Antibiotic policy

Dr.T.V.Rao MD

Dr.T.V.Rao MD 1

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Discovery Of Penicillin changes the History of Medicine

Dr.T.V.Rao MD 2

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Why we Need Antibiotics

Nearly One half of the Hospitalized patients receive antimicrobial agents.

� Antibiotics are valuable Discoveries of the Modern Medicine.

� All current achievements in Medicine are attributed to use of Antibiotics

� Life saving in Serious infections.

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What went wrong with

Antibiotic Usage

� Treating trivial infections / viral Infections with Antibiotics has become routine affair.

� Many use Antibiotics without knowing the Basic principles of Antibiotic therapy.

� Many Medical practioners are under pressure for short term solutions.

� Commercial interests of Pharmaceutical industry pushing the Antibiotics, more so Broad spectrum and Newer Generation antibiotics. as every Industry has become profit oriented.

�Poverty encourages drug resistance due to under utilization of appropriate Antibiotics.Dr.T.V.Rao MD 4

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Introduction

� “The end of infectious diseases” was a popular idea in the 1970s

�Infectious diseases are still important in the 21st

century due to:

� Boundless nature

� Emergence of new infections

� Re-emergence of old infections

� Increase in drug - resistant infections

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�� The last decade has seen the inexorable proliferation of a

host of antibiotic resistant bacteria, or bad bugs, not just MRSA, but other insidious players as well. ...For these bacteria, the pipeline of new antibiotics is verging on empty. 'What do you do when you're faced with an infection, with a very sick patient, and you get a lab report back and every single drug is listed as resistant?' asked Dr. Fred Tenover of the Centers for Disease Control and

Prevention (CDC). 'This is a major blooming public health crisis.'"

Science magazine; July 18,

2008

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Four main groups of Bacteria a

Concern for Antibiotic Resistance

Gram positive

Gram negative

Anaerobes

Atypical

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Gram +veSkin, Bone & Respiratory

Gram -veGI-tract, GU &

RespiratoryAnaerobesMouth, teeth,

throat, sinuses & lower bowel

Generally. Infecting Microbes..

AtypicalsChest and genito-

urinary

PeritonitisBiliary infection

PancreatitisUTIPID

CAP/HAP/VAPSinusitis

CellulitisWound infection

Line infectionOsteomyelitis

PneumoniaSinusitis

Dental infection Peritonitis

AppendicitisAbscesses

Pneumonia Urethritis

PID

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Why inappropriate use of antibiotics contributes to

antibiotic resistance – the “why”

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��Misuse of antibiotics in hospitals is one of

the main factors that drive development of antibiotic resistance.

�Patients in hospitals have a high probability of receiving an antibiotic and 50% [adapt to national figure where available] of all antibiotic use in hospitals can be inappropriate.

In-patients are at high risk of

antibiotic-resistant infections

Dr.T.V.Rao MD 10

�� Studies prove that misuse of antibiotics may cause

patients to become colonized or infected with antibiotic-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and highly-resistant Gram-negative bacilli.13-14

� Misuse of antibiotics is also associated with an increased incidence of Clostridium difficile infections.15-17

Misuse of Antibiotics Drives

Antibiotic Resistance

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Basis of Antibiotic Resistance

�The antibiotic resistance is guided by Genomic changes

�Spread of R plasmids among the Bacteria

�Do remember Antibiotics are used in Animal husbandry apart from Medical use

�The discovery of antibiotic resistance was discovered with spread of R plasmids from animal sources

�The Human gut forms the interconnecting area in R plasmids transmission leading ultimately to antibiotic resistance

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Plasmids played a Major Role in

spread of Antibiotic resistance.

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Multiple Mechanism of Drug

Resistance

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Spread of Antibiotic Resistance

� Indiscrimate use of Antibiotics in Animals and Medical practice

� R plasmids spread among co-inhabiting Bacterial flora in Animals ( in gut )

� R plasmids may be mainly evolved in Animals spread to Human commensal, -Escherichia coli followed by spread to more important human pathogens Eg Shigella spp.

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Why Everyone worried about

Antibiotic ( misuse ) Use.

Drug resistance can reverse Medical progress

The following diseases are already in the list of attaining the drug resistance, and Medical profession will find difficult to cure in future.

1. Tuberculosis2. Malaria3. Sore throat and Ear Infections.

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�Misuse of antibiotics can include any of the following

�When antibiotics are prescribed unnecessarily; �When antibiotic administration is delayed in critically ill patients; �When broad-spectrum antibiotics are used too generously, or

when narrow-spectrum antibiotics are used incorrectly;�When the dose of antibiotics is lower or higher than appropriate

for the specific patient;�When the duration of antibiotic treatment is too short or too long; �When antibiotic treatment is not streamlined according to

microbiological culture data results.

What is Misuse of

Antibiotics?

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Aim of Antibiotic Policy

�Reduce the Antimicrobial resistance� Initiate best efforts in the hospital area as many

resistance Bacteria are generated in Hospital areas and in particular critical care areas.

� Initiate good hygienic practices so these bacteria do not spread to others

�Practice best efforts, these resistance strains do not spill into critically ill patients in the Hospital

�To prevent spill into Society, as they present as community associated infections..

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Objectives of Antibiotic Policy.

�Antibiotics should not be used casually�Policy emphasizes, avoiding the use of powerful

Antibiotics in the Initial treatments.�We should create awareness that we are sparing

the powerful Broad spectrum Drugs for later treatment

Patient saves Money Doctors save Lives.

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Aims of the Antibiotic

Policy

�Create awareness on Antibiotics as misuse is counterproductive.

�More effective treatments in serious Infections.

�Reduce Health care associated infections spilling to society and increase of Community associated Infections.

( A growing concern in Developing world )

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Policy Deals on Broad

Basis� Clinicians /

Microbiologists / Pharmacists and Nurses do take part.

� Policies are framed on demands of the Clinical areas, depending on recent Infection surveillance data contributed from Microbiology Departments.

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Antibiotic working Group

Monitors

Formulate Optimal guidelines in Treatment of Infections with minimal risk of Health care associated Infections.

Create a plan for monitoring the Use of Antibiotics across the Hospital

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Education On Antibiotic policy

�Acton plan for Education to all concerned clinical staff on Antibiotic prescriptions.

� Evaluate the feed back of success and failures of the policy.

�Create Infection surveillance Data�Developing facilities in Microbiology

departments for auditing data and guidance�Restrictions in prescribing and Antibiotic

availability.�A continuous education to Junior Doctors

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Ideal Sample Collection is Essential Requirement

�Proper specimen collection is combined responsibility of Clinical and Microbiological Departments.

�Continuous training of junior staff on sample collection, and is most neglected necessity

�A good clinical history is greatly helpful in differentiating community acquired infections from hospital acquired infections.

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Pitfalls in Specimen

collection

�A proper specimen collection is most neglected area of Microbiology.

�Scientific approaches in Sample collection is concern for successful Microbiological evaluations,

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Microbiology Services

�Constant up graduation of Microbiology departments is good investment.

�Quality control methods in testing of antibiotic resistance pattern is a top priority.

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Role of Microbiology

Department

� Microbiology departments asses trends in development of antimicrobial resistance.

� The results of sensitivity/resistance patterns should be correlated with Antimicrobial agents currently used in the Hospital.

� Identify and forecast that nature of relation between antibiotic use and resistance.

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Better services from

Microbiology Departments.

� Basic infrastructure should be updated for detection of MRSA and ESBL producers.

� Documentation of all Opportunistic infections.and Hospital infection outbreaks

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�� Measures that guide antibiotic prescribing are likely to decrease antibiotic resistance in hospitals.32-34 Such measures include:

� Obtaining cultures� Take appropriate and early cultures before initiating empiric

antibiotic therapy, � and streamline antibiotic treatment based on the culture results35

� Monitoring local antibiotic resistance patterns� Being aware of local antibiotic resistance patterns (Antibiograms)

enables � appropriate selection of initial empiric antibiotic therapy

Measures that can decrease

antibiotic resistance

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�� The ESKAPE Pathogens: The so-called ESKAPE

Pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and ESBL positive bacteria, such as E. coli and Enterobacter species) represent a grouping of antibiotic-resistant gram-positive and gram-negative bacteria that cause the majority of U.S. HAIs. The group is so-named because these bacteria effectively “escape” the effects of most approved antibacterial drugs.

PRIORITY ANTIBIOTIC-RESISTANT BACTERIA PATHOGENS

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Advantages of

Antibiotic Policy

�Saves the Lives

�Reduces the morbidity

�Saves Health related costs

�Reduces the Antibiotic related toxicity.

�Patients are satisfied.

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Staff Education on Antibiotic

Policy

�Staff education is most Important principle in success

�Draw your own plans according to nature of patients, your past experiences

�Induction training for new staff�Continuing Medical Education to both Junior and

Senior Doctors�Include nursing staff, pharmacists for the success

of the Programme

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Training in rational prescribing has expanded in universities throughout the

world

� Problem-based pharmacotherapy

� In 18 languages

� For medical students, clinical officers

� Measurable improvement in prescribing

� Now also: Teacher’s Guide to Good Prescribing

Achievements

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Patient Education on Antibiotic

Policy

�Education of the patients and society is important in Developing world.

�Educate the patients many infections are trival,viral, Do not need Antibiotics

�If they understand Unnecessary consumption of Antibiotics kills the Normal flora, and reduces the Immunity and makes them potential victims in future.

�A difficult task in Developing countries.

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Proved success of Antibiotic

Policies

Studies Prove

1 Rapid reversal of major clinical problems of resistance to Chloramphenicol ,Erythromycin, and Tetracycline in Staphylococcus aureus on withdrawal of antibiotics.2 Out breaks of Erythromycin resistant Group A Streptococci and Penicillin resistant Pneumococci, can be controlled by major reduction in prescription of Erythromycin and Penicillin.3 Control of multiple resistant Gram – ve bacteria and role played by reducing the prescription of 3rd

generation of Cephalosporins.

( I.M.Gould Review of the role of antibiotic policies in the control of antibiotic resistance, Journal of Antimicrobial Chemotherapy 1999 43, 459 – 465. )

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Make your conclusions and

contribute to Antibiotic Policy

�It is true to say that there is no absolute proof of causative association between antibiotic use and resistance, But many authorities believe the association to be virtually certain.

�It is pragmatic and essential approach to control of antibiotic resistance with control of antibiotic use.

�Make every one a partner in prevention of Antibiotic resistance, and success will follow.

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Antibiotic resistance –

a problem in the present and the

future

�Antibiotic resistance is an increasingly serious public health problem: resistant bacteria have become an everyday concern in hospitals across World

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CDC reports

�CDC reports that nearly 2 million health care-associated infections (HAIs) and 90,000 HAI-related deaths occur annually in the U.S. Many of these infections and deaths are caused by antibiotic-resistant infections.

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New Innovations in

Diagnostic Microbiology� New rapid diagnostic tests

would greatly facilitate clinical trials of critically needed new antibiotics. The tests would enable investigators to identify potential study subjects more easily, which would permit smaller and less expensive studies of antibiotics as they move through development

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Infection Control Team

�Leadership and dedicated staff; training and education; mechanisms that serve to improve antibiotic resistance

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Best way to keep the matters in

Order

Every Hospital should have a policy which is practicable to their circumstances.

Rigid guidelines without coordination will lead to greater failures

The only way to keep Antimicrobial agents useful is to use them appropriately and Judiciously

(Burke A.Cunha, MD,MACP Antimicrobial Therapy. Medical Clinics of North America NOV 2006)

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Prudent prescribing to reduce

antimicrobial resistance

• Only use an antimicrobial when clearly indicated.

• Select an appropriate agent using local antimicrobial prescribing policy.

• Prescribe correct dose, frequency and duration.

• Limit use of broad spectrum agents and de-escalate or stop treatment if appropriate (Hospital).

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�� Antibiotic prescribing practices and decreasing antibiotic

resistance can be addressed through multifaceted strategies including:29-31

� Use of ongoing education

� Use of evidence-based hospital antibiotic guidelines and policies

� Restrictive measures and consultations from infectious disease physicians, microbiologists and pharmacists

Multifaceted strategies can address and

decrease antibiotic resistance in

hospitals

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�� Training and educating health care professionals on the

appropriate use of antibiotics must include appropriate selection, dosing, route, and duration of antibiotic therapy. To ensure that training and education is working, there should be extensive collaboration between the antibiotic stewardship and hospital infection prevention and control teams. Without benchmarks, it is difficult to track successes and weaknesses

Continuous Medical

Education a Must ..

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Computerized Decisions a

Emerging Need …..

� Computerized decision support can preserve physician autonomy and has been shown to improve antibiotic use by a number of different measures: fewer susceptibility mismatches, allergic reactions and other adverse events, excess dosages, and overall amount and cost of antibiotic therapy

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Implementation of WHONET CAN

HELP TO MONITOR RESISTANCE

� Legacy computer systems, quality improvement teams, and strategies for optimizing antibiotic use have the potential to stabilize resistance and reduce costs by encouraging heterogeneous prescribing patterns and use of local susceptibility patterns to inform empiric treatment.

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Hand Washing Reduces the Spread

of Antibiotic Resistant Strains

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��The Programme created by Dr.T.V.Rao MD for ‘e’ Learning

resources for Medical Professionals in Developing World.

� Email

�[email protected]

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