Combatting antibiotic resistance 2022

Resistance to antibiotics is a growing public health crisis, especially in countries with fragile health systems and in regions at war. The World Health Organization has estimated that antibiotic-resistant bacteria caused nearly 1.3 million deaths in 2019, a toll that will increase significantly in the coming years if effective action is not taken.

To mark World Antimicrobial Awareness Week 2022 (18-24 November) we present a snapshot of MSF’s recent work on responding to this growing threat. Since many humanitarian settings lack laboratory capacity to diagnose these infections, MSF and partners have developed two new technologies with the potential to dramatically expand the availability of accurate diagnosis—allowing clinicians to then tailor antibiotic treatment accordingly. Other work from diverse contexts describes practices and challenges related to optimizing rational antibiotic use within health facilities and communities. Lastly, several studies characterize the patterns and prevalence of antibiotic resistance among MSF patients, from hospitalized neonates in Central African Republic to acute trauma patients in Haiti and Yemen.

10 result(s)

Journal Article > ResearchFull Text

J Glob Antimicrob Resist. 1 June 2022; Volume S2213-7165 (Issue 22); 00157-6.

M'Aiber S, Maamari K, Williams A, Albakry Z, Taher AQM, et al.

J Glob Antimicrob Resist. 1 June 2022; Volume S2213-7165 (Issue 22); 00157-6.

BACKGROUND
Iraq has suffered unrest and conflicts in the past decades leaving behind a weakened healthcare system. In 2018, Médecins Sans Frontières (MSF) opened a tertiary orthopaedic care centre in Mosul providing reconstructive surgery with access to microbiological analysis.

METHODS
A retrospective cross-sectional analysis of microbiological and clinical data of patients admitted between April 2018 - December 2019.

RESULTS
There were 174 patients who were included in this study; there were more males than females (135 to 38 respectively), and the mean age was 32.6 years. Of the 174 patients, the majority had more than one bacterial isolate detected (n= 122, 70.1%); 141 (81.0%) had at least one multi-drug resistant (MDR) isolate detected during their hospital stay. Staphylococcus aureus (n=197, 48.2%) was the most common organism isolated. Overall, most isolates detected were MDR (n=352, 86%), mostly MRSA (n=186, 52.8%) or ESBL-producing Enterobacterales (n=117, 33.2%). Among patients admitted to the Operating Department (n=111, 63.7%), 81.1% (n=90) were admitted for violent trauma injuries. Patients who had more than one procedure performed per surgery had significantly increased odds of having at least one MDR organism isolated (OR 8.66, CI 1.10-68.20, p=0.03).

CONCLUSION
This study describes a high prevalence of antibiotic resistance in patients with trauma-related wounds in Mosul, Iraq. It highlights the importance of microbiological analysis and ongoing surveillance to provide optimal treatment. Additionally, it underscores the importance of infection prevention and control measures and antibiotic stewardship.

Conference Material > Abstract

Langendorf C

Epicentre Scientific Day 2022. 1 June 2022

BACKGROUND
The Mini-Lab is a simplified and modular bacteriology laboratory being developed by MSF to improve access to microbiology diagnostics and antibiotic resistance surveillance in resource-limited settings. After a first pilot study in Haiti in 2020, this second evaluation aimed to assess the performance and ease-of use of the Mini-Lab integrated in the clinical routine of an MSF-supported hospital which has had no prior access to microbiology.

METHODS
The study was conducted after the implementation of the Mini-Lab in an MSFsupported hospital in Carnot, CAR, along with an antibiotic stewardship program. We included hospitalized patients with successful blood culture sampling on admission or during hospitalization, and who consented to study participation. The bacteria identified from blood culture in the Mini-Lab were shipped to a reference laboratory in Bicêtre hospital, France for identification (ID) and antibiotic susceptibility testing (AST) using reference methods. Laboratory technicians evaluated the usability of the Mini-Lab through repeated ease-of use questionnaires and competency assessment.

RESULTS
Between September 2021 and February 2022, we included 835 patients who had a total of 960 blood cultures. Positivity rate with pathogens was 12.5%. Over 121 pathogens identified in the Mini-Lab, 74 have been tested with reference methods so far and 68 (92.0%) gave ID results concordant with the Mini-Lab with 97.4% agreement to genus. No particular organism-antibiotic combination caused systematic errors on AST. Upon completion of the initial training, the laboratory technicians reported most of the aspects of the Mini-Lab easy to use, except for preparation and reading of ID and AST methods, which were reported to be simple after 3 months of experience. Assessment of the laboratory technicians' competencies after the initial training yielded very high scores (>90%) and 100% after 3 months.

CONCLUSION
The comparison of the Mini-Lab results with the reference methods for ID and AST showed overall very good results. We did not highlight any major malfunction preventing its deployment in other resource-limited countries.

KEY MESSAGE
The performances of the simplified and modular bacteriology laboratory, the Mini-Lab, are overall very good. We did not highlight any major malfunctions preventing its deployment in other fields.

This abstract is not to be quoted for publication

Journal Article > ResearchFull Text

BMC Pediatr. 13 December 2021; Volume 21 (Issue 1); 750.

Nebbioso A, Ogundipe OF, Repetto EC, Mekiedje C, Sanke-Waigana H, et al.

BMC Pediatr. 13 December 2021; Volume 21 (Issue 1); 750.

BACKGROUND
Infectious diseases account for the third most common cause of neonatal deaths. Globally, antibiotic resistance (ABR) has been increasingly challenging neonatal sepsis treatment, with 26 to 84% of gram-negative bacteria resistant to third-generation cephalosporins. In sub-Saharan Africa, limited evidence is available regarding the neonatal microbiology and ABR. To our knowledge, no studies have assessed neonatal bacterial infections and ABR in Central-African Republic (CAR). Therefore, this study aimed to describe the pathogens isolated and their specific ABR among patients with suspected antibiotic-resistant neonatal infection admitted in a CAR neonatal unit.

METHODS
This retrospective cohort study included neonates admitted in the neonatal unit in Bangui, CAR, from December 2018 to March 2020, with suspected antibiotic-resistant neonatal infection and subsequent blood culture. We described the frequency of pathogens isolated from blood cultures, their ABR prevalence, and factors associated with fatal outcome.

RESULTS
Blood cultures were positive in 33 (26.6%) of 124 patients tested (17.9% for early-onset and 46.3% for late-onset infection; p = 0.002). Gram-negative bacteria were isolated in 87.9% of positive samples; with most frequently isolated bacteria being Klebsiella pneumoniae (39.4%), Escherichia coli (21.2%) and Klebsiella oxytoca (18.2%). All tested bacteria were resistant to ampicillin. Resistance to third-generation cephalosporins was observed in 100% of tested Klebsiella pneumoniae, 83.3% of isolated Klebsiella oxytoca and 50.0% of tested Escherichia coli. None of the tested bacteria were resistant to carbapenems. Approximately 85.7 and 77.8% of gram-negative tested bacteria were resistant to first-line (ampicillin-gentamicin) and second-line (third-generation cephalosporins) treatments, respectively. In hospital mortality, adjusted for blood culture result, presence of asphyxia, birth weight and sex was higher among neonates with positive blood culture (adjusted relative risk [aRR] = 2.32; 95% confidence interval [CI] = 1.17-4.60), male sex (aRR = 2.07; 95% CI = 1.01-4.26), asphyxia (aRR = 2.42; 95% CI = 1.07-5.47) and very low birth weight (1000-1499 g) (aRR = 2.74; 95% CI = 1.3-5.79).

CONCLUSION
Overall, 77.8% of confirmed gram-negative neonatal infections could no longer effectively be treated without broad-spectrum antibiotics that are not routinely used in sub-Saharan Africa referral hospitals. Carbapenems should be considered an option in hospitals with surveillance and antibiotic stewardship.

Journal Article > ReviewFull Text

Clin Microbiol Infect. 1 October 2021; Volume 27 (Issue 10); 1414-1421.

Ronat JB, Natale A, Kesteman T, Andremont A, Elamin W, et al.

Clin Microbiol Infect. 1 October 2021; Volume 27 (Issue 10); 1414-1421.

BACKGROUND
In low- and middle-income countries (LMICs), data related to antimicrobial resistance (AMR) are often inconsistently collected. Humanitarian, private and non-governmental medical organizations (NGOs), working with or in parallel to public medical systems, are sometimes present in these contexts. Yet, what is the role of NGOs in the fight against AMR, and how can they contribute to AMR data collection in contexts where reporting is scarce? How can context-adapted, high-quality clinical bacteriology be implemented in remote, challenging and underserved areas of the world?

OBJECTIVES
The aim was to provide an overview of AMR data collection challenges in LMICs and describe one initiative, the Mini-Lab project developed by Médecins Sans Frontières (MSF), that attempts to partially address them.

SOURCES
We conducted a literature review using PubMed and Google scholar databases to identify peer-reviewed research and grey literature from publicly available reports and websites.

CONTENT
We address the necessity of and difficulties related to obtaining AMR data in LMICs, as well as the role that actors outside of public medical systems can play in the collection of this information. We then describe how the Mini-Lab can provide simplified bacteriological diagnosis and AMR surveillance in challenging settings.

IMPLICATIONS
NGOs are responsible for a large amount of healthcare provision in some very low-resourced contexts. As a result, they also have a role in AMR control, including bacteriological diagnosis and the collection of AMR-related data. Actors outside the public medical system can actively contribute to implementing and adapting clinical bacteriology in LMICs and can help improve AMR surveillance and data collection.

Journal Article > ResearchFull Text

JAC Antimicrob Resist. 6 September 2021; Volume 3 (Issue 3); dlab140.

Acma A, Williams A, Repetto EC, Cabral S, Sunyoto T, et al.

JAC Antimicrob Resist. 6 September 2021; Volume 3 (Issue 3); dlab140.

BACKGROUND
Antibiotic resistance (ABR) is recognized as an increasing threat to global health. Haiti declared ABR an emerging public health threat in 2018, however, the current surveillance system is limited. We described the microbiological data from a Médecins Sans Frontières trauma hospital, to increase knowledge on ABR in Haiti for similar facilities.

METHODS
A retrospective cross-sectional analysis of routine microbiological data of samples taken from patients admitted to the inpatient ward or followed up in the outpatient clinic of the trauma hospital from March 2012 to December 2018. Resistance trends were analysed per isolate and compared over the 7 year period.

RESULTS
Among 1742 isolates, the most common samples were pus (53.4%), wound swabs (30.5%) and blood (6.9%). The most frequently detected bacteria from these sample types were Staphylococcus aureus (21.9%), Pseudomonas aeruginosa (20.9%) and Klebsiella pneumoniae (16.7%). MDR bacteria (32.0%), ESBL-producing bacteria (39.1%), MRSA (24.1%) and carbapenem-resistant Enterobacteriaceae (CRE) species (2.6%) were all detected. Between 2012 and 2018 the number of ESBL isolates significantly increased from 3.2% to 42.9% (P = 0.0001), and resistance to clindamycin in MSSA isolates rose from 3.7% to 29.6% (P = 0.003). Two critical WHO priority pathogens (ESBL-producing CRE and carbapenem-resistant P. aeruginosa) were also detected.

CONCLUSIONS
Over a 7 year period, a high prevalence of MDR bacteria was observed, while ESBL-producing bacteria showed a significantly increasing trend. ABR surveillance is important to inform clinical decisions, treatment guidelines and infection prevention and control practices.

Conference Material > Abstract

Langendorf C

Epicentre Scientific Day 2021. 10 June 2021

BACKGROUND
Antibiotic resistance (ABR) in children is responsible for high mortality, especially in low-income countries. Strengthening the rational use of antibiotics (ATBs) and improving access to quality ATB are important factors in the fight against ABR. This study described ATB use in pediatric medical settings and in select communities in Niger and Uganda in order to identify constraints and possible opportunities for improvement.

METHODS
Descriptive study with mixed qualitative and quantitative methods in 4 different public health facilities in Niger and Uganda. Quantitative data were collected retrospectively from the consultation and inpatient records of all patients who consulted or were hospitalized in the study facilities on the 1st or 15th day of the month, between January and December 2019. Semi-structured interviews and focus groups were conducted among healthcare personnel and caregivers.

RESULTS
In Niger, ceftriaxone, alone or in combination with gentamicin, accounted for approximately 60% of first-line prescriptions in referral hospitals. Amoxicillin accounted for approximately 70% in peripheral structures. In Uganda, the most common ATB prescribed for in-patients was injectable ampicillin+gentamycin (26.6%), and oral amoxicillin-clavulanate (46.8%) for out-patients. In both countries according to those interviewed, practitioners faced numerous constraints. These were principally the lack of nursing staff, unavailability of ATBs, and limited financial means of families. Self-medication was reported as a widespread practice for economic reasons. In Uganda, health care providers reported facing multiple pressures to prescribe ATBs, from caregivers as well as from drug company representatives. Caregivers interviewed reported struggling to give ATBs at home to their children and the need for adapted pediatric formulations.

CONCLUSIONS
In Niger and Uganda, the lack of health care personnel, the unstable availability of essential ATBs, limited financial means and self-medication lead health care professionals to adapt ATB prescriptions. Limiting the spread of ABR will necessitate multiple different interventions and development of laboratory capacities.

KEY MESSAGE: In Niger and Uganda, the lack of health care personnel, the unstable availability of essential ATBs, limited financial means and self-medication lead health care professionals to adapt ATB prescriptions.

This abstract is not to be quoted for publication.

Journal Article > ResearchFull Text

Nat Commun. 19 February 2021; Volume 12 (Issue 1)

Pascucci M, Royer G, Adamek J, Al Asmar M, Aristizabal D, et al.

Nat Commun. 19 February 2021; Volume 12 (Issue 1)

Antimicrobial resistance is a major global health threat and its development is promoted by antibiotic misuse. While disk diffusion antibiotic susceptibility testing (AST, also called antibiogram) is broadly used to test for antibiotic resistance in bacterial infections, it faces strong criticism because of inter-operator variability and the complexity of interpretative reading. Automatic reading systems address these issues, but are not always adapted or available to resource-limited settings. We present an artificial intelligence (AI)-based, offline smartphone application for antibiogram analysis. The application captures images with the phone's camera, and the user is guided throughout the analysis on the same device by a user-friendly graphical interface. An embedded expert system validates the coherence of the antibiogram data and provides interpreted results. The fully automatic measurement procedure of our application's reading system achieves an overall agreement of 90% on susceptibility categorization against a hospital-standard automatic system and 98% against manual measurement (gold standard), with reduced inter-operator variability. The application's performance showed that the automatic reading of antibiotic resistance testing is entirely feasible on a smartphone. Moreover our application is suited for resource-limited settings, and therefore has the potential to significantly increase patients' access to AST worldwide.

Journal Article > ReviewFull Text

Trop Med Int Health. 16 January 2021; Volume 26 (Issue 5); 504-517.

Nair MM, Mahajan R, Burza S, Zeegers MP

Trop Med Int Health. 16 January 2021; Volume 26 (Issue 5); 504-517.

OBJECTIVES
To explore the current evidence on interventions to influence antibiotic prescribing behaviour of health professionals in outpatient settings in low‐income and lower‐middle‐income countries, an underrepresented area in the literature.

METHODS
The systematic review protocol for this study was registered in PROSPERO (CRD42020170504). We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) for studies relating to antibiotic prescribing of health professionals in outpatient settings in low‐income and lower‐middle‐income countries. Behavioural interventions were classified as persuasive, enabling, restrictive, structural or bundle (mix of different interventions). In total, 3,514 abstracts were screened and 42 studies were selected for full‐text review, with 13 studies included in the final narrative synthesis.

RESULTS
Of the 13 included studies, five were conducted in Vietnam, two in Sudan, two in Tanzania, two in India and two in Kenya. All studies were conducted in the outpatient or ambulatory setting: eight took place in primary health centres, two in private clinics and three in pharmacies. Our review found that enabling or educational interventions alone may not be sufficient to overcome the ingrained incentives to link revenue generation to sales of antibiotics, and hence, their inappropriate prescription or misuse. Bundle interventions appear to be very effective at changing prescription behaviour among healthcare providers, including drug sellers and pharmacists.

CONCLUSIONS
Multi‐faceted bundle interventions that combine regulation enforcement with face‐to‐face education and peer influence may be more effective than educational interventions alone at curbing inappropriate antibiotic use.

Journal Article > CommentaryFull Text

J Antimicrob Chemother. 10 April 2019; Volume 1 (Issue 1); dlz002.

Kanapathipillai R, Malou N, Hopman J, Bowman C, Yousef N, et al.

J Antimicrob Chemother. 10 April 2019; Volume 1 (Issue 1); dlz002.

Médecins Sans Frontières (MSF) has designed context-adapted antibiotic resistance (ABR) responses in countries across the Middle East. There, some health systems have been severely damaged by conflict resulting in delayed access to care, crowded facilities and supply shortages. Microbiological surveillance data are rarely available, but when MSF laboratories are installed we often find MDR bacteria at alarming levels. In MSF’s regional hospital in Jordan, where surgical patients have often had multiple surgeries in field hospitals before reaching definitive care (often four or more), MSF microbiological data analysis reveals that, among Enterobacteriaceae isolates, third-generation cephalosporin and carbapenem resistance is 86.2% and 4.3%, respectively; MRSA prevalence among Staphylococcus aureus is 60.5%; and resistance types and rates are similar in patients originating from Yemen, Syria and Iraq. These trends compel MSF to aggressively prevent and diagnose ABR in Jordan, providing ABR lessons that inform the antibiotic choices, microbiological diagnostics and anti-ABR strategies in other Middle Eastern MSF trauma projects (such as Yemen and Gaza).

As a result, MSF has created a multifaceted, context-adapted, field experience-based, approach to ABR in hospitals in Middle Eastern conflict settings. We focus on three pillars: (1) infection prevention and control (IPC); (2) microbiology and surveillance; and (3) antibiotic stewardship.

MSF Science Portal

Combatting antibiotic resistance 2022

Linked Items

The antibiotic resistance patterns shown in an acute trauma hospital in Aden, Yemen from 2018 to June 2021

The challenge of antibiotic resistance in post-war Mosul, Iraq: An analysis of 20 months microbiological samples from a tertiary orthopaedic care centre

Integration of an all-in-one bacteriology laboratory (Mini-Lab) in an MSF hospital: evaluation in Carnot, CAR

When first line treatment of neonatal infection is not enough: blood culture and resistance patterns in neonates requiring second line antibiotic therapy in Bangui, Central African Republic

AMR in low-resource settings: Médecins Sans Frontières bridges surveillance gaps by developing a turnkey solution, the Mini-Lab

Prevalence of MDR bacteria in an acute trauma hospital in Port-au-Prince, Haiti: a retrospective analysis from 2012 to 2018

Practices and challenges related to antibiotic use in paediatrics in Niger and Uganda

AI-based mobile application to fight antibiotic resistance

Behavioural interventions to address rational use of antibiotics in outpatient settings of low‐income and lower‐middle‐income countries

Antibiotic resistance in conflict settings: lessons learned in the Middle East