Antibiotic Resistance: Stemming the Tide of a Public Health Threat

1. Antibiotic Resistance:Stemming the Tide of a Public Health Threat Teresa Lowery, MD, MPH, FAAFP, ABFM Medical Health Specialist, Region 2/3

2. Objectives • In this webinar, we will • Define “antibiotic resistance”; and discuss why it has quickly become a growing public health threat. • Discuss how health care providers and staff can help promote discretionary antibiotic use and help decrease the trend of antibiotic resistance. • Discuss the appropriate use of antibiotics in common infections seen in the outpatient setting such as upper respiratory tract infections and in skin infections including MRSA (Methicillin Resistant Staphlococcoccus Aureus). • Review some of the common facts and questions asked regarding this topic.

3. Antibiotic Resistance: The History of Antibiotics—How did we get here? • What is an antibiotic? • Term “antibiotic” originally referred to a natural compound produced by a fungus or another microorganism that kills bacteria which cause disease in humans or animals. • Some antibiotics may be synthetic compounds (not produced by microorganisms) that can also kill or inhibit the growth of microbes. • Microbes are living organisms that multiply frequently and spread rapidly (these are bacteria, viruses, fungi and parasites). Some microbes cause disease and others exist in the body without causing harm and may actually be beneficial.

4. Antibiotic Resistance: The History of Antibiotics—How did we get here? • Antimicrobial Drug Resistance—how do we define it? • It is the ability of microbes to grow in the presence of a chemical (drug) that would normally kill them or limit their growth. • Why does this matter? • As more microbes become resistant to antimicrobials, the protective value of these medicines is reduced. • How does this happen? • Overuse and misuse of antimicrobial medicines are among the factors that have contributed to the development of drug-resistant microbes.

5. Antibiotic Resistance: The History of Antibiotics—How does this happen? • Causes: (There is a complicated scientific explanation, but here is a quick and fun way to remember them) • Natural—Selective Pressure —“Only the strong survive” • Mutation—Divide and Conquer —“We don’t die, we multiply!” • Genes Transfer—Sharing is Caring—“I will give you what I have to save you”

6. Causes • Societal Pressures—“Our fault” • Inappropriate Use— “Just give them what they want” • Inadequate Diagnostics—“I don’t know what I’m treating” • Hospital Use—“It’s a germ’s playground” • Agricultural Use—“What’s in that beef?”

7. Antibiotic Resistance: A new public health threat? Really?? • Antibiotic resistance (AR) occurs everywhere in the world and is not limited to industrialized nations • Children and critically ill may be most vulnerable • Affects healthcare settings and community at large • The effects are far reaching and expensive • AR is also emerging in some fungi • Has affects with HIV, influenza and malaria treatment • MRSA is noted to have increasing frequency • Drug resistant Klebsiella and E. Coli species have been isolated in hospitals

8. Antibiotic Resistance: PrescribingAttitudes, Behaviors, Trends and Costs • Patient and parent pressure—“Give Momma what she wants” (62 percent vs. 7 percent) • Acute Upper Respiratory Tract Infections—“Doc, how do I get rid of this cold?” (70% usage) • Prescribing habits are improving, but slowly • $1.1 Billion is spent annually on unnecessary antibiotic Rx • Get Smart is a national campaign which has been launched to educate and help reduce the number of antibiotics prescribed

9. AR: Use In Acute Upper Respiratory Tract Infections • Achoo!!! May I have an antibiotic please?? • Uncomplicated URI (Upper Respiratory Infection)–so common, so over treated • The Common Cold—runny nose, sore throat, cough, sneezing and nasal congestion. Antibiotic use has decreased but broad spectrum antibiotic use has increased • The Common Color Myth of “Boogies”- If it is colored, it is bacterial, right?? NO!!! This is not necessarily true! • What’s the harm in treating these? AR, increased cost, increased incidence of side effects, including anaphylaxis

10. AR: Use in Upper Respiratory Tract Infections: Is it a Cold of is it the Flu?? • Influenza—acute URI caused by the influenza virus A or B • Abrupt onset of fever, headache, myalgia, malaise are the cardinal symptoms • Supportive care is the foundation of treatment, but antiviral therapy (not amantidine) may decrease the duration of illness by one day if started within 48 hours • Who needs treatment? Pregnant women, students with severe illness, and those with chronic illness should be treated • Empiric therapy with antibiotics should not be continued after influenza is diagnosed unless there is concern about a secondary bacterial process • Vaccination is the mainstay of prevention

11. Use in URIs • Rhinosinusitis (or sinusitis) is defined as inflammation of the nasal mucosa and sinuses. Symptoms include nasal obstruction, anterior or posterior purulent nasal discharge, facial pain, decrease sense of smell, and cough. Students may also have sore throat, fatigue, bad breath and headache and fever. • Is it bacterial or viral?? How would you know? • The diagnosis of a bacterial cause should not be made until symptoms have persisted for at least 10 days or after initial improvement followed by worsening of symptoms. • Also Look for 1) purulent nasal discharge 2) maxillary tooth pain 3) unilateral maxillary sinus tenderness 4) worsening symptoms after initial improvement.

12. Rhinosinusitis cont’d • Watchful waiting and symptomatic treatment if follow up can be ensured for mild bacterial sinusitis is advised but worsening symptoms within 7 days warrant the use of antibiotics. • The clinical cure rate for treated vs. placebo was 90% to 80% in studies. • Amoxicillin is first line, while Bactrim or Septra can be used for students allergic to Penicillin (PCN), alternatives include (cephalosporins, macrolide family, respiratory floroquinolones). • Conflicting studies regarding length of treatment (5 days vs. 10 days) and dose (high dose e.g., 1000mg tid or 875mg bid). • A different antibiotic is justified if symptoms worsen in within 7 days.

13. Use in URIs • Otitis Media—diagnosis requires an acute onset of symptoms, the presence of middle ear effusion and signs and symptoms of middle ear effusion. • Amoxicillin is first line treatment. If no response in 48-72 hours, reexamination of student is necessary and Augmentin (amox with clavulanate) should be initiated. Bactrim should not be used for PCN allergic, instead (macrolides, cephalosporins are alternative treatment). • Longer courses of antibiotics (more than seven) have lower failure rates than shorter courses for more severe diseases, 5-7 days may be effective in milder cases. • Serous otitis (non-acute otitis with effusion) should not be treated with antibiotics.

14. Pharyngitis and Tonsillitis • Mostly viral (especially if accompanied by sneezing, cough, watery eyes, mild headache, mild body aches, runny nose and low grade fever—less than 102F). • When bacterial, the leading pathogen is group A, beta-hemolytic Streptococcus. • Testing for rapid strep A is advised for possible diagnosis and treatment with appropriate antibiotics to avoid rheumatic fever and reduce communicability. • When Rapid Strep A testing is not available, the Centor Criteria can be used to aid in diagnosis. This criteria is based on the age and the presence of absence of fever, tonsillar erythema or exudates, anterior cervical lymphadenopathy and cough.

15. Modified Centor Criteria for Pharyngitis and Tonsillitis

16. Pharyngitis and Tonsillitis Treatment • The recommended treatment is a 10-day course of penicillin (PCN). Erythromycin can be used in patients who are PCN allergic. Amoxicillin, azithromycin and first generation cepholosporins are appropriate alternatives. (Sulfonamides and tetracyclines have questionable efficacy.) • There is no need for post treatment test of cure of culture after treatment

17. Laryngitis • Acutely by definition is inflammation of the vocal cords and larynx lasting less than 3 weeks. Symptoms include muffling of the voice (hoarseness), sore throat, and other classic URI symptoms such as cough, fever, runny nose and headache. • Studies have found that antibiotic treatment does not reduce the duration of symptoms or lead to voice improvement. • Symptoms are usually self limited; syndrome is viral (90% of time) and does not respond to antibiotic therapy.

18. Bronchitis • Bronchitis (acute) is defined as a self-limited inflammation of the large airways (including the trachea) that presents with cough and possibly phlegm production. • Signs and symptoms also include soreness in chest, fatigue, mild headache, mild body aches, low-grade fever, watery eyes and sore throat. • Predominantly viral in cause, therefore antibiotics are not needed in most students. • Purulent sputum alone is not an indication for an indication of antibiotic therapy. Expect cough to last 2 weeks for most students (and as long as 6-8 weeks for some students). • Advise individualized care focusing on symptom relief, as well as explaining to students why antibiotics are not indicated.

19. Bronchitis • Very important to differentiate pneumonia and influenza from bronchitis because antibiotics are indicated for pneumonia. • If student has fever and rigors, get chest x-ray. • Few cases of atypical bronchitis are caused by Bordetella pertussis or atypical bacterial such as Chlamydia pneumoniae and Mycoplasma pneumoniae. However, these are usually also self limited. • Suspected cases of pertussis should be treated with macrolides early in the course of the disease to help prevent spread rather than to change the course of the disease. (Suspect if cough greater than 14 days). Treatment prophylaxis is advised for close household contacts and roommates.

20. MRSA: The Not So New Threat • Methacillin Resistant Staphlococcus Areus • Staph Aureus, commonly known as staph, was discovered in 1880s. During this era, it commonly caused painful skin and soft tissue conditions such as boils, scalded-skin syndrome, and impetigo. More serious forms can progress to bacterial pneumonia and bacteria in the bloodstream-both of which can be fatal. S. Aureus can also be acquired from improperly prepared and stored food and can cause a form of food poisoning. • In 1940-1950s developed resistance to PCN. Methacillin was introduced at this time to treat it, but in 1961, strains of resistant S. Aureus to methacillin were identified.

21. MRSA: The Not So New Threat • MRSA can be categorized according to where it was acquired: hospital-acquired MRSA (HA-MRSA) or community-associated MRSA (CA-MRSA). • Our students for the most part, would fall into the latter category of CA-MRSA. • CA-MRSA is caused by newly emerging strains unlike those responsible for HA-MRSA and can cause infections in otherwise healthy persons with no links to healthcare systems. • Infections typically occur as skin or soft tissue infections, but can develop into more invasive, life threatening infections. • May occur most often in those who are involved with football, wrestling, as well as those kept in close quarters (e.g., soldiers), inmates, childcare workers, and residents of long-term care facilities.

22. CA-MRSA Transmission • Origin can be elusive, but close skin to skin contact and sharing personal items such as towels, razors, sports equipment, compromises in personal hygiene and limited health care contribute to transmission • Most often enters the body through a cut or scrape and appears in the form of a skin or soft tissue infection such as a boil or abscess. The site involved is usually red, swollen, warm and painful and is often mistaken as a spider bite. Often students may report that it started off as a pimple.

23. CA-MRSA Diagnosis/Treatment • Tissue sample or fluid from boil is often obtained for culture from a spontaneously draining site or via incision. • Culture and sensitivity should be obtained in order to make a certain diagnosis. • Keep in mind that not all pimples and skin lesions are MRSA. It may be folliculitis or cellulitis caused by typical skin bacteria. • Mild to moderate skin infections may be treated with incision and drainage as first line treatment. Oral Bactrim and Clindamycin are often used as first line antibiotics for moderate skin infections for a 10 day course. More severe infections may require a longer duration of oral course, IV antibiotics or hospital admission for treatment.

24. CA-MRSA Prevention • The best defense against spreading MRSA is to practice good hygiene: • Proper hand washing • Showering promptly after exercising • Keeping cuts and scrapes clean and covered with a bandage until healed • Avoiding contact with other people’s wounds or bandages • Avoid sharing personal items, such as towels, washcloths, razors, clothes or uniforms • Washing sheets, towels and clothes that become soiled with water and laundry detergent with bleach and hot water when possible. Drying clothes in hot dryer rather than air drying also kills bacteria in clothes.

25. Common Questions and Answers • Are antibacterial-containing products (soaps, household cleansers, etc. better for preventing the spread of infection? • And does their use add to the problem of resistance?

26. Common Questions and Answers • Can antibiotic resistance develop from acne medication?

27. Common Questions and Answers • Do probiotics have a role in preventing or treating drug resistance or drug-resistant infections?

28. Common Questions and Answers • What can we do for our students to help them feel better if antibiotics won’t treat their illness because it is caused by a virus?

29. Common Questions and Answers • How do we effectively educate our students (and colleagues) about the real dangers and public health crisis of antibiotic resistance?

30. Antibiotic Resistance: Summary/Conclusion • As health care workers, we owe it to our profession and to our patients (students) to do always do what is ultimately in their and our society’s best interest. This may mean making the very difficult decision to not use antibiotics when they are not warranted. • We can help prevent the spread of antibiotic resistance by only prescribing antibiotic therapy when likely to be beneficial to our students, using an agent that targets the likely bacterial pathogens and using the antibiotic for the appropriate dose and duration.

31. Your Questions and Comments