‘Antibiotic Ireland’ Antimicrobial Resistance A Major Cause for Concern

Improper Prescribing or Patient’s Misconceptions, Expectation and Pressure on Dr’s to prescribe ?

Theresa Lowry-LehnenRGN, BSc (Hon’s) Nursing Science/ Specialist Practitioner, PGCC, Dip

Counselling, Dip Adv Psychotherapy, BSc (Hon’s) Clinical Science, PGCE (QTS), H.

Dip. Ed, MEd, PhD student Health Psychology

PenicillinThanks to the work of Alexander Fleming (1881-1955), Howard Florey ( 1898-1968) and Ernst Chain (1906-1979), penicillin was first discovered, developed and eventually produced on a large scale for human use in 1943. Antibiotic therapy has played a major role in the treatment of bacterial infectious diseases and the entire world has benefited from one of the greatest medical advancements in history.

E. Chain H. FloreyA. Fleming

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A chemical substance produced by a microorganism, which has the capacity to inhibit the growth of or to kill other microorganisms; antibiotics sufficiently nontoxic to the host are used in the treatment of infectious diseases.

ANTIBIOTICS

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Basic Classes of Antibiotics

Although a large number of antibiotics exist, they fall into only a few classes with an even more limited number of targets.

–β-lactams (penicillins) –cell wall biosynthesis

–Glycopeptide (vancomycin) –cell wall biosynthesis

–Aminoglycosides (gentamycin) –protein synthesis

–Macrolides (erythromycin) –protein synthesis

–Quinolones (ciprofloxacin) –nucleic acid synthesis

–Sulfonamides (sulfamethoxazole) –folic acid metabolism

Cause for Concern Antibiotic resistance: a global problem

Resistance is inevitable with improper use.

No new class of antibiotic has been introduced over the last two decades

Appropriate use is the only way of prolonging the useful life of an antibiotic.

Antibiotic MisuseAntibiotic misuse, sometimes

called antibiotic abuse or antibiotic overuse, refers to the misuse or overuse of antibiotics, with potentially serious effects on health.

It is a contributing factor to the creation of multidrug-resistant bacteria, informally called "super bugs": relatively harmless bacteria can develop resistance to multiple antibiotics and cause life-threatening infections

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Several International studies have demonstrated that patterns of antibiotic usage greatly affect the number of resistant organisms which develop. Overuse of broad-spectrum antibiotics, such as second- and third-generation Cephalosporins, generate resistant strains.

Misuse of Third Generation Cephalosporins

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New Resistant Bacteria

Mutations

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Antibiotic Resistance

Susceptible Bacteria

Resistant Bacteria

Resistance Gene Transfer

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Resistant Strains

The resistant strains arise either by mutation and selection or by genetic exchange in which sensitive organisms receive the genetic material ( part of DNA) from the resistant organisms and the part of DNA carries with it the information of mode of inducing resistance against one or multiple antimicrobial agents.

Bacterial Resistance Bacteria develop resistance to antibiotics in many ways:

Some doctors give patients antibiotics when they might not be helpful. For example, a patient with a cold may pressure a doctor into prescribing an antibiotic because the patient hopes to get a quick fix to his/her illness. Antibiotics won't cure a cold because colds are caused by viruses, not bacteria.

Antibiotics have no effect on viral infections. The treatment for a cold is generally rest, plenty of fluids and medicines for fever and headache (if required).

Antibiotics are misused because many patients do not take them according to their doctor's instructions. They may stop taking their antibiotics too soon, before their illness is completely cured. This allows bacteria to become resistant by not killing them completely.

Some patients save unused medicine and take it later for another illness, or pass it to other ill family members or friends. These practices may result in the wrong antibiotics being used. They can also lead to the development of resistant bacteria.

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75% of outpatient antibiotics are used inappropriately (WHO 2012).

Patient’s misconceptions, expectations and pressure on Doctors to prescribe antibiotics inappropriately is a real problem in Ireland and globally.

Patients then frequently ask - Why am I no better after taking the antibiotics?

Side effects include gastric disturbances, diarrhoea, rash and allergy.

Improper Use of Antibiotics

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Illnesses Caused by Viruses and Bacteria

Differentiate Before a Decision

Virus Common cold Influenza (flu) Acute Bronchitis Viral sore throats Measles Chicken Pox Diarrhoea (99%)

Bacteria Urine infections Strep Throat Boils/abscesses Gangrene Some pneumonia’s Some Ear infections

(half) Some Sinus infections

(< half) Tuberculosis Bacterial Meningitis

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For the treatment of bacterial infections. However; Not all fevers are due to bacterial infections Not all infections are due to bacteria Most viral infections self resolve

in 1-3 weeks; colds, flu, gastric virus’s

There is no evidence that antibiotics will prevent secondary bacterial infection in patients with viral infection

When is an Antibiotic Necessary ?

Inappropriate use of Antibiotics

Antibiotics have no effect on viral infections such as the common cold.

They are also ineffective against most sore throats, which are usually viral and self-resolving.

Most cases of bronchitis (90–95%) are viral, passing after a few weeks—the use of antibiotics  against bronchitis is superfluous and can put the patient at risk of suffering adverse reactions

Patient concerns

Expect to be cured Need to return to work/school Similar symptoms treated with

antibiotics in the past.

Prescriber concerns

• Patient satisfaction • Time pressures• Diagnostic uncertainty

ANTIBIOTIC PRESCRIPTION

Reasons for unnecessary and inappropriate

prescribing

Rhinitis and sinusitis

RHINITIS:

1. Antibiotics should not be given for viral rhino-sinusitis.

2. Muco-purulent rhinitis (thick, opaque, or discolored nasal discharge) frequently accompanies viral rhino-sinusitis. It is not an indication for antibiotic treatment unless it persists without improvement for more than 10-14 days.

SINUSITIS: Diagnosed as sinusitis only in

the presence of: prolonged nonspecific upper

respiratory signs and symptoms (e.g. rhinorrhea and cough without improvement for > 10-14 days), or

more severe upper respiratory tract signs and symptoms (e.g. fever >39C, facial swelling, facial pain).

2. Initial antibiotic treatment of acute sinusitis should be with the most narrow-spectrum agent which is active against the likely pathogens

Antibiotics for Cold’s?

Sore throat – the evidence base

Most sore throats are viral and self- limiting Strep is isolated in 30% of sore throats BUT

asymptomatic carriage can be as high as 40%

Typical features only present in 15% of patients with strep throat

Recent studies do not support antibiotics as preventative of non-suppurative complications (which are rare anyway).

Chronic Cough

Think…….Post nasal drip syndromeAsthma Gastroesophageal reflux

Cough & Bronchitis 1.Coughs and bronchitis in children rarely warrant antibiotic treatment.2. Antibiotic treatment for prolonged cough (>10 days) may occasionally be warranted:- Pertussis should be treated according to established recommendations.- Mycoplasma pneumonia infection may cause pneumonia and prolonged cough (usually in children > 5 years); a macrolide agent (or tetracycline in children ≥ 8 years) may be used for treatment.- Children with underlying chronic pulmonary disease (not including asthma) may occasionally benefit from antibiotic therapy for acute exacerbations.

Asthma

Guidelines do not recommend antibiotics for asthma attacks. The worse the symptoms, the more often this practice seems to occur.

Unless there is a coexisting bacterial infectious such as pneumonia or sinusitis, antibiotics should not be used.

Over use can cause drug resistant bacterial infections. In adults, bacterial infections are almost never

the cause of asthma exacerbations, and antibiotics are rarely needed.

The most common triggers of an asthma attack in adults are viral infections, allergens, and irritants, non of which responds to an antibiotics.

Clinical differentiation is possible between bacterial and viral infection most of the time

Viral infection is disseminated throughout the system (URT/LRT). Fever is usually high at onset, settles by day 3-4.

Bacterial infection is localized to one part of the system ( acute tonsillitis does not usually present with running nose or chest signs). Fever is generally moderate at the onset and peaks by day 3-4.

Antibiotic Prescription

A Balancing ActA Balancing Act

Appropriate Initial Antibiotic TreatmentAppropriate Initial Antibiotic Treatment

Avoid UnnecessaryAntibioticsAvoid UnnecessaryAntibiotics

Patient Do’s DO ask your doctor whether your infection or

your family member's infection will respond to antibiotics.

DO ask your doctor about antibiotic-resistant bacteria and what you can do to help prevent its occurrence. 

DO follow the instructions for taking antibiotic’s.  Always take the exact amount specified on the label at a specified time.  Take the medicine for the entire time that your doctor has prescribed.  Even if you feel better, take all of the medicine!

PATIENT DO NOT’S DO NOT always expect the doctor to prescribe an

antibiotic. Many infections are viral and will not respond to antibiotics.

DO NOT take antibiotics prescribed for a different illness which have been stored at home.

DO NOT share or give antibiotics to other people.  Their illness is probably different and they might even be harmed by this medicine.

DO NOT take antibiotics due to exposure to someone with an infection.  This only increases the chance of picking up a resistant infection. If exposed to an infectious disease, seek medical advice.

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Inappropriate specimen selection and collection Inappropriate clinical tests Failure to use stains/smears Failure to use cultures and susceptibility tests Use of antibiotics with no clinical indication

(example viral infections) Broad spectrum antibiotics when not indicated Inappropriate choice of empiric antibiotics Empiric therapy is a medical term referring to

the initiation of treatment against an anticipated and likely cause of infection prior to determination of a firm diagnosis. Most often used when antibiotics are given to a person before the specific microorganism causing an infection is known.

Practices Contributing to Misuse of Antibiotics and

Resistance

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Ineffective and unsafe treatment

Exacerbation or prolongation of illness

Distress and harm to the patient

Higher cost Increased mortality and morbidity

Bad prescribing habits lead to:

HSE (2013) ‘Keeping antibiotics effective is everyone’s responsibility’

Misuse of antibiotics threatens to undermine the progress that has been made in medicine over recent decades. The overuse of antibiotics makes patients less likely to respond to treatment, warns Ireland’s leading clinicians.

Launching the action on antibiotics campaign to mark European Antibiotic Awareness Day (November 2013), Dr Fidelma Fitzpatrick, Consultant Microbiologist and HSE/RCPI Clinical Lead said that a casual attitude to antibiotics is damaging their effectiveness and that we are we are seeing an alarming global rise in so called ‘superbugs’, such as drug-resistant bacteria that cause pneumonia and meningitis, MRSA and E.coli.

HSE (2013) ‘Keeping antibiotics effective is everyone’s responsibility’

“Taking antibiotics when they aren’t needed means that they might not work when you really need them for a serious infection.  That is why the action on antibiotics campaign - supported by the Department of Health, Health Service Executive, Irish College of General Practitioners, Irish Pharmacy Union, Royal College of Physicians and Royal College of Surgeons in Ireland – is aiming to raise public awareness on the correct use of antibiotics and to preserve this precious resource for the use of future generations. 

(Dr Fidelma Fitzpatrick, Consultant Microbiologist and HSE/RCPI Clinical Lead)

HSE (2013) ‘Keeping antibiotics effective is everyone’s responsibility’

“Leading clinicians from the Health Service Executive, general practice, hospital care, surgery, dentistry and pharmacy all agree that everyone has an important role to play in ensuring correct use of antibiotics, and tackling the global health threat of antibiotic resistance.  The evidence is very clear – overuse and misuse of antibiotics has allowed bacteria to develop resistance and they are becoming immune to the drugs we use to defend ourselves against them”.

(Dr Fidelma Fitzpatrick, Consultant Microbiologist and HSE/RCPI Clinical Lead)

HSE (2013) ‘Keeping antibiotics effective is everyone’s responsibility’

“Antibiotics have utterly transformed modern medicine.  Before antibiotics were available, common injuries such as cuts and scratches that became infected could result in death or serious illness because there was no treatment available.  Thankfully, this does not happen anymore as we have antibiotics available to treat these infections.   However antibiotics must be used appropriately and by misusing them we face the risk of returning to the pre-antibiotic era,”

(Dr Fidelma Fitzpatrick, Consultant Microbiologist and HSE/RCPI Clinical Lead)

32USA (2011)

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Between 1962 and 2000, no major classes of antibiotics were introduced

Fischbach MA and Walsh CT Science 2009

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12 Steps to Prevent Antimicrobial Resistance

12 Break the chain 11 Isolate the

pathogen 10 Stop treatment

when cured 9 Know when to say

“no” 8 Treat infection, not

colonization 7 Treat infection, not

contamination 6 Use local data 5 Practice antimicrobial

control 4 Access the experts3 Target the pathogen

2 Get the catheters out 1 Vaccinate

Prevent Transmission

Use Antimicrobials Wisely

Diagnose & Treat Effectively

Prevent Infections

Prescribers- Choose the Appropriate Treatment

Think before prescribing. Are antibiotics necessary or correct for this illness?

Are you using the Right drug for the Right bug ?

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Doctors, Nurses and Health ProfessionalsWhen patients demand antibiotics inappropriately;

Provide educational materials and explain how the risks of antibiotics outweigh the benefits when used inappropriately.

Build cooperation and trust.Responsibility to the community is to use antibiotics correctly, for appropriate indications.

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Parents

Be fully informed about the appropriate use and misuse of antibiotics.

Are you demanding or pressurizing your Dr into prescribing antibiotics unnecessarily for your child?

Are misconceptions/ demands for inappropriate antibiotics doing your child more harm than good? The answer is YES.

References ADA Council on Scientific Affairs. Combating antibiotic resistance. 2004;135:484. American Academy of Pediatrics and American Academy of Family Physicians, Pediatrics

2004;113:1451-1. Fatehy, H, Consultant Pulmonologist: Abuse of antibiotics in clinical Practice .Power-point-

accessed on slideshare, February 4th 2014. Harrison JW, Svec TA (April 1998). "The beginning of the end of the antibiotic era? Part II.

Proposed solutions to antibiotic abuse". Quintessence International 29 (4): 223–9 Health, United States, 2009: U.S. Department of Health and Human Services, Centers for

Disease Control and Prevention, National Center for Health Statistics, 2009. Health, United States, 2010: U.S. Department of Health and Human Services, Centers for

Disease Control and Prevention, National Center for Health Statistics, April 2010. HSE Guidelines (2013) Keeping antibiotics effective is everyone’s responsibility. HSE,

Ireland Hueston WJ (March 1997). "Antibiotics: neither cost effective nor 'cough' effective". The

Journal of Family Practice 44 (3): 261–5. PMID 9071245 Neuhauser et al (February 2003). 

"Antibiotic resistance among gram-negative bacilli in US intensive care units: implications for fluoroquinolone use". JAMA 289 (7): 885-8.doi:10.1001/jama.289.7.885. PMID 12588273

T.Rao MD, Antibiotics- Use, Misuse and Consequences (Power-point)- accessed on slideshare, February 4th 2014)

Weiss AJ, Elixhauser A. Origin of Adverse Drug Events in U.S. Hospitals, 2011. HCUP Statistical Brief #158. Agency for Healthcare Research and Quality, Rockville, MD. July 2013.PMID 9643260

WHO (2012) Heath Information Statistics.