ANTI-MICROBIAL USAGE IN THE COMMUNITY AND RESISTANCE IN E.COLI FROM URINE OF PREGNANT WOMEN IN INDIA Thomas K1, Mathai E1, Mathai M1, Chandy SJ1, Joseph I1, Oommen R1, Mathew J1, Antonisamy B1, Banerjee M1, Cherian S1, Rajaratnam A1 Holloway K2, Sorensen T2 1Rational Antimicrobial Use Study Team, Christian Medical College, Vellore, India 2WHO, Geneva

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INTRODUCTION Increasing resistance to anti-microbial agents Increasing use of antimicrobials Monitoring the relationship an important tool : - to determine the association - to demonstrate need for rational drug use  - to identify target areas for intervention

AIM Phase 1: To establish an integrated surveillance model of anti-microbial resistance and use Phase 2: To develop an intervention to improve rational antimicrobial use and contain resistance.      

METHODS A. ANTIMICROBIAL USAGE Geographical areas: 1. Urban area - Vellore town 2. Rural area - KV Kuppam block Drug usage was studied using two methodologies: 1. Individual Patient Drug Use 2. Bulk Drug Use

1. Individual Drug Use 15 facilities in each area- private practitioners, hospitals and pharmacy shops Monthly visit - structured questionnaire format 30 patients prescribed or dispensed any antimicrobial included per facility Main outcome measure: - Percentage of patients prescribed a specific antimicrobial       

2. Bulk Drug Use 5 pharmacy shops in each area : - purchase and sales data 5 hospitals (PHCs and RUHSA)in rural area : - drug stock register CMC hospital (tertiary care) in urban area : - pharmacy computer system The DDD/1000 patients /month : - calculated for a specific antimicrobial

B. ANTIMICROBIAL RESISTANCE: 100 women recruited per month from antenatal clinics 1. CMC Hospital, Vellore (urban) 2. RUHSA hospital, KV Kuppam Block (rural).   Women symptomatic of UTI - midstream urine cultured Asymptomatic women - deliberate contamination of urine Cultured in Maconkey agar. Susceptibility test in isolates - for antimicrobials used in gram negative infections Primary microbiological outcome : - Percentage of isolates resistant to specific antimicrobials

RESULTS Antimicrobial Usage Pattern 5400 patients (47.3 %) given antimicrobials - from a total of 11,421 patient encounters. 406 patients (7.5 %) given more than one antimicrobial. 2091 patients (38.7 %) had at least one injection The commonly prescribed antimicrobials were: Fluoroquinolones – 14.0 % Cotrimoxazole – 7.1 % Amoxycillin/Ampicillin – 11.4%   Cephalosporins – 5.6 %  

Preliminary Data Analysis of Resistance in E. coli : 535 consecutive E. coli isolated from contaminated urine E. coli resistance determined for specific antimicrobials: Cotrimoxazole – 23.8 % Chloramphenicol – 7.8 % Tetracyclines – 21.0 % Norfloxacin – 3.8 % Ampicillin – 20.1 % Cefalexin – 2.4 % Nalidixic acid – 18.3 % Nitrofurantoin – 0.6%

USE of ANTIMICROBIALS & RESISTANCE of E. coli - in RURAL & URBAN AREAS INDIVIDUAL DRUG USE 20 30 25 15 20 % Drug use 10 % Ecoli resistance 15 10 5 5 F’quinolones Nalidixic acid Tetracyclines Ampi / Amox Cephalexin Cotrimoxazole Rural drug use Urban drug use Rural resistance Urban resistance

USE of ANTIMICROBIALS & RESISTANCE of E. coli - in RURAL & URBAN AREAS BULK DRUG USE 30 600 25 500 400 20 % Ecoli resistance DDD / 1000 patients 300 15 200 10 100 5 Ampi / Amox Cephalexin Cotrimoxazole F'quinolones Nalidixic acid Tetracyclines Rural drug use Urban drug use Rural resistance Urban resistance

INDIVIDUAL patient USE of COTRIMOXAZOLE and RESISTANCE of E. coli - in health facilities RURAL AREA 60 60 50 50 40 40 30 % E.coli resistance 30 % Drug use 20 20 10 10 Aug Sept Oct Nov Dec Jan Pharmacy shop use GP use Hospital use E.coli resistance

INDIVIDUAL patient USE of COTRIMOXAZOLE and RESISTANCE of E. coli - in health facilities Pharmacy shop use GP use Hospital use E.coli Resistance URBAN AREA 1 2 3 4 5 6 Aug Sept Oct Nov Dec Jan % Drug use 10 15 20 25 30 35 % E.coli resistance

BULK USE of COTRIMOXAZOLE and RESISTANCE of E. coli - in health facilities RURAL AREA 200 400 600 800 1000 1200 1400 Aug Sep Oct Nov Dec Jan DDD / 1000 patients 5 10 15 20 25 30 35 % Ecoli resistance Pharmacy shop use Hospital use Ecoli resistance

BULK USE of COTRIMOXAZOLE and RESISTANCE of E. coli - in health facilities URBAN AREA 250 35 30 200 25 150 DDD / 1000 patients % Ecoli resistance 20 100 15 10 50 5 Aug Sep Oct Nov Dec Jan Pharmacy shop use CMC hospital use % Ecoli resistance

INDIVIDUAL patient USE of FLUOROQUINOLONES and RESISTANCE of E. coli - in health facilities RURAL AREA 30 8 7 25 6 20 5 15 % Ecoli resistance 4 % Drug use 3 10 2 5 1 Aug Sep Oct Nov Dec Jan Pharmacy shop use GP use Hospital use Ecoli resistance

INDIVIDUAL patient USE of FLUOROQUINOLONES and RESISTANCE of E. coli - in health facilities URBAN AREA 30 10 25 8 20 6 15 % Ecoli resistance % Drug use 4 10 2 5 Aug Sep Oct Nov Dec Jan Pharmacy shop use GP use Hospital use Ecoli resistance

BULK USE of FLUOROQUINOLONES and RESISTANCE of E. coli - in health facilities RURAL AREA 200 8 150 6 DDD / 1000 patients 100 4 % Ecoli resistance 50 2 Aug Sep Oct Nov Dec Jan Pharmacy shop use Hospital use % Ecoli resistance

BULK USE of FLUOROQUINOLONES and RESISTANCE of E. coli - in health facilities URBAN AREA 200 4 150 3 % Ecoli resistance DDD / 1000 patients 100 2 50 1 Aug Sep Oct Nov Dec Jan Pharmacy shop use CMC hospital use Ecoli resistance

INDIVIDUAL patient USE of AMPICILLIN / AMOXYCILLIN and RESISTANCE of E. coli - in health facilities RURAL AREA 5 10 15 20 25 30 35 Aug Sep Oct Nov Dec Jan % Drug use % Ecoli resistance Pharmacy shop use GP use Ecoli resistance Hospital use

INDIVIDUAL patient USE of AMPICILLIN / AMOXYCILLIN and RESISTANCE of E. coli - in health facilities Pharmacy shop use GP use Ecoli resistance Hospital use URBAN AREA 5 10 15 20 Aug Sep Oct Nov Dec Jan % Drug use 25 30 35 40 % Ecoli resistance

BULK USE of AMOXYCILLIN/AMPCILLIN and RESISTANCE of E. coli - in health facilities RURAL AREA 200 35 30 150 25 DDD / 1000 patients 20 % Ecoli resistance 100 15 10 50 5 Aug Sep Oct Nov Dec Jan Pharmacy shop use Hospital use Ecoli resistance

BULK USE of AMOXYCILLIN/AMPCILLIN and RESISTANCE of E. coli - in health facilities URBAN AREA 40 400 35 30 300 25 DDD / 1000 patients % Ecoli resistance 20 200 15 10 100 5 Aug Sep Oct Nov Dec Jan Pharmacy shop use CMC hospital use Ecoli resistance

Conclusions High levels of antimicrobial use in community - 43.7% Commonly used antimicrobials : Fluoroquinolones - general practice (private sector) Cotrimoxazole - rural hospitals ( mainly public sector) Amoxycillin / Ampicillin - pharmacy shops and general practice (private sector) Antimicrobials with higher resistance in E.coli are : Cotrimoxazole Ampicillin Tetracyclines Nalidixic acid

Resistance levels appear to be similar in both rural and urban areas At Phase I completion, conclusions to be drawn on : - antimicrobial use, resistance and their relationship - the facilities and antimicrobials needing interventions Phase I information can be used : - to plan multidimensional interventions targeting health administrators, providers and consumers (Phase II) The interventions may improve rational antimicrobial use and ultimately control bacterial resistance

A GOOD DOCTOR KNOWS WHAT MEDICINE TO PRESCRIBE… A BETTER DOCTOR KNOWS WHAT NOT TO PRESCRIBE… THE BEST DOCTOR KNOWS WHEN NOT TO PRESCRIBE..!

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