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read the transcript - Antibiotic Awareness

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine HébertRenéeRita:Good morning. My name is Renée Barclay and I’m with NCCID. We’rea partner in I’d like to thank you for joiningus and welcome to this webinar which is presented as part ofAntibiotic Awareness Week. During this one hour session we willhear from three Canadian experts in the field of antimicrobialresistance.We suggest that you listen to the presentation on your computerspeakers however, if you need to, please feel free to listen bytelephone using the toll free number and code listed on the screen. Ifyou are not a presenter, we suggest that you put your phone on muteso that other participants don’t hear you. The upcoming threepresentations will be about twenty minutes in duration. During thepresentation, we invite you to post questions by typing them in thebox on the left of your screen; it’s just in the lower left-hand corner.I would now like to introduce Rita Finley. She’s the SeniorEpidemiologist, Outbreak Management division at the Centre forFood-borne, Environmental and Zoonotic Infectious Diseases. Andshe’s with Public Health Agency of Canada. She will be speaking withus today about the Canadian Integrated Program for AntimicrobialResistance and Surveillance. Welcome, Rita.Hi. Good morning everyone, and thank you very much for joining ustoday. I am going to be giving you a brief introduction to issuesaround the use of antimicrobials in food animals and its contributionto the development and spread of antimicrobial resistance in foodbornebacteria which, as most of you know, can then cause a [incomp– seize? 1:42] in the Canadian population consumption ofcontaminated food products. I will also be giving a quick overview ofthe National Integrated Surveillance Program that monitorsantimicrobial resistance in [incomp 1:54] organisms andantimicrobial use in both the human and animal populations.And like Renee said, I’m a Senior Epidemiologist within the PublicHealth Agency of Canada. And I am also the Lead Coordinator of thehuman component of the Canadian Integrated Program forAntimicrobial Resistance Surveillance, or CIPARS.So, what are the main issues with regards to antimicrobial use inanimals? Both the use of antimicrobials in humans and animals isPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 1

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertconsidered to be a major driver of antimicrobial resistance. Inanimals, there is a widespread use of antimicrobials for differentpurposes. This may be uses for therapeutic purposes to treat disease,however, depending on the treatment and the animal, antimicrobialsmight be given to either a single animal or to the entire herd throughfeed and water, thereby exposing healthy animal to these products.Another purpose of using antimicrobials may be used for growthpromotion to help growing animals digest their food more efficiently,get maximum benefit from it, and allow them to develop into strongand healthy individuals. And be able to then provide enough food forthe current demand among our population.During the use of antimicrobials for growth promotion, theantimicrobials are provided at a very low sub-therapeutic dose overa period of time, which then may lead bacteria to develop resistance.And lastly, they could be used also for prophylaxis to prevent disease.Of concern is the issue that some of the classes of antimicrobials, orsome of the antimicrobials used in animals belong to the same class,or are related to classes that are used in humans, which, in the eventof a human infection with a resistant strain, could limit treatmentoptions and increase the length of hospitalization or the need forhaving to use a more toxic substance.The transmission of resistant pathogens from animals to humanscould be through contaminated food, the consumption ofcontaminated food and/or water which could be, the water couldhave been contaminated through fecal organisms, or feces. And it canalso be through animals to workers and their owners, either directlythrough contact with them or through the environment in which theylive in.So when we speak about increasing concerns of antimicrobialresistance related to antimicrobial use or presence of resistantorganisms in animals, we can classify the risk into two types ofhazards – the direct hazard and the indirect hazard.For the direct hazard, we include those resistant organisms thatinfect humans after food has been ingested or handled. Theseinclude, not only bacterias such as Shigella and [Gabriel 4:45], but weare also talking about Campylobacter and Salmonella. ThePUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 2

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine HébertEnterobacter comes through the organisms that carry resistancegenes, such as generic E.coli, that are part of the Commensal bacteriafamily. These are reservoirs of resistance genes for pathogenicbacteria and can transfer the resistance gene from a resistantbacterium through a pathogen bacterium, directly or via anotherCommensal organism. There are, however, good indicators ofselective pressure of antibiotic usage reflecting the potential forresistance in future infections. And, they act as a reservoir ofresistance. And as the reservoir increases, the plasmid reservoirbecomes larger and enables more frequent horizontal transfer ofresistance to pathogens in bacteria, such as Shigella and Salmonella.So, if you attended the webinar that we had on Monday, DoctorButler-Jones who is the Chief Public Health Officer of Healthintroduced this slide, and I believe some of you are familiar with itfrom other presentations. But this diagram is just a representation,pictorial representation of the epidemiology of antimicrobialresistance in food, and it just represents the complexity of this issue.This public health issue, as you can see, is not as straight-forward asresistance being present in our bacteria, and bacteria in a food item,but is then consumed by a Canadian who then becomes ill with aresistant strain. There are many other factors that can introduce andimpact the development of resistance.This diagram also showcases where in the food system ourantimicrobial is used. As you can see, there are six different areasthat are encased in a circle, and these are areas where antimicrobialsare used either for treating disease, growth promotion, or preventionof disease through the use of prophylaxis, as I mentioned in theearlier slide.In order to have better information on antimicrobial resistance in thefood chain and address this complex issue, the Canadian IntegratedProgram for Antimicrobial Resistance Surveillance, or CIPARS, wasestablished. I will be speaking more about this program in the nextcouple of slides.Since the 1990’s, or a little bit earlier, antimicrobial resistancebecame a priority and a public health concern for severalorganisations and governing bodies around the world. In 1998, thePUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 3

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine HébertWorld Health Assembly Resolution urged members, member statesto develop sustainable systems to detect resistant pathogens tomonitor volumes and patterns of use of antimicrobials, not only onthe animal sector, but also on the human sector. And the impact ofany control measures that are implemented in either population.Later, in 2001, the WHO released the Global Strategy for Containmentof Antimicrobial Resistance. And within this strategy, theyhighlighted the importance of having an inter-disciplinarycollaboration to address antimicrobial resistance appropriately andeffectively.As I mentioned previously, it’s a very [audio shuts down?] not only totake action but also have a representation of all the different sectors.In addition, in Canada in 2002, the report from the AdvisoryCommittee on Animal Uses of Antimicrobials and Impact onResistance in Human Health, provided recommendations on howbest to address AMR. And among the recommendations are these twomain ones, which are to design and implement a national monitoringprogram of antimicrobial use in food animals and implementation ofongoing permanent national surveillance system of same, or arisingfrom food animal production.The national program was to provide the information collectedthrough surveillance on an annual basis through reports,publications, presentations, and be deciding a manner that wouldallow it to support and provide information for human health riskanalysis. integrate the animal health information with humansurveillance initiatives, and have methodologies that would allow itto be comparable to other international [audio] initiatives, such as inDenmat in Denmark and NARMS in the United States. The result ofthe World Health Assembly, WHO guidance and the committee reportand many other recommendations.The Canadian Integrated Program for Antimicrobial ResistanceSurveillance was established in 2002. This program is coordinated bythree centres within the Public Health Agency, in partnership withHealth Canada’s Veterinary Drug Directorate, the Canadian FoodInspection Agency, Provincial Agriculture and Public Health BuddiesAgricultural and Agri-Food Canada, academia and the privatePUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 4

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertindustry.So, the main objectives of this program, or CIPARS, is to provide aunified approach to monitor trends in antimicrobial resistance andantimicrobial use in humans and animals, and to be able todisseminate timely results so that we can have an impact and be ableto determine whether or not there’s any measures that can beimplemented, or any programs that can be implemented to curtail orreduce, I guess, the resistance trends being observed.We also have as an objective to facilitate the assessment of the publichealth impact of antimicrobials used in both humans and animals,and to allow accurate comparisons with other countries that usesimilar surveillance systems, such as Denmark and the United States.So you can see that our objectives match the recommendations thatwere posed by different organizations and reports.And I hope you can see that this diagram on your computer, andbasically, this is, again, a pictorial representation of all the differentprograms that make up CIPARS. And we have two arms to it. Themonitoring of antimicrobial resistance, and data of antimicrobial use.As you can see in this picture, we have different surveillancecomponents to our program that are carried out either by passive oractive surveillance which come together systematically to give us agood overview of the status and trends of AMR and antimicrobial usein both populations. At the bottom of the diagram, and I hope you cansee it clearly, there’s a legend where it shows that those arrows thatare in green are identifying where the methods of data representpassive surveillance. And the yellow arrows represent activesurveillance methodologies.So focussing on the antimicrobial resistance piece of CIPARS, on thehuman side, data is collected through passive surveillance in whichsome of the isolates are submitted by Provincial Public HealthLaboratories through to the National Microbiology Laboratories forsusceptibility testing.As of 2010, we have received a total of a little over 25 000 Salmonellastrains. And in 2010 we changed our testing scheme so that insteadof focussing on all different Salmonella [incomp 11:47] types, we’refocussing mainly on the top Salmonella strains that are related toPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 5

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Héberthuman infections in Canada.On the animal side, antimicrobial resistance information is obtained,again through passive surveillance of sick animals from isolatessubmitted by Veterinary Laboratories. These are animals that nevermake it into the abattoir or are introduced into the retail level. Theimportance of this piece of information is that it can give just aglimpse of potential issues that could be introduced by healthyanimals to consumers. And this piece collects information only onSalmonella.The farm surveillance piece is based on [sentinel incomp12:45..[music from someone’s phone] and we collect E. coli andSalmonella information from these sentinels. The next up in the foodchain is abattoir, which provides information on what is coming infrom farms and entering the food chain. And this component takesplace across federally inspected abattoirs across the country [loudvoices from someone’s phone – Renee makes an announcement,apology to Rita]Okay, so going back to the, let me see, the Salmonellainformation is obtained from chicken and pork samples;Campylobacter from chicken and cattle; and E. coli from chicken,pork, and cattle. And the final component of the AMR surveillance isthe retail piece, which gives us a picture of what consumers are beingdirectly exposed to by bringing it into their homes, and consumption.It consists of sampling from fresh raw meat samples from grocerystores, and sampling consists of chicken and ground beef which aretested for E. coli, Salmonella, and Campylobacter, contamination andresistance patterns – ground beef for E. coli, and pork for both E. coliand Salmonella.And as you can see at the bottom, we also have the antimicrobial usecomponent to our program. And on the human side, we collect theinformation on consumption of oral antimicrobial dispensed byCanadian pharmacies. And this is data that’s being provided by IMSBrogan. It is provided, it’s based on information provided by 5 000pharmacies and is extrapolated to an overall universe of 7 000pharmacies, so it gives us a full picture of what’s being prescribed bypharmacies across the country.PUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 6

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine HébertOnce we’ve obtained information, we classify it using the HealthCanada Veterinary Drug Directorate’s classification of antimicrobials.We analyse it and convert the data to define daily doses.And the farm surveillance component also provides us with aplatform to obtain information of antimicrobial use for swine herdsincluded in this program. And we also have another piece ofinformation that comes through the Canadian Animal HealthInstitute; however it doesn’t provide information on which animalsectors are being prescribed which drugs.So, what have we observed through our surveillance program todate? We have found that chicken isolates demonstrate significantresistance to antimicrobials with certain Salmonella serovarsmirroring certain patterns in chicken and human isolates. As you cansee, between 2002 and 2008 we’ve seen a dramatic increase anddecrease, depending on the Salmonella sero type, across chickensamples obtained from clinical case, abattoir, and retail, and what weare seeing in humans as well. So as of 2004, Heidelberg strains havedecreased on the chicken and human sectors, while SalmonellaEnteritidis has been observed to increase across the chicken samplesand human strains as well.And as you can see here in blue, Salmonella Kentucky is a sero typethat is slowly emerging among the chicken samples that we’ve beencollecting and monitoring since 2003. However, on the human side, itdoesn’t seem to be causing a lot of human infections. However, whathas us concerned is the issue that antimicrobial resistance observedaround, across the Salmonella Kentucky isolates obtained fromhuman infections is mirroring what was being observed from theanimal sector as well.So, as you could see, there’s resistance to all least one antimicrobial.The increase has been observed in both human and chicken isolates,as well as resistance to Streptomycin and Tetracycline which is seento be increasing. And in 2008, having 50% of those Kentucky strainsfrom humans have resistance to this pattern.The other issue that we’ve been able to identify in, through ourprogram is the use of extra-label use of Ceftiofur and resistance tothis antimicrobial in Salmonella Heidelburg. Ceftiofur can be used inPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 7

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertmany animal species, however it’s not labelled for use in chickens inCanada, and is currently being used in the extra-label manner for thecontrol of E. coli in broilers, and it is done through the injection ofthis antimicrobial into the egg. Salmonella Heidelberg, it is notifiableat the national level on the human side. It is found among the topthree serovars in humans since1995, causing diarrhoea, vomitingand fever. And it can be quite invasive, causing septicaemia,myocarditis, extra-intestinal infections, and death. The treatmentconcern is that when there’s resistance to ceftiofur, there is gonna beresistance to Ceftriaxone, which is one of the drugs of choice fortreatment of pregnant women and children.So where else are we seeing resistance to Ceftiofur among our animalisolates? As you can see, among the different components of CIPARS,whether it’s the abattoir component, retail, or the clinical side, we’reseeing mainly the resistance present among chicken isolates. And indiagnostic clinical Salmonella, we’re seeing the majority fromturkeys, but however remember that the diagnostic clinicalSalmonella is seen in sick animals that never make it into the foodchain.And this is just a graph that shows what’s been happening withSalmonella Heidelberg and resistance to Ceftiofur since the beginningof the surveillance program. In 2003 we started noticing a high levelof resistance in Heidelberg infections in humans, and what’s beingpurchased from the retail level in Quebec. And the data was sharedwith industry in that province, and as of 2005 there was a voluntarywithdrawal of this use in the poultry industry. In 2007, however,there was a partial reinstitution of this antimicrobial in the poultryindustry, and as you can see from this graph, there’s been a reemergenceof resistance to Ceftiofur in both Salmonella Heidelbergfrom human infections, and also from E. coli and Heidelberg isolatedfrom chicken retail samples.And as you can see, the incidence rate of persons sick with Ceftiofurassisted Heidelberg is also on the increase in provinces like Quebec,Ontario, and British Columbia.As I mentioned before, we also have information on antimicrobialsthat are dispensed in retail pharmacies in Canada. We have thePUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 8

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertinformation at the provincial levels but we can also summarize it atthe national level. And here’s just a brief overview of what we’vefound for data for 2009. There seems to be quite a variation amongtotal number, total cost of antimicrobials and total consumption ofantimicrobials across the different provinces in the country, withNewfoundland and Labrador having the highest levels ofconsumption and total cost per 1000 inhabitant days, while Quebechas the lowest level of consumption, and B.C. has the lowest level,total cost of antimicrobials.If we compare what’s being dispensed for animals and compared tothe human information that we have, and you can find thisinformation in our 2008 CIPARS annual report, we can see that totalactive ingredients in kilograms of antimicrobials dispensed bypharmacies for human consumption is a total of 197 000 kilograms,while in animals it is 1.6 million kilograms. However, this does notinclude antimicrobials imported for personal use under the personaluse provision of the Federal Food and Drugs acts and regulations,and doesn’t include active pharmaceutical ingredients which aredrugs imported in non-dosage form and compounded by licensedpharmacists or veterinarians, and used in veterinary medicine andused in food animal production.And finally, just another piece or source of information ofantimicrobial use. This is information that’s collected through asentinel farm surveillance program from, through swine herds. Andin 2008, you can see that the only category one antimicrobial use ingrower finisher pig herds used was injectable Ceftiofur. The mostcommonly used antimicrobials, overall, were Penicillins, which wereadministered primarily via drinking water or injection. Macrolideswere the most common antimicrobial administered through feed.And there were five herds that were part of this program in which noantimicrobials were used by any routes in the grower finisherproduction stage.So as I mentioned in the beginning, this program is based oncollaboration not only among the federal levels and also with theprovincial/territorial levels. And in order to make it successful wereally need to have those collaborations in existence, and have aPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 9

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine HébertRenéeRitawonderful collaborating relationship with other governmentagencies, and provincial, and academic, and industry levels.So this slide is just to acknowledge everyone that makes this programpossible and that provides information for us just to keep a goodsense of what is happening across the animal and human sectors, interms of Enteric disease and resistance.And if you need more information on CIPARS, we have our reportsavailable in both English and French at our phac website. And itincludes annual reports, short reports, and certain issue papers thatwe put out based on issues that we have identified as a public healthconcern among our surveillance system. And I don’t know if there’sanyone with any questions, or if I’ve run out of time.We, we’re a bit pressed for time, Rita, but there is one question about,how does Canada’s antimicrobial use compare to use in othercountries?That’s a really good question, and we are able to compare ourinformation with that of the European countries. I’m just gonna pullthat out for you in just a second. So, the European Surveillance andAntimicrobial Consumption puts out information, and I think they’rea year behind so I can speak to 2008 data that we have for Canada tothe European countries. So we’re very similar in levels ofconsumption with Finland and the Czech Republic. The ... I’m tryingto think. We have half the level of consumption that was estimated inGreece. Overall, in 2008 we ranked 14 th out of 31 European countriesthat were able to provide information. And this is in terms ofincreasing levels of consumption. We’re really low compared to thesecountries in terms of consumption of Macrolides, Lincosamides , andStreptogramins; similar for Quinolones. And we were 18 th for ourlevel of Tetracycline consumption and Penicillin consumption. So Ithink we’re, if we compare ourselves to the data that’s available forthe European countries, we’re kind of in the middle of the 31countries that provide information on an annual basis.And I just noticed today that there is a group now that’s gonna beposting data for the United States on levels of prescriptionsdispensed by pharmacies, so we’ll be connecting with them to try toget a sense of, how do we compare for the United States? LatinPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 10

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine HébertRenéeAmerican countries, as far as I know, don’t put out any informationon antimicrobial use, as in the majority of the countries they don’trequire prescriptions for getting access to antimicrobials, so it’sharder to compare ourselves to those countries at this time.Okay. Great! Thank you very much, Rita. We appreciate yourpresentation. And we will now be hearing from Doctor LynoraSaxinger, who is gonna be speaking about reducing antibioticoveruse in hospitals. She is the Associate Professor and Chair ofAntibiotic Stewardship committee at the division of InfectiousDiseases at the University of Alberta. Thank you for joining us, Dr.Saxinger.Lynora My pleasure. Is this coming through okay.It sounds okay to me, yeah.Okay, great. And just to remind people, there’s been a poll put up onthe screen. In my screen it’s in the lower right-hand corner. I’m justcurious as to the audience that I’m addressing because my talk isfairly clinical, and so we’re going from agricultural and veterinary useall the way up to kind of very high-end hospital use. And so I wouldask everyone to go ahead and vote in that poll.And, as mentioned, I have this kind of provocative title ... Oh no. Nowthe poll is in the middle of my screen...and I can’t see my own slides.(laughs) So we’ll wait for a second for the poll to disappear, perhaps.So next slide. How am I advancing here? Okay, there we go.So starting at the beginning, antibiotic use creates antibiotic resistantorganisms. I’ll point out that antibiotic resistance existed well beforepeople did, because microbes have had genetic arsenals to battleother in the field, so to speak. But certainly, using antibiotics is thebiggest driver of antimicrobial resistance today. And the littlepictogram on the right just shows how the population will havesome, potentially have some resistant organisms within the pool,exposing the organisms to the antimicrobials, then result in a finalpopulation that is highly resistant.And, again I can’t see my own slides. I don’t know how to make thepoll go away. [RENEE: Um...I’ll try to get the poll off to the side foryou...there.] That’s somewhat better.So, the collateral damage, of course, of use of antimicrobials isPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 11

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertincreasing resistance in common pathogens, like Strep pneumo andTB, and selection for, and transmission of, ARO strains withinhospitals to vulnerable populations. So, a really great example isVancomycin resistant Enterococci in transplant patients, andClostridium difficile outbreaks in, basically patients throughouthospitals. But the landscape of resistance is really quite complexbecause things that work well to prevent resistance in some bacteriamay in fact exacerbate resistance in others. So the use = resistance.Relationship is not entirely clear cut. And I’m just going to go througha way to classify the relationship, starting with what the bacteria aredoing with our antibiotics.So on the right of the antibacterial cell, and it just has cartoons ofvarious ways that bacteria can get around antibiotics. So they canspit them out using efflux mechanisms so the antibiotic molecule isactually pumped back out of the cell. It can chew them up usingenzymatic degradation. It can also disarm them using enzymaticalterations of the antibiotic structure so it no longer works. And then,what I’ve termed ‘ducking’ is basically – cell wall changes and targetsite mutations of the bacteria, so that the target site of theantimicrobial no longer allows a fit. And, bacteria can also share andexchange their weaponry to defeat antibiotics with conjugation,transduction and transformation, wherein they can exchange geneticmaterial that encodes for resistance genes.And you could break resistance down into: simple, moderatelycomplex, and complex resistance. Simple resistance is basically justdoing the math. Mycobacterium tuberculosis actually infects about athird of the world population, many of whom have latent infectionwhich does not have clinical consequence. But it also causessignificant morbidity, mortality. And it only develops resistance bychromosomal gene mutations at a predictable rate. So, Isoniazid, youget 1 x 10 -6 resistant mutants per cfu. Rifampin, it’s 1 x 10 of a 9 th . Sofor both, it’s about 10 -15 per cloning forming units.And when you look at someone with active TB, they usually havefewer than that M. tb organisms in their infection, and so developinga resistance to both antibiotics will be rare because you need to havea larger population to select for dual resistance. Unless the meds arePUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 12

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertimproperly taken, in which case you can have multiplication of thebacteria and expansion of the numbers with sub therapeuticconcentrations.The moderately complex resistance would be things likeStaphylococcus aureus and Enterococci. I have a picture of a babythere because these strains are born, not made. They don’t developresistance during therapy, with the exception of VancomycinIntermediate Staph aureus, which is fortunately rare. But both ofthese types of organisms can exchange DNA with a variety of otherspecies, so multi-drug resistant strains can circulate, even in theabsence of prior exposure. And that can spread between hospital andcommunity.Going back to Rita’s complicated ecosystem diagram, the flowbetween hospital and community in these particular organisms isdefinitely there. And these actually are often best controlled usinginfection control as well as antimicrobial stewardship. But complexresistance is where our patients will have the most problems, andthis is where there’s a very direct and complicated relationshipbetween use and resistance. So if you use non-fermentative gramnegativebacteria as exemplars of this type of resistance, such asPseudomonas aeruginosa and an emerging pathogen calledAcinetobacter baumanii, intrinsic resistance mechanisms thatactivate on exposure are very common. So Pseudomonas can actuallydo almost everything I showed you in that first cartoon, can reduceexpression of the outer-membrane proteins that will allow entry, soit can block entry. It can activate one or more of several multidrugresistantpumps that efflux a variety of antibiotics so can caneither block entry or spit them out. And it can also increaseproduction of b-lactamases and other native enzymes in response toexposure to an antimicrobial. And these porin and pump mechanismsmake it possible that when you expose the bug to one class ofantibiotics, you can see emergence to other classes as well.And then in addition to the intrinsic mechanisms, gene swapping isvery common in these organisms, and both Pseudomonas andAcinetobacter can readily exchange DNA with multiple other species.And there was a report in, I think in 2007, of an Acinetobacter thatPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 13

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Héberthad basically panned resistant strain in a human infection thatcontained an 86-kb region that encoded 140 determinants that gaveresistance to at least 7 classes of antibacterial agents. And when theyanalysed that segment, it suggested that there had been genesacquired from Pseudomonas, Salmonella, and E. coli, among others.So that’s a bit of a frightening story.So, as doctors looking at these isolates, what are we, what are ouroptions? One thing that’s been tried is combination antibiotictherapy. This works in simple resistance like TB because we justcan’t develop resistance to two agents at once in simple resistance.But in complex resistance, it can co-select resistance. Examples ofthat would be Fluoroquinolone selection for resistance to imipenemin Pseudomonas isolates, and Cephalosporin selection of resistanceto Vancomycin and E. Faecium. So using the drug that might select fora resistance to other agents that might be of potential importance.And combination therapy, as a net approach, has not been shown toreduce resistance of emergence overall. There is a role in someinfections, though.Antimicrobial cycling also seemed like a good idea, but has beenshown to not be useful, at least in the ways that it’s been tried. This iswhere you use a broad spectrum empiric antibiotic for a period oftime, so when you’re starting someone on a very powerful agent, youchoose one agent for maybe three months, and then the next threemonths you suggest that everyone choose a different agent. And thistries to change selective pressure being applied to the residentbacteria, but it doesn’t work. It’s difficult to enforce, there’s variedmicrobiology, resistance patterns, and patient intolerance of drugs,so you can’t use the drug du jour. And the theoretical underpinningsof cycling strategies might be flawed in that we already havemultidrug resistance in our hospitals. Some antibiotic classes canselect for resistance to other classes. And designing a regimen toreduce selection pressure is virtually impossible.So the other option is to stop irritating them. Use antibiotics asneeded to prevent sequelae of serious infections. And there’s threepossible ways that we can reduce antibiotic use, and this is justlogical. Either before therapy, we choose only to treat patients whoPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 14

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Héberthave a true bacterial infection; during therapy, avoid the use ofunnecessary combinations, and unnecessary excess spectrum; andtowards the end of therapy, treat only for as long as is required tocure the infection. That seems very simple but actually it’s morecomplicated in practice. Reducing prescriptions for viral infections inthe community is probably the most important thing overall in termsof volume of use, as shown in Rita’s graph.But what do we do in hospital? Because in hospital is kind of wherethe most ill patients are, the most vulnerable patients are, allconcentrated in a place where we use a tremendous amount ofantimicrobials. So, we know that broad spectrum antibiotics savelives, and delaying appropriate treatment of patients with a range ofserious infections can be fatal. So, withholding antibiotics whileyou’re trying to figure out what’s going on is often inappropriate. Andthis points out the challenges in intervening at the time of acuteillness, because you don’t want to withhold potentially life-savingtherapy.So the point, I think, where we can do some work is rationalizingantibiotic use by shortening duration of therapy when clinicalimprovement is secured. And streamlining to the most targeted,safest choice of antibiotics when culture results are available. Butfrankly, and this is almost embarrassing, there really is a lack of dataon the most appropriate duration of therapy for common infections.Physicians often extend courses beyond clinical improvement just tobe sure, and certainly, most patients don’t experience full resolutionof the signs and symptoms, and inflammatory manifestations of aninfection very early. So although you might have killed all of thebacteria involved in a Cellulitis infection or in a Pneumonia, you stillwill have redness and swelling of the limb, or you still will have chestx-ray chances. And people just are not comfortable leaving patientsoff antimicrobials, because antimicrobials create the feeling of safetyfor everybody.So shortening therapy, what patients truly need, and clinical acumenbecomes an interesting thing to discuss. There’s an underlying beliefthat antibiotics are at worst a neutral therapeutic choice. People feelsafer with them. They don’t think they can do any harm. But, on anPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 15

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertindividual level, they can have side effects, hypersensitivity, rashes,become colonized and then experience the effects of C. diff infection.And, as a society – these are societal drugs because the drug use inone patient affects everybody who might be exposed to that patient’seventual resistance flora – you see emergence and spread ofantimicrobial resistant pathogens. So this belief about the safety ofhaving people on antimicrobials for prolonged courses is ill-advisedand actually potentially dangerous.Now, I’m just gonna remind people that in the past, occasionallypeople would get severe bacterial infections. Actually, I would argue,very commonly because they were more common then. And beforeantibiotics were introduced, people often survived severe bacterialinfections. There’s very eloquent and detailed descriptions in medicaltextbooks from the 1800’s of classic courses of diseases in theabsence of antibiotics. And trying to predict whether patients wouldlive or die, because that was the only role of the physician at the time.This is just a picture from when a newly-minted physicianadministered oxygen to a 16 year old with bacterial pneumonia, andhe recovered, living to the ripe age of 91. And he actually got apublication out of that. He wrote it up and explained the physiology.And people lived without antibiotics in the past.So, how much do we need? When Penicillin was introduced in 1944,there was a whole series of case reports showing things that treatinga hundred patients with Penicillin who had pneumococcalpneumonia. And they said, in general the results were satisfactorywith doses of 10 000 units every 4 hours for one and a half to twodays. And then later, most of the patients, 31, were treated for threeto four days. And as long as there’s no complicating factors, the initialimprovement persisted as a permanent cure.Now, I will admit that, in general, we’ve probably shifted bacterialtolerance of antibiotics up and our bacteria are not as sensitive asthey were back in the 1940’s, but that idea that the initialimprovement persists as permanent cure in the absence ofcomplicating factors, I think, is one that we might might be worthtalking about a little bit more.And then a few brave people have done studies in a very, very illPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 16

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertgroup of patients. So, patients who were in the ICU with ventilatorassociated Pneumonia. So they’re intubated, on a ventilator, ill. Andthey compared 8 vs. 15 days of antibiotics in 401 patients withventilator associated pneumonia that was diagnosed fairlyrigorously, and there was no difference in pulmonary infection,mortality, ventilator-free days, organ-failure free days, and the lengthof ICU stay between the groups.The one comment I would make on some of these papers is that thereis some dependence on which pathogen is present. And so, I don’tthink that you can just have a blanket approach to things. Butcertainly, if a ventilator associated Pneumonia patient can improveafter 8 instead of 15 days of antibiotics, it makes me wonder why somany patients basically remain on antibiotics until they leavehospital.Sorry, I’m just gonna turn that off. ..So basically, I think we usually over-treat. There’s been a few studieson community acquired pneumonia 3 vs. 8 days of Amoxil, and the 3day regimen was equivalent in efficacy to the 8 day regimen, if thepatient substantially improved in the first 3 days. Again, this is notone size fits all, and it requires some follow-up and clinical acumen.This would be considered non-definitive. If you look at their graphs,there was a trend towards better outcomes in the 8 day group, butagain, it depended, I think, on the underlying condition of the patient.And so it supports more studies. But here’s an open question: whofunds studies of using established antimicrobials in a different way ina hospital setting?So there are some consequences of inducing complicated resistance.This is gonna be accelerated cause we’re running short on time. Afew cases from last week; I was on call. So there’s a 33 year old manwith head trauma in a collision, in severe neurologic compromise. Hehad recurrent isolation of Pseudomonas in bronchial secretions, andhe developed a clinical Pneumonia. Before he developed thePneumonia, he’d had a little bit of flirtations with various antibiotics.He’d been put on Ceftazium for a few days. And then when we sawhim, prior to my involvement, he actually had a Pneumonia with aPseudomonas, and he was given Colistin plus Aztreonam, whichPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 17

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertshould be raising red flags with people who are familiar with thistype of therapy. He required a decortication because of an Empyema,he had to have a surgical clean-out of his chest, and he remainedcolonized with this bug. And when it was first isolated, it wassensitive to Aztreonam, and intermediate to Ceftazidime, andsensitive to Colistin, but resistant to all Aminoglycocides,Carbopanems, and Pip Tazo. And then after he was exposed toCeftazidime for four days, just towards the end ofSeptember/beginning of October, we actually induced Aztreonam ofCeftazidime resistance, leaving it susceptible only to a single agent,Colistin, which we are unfortunately having to use more of these daysfor multi-resistant bugs.Another case is a 38 year old man with leukemia who is recentlydischarged from the ward after induction chemotherapy. He wasdoing very well. He was afebrile but he was still neutropenic and sohe was put on oral Cipro and Clavulin as an outpatient. He returnedto the hospital with very severe sepsis requiring massive support,and they started him on Vanco, Pip Tazo, and Tobramycin. We wereasked to see him when his blood cultures became gram negativebacilli, and we actually changed him to Imepenam because we wereconcerned that this arose while he was on Clavulin and Cipro. Andthe susceptibility results, which came back after he died, showed thathis isolate was really susceptible only to Colistin. He had septic shockin spite of maximal support, and after an intra-cerebral bleed relatedto his abscess, care was withdrawn. And so this 38 year old man diedof a multi-resistant Pseudomonas.And a third case from the same week – a 90 year old man who camein with vomiting with tube feeds. Quite unwell, but systematicallystable. And his daughter is his main caregiver and very devoted. Hisurine analysis showed more than 50 White Cells. He was sent homeon oral Cefixime from the Emergency Room. The blood culturesbecame positive for gram negative bacilli. The patient’s family wascalled, they came in and they started outpatient Ceftriaxone becauseapparently, he looked quite well. The patient was actually receivingthe Ceftriaxione when the following result was received. He had an E.coli isolate that was susceptible only to Carbopenems, Colistin, andPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 18

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine HébertAmikacin – so he had an E.S.B.L. E. coli. He’d had no recent infectionsor antimicrobial therapy. He’s been in a healthcare setting for a hipfracture several months before, but that was the only evidentpotential risk for E.S.B.L. acquisition unless he acquired it in thecommunity.So this is not really a brave new world, this world of very resistantmicrobes affecting people in hospital. There’s been a lag in newantibiotic development for resistant gram negatives. So we haveColistin, Aminoglycosides, Tigecycline if it’s not a Pseudomonas. Andthen what? Not so much. And so I put up that picture to remind usthat what we’re looking at is what our children will inherit in termsof resistance.And so after going through all this and thinking about materials forthis talk, I decided that the most practical tactic to reduce antibioticoveruse right now is looking and focussing on duration of therapy.We have to get back in the motive, looking at the patient’s progress todetermine shorter vs. longer courses. We should be getting somestudies going on duration for common infections. If people areunsure about how patients will do if antibiotics are stopped, theyshould see the patient and follow-up to make sure they’re okay. Itmakes really no sense to give 10 to 14 days of antibiotics for skininfections when we know you only need 7 or 8 days to treat mostventilator-associated Pneumonias. We really should be trying topreserve Quinolones because there are no oral options for gramnegatives in the pipeline. And this is kind of a side issue, which I thinkis nonetheless important. We need rapid diagnostics to allow earlierstreamlining of therapies, so that we can reduce the brut of therapygiven at the onset.And so, I’m finishing with this slide, which is how I was trying toconceptualize the risk and benefit in antimicrobial use. When westart off with broad, empiric life-saving therapies in hospital, we’redoing a very good thing. But quite quickly there’s increasing risk ofside effects – adverse events in toxicity that take place – and selectionof resistance and creation of resistance begins to accelerate. At theend, you pretty much have inevitable super-infection with organismsthat are not covered by the broad therapy, and resistant pathogens.PUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 19

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine HébertRenéeAnd so, what we should really be looking at doing is having peoplestop treatment before the risk-benefit crosses and follow the patientfor outcomes. And with that I’m going to close.Thank you very much, doctor Saxinger. It’s really interesting. And,because we’re a bit tight on time, I’m going to hold off on thequestions for now, but I will just mention that the presentations willbe available on our website. They will be translated and available onour website, at for those who want to seethem afterwards. And with that, I will introduce our next speaker,which is doctor Daniel Thirion. And he is Clinical Associate Professorand Pharmacist at the Faculty of Pharmacy, Université de Montréal,and McGill University Health Centre. Hello Daniel. Are you there?Yes I am. Hello everyone. Thank you for inviting me again for thisopportunity, a presentation on Antimicrobial Resistance. First, I wantto thank also the first two speakers, who have done an excellent jobon presenting two important issues in regards to antimicrobialresistance.What I’m going to try to do is present different aspects that wereinitially discussed, and hopefully, this will give a complete view of theissues surrounding antimicrobial resistance. So, actually, I’m justgonna skip the objectives. Initially, what I was going to present wasperspective of the global problem on antimicrobial resistance, thepathways to resistance, and just identify some of the concerns ofresistance in Canada and try to identify the strategies that we’reimplementing to avoid emergence of resistance and how we have toadapt therapy and practice.So usually, when I present antimicrobial resistance to clinicians, thisis a slide I use; it takes about half an hour to explain. And I’ll go overit much quicker. The important concepts that are needed tounderstand, first is the genetic development of antimicrobialresistance, and selection of resistance in a single patient. This isactually very well explained on the FDA video that’s available if youjust look on, through Google, it’s actually pretty easy to find. And so,genetic development of resistance, I think, was well explained on thefirst two presentations, and I won’t go over that. And selection ofresistance actually was also well explained by Dr. Saxinger, so I won’tPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 20

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertgo into that.What’s important also to recognize, is the emergence of resistanceeither through therapy or through a population. And this also was...Ithink I’m putting an emphasis again on this, there are some infectionsand specific species of bacteria who are more susceptible to produceresistance when they are exposed to antibiotics. And we see this incommunity, associated with Streptococcus pneumoniae. Or we cansee this maybe more in the hospital, associated with gram negativeinfections.And as we look toward the other end of the spectrum, we know thatsome bacteria are actually more susceptible to transmission ofresistance than the strains of resistance, and this we see more withMRSAs. So, as already mentioned, for Staph aureus, the mostimportant interventions are infection control. And with otherresistance such as Strep pneumo, the most important interventions isantimicrobial stewardship. And I think, overall, if we want to curbthis, we want to be able to maintain both of these programs, infectioncontrol and stewardship as a collaborative practice, to be able toaddress the whole issue of antimicrobial resistance in ourpopulations.Next point is laboratory testing for resistance, so if you want tounderstand resistance and the problems, you have to be able tounderstand the laboratory aspects of testing for resistance and howyou detect it and interpret those results.And after that, you go on to empiric drug selection according to thoseresults, and adjust therapy according to sensitivity results. We alsoadjust empiric drug therapy according to surveillance studies thatshow us some patterns of resistance in certain areas that are eitherin the hospital or in the community setting.Okay, so that goes over that slide in about...record time.Just so that we understand what’s going on, and again, this waspresented a little bit earlier, I’m gonna go to the next slide. I knowthere’s some lag so I hope this pops up at the same time I see it. If youlook at this graphic that was published about ten years ago, it showsthe mortality rate per 100 000 patient years in the 20 th century. Andwe see that mortality rate associated to infectious diseases was closePUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 21

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertto 50% of all mortality causes. And most of the patients usually diedeither from Influenza followed by complications of Pneumonia, orfrom Tuberculosis.And the decrease in mortality that we saw over the 20 th century ismostly due to three factors. These three factors are: one, personalhygiene (people washing their hands, washing their food before theyeat it); and second is cleaning up our cities (having a good system forevacuation of trash and sewer systems); and our third impact wasthrough development of antimicrobials, mostly for treatment ofTuberculosis and other severe infections.And as we know, the problem is that we do have constant emergenceresistance associated with the use of antibiotics. But we have stoppeddevelopment of new antimicrobials, especially for the gram negativeswhich continues to be an issue.So I’m just gonna show you the next slide over here. So, through theFDA, there was 500 new registrations for new drugs, but only 6 ofthem were for antibiotics. And this is not a guarantee that the Stateswill reach clinical setting use.Okay, so you do have an idea of what the impact is for antimicrobialresistance. We do know that when resistance pops up, it causes adelay in therapy. We delay therapy, then the patients are at higherrisk of complications. They either need more surgical procedures orit leads to more diagnostic procedures to make sure that there’s aresistance or something else is going on. And, at the end of the wholething, patients are at risk of complications, are also at higher risk ofmortality and increased length of stay in hospitals.If you want to convince someone about the impact of antibiotics, thisis actually a pretty good study that was done by our Intensivist inWestern Canada, where you see that if you’re using the rightantibiotic up-front on the first day, for patients who are at high riskfor complications, you will have a much better survival than patientswho are exposed to the wrong antibiotic, so an antibiotic that doesnot cover the pathogen question.This is actually – and I want to make sure that everybodyunderstands this – this is actually very important for patients whoare at high risk of complications or at risk of mortality, and thisPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 22

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Héberthappens mostly in the intensive care unit. We’re not talking aboutpatients who are in the community setting as if their risk ofcomplications and is much slower. So if you don’t get the rightantibiotic you still have a chance of catching the patient two to threedays later, waiting for lab results and adjusting therapy. And this isactually quite important when we’re trying to choose whichantibiotics we’re putting on our therapeutic guidelines.When we’re doing this for Quebec, we’ve decided that foroutpatients, we can use a certain antibiotic and we can expect ahigher level of resistance in the community and still use thatantibiotic because the patients are at lower risk of complications.However, if it’s in the hospital setting, for patients who are very sick,then we will use broader spectrum antibiotics and hopefullystreamline them very quickly once therapeutic results are available.Again, if you want to look over where are the consequences ofantibiotic resistance we can check on, there’s a review here fromMaragakis which shows the risk of death, length of stay, andattributable costs associated with different types of infections. I don’twanna go into too, too many details with this, but you do see a higherrate of mortality associated with resistance. Okay, I mentioned thatdevelopment resistance can be well explained through the video onthe FDA website, so you do have the website here that’s mentioned ifyou want to go and find it.Very briefly, on this next slide, we’re seeing antimicrobial resistancepathways. So again, I think Doctor Saxinger had one of these slides upthere showing a similar pattern of mechanisms of action andresistance. And actually, I come up with the same explanation from afrancophone perspective, I guess. So we have these little Pac Mansthat chew up the antibiotics, we have some that try to pump out theantibiotics, we have other mechanisms that just try to duck bymutating and changing the target site for the antibiotics.Okay. So as I mentioned, for emergence of spread of antimicrobialresistance, some are most importantly spread through contact, andthis is actually important for MRSA. And we just keep on sending outthe same message of washing your hands and respecting infectioncontrol procedures. While in other cases it’s selective pressure onPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 23

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertexposure to antibiotics, and we can see this with Strep pneumo. Andactually, I would like to relate this issue to our, one of the firstspeakers who was showing the amount of antibiotics used in theprovince. And, as you didn’t notice, in Quebec, there was the lowestuse of antibiotics per capita sold in the community. And this, I couldsay, is probably the result of Clostridium difficile, as a lot ofphysicians became aware of the problem with C. diff and the cause ofdeath that was associated with it, and stopped prescribing antibioticsfor indications where it was not really necessary. And the populationwas also aware of this and stopped requesting for antibiotics. And Ithink that shows how much potential we can go and get in the otherprovinces to decrease antibiotic use.Now, that’s one of the aspects, is trying to address the indication ofantibiotics and decrease that aspect. The other impact that we didn’thave was publishing provincial guidelines on how to diagnose, andwhich infections require what kind of antibiotic, for what type ofduration. And that pertains to the second aspect of it, is the durationof therapy.Okay, so, interventions to overcome antimicrobial resistance...this isfor specific patients who get a resistant infection, and we do adjusttherapy for different aspects. For example, in certain situations, inempiric situations, if we suspect resistance, we’ll either add on anantibiotic or choose an antibiotic that has broader spectrum. Thismostly occurs for severe infections for patients admitted into the ER,or going into the ICU. What we might also want to do is increase doseof certain agents, and we have seen this with Amoxicillin where we’reusing higher doses in the community empiric therapy to treat for aStreptococcus pneumoniae.Now, all these adjustments cannot be done vaguely. You do needgood data to make appropriate decisions. And it really depends onwhat kind of resistance we’re seeing, and what is the bug, and whatkind of antibiotic you’re using. So if we’re looking at the Amoxicillin,we have data that supports increased dosing does have some efficacyfor increasing resistance for Streptococcus pneumoniae. However,with MRSA, it’s an alteration of the target site with Penicillins. Evenincreasing doses will have no efficacy, and in those cases, you have toPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 24

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertchange antibiotic classes.There’s other aspects we also use, and this was also brieflymentioned, to prevent emergence of resistance during therapy. Thereis some limited evidence that combination therapy can be effective.We’ve seen this a little bit with Pseudomonas, and we’ve seen thisalso in T.B. or, again, in certain fungal infections such asStreptococcus Meningitis. We will also use some type of interventionwith pharmacological agents when we’re talking about transmissionof resistance between patients or within the institution. So you’veprobably heard of using Puracyn or other agents such as Rifampin or[tmpsmx 58:55] to decolonize patients who are positive with MRSA.unfortunately, these measures are only short-lived; they are effectivein the short term. However, resistance does emerge during thesetypes of interventions in your institutions.Just to get an idea of what’s going on, CCAR was an organization thatwas sort of a central link to all of our organizations who had aperspective on how to address antimicrobial use. Unfortunately theiractivities have stopped recently.But just to show all the aspects of stewardship, it’s actually quitebroad, and it’s not just one type of professional or just one type ofgroup or organization that can address antimicrobial resistance onits own. And that’s why it’s important to have certain champions ineach of the fields to be able to promote appropriate use of antibioticsor infection control, or modify practices to be able to curbantimicrobial resistance. And, I’m not showing a slide on this, butthese interventions do have an impact, and we can definitely see itwith MRSA.If we’re looking down south of the border, in the U.S. the MRSA ratesin their community is increasing and has passed the 50% mark. Soempirically, they do have to cover for MRSA. And we’re still not doingthat in Canada because our MRSA rates vary between areas, but cango between 5% and 30%, depending on the situation.Surveillance methods has already been presented, but in the humanpopulation we’d have two groups that are surveying resistance inCanada: one is called the CAN-R which is mostly a research initiativethat was initiated in Winnipeg; the other one is of course, from ourPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 25

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine Hébertfederal governments, which is The Canadian Nosocomial InfectionSurveillance Program where you can find most of the data.In Québec we have our own groups. One of them is called L’Institutnational de santé publique du Québec, where we do have anantimicrobial resistance committee who is overlooking surveillanceand interventions that have to be performed to curb certain aspectsof resistance that are, that can be a threat to public health.And this is an example of interventions that can be performed to tryto curb antimicrobial use. This is the one that we’re using for ourcommunity practice. In Québec, we have a group that’s called LeConseil du médicament, or now called INESSS, Institut nationald’excellence en santé ... okay, it’s a really complicated thing in French!But what I’m just saying is that we do have guidelines that wedistribute to all health care practitioners who have an issue withantibiotics. So either prescribing it, surveying it, or administrating it,so it’s mostly our nurses, pharmacists, and physicians that arereceiving these guidelines and that are constantly being updated.And I do know that there are other guidelines that exist acrossCanada, including the Bugs n’ Drugs that’s in Western Canada, and forCanada, we do publish another book that’s called The Snippets forSnappy Antimicrobial Therapy. And the reason we do this is becausethe resistance patterns in Canada are different than the resistancepatterns that are in the U.S. or around the world, so that’s why we doneed our local guidelines to be able to chose our antibioticsappropriately, according to the indications.And last but not least, as mentioned from the second talk, isAntimicrobial Stewardship. Here is one of the definitions. But Iwanna point out, and this is actually critical, there is one aspect that’smissing in this and its indications. So it’s making the right diagnosisfor antibiotics. Using antibiotics for viral infections, as you do know,is not necessary. You can use antivirals for viral infections, butantibiotics is not required. And that’s where we’re seeing most of ourimpact in our Stewardship Program in our institutions.The other aspects, of course, are choosing the right antibiotic, at theright dose, given through the right route of administration for theappropriate amount of time. And this is actually to improve outcomesPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 26

Antibiotic Awareness Week, November 2011Rita Finley, Lynora Saxinger, Daniel ThirionTranscription: Marjolaine HébertRenéeand avoid emerging resistance within our institutions and within ourpopulations.So, just a brief review, but I don’t wanna go over this because I knowyou’ve already seen this aspect of what are the goals of AntimicrobialStewardship and its benefits. In Québec, again – I’m sorry to poundyou with Québec stuff, but, and there are excellent examples acrossCanada, especially in Ontario for stewardship, that they’re taking alead on this, but we do have a framework for optimal antimicrobialuse in our institutions, and trying to push forward appropriatesurveillance and intervention methods across the whole province.So just in summary, the messages that I want you to go home withare actually pretty simple. First, wash your hands – don’t get the bugand don’t give the bug. And use antibiotics appropriately. So, whenneeded, for the right one, with the right one, the right dose, and forthe determined amount of time. And I’ll conclude on saying, youshould spread the word – not the disease.So, thank you very much everyone for participating. You do have myslides and I will remain available if you have any questions, eithernow or through the internet, through email.Thank you very much, Daniel. We really appreciate that, and we are abit over so I won’t put it out for any more questions. But as youmentioned, we will have all the slides up on website. They will be translated andavailable in both official languages, so we invite you to go there. Andalso, to check out the resources that we have for healthcareproviders.And finally, we have a survey about today’s webinar. We’d appreciateyour feedback, if you wouldn’t mind just spending just a few minutes.It’s not long, just to tell us what you thought about today’s webinar.Thank you very much. This concludes the Antibiotic Awarenessweek. Thank you for joining us, and have a good afternoon. Bye-bye.END OF RECORDINGPUBLIC HEALTH AGENCY of CANADA//AGENCE DE LA SANTÉ PUBLIQUE du CANADA 27

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