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TheResistanceProblem PRSP PenicillinResistantStrep pneumoniaeQRSP QuinoloneResistantStrep pneumoniaeMRSA MethicillinResistantStaph aureusVRE VancomycinResistantEnterococciVREinCanada 1993 firstisolated 1997 800casesMRSAinOntario 1992 9000casesResistanceratesdifferdramaticallybetweenCanadaandtheU S TheProblem GraphofGlobalResistancepatterns PrinciplesofAntibioticPrescribing AntimicrobialResistance UnderstandingResistance Darwin stheoryofnaturalselectionMinimumInhibitoryConcentration MIC ClinicalandLaboratoryStandardsInstitute CLSI reportingsystembasedonMIC Susceptible S Intermediate I Resistant R InterpretationofSusceptibilityData InvitrosusceptibilitytestingonlyinvolvesthebugandthedrugAntimicrobialresistancevsclinicalresistanceMICvalueneedstobeconsideredincontextofpatientfactorsTypeofinfectionLocationofinfectionAntibioticdistributionAntibioticconcentrationatsiteofinfection ContributingFactorstoResistance OveruseinhumansMorethan50 ofantibioticsinCanadaareprescribedforviralURTI sAnimalandagriculturaluse Accountsfor50 ofallantimicrobialsUsedforprevention treatmentofinfectionandgrowthpromotionEvidenceofresistantstrainsinlivestock ImplicationsOfResistance TreatmentfailureForcedtousemoretoxicalternativesPossibilityofnoalternateagents e g vancomycin resistantS aureus LongerhospitalstaysForcedtousemoreexpensivealternativesandotherincreasedhealthcarecosts S pneumoniae SpectrumofDiseaseOtitisMediaSinusitisBronchitisPneumoniaMeningitisTreatmentPenicillinCephalosporinsMacrolidesTMP SMXTetracyclinesQuinolones PRSP Prevalence 1980s 2 0 1998 16 0 withupto5 withhigh levelresistance 1999 12 0 2000 12 3 16 9 CMAJ2002 167 8 Figure1 PercentageofPenicillinNon SusceptibleS pneumoniaeinCanada 1988 2007 CanadianBacterialSurveillanceNetwork March2008 PenicillinResistantS pneumoniaeIsolatesOntario1988 1993 2005 CanadianBacterialSurveillanceNetwork March2006 Figure5 Macrolide ResistantPneumococci CanadianBacterialSurveillanceNetwork 1988 2007 CanadianBacterialSurveillanceNetwork March2008 Figure4 PercentageofNon susceptibleIsolatesofS pneumoniaeinGeographicRegionsofCanada 2007 CanadianBacterialSurveillanceNetwork March2008 JAMA1998 279 365 370 941childreninobservationalstudyNasopharyngealcarriageofS pneumoniaedeterminedLowdosesandlongdurationof lactamtreatmentwasassociatedwithincreasingpenicillinresistance PRSP Cause Spread BMJ2002 324 461childreninAustraliaExaminednasopharyngealcarriageofS pneumoniaeLikelihoodofcarryingPRSPdoubledinchildrenwhohadusedabeta lactamintheprevious2months 7daysofantibioticsresultedinhigherPRSPcarriagePRSPpresenteveninchildrenwhohadnottakenantibioticsfor6months likelyacquiredthroughtransmissionfromothers PRSP Cause Spread PenicillinexposureselectsresistancewithS pneumoniaeWidespreaduseofantibioticsselectsforresistantstrains allowingthemtoproliferateandspreadgenestootherbacteria Message 1 PenicillinexposureselectsresistancewithS pneumoniae2 Penicillinresistanceisassociatedwithmulti drugresistance Message 2 QuinoloneResistantS pneumoniae QuinoloneResistantS pneumoniae Figure6 Fluoroquinolone ResistantPneumococci CanadianBacterialSurveillanceNetwork 1997 2007 CanadianBacterialSurveillanceNetwork March2008 Resistant Figure7 Fluoroquinolone ResistantPneumococciinRespiratoryIsolatesfromAdults 64years 1988 2007 CanadianBacterialSurveillanceNetwork March2008 Recommendations quinolonesbereservedfortreatmentfailureorknownresistancestandard lactamtreatmentiseffectiveinsensitiveandintermediateresistantpneumococciArchInternMed 2000 160 1399 1408 PRSP Significance PenicillinexposureselectsresistancewithS pneumoniaePenicillinresistanceisassociatedwithmulti drugresistance3 Resistanceisrelativeandcanbeovercomewithincreasingdosesofpenicillins iftolerated However S pneumoniaeresistancetomacrolidesandTMP SMXishighlevelandcannotbeovercomebyincreasingdosages Message 3 Finland NEnglJMed August1997 Resistance Whatcanbedone Anti infectiveGuidelines IndependentphysicianpanelArmslengthfromgovernment industryFocusonoptimalpatientcareBestavailableevidence includingCanadianreferencesPublished1994 1997 2001 2005 Penicillin ResistanceRatesandPrescriptions CanadianBacterialSurveillanceNetwork 1988 1993 2005 CanadianBacterialSurveillanceNetwork Feb 2006 Erythromycin ResistanceRatesandPrescriptions CanadianBacterialSurveillanceNetwork 1988 1993 2005 CanadianBacterialSurveillanceNetwork Feb 2006 TakeHomeMessages Antibioticsaregooddrugs whenusedproperlyAlwaysconsiderifinfectionisBacterialvsViralTrytouseNOan