ANTIBIOTIC POLICY an update

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. 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.'" 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. 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 Abscesses Gram +ve Skin, Bone & Respiratory Atypicals Chest and genito-urinary Cellulitis Wound infection Line infection Osteomyelitis Pneumonia Sinusitis 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. 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 antibioticand 50% [adapt to national figure where available] of all antibiotic use in hospitals can be inappropriate. Dr.T.V.Rao MD

11. 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 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. 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. 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 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 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 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 Dr.T.V.Rao MD

31. 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. 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 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 Dr.T.V.Rao MD

34. Problem-based pharmacotherapy In 18 languages For medical students, clinical officers Measurable improvement in prescribing Now also: Teacher’s Guide to Good Prescribing Achievements Training in rational prescribing has expanded in universities throughout the world Dr.T.V.Rao MD

35. 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. 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. CDCreports • 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. Multifaceted strategies can address and decrease antibiotic resistance in hospitals • 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 Dr.T.V.Rao MD

45. 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 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 Dr.T.V.Rao MD