Rational Antibiotic Use

1. RationalAntibioticUse Meral Sönmezoğlu, MD InfectousDiseasesDepartment YEDİTEPE UNIVERSITY HOSPITAL

2. AntibioticUse • Antibiotics are among the most commonly used types of drugs • have had a significant impact to decrease morbidity and mortality in infectious diseases. • However, irrational use of antibiotics leads to : • resistance, • treatment failure, • waste of scarce resources.

3. Is an antibiotic necessary ? • Useful only for the treatment of bacterial infections • Not all fevers are due to infection • Not all infections are due to bacteria • There is no evidence that antibiotics will prevent secondary bacterial infection in patients with viral infection

4. AntibioticUse • Generally 40-50% misuse • Over 20% of yearlydrugconsumption is antibiotics • Problems is not onlyfordevelopingcountries • In USA, 50-70% of URTI areprescribedantibiotics • Of the 20% allantibioticsareprescribedfor RTI

5. WHO, Dept. Essential Drugs and Medicines Policy Drug Purchases through the Private Sector • 50-90% of all drug purchases are private • 25% to 75% illness episodes self-medicated • 1/2 consumers buy 1-day supply at a time • 50% of people worldwide fail to take drugs correctly • Results not always therapeutic • over-treatment of mild illness • inadequate treatment of serious illness • mis-use of anti-infective drugs • over-use of injections

6. ANTIBIOTICS in TURKEY • InTurkey 26.3% of total drugexpenditure in 1996 • 22.4% of alldrugs *. • Yearly 400 million USD • *Turk. J. Hosp. Infect. 2000; 4: 144-147 • **IMS Türkiye 2002

7. Medicine in Turkey TürkiyeİlaçPazarındadağılım DünyaTürkiye Kalp-DolaşımSistemi % 20 % 15 MerkezSinirSistemi % 17 % 11 Gastro-intestinal Sistem % 15 % 12 SolunumSistemi % 10 % 9 Anti-enfektifler % 9 % 22 LokomotorSistem % 6 % 11 ÜrogenitalSistem % 5 % 4 . . . SCRIP No: 2809/10 20-25 Aralık 2002, s. 19 - IMS Türkiye, 2002

8. Antiinfectives in Turkey Türkiyepazardabulunantoplam 3.346 ilacın(form olarak) 557’si anti-enfektif, 355’i antibiyotikalanındadır. Antibiotics % 10,5 IMS Türkiye, 2002

9. %14.7

10. Antibiotic use in eastern Europe: a cross-national database studyin coordination with the WHO Regional Office for Europe LancetInfectDis, 2014

11. Europe

12. Overall volume of antibiotics prescribed, 2013 (05 Oct 2015)

13. WHO • Almost ten years since the WHO global strategy for containment of antimicrobial resistance was published, • the World Health Organization has announced this topic as the theme for World Health Day in 2011

14. Antimicrobial resistance is the theme of WHO's World Health Day 2011. • WHO strongly recommends that governments focus control and prevention efforts in four main areas: • surveillance for antimicrobial resistance; • rational antibiotic use, including education of healthcare workers and the public in the appropriate use of antibiotics; • introducing or enforcing legislation related to stopping the selling of antibiotics without prescription; and • strict adherence to infection prevention and control measures, including the use of hand-washing measures, particularly in healthcare facilities.

15. The global action plan sets out five strategic objectives: • to improve awareness and understanding of antimicrobial resistance; • to strengthen knowledge through surveillance and research; • to reduce the incidence of infection; • to optimize the use of antimicrobial agents; and • develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.

17. World Health Day – 7 April 2011 Antimicrobial resistance: no action today, no cure tomorrow

18. WHO • .

19. 18 Kasım, Avrupa Antibiyotik Farkındalık Günü olarak kabul edilmiştir. • Avrupa Antibiyotik Farkındalık Günü hem toplumda hem de hastanelerde akılcı antibiyotik kullanımına yönelik ulusal kampanyalar için bir platform hazırlamakta ve destek sağlamaktadır. • Ülkemizde de bu amaçla bir kampanya yapılmaktadır. Avrupa Antibiyotik Farkındalık Günü hakkında:

26. 1980-2011 InfectionTimeline • Your Text here • Loremipsum dolor sit amet, consectetueradipiscingelit, seddiamnonummynibheuismodtinciduntutlaoreetdolore magna aliquameratvolutpat. Utwisienim ad minim veniam, quisnostrudexercitationullamcorpersuscipitlobortisnislutaliquip ex ea commodoconsequat. • Duisautemveleumiriure dolor in hendrerit in vulputatevelitessemolestieconsequat, velillumdoloreeufeugiatnullafacilisis at veroeros et accumsan et iustoodiodignissim qui blanditpraesentluptatumzzrildelenitaugueduisdoloretefeugaitnullafacilisi.

28. Mortalityduetoinfections DM Morenset al. Nature463, 122-122 (2010) doi:10.1038/nature08554

30. Medical error—the third leading cause of death in the US BMJ 2016; 353 (Published 03 May 2016)

31. Mortalityduetoinfections Total death rate worldwide • 41% of alldiseasesareinfectionsallovertheworld(WHO, 2002)

32. Mortalityduetoinfections

33. Mortalityeffect of appropriateness

34. New antibioticdevelopment

35. New antibioticdevelopment

36. Whynewantibiotic? • Bacteriamorerapidthanantibiotics Resistantbacteria

38. Factors Contributing to Antibiotic Overuse • .

39. Rational use of drugs Requires that; • Thepatientsreceivemedicationsappropriately • to their clinical needs, • in doses that meet • their own individual requirements for anadequate period of time, • at the lowest cost • to them and their community The conference of experts on the rational use of drugs, convened by the WHO

40. Rational use of drugs • correct drug • appropriate indication • appropriate drug considering efficacy, safety, suitability for the patient, and cost • appropriate dosage, administration, duration • no contraindications • correct dispensing, including appropriate information for patients • patient adherence to treatment

41. Rationalantibioticuse • HospitalAntibioticPolicies • HospitalAntibioticCommitties

42. WhenIrrational use • Increasedtreatmentcosts. • Interferencewithpatient’s normal flora. • Selection of drugresistantorganisms. • Increasedincidence of untowardsideeffects

43. Consequences of inappropriateantibiotic use • Antimicrobialresistance. • Adverse drugreactions and medicationerrors. • Lostresources. • Eroded patient confidence.

44. WHO, Dept. Essential Drugs and Medicines Policy Adverse drug eventsReview by White et al, Pharmacoeconomics, 1999, 15(5):445-458 • 4-6th leading cause of death in the USA • Estimated costs from drug-related morbidity & mortality 30 million-130 billion US$ in the USA • 4-6% of hospitalisations in the USA & Australia • commonest, costliest events include bleeding, cardiac arrhythmia, confusion, diarrhoea, fever, hypotension, itching, vomiting, rash, renal failure

47. WHO, Dept. Essential Drugs and Medicines Policy Overuse and misuse of antimicrobials contributes to antimicrobial resistance • Malaria • choroquine resistance in 81/92 countries • Tuberculosis • 2 - 40 % primary multi-drug resistance • Gonorrhoea • 5 - 98 % penicillin resistance in N. gonorrhoeae • Pneumonia and bacterial meningitis • 12 - 55 % penicillin resistance in S. pneumoniae • Diarrhoea: shigellosis • 10-90+ % amp, 5-95% TMP/SMZ resistance Source: DAP, EMC, GTB, CHD (1997)

48. Resistantbacteria

49. Meticillin-resistantS. aureus (MRSA) –EU mostseenresistantbacteria