical education program (in all
clinical specialties).
• To provide surveillance of AMR trends and
consumption of antimicrobials.
• To ensure control of the spread of MDR
bacteria.
• To develop mechanisms for containment of
antibiotic resistance.

33. А
Analysis of antibiotic use in Arkhangelsk Regional
Hospital
Marina Korobeynikova,
Head of Clinical Pharmacology Department

34. BED CAPACITY OF THE HOSPITAL
UNIT
# of
beds
Obstetric Unit for pregnancy
pathology at the Perinatal Center 55
Obstetric physiological pregnancy unit
at the Perinatal Center 55
Gynecology unit at the Perinatal
Center 35
ICU at the Perinatal Center 12
Newborn pathology and premature
newborns unit at the Perinatal Center 60
Newborns ICU at the Perinatal Center 18
TOTAL # of BEDS at the PERINATAL CENTER 235
UNIT
# of
beds
1st ICU 6
2nd ICU 10
Adult infectious diseases unit 63
Gastrointestinal unit 20
Pediatric infectious diseases unit 40
Cardiac unit 60
Neurological unit #1 25
Neurological unit #2 25
Neurosurgical unit 30
ICU at the Central Infectious Hospital 6
Hematology unit 30
Cardiovascular Surgery unit 30
Traumatology and Orthopedics unit #1 30
UNIT
# of
beds
Traumatology and Orthopedics unit
#2 30
Complicated cardiac arrhythmias
surgery and pacing unit 20
Thoracic surgery unit 30
Maxillofacial surgery unit 30
Otorhinolaryngology unit 35
Pulmonary unit 20
Rheumatology unit 20
internal medicine unit at Solovetsk
Hospital affiliate 10
Surgery unit #1 30
Surgery unit #2 30
Surgery unit #4 30
Endocrinology unit 20
TOTAL # of BEDS (INPATIENT DEP.) 927

35. Reference items 2016 2017 2018 Dynam
ics
Number of
admitted samples
62 767 67 848 76 593 +13,3
%
Number of
performed tests
111 588 121
275
134
928
+11,3
%
Production
capacity
224 874 239
474
268
297
+12,0
%
Actually
completed
232 300 251
082
287
269
+
14,4%
Laboratory tests performed in
2016-2018

36. Number of microbiological tests performed in the
Archangelsk Regional Hospital facilities and
branches
33
21,5
12,8
9,6 10,2
5,8
18,4
28,3
19,21
12,1
10,8
12,3
5,9
11,4
27,4
19,1
2,9
21,5
14
5,3
9,8
0
5
10
15
20
25
30
35
2016
2017
2018

37. Antibiotic-resistant strains
prevalence
6,4
8,9
14,7
35,4
39,8
30,5
30,2
39,3
0
5
10
15
20
25
30
35
40
45
2011 2012 2013 2014 2015 2016 2017 2018
10,5
14,9 14,6
22,1
16,6
15,6
0
5
10
15
20
25
2011 2012 2013 2014 2015 2016 2017 2018
Klebsiella ESBL +
 MRSA
43,4
26,6
39,6
64
57,5 58,7
31,4
61,3
0
10
20
30
40
50
60
70
2011 2012 2013 2014 2015 2016 2017 2018
E. Coli ESBL+

38. 0
10
20
30
40
50
60
70
80
90
73,7
88,7
83,8
77,7
83,3
20
67,3
52,6
79,3
77,4
38,9
22,2
20
75,4
71,4
59
57,1 60
50
68,7
59,6
2016 2017 2018
Acinetobacter MBL+

39. The program for efficient use of antibiotics is
designed to address the following aspects:
• Enhancement of medical care quality for surgical patients
through reasonable use of AB for treatment and prevention;
• Containment of development and spread of antibiotic-
resistant strains and microоrganisms;
• Enhancement of medical staff competence in the matters of
AB use through development of clear guidelines for
antimicrobial therapy;
• Optimal use of healthcare resources.

40. The program for efficient use of
antibiotics
Participants:
• Clinical pharmacology department
• Laboratory of clinical microbiology
• Hospital epidemiology department
• Heads of the units, physicians

41. The program for efficient use of
antibiotics
• Development, implementation and
evaluation of the effectiveness of measures
designed to prevent unreasonable use of
antimicrobial drugs, by assessing the
adequacy of the indications for antibiotics
prescription;

42. The program for efficient use of antibiotics
• Development/updating of the hospital antibiotic formulary
(logbook);
• Development/updating of the protocols for prevention and
empirical/ targeted infections therapy and their
introduction into the inpatient department clinical practice;
• During 2016-2018 local standards were revised and
introduced;
• Intraoperative antimicrobial prophylaxis in surgery,
traumatology, obstetrics, gynecology;
• Initial antimicrobial therapy in surgery and traumatology;
• Initial antimicrobial therapy of sepsis in neonatology;
• Antimicrobial therapy of pneumonia.

43. The program for efficient use of antibiotics
• Assessment of antibiotic use quality and reporting of
assessment results;
• Surveillance of antibiotic resistance based on data provided
by microbiology laboratory;
• Control over the intensity of antibiotics use (in the inpatient
settings at large or by individual physicians)

44. DDD – defined daily dose
• Standardized unit measure of drug
consumption;
• Average maintenance dose of the medication
when used according to the main indication
in adults;
• Estimated value determined on the basis of
the data on actually applied doses. The data
is obtained by analyzing various medical
sources.

45. АВС analysis
• method of breaking down medicinal agents
into three groups according to their annual
consumption
• А -70%
• В-20%
• С-10%

46. ampicillin
24%
cefazolin
32%
gentamycin
9%
cefoperazone
10%
oxacillin
4%
metronidazole
5%
ciprofloxacin
3%
cefuroxime
2%
benzylpenicillin
2%
amikacin
3%
carbenicillin
1%
cefotaxime
1%
ceftriaxone
1%
ceftazidime
0%
cefepime
0%
meropenem
0%
ofloxacin
0%
cefamandole
0% vancomycin
0%
DDD 2007 Arkhangelsk Regional Hospital.
ампициллин
цефазолин
гентамицин
цефоперазон
оксациллин
метронидазол
ципрофлоксацин
цефуроксим
бензилпенициллин
амикацин
карбенициллин
цефотаксим
цефтриаксон
цефтазидим
цефепим
меропенем
офлоксацин
цефамандол
ванкомицин
ampicillin
cefazolin
gentamycin
cefoperazone
oxacillin
metronidazole
ciprofloxacin
cefuroxime
benzylpenicillin
amikacin
carbenicillin
cefotaxime
ceftriaxone
ceftazidime
cefepime
meropenem
ofloxacin
cefamandole
vancomycin

47. 40,49%
21,19%
6,62%
5,99%
34%
20,46%
6,27%
6,02%
5,47%
35,27%
18,78%
6,55%
6,41%
5,76%
ABC analysis of DDD АМТ on the annual basis–А group
Ceftriaxon
Metronidazole
Ciprofloxacin Ampicilline
sulbactam
2016 2017
2018
Cefazoline

48. 19 524
604
37 311
3 444
1 498 294
18 105
620
30 082
2 799
2 765 275
16 383
647
30 772
2 747
3 251
277
0
5 000
10 000
15 000
20 000
25 000
30 000
35 000
40 000
CEPHALOSPORINS
cefazolin
310
543
1 027
890
1 202
1 593
21 79
0
500
1 000
1 500
2 000
CARBAPENEMS
имипенем меропенем эртапенемIMIPENEM MEROPENEM ERTAPENEM
2016 2017
2018
975
1 113
1 342
617
985
644
4 843
1 417
900
62
5 022
800
0
1 000
2 000
3 000
4 000
5 000
6 000
PENICILLINES
amoxycillin/
clavulanate
ampicillin ampicillin/
sulbactam
benzylpenicillin cefuroxi
me
ceftriax
one
cefepi
me
cefoperaz
one-
sulbactam
ceftazidi
me

49. 0
500
1 000
1 500
2 000
2 500
3 000
3 500
1 2 3
3 288
3 150 3 037
235
59 35
Aminoglycosides
амикацин гентамицинamikacin gentamycin
0
500
1 000
1 500
2 000
2 500
3 000
3 500
1 2 3
277
560
3 270
2 980 2 860
Linkosamides
клиндамицин линкомицинclindamycin lincomycin
0
500
1 000
1 500
2 000
2 500
1 2 3
1 582
2 424
2 193
160 205 159
Glycopeptides, Oxazolidinones
ванкомицин линезолидvancomycin linezolid
1- 2016
2- 2017
3- 2018

50. 50
35
0
10
20
30
40
50
60
Tigecycline
2017 2018
0
1 000
2 000
3 000
4 000
5 000
6 000
2016 год 2017 год 2018 год
214
796
615
2 906 2 945
2 661
5 516 5 331
5 593
Fluoroquinolones
офлоксацин левофлоксацин
ципрофлоксацин
Ofloxacin
Ciprofloxacin
Levofloxacin

51. 92150
88483
82236
4,3
3,8
3,5
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
5
76000
78000
80000
82000
84000
86000
88000
90000
92000
94000
Days of АМТ per 1 treated patient
число дней амт
число дней амт на 1 пациента
2016
2017
2018
Days of AMT
Days of amt per patient

52. • Marina Korobeynikova
• Arkhangelsk Regional Hospital
• Head of clinical pharmacology
department
• KorobeynikovaMV@aokb.ru
• 8182 -636217