JAC Advance Access originally published online on October 2, 2007
Journal of Antimicrobial Chemotherapy 2007 60(6):1193-1194; doi:10.1093/jac/dkm380
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Meeting report |
Meeting report: Messages from Moscow—the BSAC at the ninth IACMAC International Congress on Antimicrobial Therapy
1 Health Informatics Centre, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK 2 Springfield House, Breinton, Hereford HR4 7PB, UK
* Corresponding author. Tel/Fax: +44-1432-342767; E-mail: Janemsymonds{at}aol.com
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Abstract |
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The organizing committee of the Russian Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy invited an international delegation of representatives, including nine BSAC members, to contribute to their ninth congress in Moscow at the end of May 2007. The event demonstrated the value of comparing experience in the context of an educational meeting and how efficient organization can overcome potential communication problems when simultaneous audio and slide translations are used to best effect.
Keywords: antibiotics , hospital infections , antimicrobial resistance surveillance
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Introduction |
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Relations were cordial indeed when BSAC and ESCMID delegates joined the ninth Russian Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy (IACMAC) in Moscow on 30 May to 1 June 2007.
The programme was broad in scope but focused inevitably on the challenges of microbial evolution and resistance. Russian and international speakers, representing enormous collective expertise and commitment, addressed some 1000 participants by means of simultaneous audio and slide translations.
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Resistance problems |
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The accelerating pace of some forms of antimicrobial resistance was reviewed by Richard Wise, who identified the problems as a major threat to world public health. He commented that increasing resistance to cephalosporins in Gram-negative pathogens in Europe might soon preclude routine hospital use of these antimicrobials for empirical therapy and surgical prophylaxis. Surveillance data in Russian ICUs over the past 5 years, included in Mikhail Edelstein's presentation, indicated a 2–4-fold increase in resistance to third-generation cephalosporins in Enterobacteriaceae, with just over half producing extended-spectrum ß-lactamases. Disturbingly, carbapenem resistance in Pseudomonas had doubled over the study period, standing now at ~60%.
The complex relationships between reduced antibiotic prescribing and resistance were reviewed. Peter Davey noted that antibiotic consumption in Russia was the lowest out of 25 European countries and there may be no coincidence that ß-lactam resistance rates in Russian respiratory pathogens remain relatively low. Multicentre studies in 2003–05, described by Roman Kozlov, President of the IACMAC, showed that ampicillin resistance in Haemophilus influenzae was a modest 4.6%; only 1.2% of Streptococcus pneumoniae were penicillin-resistant and a further 6.9% showed intermediate susceptibility. Nevertheless, concern remains that respiratory infections are the commonest cause of premature death in Russia.
Resistance in Mycobacterium tuberculosis presents special problems in Russia. Vladimir Mishin reported that multidrug resistance rates at initial presentation varied from 8% to 17% in various localities; however, drug-resistant mutants were detected in the sputum of over 50% of untreated patients and accumulation of mutations accounted for resistance rates of 28% to 50% in relapsed patients.
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Reporting and surveillance of resistance |
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Monitoring resistance requires consistently reliable data. Ian Morrissey expressed confidence in UK surveillance systems as long as efforts to minimize inter-laboratory variation are maintained.
Peter Appelbaum was concerned about the extent of unrecognized glycopeptide resistance in Staphylococcus aureus, stressing that laboratory methods must be able to detect intermediate glycopeptide resistance. Since routine automated and disc tests are unreliable, brain heart infusion (BHI) agar incorporating 3 mg/L vancomycin should be used to screen for heterogeneous glycopeptide resistance, if Etests are not feasible.
The limitations of routine susceptibility tests were also included in Mark Wilcox's presentation on coagulase-negative staphylococcal infections, where planktonic organisms in biofilms can compromise the reliability of in vitro tests. In similar vein, Andrei Dekhnich, in a wide-ranging review of chronic infections, noted the potential for ß-lactamases to accumulate in biofilms and so inhibit antibiotic activity.
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Evolving pathogens |
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Epidemic dispersal of organisms in various localities may be influenced by antibiotic prescribing practices. Giuseppe Cornaglia described how international differences in macrolide use, rather than overall consumption, may select distinct resistance genotypes in ß-haemolytic streptococci, which are reflected in different resistance rates and mechanisms. Mark Enright described how multilocus sequence typing of S. aureus showed that epidemic hypervirulent 80/81 strains, which circulated before the introduction of flucloxacillin, had acquired resistance genes and were re-emerging as community-acquired methicillin-resistant S. aureus (MRSA) with the capacity to produce Panton-Valentine leucocidin (PVL).
New presentations of evolving bacteria require revised approaches to therapy. Marina Morgan gave a comprehensive review of clinical experience of community MRSA, including in vitro evidence for adjunctive therapy with both intravenous and inhaled immunoglobulin to control hypotension in necrotizing pneumonia caused by PVL-producing S. aureus. It was reassuring to note that antimicrobial therapy is usually unnecessary in patients with localized skin abscesses (<5 cm diameter), where drainage alone is sufficient.
Enhanced virulence has also been a feature in recent UK outbreaks of Clostridium difficile ribotype 027. Mark Wilcox explained how pathogenicity could be attributed to prolonged toxin production, and how, in severe disease, this enhances transmissibility.
An exception to the gloom about the future of antimicrobials was described by Anna-Maria Geretti in the context of highly active antiretroviral therapy for HIV, where as a result of improving treatment strategies, triple-class resistance had fallen from 15% to 8% between 1999 and 2004 in the UK. Clinical success and prevention of viral rebound require that compliance should exceed 95% of all doses; although new formulations have greatly simplified medication and improved safety, there is still a need for even better tolerability to facilitate long-term adherence.
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Strategies to control resistance: prescribing guidelines |
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An inherent theme of the meeting was the need to preserve the utility of current antibiotics, given the prevailing pessimism on the prospect of new agents. The roles of prescribing guidelines and interventions were closely scrutinized. Some 35 000 copies of the third edition of evidence-based ‘Practical Guidelines on Anti-infective Chemotherapy’ for Russia had been published and were discussed by Sergey Kozlov and Nikita Afanasiev.
There has been an international proliferation of guidelines for managing hospital-acquired pneumonia but Robert Masterton cautioned on the limitations of many randomized clinical trials used in systematic reviews. In the context of community-acquired pneumonia, Igor Berezniakov provided evidence in support of ß-lactam monotherapy in non-severe infections and for conversion from intravenous therapy to oral after 3 days in responsive patients.
Erwin Brown summarized the BSAC Working Party report on Appropriate Antibiotic Prescribing in Hospitals, emphasizing the design limitations of many published studies—only 19% of 350 publications on hospital interventions reviewed were considered suitable for inclusion in the working party analysis. Although the incidence of multidrug-resistant Gram-negative bacilli and C. difficile can be influenced by restrictive antibiotic policies, there remains a need for more comprehensive evidence from interrupted time studies in multiple hospital sites.
Peter Davey pointed out two problems with current information on the impact of prescribing interventions in routine hospital practice. First, most information about impact on microbial outcomes concerns outbreak management strategies. Second, only one study had investigated the impact on clinical outcomes of reduction of ‘unnecessary’ antibiotics in hospital patients. He advocated large-scale, well-designed studies which could be conducted over 1–2 years in order to identify more precisely where reduction in antibiotic prescribing might influence resistance without compromising clinical efficacy.
The importance of using current agents effectively in critical care patients was reviewed by Robert Masterton, who stressed how increased doses and infusion times in serious Gram-negative infections could minimize resistance as well as improve clinical responses.
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Conclusions |
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The meeting moved on, largely in Russian, with a wide-ranging programme, including bioterrorism, sexually transmitted diseases in Russia and therapy of surgical infections.
It memorably demonstrated the value of international cooperation in the context of an educational meeting, where effective organization admirably overcame any potential for communication problems.
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Transparency declarations |
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None to declare.
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