Dr.T.V.Rao MD 1

ANTIBIOTIC POLICYan update

Dr.T.V.Rao MD

Dr.T.V.Rao MD 2

Discovery Of Penicillin changes the History of

Medicine

Dr.T.V.Rao MD 3

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.

Dr.T.V.Rao MD 4

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 5

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

Dr.T.V.Rao MD 6

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

Dr.T.V.Rao MD 7

Four main groups of Bacteria a Concern for Antibiotic

Resistance

Gram positive

Gram negative

Anaerobes

Atypical

Dr.T.V.Rao MD 8

Gram +ve Skin, Bone & Respiratory

Gram -ve GI-tract, GU

& Respiratory

AnaerobesMouth, teeth,

throat, sinuses &

lower bowel

Generally. Infecting Microbes..

AtypicalsChest and

genito-urinary

PeritonitisBiliary

infectionPancreatitis

UTIPID

CAP/HAP/VAP

Sinusitis

CellulitisWound

infectionLine infectionOsteomyelitisPneumonia

Sinusitis

Dental infection

Peritonitis Appendicitis

Abscesses

Pneumonia Urethritis

PID

Dr.T.V.Rao MD 9

Why inappropriate use of antibiotics

contributes to antibiotic resistance – the “why”

Dr.T.V.Rao MD 10

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 11

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

Dr.T.V.Rao MD 12

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

Dr.T.V.Rao MD 13

Plasmids played a Major Role in spread of Antibiotic

resistance.

Dr.T.V.Rao MD 14

Multiple Mechanism of Drug Resistance

Dr.T.V.Rao MD 15

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.

Dr.T.V.Rao MD 16

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.

Dr.T.V.Rao MD 17

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?

Dr.T.V.Rao MD 18

Why we Need Antibiotic

Policy

Dr.T.V.Rao MD 19

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..

Dr.T.V.Rao MD 20

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.

Dr.T.V.Rao MD 21

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 )

Dr.T.V.Rao MD 22

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.

Dr.T.V.Rao MD 23

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

Dr.T.V.Rao MD 24

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

Dr.T.V.Rao MD 25

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.

Dr.T.V.Rao MD 26

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,

Dr.T.V.Rao MD 27

Microbiology Services

Constant up graduation of Microbiology departments is good investment.

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

Dr.T.V.Rao MD 28

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.

Dr.T.V.Rao MD 29

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

Dr.T.V.Rao MD 30

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

Dr.T.V.Rao MD 31

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

Dr.T.V.Rao MD 32

Advantages of Antibiotic Policy

Saves the Lives Reduces the

morbidity Saves Health related

costs Reduces the

Antibiotic related toxicity.

Patients are satisfied.

Dr.T.V.Rao MD 33

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

Dr.T.V.Rao MD 34

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

Dr.T.V.Rao MD 35

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.

Dr.T.V.Rao MD 36

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. )

Dr.T.V.Rao MD 37

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.

Dr.T.V.Rao MD 38

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

Dr.T.V.Rao MD 39

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.

Dr.T.V.Rao MD 40

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

Dr.T.V.Rao MD 41

Infection Control Team

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

Dr.T.V.Rao MD 42

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)

Dr.T.V.Rao MD 43

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).

Dr.T.V.Rao MD 44

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

Dr.T.V.Rao MD 45

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 ..

Dr.T.V.Rao MD 46

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

Dr.T.V.Rao MD 47

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.

Dr.T.V.Rao MD 48

Hand Washing Reduces the Spread of Antibiotic

Resistant Strains

Dr.T.V.Rao MD 49

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

resources for Medical Professionals in Developing

World. Email

doctortvrao@gmail.com