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Dr.T.V.Rao MD 1
Antibiotic Resistance
What Can We Do ?
Dr.T.V.Rao MD
Dr.T.V.Rao MD 2
The emerging clinical impact of
antimicrobial resistance, urgent implementation of the Global Strategy for the Containment of Antimicrobial Resistance is a Priority . However, at the same time, a clear research agenda highlighting the most important current knowledge gaps needs to be defined to guide the direction of future research efforts.
Antimicrobial Resistance
Dr.T.V.Rao MD 3
ß-lactams B-lactamases, altered PBP, efflux Macrolides MLS, efflux Aminoglycosides AME, permeability Fluoroquinolones altered topoisomerases,
efflux Tetracycline's efflux, altered target Chloramphenicol CAT, efflux Sulfonamides altered dihydropteroate synthase Trimethoprim altered dihydrofolate reductase Vancomycin bypass pathway Streptogramins MLS, efflux, enzyme
modification Rifampicin altered target
Antibiotics and Mechanisms of
Resistance
Dr.T.V.Rao MD 4
Genetic diversity – nucleotide substitution, DNA rearrangements and
gene acquisition • Gene acquisition – transformation, transduction and conjugation • Mobile genetic elements – gene cassettes – integrons – insertion sequence elements and transposons – plasmids
Genetics of Antimicrobial
Resistance
Dr.T.V.Rao MD 5
Enormous biomass of
microorganisms • Genetic plasticity • Antibiotics are microbial products, organisms
have seen them before!
• *Excessive antibiotic use • World wide travel • *Lax infection control practices
Why Are ResistantInfections Happening?
Dr.T.V.Rao MD 6
How Much Antibiotics ? 22,000 t
11,000 t dispensed to humans (50%) in 150 million prescriptions
written annually by physicians
8 -10,000 t given to animals (40%) to treat or prevent infections mixed into feed to promote growth of agricultural
animals
20-30 t Plant (0.1%)
30-200 t Aquaculture (1%)
Dr.T.V.Rao MD 7
Drugs for Human Treatment
are Excreted into Sewage Some drugs
excreted in metabolized amounts via the urine and feces
Some yield bioactive metabolites.
Some excreted as conjugates
Dr.T.V.Rao MD 8
Metabolism of Antibiotics
Dr.T.V.Rao MD 9
Veterinary Medicines in the Environment
Dr.T.V.Rao MD 10
Antimicrobial Prescribing Facts
1/3 of all hospitalised inpatients at any given time receive antibiotics
~ up to 1/3 to ½ are inappropriate ~ up to 30% of all surgical prophylaxis in
inappropriate Antimicrobials account for upwards of
30% of hospital pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets.
Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences , increased morbidity, mortality,increased cost, increased litigation and reduce quality of life
Dr.T.V.Rao MD 11
Why So Many Mistakes
High number and complexity of drugs
High number and complexity of syndromes and pathogens
Poor training in antibiotic use
Variability over time and place in- pathogen prevalence- antibiotic susceptibilities- antibiotic formularies
Dr.T.V.Rao MD 12
Hospital acquired infections cause of many
Deaths Every year, many
lives are lost because of the spread of infections in hospitals. Health care workers can take steps to prevent the spread of infectious disease
Dr.T.V.Rao MD 13
Biomedical research Health policy and systemsresearch
Social sciences andbehavioral research
Operational research
Basic research:physical and biological
sciences includingchemistry,
pharmacology, toxicology,
genetics, etc
Research onpolicy formulation, relationship
to evidence,prioritization, etc
R&D for drugs, vaccines,
diagnostics, appliances, etc
Research onhealth systems management,
functions, efficiency, effectiveness, system factors
affecting accessscale-up, monitoring and
evaluation, etc
Research onsocial and behavioural
factors influencing health and their relation
to equity, access, lifestyle and health-seeking behaviours,
etc
Research onfactors
affecting functioning of
programs, effectiveness of
targeting, impact on behavior, disease
burdens and public health,
etc
Understanding the biological nature of diseases; creating
products to prevent or treat disease states
Understanding how to test, scale-up and follow through the introduction of interventions and optimize their benefits
InnovationImpact
The spectrum of health research
Dr.T.V.Rao MD 14
Ongoing effort by a health care institution to
optimize antimicrobial use among hospitalized patients to ...
- Improve patient outcomes - Ensure cost-effective therapy,
and - Reduce adverse sequelae of
antimicrobial use (including antimicrobial resistance).
What is Antimicrobial Stewardship
Dr.T.V.Rao MD 15
What Can We Do?Strengthen our Microbiology
Departments ?
Keep aware National/
Provincial Surveillance Programs
Get to know your microbiology laboratory
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What Can We Do?
–Expect rapid turn around times
– Appropriate susceptibility test reporting
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What Can We Do?
Infection Control in the office & hospital
• Decrease antibiotic prescriptions for viral URI’s by half!
• Improve communication with patients
Dr.T.V.Rao MD 18
Hand Washing a must for Safety of our
Patients Proper hand washing
is the most effective way to prevent the spread of infections in hospitals. If you are a patient, don't be afraid to remind friends, family and health care providers to wash their hands before getting close to you.
Dr.T.V.Rao MD 19
Preventive Measures ….
Covering coughs and sneezes Staying up-to-date with immunizations Using gloves, masks and protective clothing Making tissues and hand cleaners available Following hospital guidelines when dealing with blood or contaminated items
Dr.T.V.Rao MD 20
Organize your Clinical Microbiology Laboratory
Bench Microbiologists
should bring in change with dedication to bench work, and Proficiency Testing to improve the quality to services in Health care
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What most Proficiency Testing
does not tend to look at: Are negative samples reported as negative? Are contaminated samples reported as
contaminated? Are complex samples submitted for referral? Are pre-analytic factors addressed?
Improper containers and transport Outdated samples. Mislabeled samples. Rejection criteria
Are post-analytic factors addressed? Interpretive commentary included
Dr.T.V.Rao MD 22
PT providers should publish scientifically credible reports in peer-reviewed journals.
Ensure all clinical laboratories participate in PT, including waved tests.
Develop a methodology-based approach for PT (one material for many assays).
Samples should mimic patient samples with a minimum of matrix effect.
Small adjunct studies with fresh frozen samples in conjunction with “routine” PT.
Evaluate alternatives to current CLIA requirements for frequency and scoring.
Develop innovative approaches to PT.
CDC ReportApril 2008
Dr.T.V.Rao MD 23
Does Proficiency Testing improve
quality? Probably yes, but hard to
prove. Accredited programs do
better on PT Laboratories with
consistently high PT performance do better with accreditation
Clinical Error? Clinical error detection? OFIs and Continual
Improvement?
Dr.T.V.Rao MD 24
Medical laboratory proficiency testing
Medical laboratory proficiency testing has been around for 60 years
Respected as a valued monitoring tool Inter-laboratory comparisons Internal audit Inter-technologist education
Starting to show its age Testing the wrong thing in the wrong way Falling behind laboratory reality
Dr.T.V.Rao MD 25
What is Antimicrobial Stewardship?
A marriage of infection control and antimicrobial management
Mandatory infection control compliance Selection of antimicrobials from each class of drugs
that does the least collateral damage Collateral damage issues include
- MRSA- ESBLs- C.difficile- stable DE repression- MBLs and other carbapenemases- VRE
Appropriate de-escalation when culture results are available Dellit TH et al Clin Infect Dis 2007; 44: 159-177
Dr.T.V.Rao MD 26
A. Be able to list the recommended
components of an antibiotic stewardship program
B. Be able to detect antibiotic use improvement opportunities from the analysis of utilization data
C. Be able to explain the barriers for successful implementation of such a program
Objectives for Starting Antibiotic Stewardship
Dr.T.V.Rao MD 27
Why Develop an Antimicrobial Stewardship
ProgramFrom an Infection Preventionist
Perspective:
Track and Reduce antimicrobial resistance
Encourage appropriate treatment patterns ~ The right antibiotic, for the right duration
Develop a collaborative practice between MDs/LIPs, Pharmacy, Laboratories and Infection Preventionists’ with best patient outcome in mind.
Dr.T.V.Rao MD 28
WORKSTREAMS
1. INFORMATION MANAGEMENT (HPS AND ISD)
2. EDUCATION (NES)
3.ORGANISATION AND ACCOUNTABILITY (NQIS)
Dr.T.V.Rao MD 29
4.INFECTION MANAGEMENT
(SPA,NQIS,NES,HPS-ISD, Professional Organisations) All the work-streams work in
parallel but with vertical integration
Work stream work underpinned by an AMT Clinical Network
WORKSTREAMS
Dr.T.V.Rao MD 30
INFECTION MANAGMENT PHILOSOPHY
HIGH BURDEN, HIGH IMPACT CONDITIONS EVIDENCE OF BENEFIT FOR INTERVENTION ALSO TARGET SYSTEMS CHANGE TO BRING
ABOUT DESIRED BENEFIT INTEGRATE, DEVELOP AND IMPLEMENT
EXISITING AND NEW PROJECTS OVER 3 YEAR TIME FRAME: WORK CLOSELY WITH WORK PROGRAMMES OF KEY STAKEHOLDERS (e.g HPS, SPA)
IMMEDIATE OPPORTUNITIES AROUND SNAP-CAP, C.difficle and Surgical Prophylaxis.
Dr.T.V.Rao MD 31
Assist providers in appropriate use of
antimicrobial therapy with improved patient outcomes
Slow the development of antimicrobial resistance
Develop evidence- based appropriate use guidelines
Educate providers and staff regarding guidelines
Track resistance patterns and report back to medical and hospital staff
Report committee progress and outcomes to P&T, and Executive Committees
Goals of Committee
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Clean Hands Saves Many Lives
Dr.T.V.Rao MD 33
Follow me for more topics of Interest on Infectious
Diseases
Dr.T.V.Rao MD 34
Programme Created by Dr.T.V.Rao
MD for Awareness on Use and Misuse of Antibiotics by Medical
Professionals
