Antibiotic policy

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ANTIBIOTIC POLICYan update

• Dr.T.V.Rao MD

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Discovery Of Penicillin changes the History of
Medicine
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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.

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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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Science magazine July 18, 2008

• 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.'"

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Four main groups of Bacteria a Concern for
Antibiotic Resistance

• Gram positive
• Gram negative
• Anaerobes
• Atypical

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Generally. Infecting Microbes..
Gram -ve GI-tract, GU Respiratory
Anaerobes Mouth, teeth, throat, sinuses lower
bowel
Peritonitis Biliary infection Pancreatitis UTI PID
CAP/HAP/VAP Sinusitis
Dental infection Peritonitis Appendicitis Abscesse
s
Gram ve Skin, Bone Respiratory
Atypicals Chest and genito-urinary
Cellulitis Wound infection Line
infection Osteomyelitis Pneumonia Sinusitis
Pneumonia Urethritis PID
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• Why inappropriate use of antibiotics contributes
  to antibiotic resistance the why

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In-patients are at high risk of
antibiotic-resistant infections

• 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.

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Misuse of Antibiotics Drives Antibiotic Resistance

• 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

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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. Tuberculosis
• 2. Malaria
• 3. Sore throat and Ear Infections.

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What is Misuse of Antibiotics?

• 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.

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Why we Need Antibiotic Policy
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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 GroupMonitors

• 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 can decrease antibiotic resistance

• 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

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PRIORITY ANTIBIOTIC-RESISTANT BACTERIA PATHOGENS

• 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.

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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 AntibioticPolicy

• 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
Achievements

• Problem-based pharmacotherapy
• In 18 languages
• For medical students, clinical officers
• Measurable improvement in prescribing
• Now also Teachers Guide to Good Prescribing

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Patient Education on AntibioticPolicy

• 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 AntibioticPolicies

• 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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Multifaceted strategies can address and decrease
antibiotic resistance in hospitals

• Antibiotic prescribing practices and decreasing
  antibiotic resistance can be addressed through
  multifaceted strategies including29-31
• Use of ongoing education
• Use of evidence-based hospital antibiotic
  guidelines and policies
• Restrictive measures and consultations from
  infectious disease physicians, microbiologists
  and pharmacists

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Continuous Medical Education a Must ..

• 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

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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
• doctortvrao_at_gmail.com