Newsletter Vol. 29 No. 3

The APUA Global chapter network includes voluntary chapters in 66 countries working to improve antimicrobial access and use.

Following our recent reports of APUA Chapter network activity, APUA recognizes the following Chapters for their leadership in APUA's global campaign to contain antibiotic resistance.

Obituary: Dr. Alexander Nanuashvili

Moisés Morejón, M.Sc.
Manuel Fajardo Hospital
APUA-Cuba President

APUA-Cuba recently took part in two large-scale conferences on antimicrobial use issues, both within Cuba and throughout the region of Latin America. The first conference was the National Workshop on Antibiotic Resistance, which was sponsored by APUA-Cuba and took place in the Cuban municipality of the Isla de la Juventud from October 13 to October 15, 2011. Over 100 representatives from 11 hospitals and research institutions throughout the country were present, holding symposia, panel discussions, and round table discussions focused on raising national awareness of the issue of antibiotic resistance and proposing counterstrategies. The participating institutions summarized their findings into a document called the Nueva Gerona Declaration on Antimicrobial Resistance.

The Nueva Gerona Declaration took as their motto the slogan of World Health Day 2011 – “Si no actuamos hoy, no habría cura mañana (No action today, no cure tomorrow).” The Declaration called all Cuban scientists and health professionals to work together to promote, implement, and oversee programs and government policies geared towards the rational and prudent use of antibiotics. It also emphasized necessary steps such as: 1) promoting education about antibiotic resistance among healthcare professionals as well as in the patient population, 2) improving laboratory capabilities and diagnostic technology, 3) scrutinizing and regulating the use of critically important antibiotics, 4) collaborating between and within healthcare facilities and their subdivisions (e.g. pharmacy, clinical laboratories, microbiology laboratories), and 5) promoting preventative measures such as hand hygiene.

Delegates at the National Workshop on Antibiotic Resistance
(left to right) Zuleica Gali, Estrella Alvarez, Gilda Toraño, Dianeliz Quiñonez, Rosa Salup, Yamila Puig, Tersilia Garcia, Deflin Alvarez, Robin Rodriguez, Fidel Espinosa, Miguel Blanco, David Leon, Moisés Morejón, Jorge Perez, Armando Caballero, Orlando Valdes, Ing Antonio Rodriguez


APUA-Cuba also attended the workshop “Antimicrobials for Veterinary Use,” sponsored by the Cuban Ministry of Public Health, and gave the first lecture there on “The Global Landscape of Infectious Disease: the Situation in Cuba.” Dr. Moisés Morejón (APUA-Cuba President) spoke about the close relationship between human and animal health and the rise in foodborne illness caused by Staphylococcus, especially those caused by multidrug-resistant staphylococci (MRSA) found in both food animals and the food industry personnel who work with them. He emphasized that the misuse of antibiotics in agriculture and food animal production is contributing to the danger of food animals becoming reservoirs of MRSA and other resistant bacteria.

Dr. Ana Granda (of the National Center for Nutrition and Food Hygiene) spoke about the need for surveillance to predict the emergence of resistant strains of bacteria around the world, and Dr. Marieta Sonali (also of the National Center for Nutrition and Food Hygiene) spoke about the emergence of foodborne disease as a growing global health problem and the need for improved food safety policies “from farm to fork” throughout Latin America. Dr. Emigdio Lemes (Drug Registration Office of the Institute of Veterinary Medicine) introduced his newly approved national project entitled “Procedures for the Responsible and Prudent Use of Antimicrobials in Veterinary Medicine in Cuba,” which proposes a ban on antibiotics as growth promoters in food animals as well as a ban on using human antibiotics in animal production. The workshop culminated with the founding of a sub-chapter of APUA-Cuba, APUA-Cuba Veterinary, to develop guidelines for the appropriate use of antibiotics in humans and animals.

APUA-Cuba has worked tirelessly throughout 2010 and 2011 and has established five sub-chapters in different parts of the country. Today, their membership is 1070 members and still growing. (Back to top)

Gustavo Lopardo, M.D.
Prof. Dr. Bernardo Houssay Hospital
APUA-Argentina President

A brief communication by APUA-Argentina entitled “Antimicrobial Stewardship Programs in a Developing Country: the Epidemiological Barrier” was recently accepted by the Pan-American Journal of Public Health (the official publication of PAHO) and is pending publication. The authors are Dr. Gustavo Lopardo (APUA-Argentina President) and his colleagues from the Hospital Prof. Dr. Bernardo Houssay and the Instituto Sacre Coeur, both in Buenos Aires.

The paper describes the process of developing an antibiotic stewardship program (ASP) in a 140-bed university hospital in Argentina. The authors recognize the benefits of an established ASP – improved clinical outcomes through reduced emergence of resistance, limited drug-related adverse effects, and limited healthcare-acquired infections. In Phase 1 of ASP development (2007-2008), the investigators implemented strict restriction policies (requirement of an infectious disease physician’s approval before any attending physician can prescribe certain antibiotics) as well as supplemental policies. In Phase 2 of development (2008-2009), the investigators stopped using restriction policies and relied only on supplemental policies of antibiotic stewardship, such as having pharmacists review prescriptions every day, giving feedback about antibiotic usage to physicians, facilitating bedside discussion about antibiotic therapy between physician and patient, and implementing the active presence of three ID physicians throughout the hospital for six hours a day.

Comparing antibiotic usage between Phase 1 and Phase 2 of ASP development revealed that some antibiotics were prescribed significantly less in Phase 2, some antibiotics were prescribed more, and some exhibited no change. The antibiotics prescribed more during Phase 2 were mostly given in the ICU in response to multidrug-resistant infections. It seemed that despite implementing both core and supplemental policies of antibiotic stewardship, other factors were capable of worsening and spreading the problem of antibiotic resistance – such as invasive measures and infection prophylaxis under inadequate hygiene standards.

The investigators concluded that infection control is most successful when it integrates vigilant hygiene (to prevent the survival and transfer of resistant bacteria) with individual assessments of a hospital or clinic’s circumstances, which might call for additional measures such as patient isolation and staff cohorting. They also acknowledged that hospitals in developing countries may lack the infrastructure to implement such measures consistently and effectively, and recommended that health authorities in those countries should promote antibiotic stewardship programs and other infection control measures. Look for the full text of Dr. Lopardo’s article and detailed study methods in the Pan-American Journal of Public Health. (Back to top)

Emma Keuleyan, M.D., Ph.D.
Medical Institute of the Ministry of the Interior

Dr. Emma Keuleyan and Research Team:
Department of Clinical Microbiology, Medical Institute - Ministry of the Interior

APUA-Bulgaria Coordinator

Dr. Rossitza Vatcheva-Dobrevska (Head of the National Reference Centre for Healthcare-Associated Infections) and Dr. Emma Keuleyan (APUA-Bulgaria President) gave an overview of infection control measures being implemented in Bulgaria. The incidence of healthcare-associated infections (HAIs) dropped from 12.7% in 2007 to 11.2% in 2008, and 10.2% in 2009. Over the past five years, the recorded incidence decreased by approximately 3%. From 1999 to 2009, the incidence decreased by approximately 10% (21.1% to 10.2%). In a national point prevalence survey conducted in 2006 among 23 acute-care hospitals in Bulgaria, the overall prevalence rate of HAI was 2.43%. Highest prevalence rates were found in intensive care units (15.2%) and surgical wards (4.1%). Of all HAIs, the most common types were surgical site infections (43.18%), pneumonia (27.27%), urinary tract infections (20.45%), and primary bloodstream infection (9.09%). Dr. Keuleyan cites lack of resources within current practice to handle AMR within hospitals.

Poster publicizing World Health Day 2011
Captions: Let's Stop Antimicrobial Resistance! ESBLs (broad-spectrum B-lactamases) cause resistance towards combinations of antibiotics - let's stop them!



APUA-Bulgaria shares national responsibility with the Ministry of Health, the National Center for Infectious and Parasitic Diseases (NCIP), the National Reference Center for Healthcare-Associated Infections (NRC-HAI), and the National Centre for Public Health and Information (NCPHI) for infection control activities. Bulgaria has also participated in a series of ECDC surveys of HAIs, such as the European Clostridium difficile infection surveillance network project (ECDIS-net), as well as a national campaign for hand hygiene. The hand hygiene campaign included an evaluation of existing resources and standards within hospitals as well as a survey of patient knowledge. For World Health Day on April 7, 2011, APUA-Bulgaria collaborated with the Bulgarian Association of Microbiologists and the Medical Institute of the Ministry of the Interior to produce a poster about broad-spectrum beta-lactamases (ESBLS).

Over the next few years, Bulgaria will focus on implementation of the Medical HAI Standard, the Program for HAI Prevention and Control, and the control of antimicrobial resistance. Goals include harmonization of national practical standards for infection prevention and control with European standards. Practical implementation in health care facilities will include measures for improving patient and personnel safety, containment of HAIs and AMR, and a better understanding of the scope and consequences of HAIs in the medical community and society. Future activities include participation in the ECDC European Point Prevalence Survey of HAI and Antimicrobial Use in European Acute Care Hospitals for 2011-2012, and the introduction of the new ECDC protocols for active HAI surveillance in hospitals to allow participation in the ECDC HAI-NET. (Back to top)


Arjana Tambic Andrasevic, M.D., Ph.D.
Zagreb University Hospital for Infectious Diseases
APUA-Croatia President

APUA-Croatia has seen rates of MRSA decrease from 23% in 2006 to 15% in 2010. Incidence of MRSA also decreased from .66/1000 bed days in 2007 to 12/1000 bed days in 2010. At the same time, rates of P. aeruginosa have been continually high (26% in BSI and 12% in clinical isolates) and carbapenem resistance has increased (34% in 2010). Dr. Smilja Kalenic (National Committee for Nosocomial Infection Control) and Dr. Arjana Tambic Andrasevic (APUA-Croatia President) report that though there are several active infection control activities occurring in Croatia, resistance levels are still high in hospitals. While all hospitals in Croatia have infection control committees and infection control nurses, Dr. Kalenic and Dr. Andrasevic note that not all have satisfactory operating infection control teams. Other areas for improvement include outcome indicators, antibiotic consumption in hospitals, antibiotic stewardship programs, and the lack of national intervention strategies to support local infection control team efforts.   

Poster disseminated by APUA-Croatia and partners for a national hand hygiene campaign


Within Croatia, many strategic partnerships have evolved. The Croatian Committee for Antibiotic Resistance Surveillance collaborates with the Croatian Ministry of Health and Social Welfare (MHSW) Reference Center for Antibiotic Resistance Surveillance at the University Hospital for Infectious Diseases. Croatia has also developed an extensive network of microbiology laboratories, and with the foundation of the APUA chapter in 2003, surveillance activities have expanded to antibiotic consumption. Activities related to antibiotic resistance control are coordinated by the Interdisciplinary Section for Antibiotic Resistance Control (ISKRA), an MHSW intersectorial coordination mechanism (ICM). The ICM’s establishment in 2006 brought together key organizations dedicated to ABR control, including APUA-Croatia, the Croatian Committee for Antibiotic Resistance Surveillance, and the National Committee for Nosocomial Infection Control. This collaborative group developed the ISKRA national guidelines on MRSA control and surgical prophylaxis.

Croatia participated in a national hand hygiene campaign after the Croatian Minister of Health signed the WHO pledge regarding HAI in 2009. This campaign is being implemented in 37 out of 43 acute care hospitals in Croatia. Croatia also began a campaign targeting hospital antibiotic use in 2010, on the recommendation of the ECDC. Various national symposia are also held to commemorate European Antibiotic Awareness Day and Hand Hygiene Day. APUA-Croatia also takes part in ongoing education programs, including a program at the Nursing School, a course for physicians and nurses to start in 2012, and two postgraduate education courses about multidrug-resistant organisms. (Back to top) 


Obituary: Dr. Alexander Nanuashvili
APUA has lost a dear friend and leader

On October 17, 2011, Dr. Alexander Nanuashvili (APUA-Georgia President) passed away after a brief illness. His tireless efforts with APUA-Georgia generated admiration and respect from his colleagues and others concerned with the prudent use of antibiotics. He was affiliated with the Infectious Diseases Department of the Tbilisi Medical Academy of Postgraduate Education in Tbilisi, Georgia. He is survived by his wife Dr. Tamar Davitashvili (Center for Infectious Pathology) and three children. We will miss him dearly.

APUA-Georgia was founded in February of 2003 in affiliation with the Service of Antimicrobial Chemotherapy by the members of the Infectious Disease Department of Tbilisi Medical Academy. On May 31, 2008, APUA-Georgia presented national guidelines for the management of bacterial meningitis and nosocomial pneumonia at the APUA-Georgia conference. In addition, APUA-Georgia has recently conducted important studies on MRSA in children, the antimicrobial activity of polymyxin B against non-fermentative Gram-negative bacteria, and ESBL in Georgia. APUA-Georgia owes much to Dr. Nanuashvili’s legacy. (Back to top)



Dr. Anibal Sosa, who has provided valuable service over many years as director of the APUA International Chapter Program, has left APUA to pursue other professional opportunities as of Sept 29, 2011. APUA is continuing its active program of chapter services. For chapter questions and issues, please contact Kathleen Young or Bonnie Marshall, who is serving as active liason. Bonnie has worked closely with Dr. Levy for many decades and has played a key technical role with chapters on several large surveillance projects funded through APUA.  (Back to top)

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