kariuki-1
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http://www.cddep.org/sites/cddep.org/files/kariuki-1.pdfTRANSCRIPT
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ANTIMICROBIAL RESISTANCE IN KENYA; What Surveillance tells us
Sam Kariuki
Kenya Medical Research Institute
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Introduction
• Although no systematic national surveillance is in place, few sentinel studies indicate that problem of antimicrobial resistance is an emerging public health problem
• Over‐the‐counter sales of pharmaceuticals still common in some retail chemists
• Use in animals restricted to commercial farming but in humans issue is critical
• Reliability of data: Quality assurance in susceptibility testing not widespread
e.g. ‐ Use of obsolete methods in AST, modified Stokes, poor quality disks, etc
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Data from sentinel surveillance on antimicrobial resistance in health facilities
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Antibiotic susceptibility for Staphylococcus aureus isolated from wound sepsis
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Antimicrobial susceptibility of E. coli from adults with diarhoeaat Mbagathi District Hospital (MDH) (N=264)
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Prevalence of resistant E. coli strains isolated from PLWHA
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0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2006 2007 2008 2009
E. coli from UTIs
SXT
GEN
CXM
AMC
NIT
NAL
CIP
CTX
Courtesy: Aga Khan University Hospital
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_____________________________________________________________________________________
Minimum inhibitory concentrations (MIC) of each of 10 antimicrobial agents for the E.coli
isolates from children
MIC (ug/ml)
------------------------------------- Resistance
Agent Range Mode MIC50 MIC90 (%of isolates)
ISOLATES FROM CHILDREN (N=168)
Amoxycillin 1-128 128 128 128 74
Augmentin 0.5-64 8 8 32 22
Ceftazidime 0.06-16 0.25 0.25 1 0
Cefuroxime 2-64 8 8 16 42
Chloramphenicol 0.5-64 8 8 64 40
Ciprofloxacin 0.004-1 0.015 0.015 0.03 0
C0-trimoxazole 0.02-64 6.4 2.56 6.4 63
Gentamicin 0.25-32 0.5 1 8 27
Nalidixic acid 1-64 4 4 8 2
Tetracycline 1-128 128 64 128 71
E. coli from children with diarrhoea
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Shigella spp n=112
0102030405060708090
100
AM
PI
SEPT
NA
L
CIP
RO
CEF
TRI
CH
LOR
%
ANTIBIOTICS
2006
2007
2008
2009
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Antibiotic resistance patterns of E. coli, Shigellaand STEC to various test drugs; 2006‐2007
0
10
20
30
40
50
60
70
80
90
100
CIP GEN AM CHL TCY FOS STX
Perc
enta
ge re
sist
ance
Test drugs
E.COLI SHIGELLA STEC
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Staphylococcus aureus, n=282
0
5
10
15
20
25
30
35
40
45
AZITHRO CIPRO NET OXA NITRO
%
ANTIBIOTICS
2006
2007
2008
2009
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Invasive non‐typhoidal Salmonella (NTS)1994‐1996
• Antibiotic MIC range Mode MIC90 %R• Ampicillin 0.5-128 64 64 48• Augmentin 0.5-64 0.5 16 8• Cefuroxime 2-128 8 32 30• Cefotaxime 0.125-16 0.25 2 0• Cotrimoxazole 0.25-64 0.5 32 46• Chloramphenicol 1-32 4 32 26• Tetracycline 0.5-64 64 128 66• Streptomycin 2-128 8 128 49• Nalidixic acid 1-4 1 3 0• Ciprofloxacin 0.015-0.25 0.03 0.125 0
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MICs for NTS, 1997‐2000
Antibiotic MIC range Mode MIC MIC90 %RAmpicillin 0.75->256 >256 >256 65Augmentin 0.5-32 0.75 16 2Cefuroxime 2-128 3 12 28Cefotaxime 0.125-16 0.25 2 0Cotrimoxazole 0.03->32 >32 >32 60Chloramphenicol 2->256 >256 >256 85Tetracycline 0.75-192 1 64 48Nalidixic acid 1->256 3 >256 11Ciprofloxacin 0.006-0.25 0.023 0.125 0
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MICs for NTS, 2002-2006(n=243)
_________________________________________________________Antimicrobial MIC (µg/ml)
Agent Range Mode MIC50 MIC90 % R___________________________________________________________Ampicillin 0.25->256 >256 82 64 48Co-amoxyclav 0.75->256 4 1 16 8Cefuroxime 2->256 >256 8 32 30Ceftriaxone 0.094-16 0.064 0.5 2 0Gentamicin 0.06->256 4 1 8 16Co-trimoxazole 0.064->32 >32 8 32 46Chloramphe 0.19->256 >256 4 32 26Tetracycline 0.064->256 3 16 128 49Nalidixic acid 1.5->2563 3 3 12Ciprofloxacin 0.064-4 0.16 0.06 0.125 0
________________________________________________________
Kariuki et al. J Med Micro 2006; 55:585
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NTS from Kilifi 2002-2005 (n=54)
_______________________________________________________Antimicrobial MIC (µg/ml)
Agent Range Mode MIC50 MIC90 % R_________________________________________________________________
Ampicillin 0.5->256 2 2 4 11Co-amoxiclav 0.38-18 1 1 3 4Ceftriaxone 0.023-0.4 0.047 0.047 0.064 0Gentamicin 0.094->8 0.19 0.25 2 4Co-trimoxazole 0.047->32 0.19 0.19 32 13Chloramph. 0.38->256 2 2 3 6Tetracycline 1.5->256 3 3 4 6Nalidixic acid 1.5-6 3 3 4 0Ciprofloxacin 0.006-0.06 0.016 0.012 0.016 0
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10‐yr Trend in resistance – Rural Kilifi
Trends in resistance during the 12-year study. Chi-squared and p-values, respectively, for trend
by year analysis for resistance were chloramphenicol (χ2= 3.794; p=0.051), gentamicin (χ2=
7.958; p=0.005), co-trimoxazole (χ2= 16.358; p< 0.001) and amoxycillin (χ2= 20.977; p< 0.001).
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Year o f N T S iso la tio n
Perc
ent r
esis
tanc
e
G entam ic in A m ox y c illin Chloram phenic ol Cotrim ox az ole
Kariuki et al. Int. J. Antmicrob Agents 2006; 28:166
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Typhoid fever 2000‐2005Antibiotic MIC range Mode MIC MIC90 %RAmpicillin 0.5- >256 >256 >256 85Augmentin 0.5-4 4 4 0Cefotaxime 0.047-.125 0.125 0.125 0Cotrim 0.019->32 >32 >32 85Chloramphe 2->256 >256 >256 85Gentamicin 0.5-1 1 1 0Tetracycline 1->256 >256 >256 85Nalidixic acid 2->256 12 36 22Ciprofloxacin 0.016- 1.5 0.25 0.5 12
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MICs for Quinolones n=140.
MICs (μg/mL) Mode Range
Non-MDR* Nalidixic Acid Ciprofloxacin MDR S. Typhi Nalidixic Acid Ciprofloxacin
S. Typhi 2 0.016 8 0.25
1-4 0.016 – 0.032 8-16 0.25 – 0.38
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0%
10%
20%
30%
40%
50%
60%
70%
80%
2006 2007 2008 2009
Klebsiella spp resistance patterns
SEPT
AMC
NITRO
NAL
GENT
CEFU
CEFO
CIPRO
Courtesy: Aga Khan University Hospital
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Vibrio cholerae ser inaba, 2005‐2007n=65
% SUSCEPTIBILITY
ANTIBIOTIC % S % I % R NA 96 0 4W 5.7 2.9 88.6C 57.1 34.3 8.6RL 2.9 0 97.1CIP 100 0 0TE 97.1 2.9 0AMP 88.6 2.9 8.5Fx 5.7 0 94.3
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Challenges
• Funding issues versus Government priorities in Public Health a challenge
• Materials e.g. media, antibiotic discs, petri dishes etc inadequate
• Equipment such as autoclaves, incubators and microscopes inadequate
• Collection of specimens not well supervised• Several labs still require training support for their staff in order to undertake quality AST and surveillance.
• National/Regional surveillance still not fully achieved
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Achievements
• Participation in EQAS through WHO/CDC programme annually.
• KEMRI, AMREF, UoN, Kenyatta National Hospital
• Kilifi WT, Gertrudes Children’s Hospital
• Aga Khan Hospital in Nairobi and Mombasa
• Internal QA for each laboratory has been set up – all use CLSI recommended standards for AST including using ATCC QC strains.
• GSS Regional Training has helped to create awareness, regular informal consultation between the laboratories has been ongoing.
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Conclusion• More sentinel sites need to be facilitated to start
surveillance.
• Partnerships between these sites and WHO/CDC will be crucial in providing training and co‐funding activities
• Strengthen local training initiatives by expanding GSS and ASM activities in the region.
• Curriculum reviews at medical schools in Kenya to include emphasis on surveillance and monitoring usage and resistance
• Expanding EQAS and internal QA programs and reviews will play a big role
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24
Thank you!
Thank you!