1. 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

2. A GOOD DOCTOR KNOWS WHAT MEDICINE TO PRESCRIBE…
A BETTER DOCTOR KNOWS WHAT NOT TO PRESCRIBE…

3. 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

4. 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.
     

5. 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

6. 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
      

7. 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

8. 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

9. 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 %

10. 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%

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

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

28. Thank You