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Presentations from NW Russian regions: Arkhangelsk

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

Publicado en: Salud y medicina
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Presentations from NW Russian regions: Arkhangelsk

  1. 1. Spread of antibiotic resistance in Arkhangelsk: challenges, opportunities and strengths T.A.Bazhukova, A.S.Vorontsova, S.Yu Lepeshkin.
  2. 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)
  3. 3. The Arkhangelsk region comprises the following geographical administrative divisions: • 21 districts; • 7 cities that have regional status (Arkhangelsk, Koryazhma, Kotlas, Mirny, Novodvinsk, Onega, Severodvinsk).
  4. 4. 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.
  5. 5. 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
  6. 6. 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
  7. 7. 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)
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. Microbial landscape in the urology unit, 2018, ratio in percentage.
  12. 12. 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
  13. 13. 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)
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 70,0% 30,0% P. aeruginosa sensitive to carbapenems resistant to carbapenems
  23. 23. 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
  24. 24. 10,0% 90,0% Acinetobacter spp. sensitive to carbapenems resistent to carbapenems
  25. 25. 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
  26. 26. 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
  27. 27. • 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.
  28. 28. 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.
  29. 29. 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.
  30. 30. 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.
  31. 31. А Analysis of antibiotic use in Arkhangelsk Regional Hospital Marina Korobeynikova, Head of Clinical Pharmacology Department
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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+
  36. 36. 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+
  37. 37. 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.
  38. 38. The program for efficient use of antibiotics Participants: • Clinical pharmacology department • Laboratory of clinical microbiology • Hospital epidemiology department • Heads of the units, physicians
  39. 39. 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;
  40. 40. 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.
  41. 41. 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)
  42. 42. 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.
  43. 43. АВС analysis • method of breaking down medicinal agents into three groups according to their annual consumption • А -70% • В-20% • С-10%
  44. 44. 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
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. • Marina Korobeynikova • Arkhangelsk Regional Hospital • Head of clinical pharmacology department • KorobeynikovaMV@aokb.ru • 8182 -636217

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