Antibiotic Resistance What Can W e D o ?

1. Antibiotic ResistanceWhat Can We Do ? Dr.T.V.Rao MD Dr.T.V.Rao MD

2. Antimicrobial Resistance • The emerging clinical impact of antimicrobial resistance, urgent implementation of the Global Strategy for the Containment of Antimicrobial Resistance is a Priority . However, at the same time, a clear research agenda highlighting the most important current knowledge gaps needs to be defined to guide the direction of future research efforts. Dr.T.V.Rao MD

3. Antibiotics and Mechanisms ofResistance • ß-lactams B-lactamases, altered PBP, efflux • Macrolides MLS, efflux • Aminoglycosides AME, permeability • Fluoroquinolones altered topoisomerases, efflux • Tetracycline's efflux, altered target • Chloramphenicol CAT, efflux • Sulfonamides altered dihydropteroate synthase • Trimethoprim altered dihydrofolate reductase • Vancomycin bypass pathway • Streptogramins MLS, efflux, enzyme modification • Rifampicin altered target Dr.T.V.Rao MD

4. Genetics of Antimicrobial Resistance • Genetic diversity • – nucleotide substitution, DNA rearrangements and gene acquisition • • Gene acquisition • – transformation, transduction and conjugation • • Mobile genetic elements • – gene cassettes • – integrons • – insertion sequence elements and transposons • – plasmids Dr.T.V.Rao MD

5. Why Are ResistantInfections Happening? • Enormous biomass of microorganisms • • Genetic plasticity • • Antibiotics are microbial products, organisms have seen them before! • • *Excessive antibiotic use • • World wide travel • • *Lax infection control practices Dr.T.V.Rao MD

6. How Much Antibiotics ? 22,000 t • 11,000 t dispensed to humans (50%) • in 150 million prescriptions • written annually by physicians • 8 -10,000 t given to animals (40%) • to treat or prevent infections • mixed into feed to promote growth of agricultural animals • 20-30 t Plant (0.1%) • 30-200 t Aquaculture (1%) Dr.T.V.Rao MD

7. Drugs for Human Treatmentare Excreted into Sewage • Some drugs excreted in metabolized amounts via the urine and feces • Some yield bioactive metabolites. • Some excreted as conjugates Dr.T.V.Rao MD

8. Metabolism of Antibiotics Dr.T.V.Rao MD

9. Veterinary Medicines in the Environment Dr.T.V.Rao MD

10. Antimicrobial Prescribing Facts • 1/3 of all hospitalised inpatients at any given time receive antibiotics • ~ up to 1/3 to ½ are inappropriate • ~ up to 30% of all surgical prophylaxis in inappropriate • Antimicrobials account for upwards of 30% of hospital pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets. • Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences , increased morbidity, mortality,increased cost, increased litigation and reduce quality of life Dr.T.V.Rao MD

11. Why So Many Mistakes • High number and complexity of drugs • High number and complexity of syndromes and pathogens • Poor training in antibiotic use • Variability over time and place in- pathogen prevalence- antibiotic susceptibilities- antibiotic formularies Dr.T.V.Rao MD

12. Hospital acquired infections cause of many Deaths • Every year, many lives are lost because of the spread of infections in hospitals. Health care workers can take steps to prevent the spread of infectious disease Dr.T.V.Rao MD

13. The spectrum of health research Biomedical research Health policy and systems research Social sciences and behavioral research Operational research Basic research: physical and biological sciences including chemistry, pharmacology, toxicology, genetics, etc Research on policy formulation, relationship to evidence, prioritization, etc Research on social and behavioural factors influencing health and their relation to equity, access, lifestyle and health-seeking behaviours, etc Research on factors affecting functioning of programs, effectiveness of targeting, impact on behavior, disease burdens and public health, etc Research on health systems management, functions, efficiency, effectiveness, system factors affecting access scale-up, monitoring and evaluation, etc R&D for drugs, vaccines, diagnostics, appliances, etc Understanding the biological nature of diseases; creating products to prevent or treat disease states Understanding how to test, scale-up and follow through the introduction of interventions and optimize their benefits Innovation Dr.T.V.Rao MD Impact

14. What is Antimicrobial Stewardship • Ongoing effort by a health care institution to optimize antimicrobial use among hospitalized patients to ... • - Improve patient outcomes • - Ensure cost-effective therapy, and • - Reduce adverse sequelae of antimicrobial use (including antimicrobial resistance). Dr.T.V.Rao MD

15. What Can We Do?Strengthen our Microbiology Departments ? • Keep aware • National/Provincial Surveillance Programs • Get to know your microbiology laboratory Dr.T.V.Rao MD

16. What Can We Do? • –Expect rapid turn around times • – Appropriate susceptibility test reporting Dr.T.V.Rao MD

17. What Can We Do? • Infection Control in the office & hospital • • Decrease antibiotic prescriptions for viral URI’s by half! • • Improve communication with patients Dr.T.V.Rao MD

18. Hand Washing a must for Safety of our Patients • Proper hand washing is the most effective way to prevent the spread of infections in hospitals. If you are a patient, don't be afraid to remind friends, family and health care providers to wash their hands before getting close to you. Dr.T.V.Rao MD

19. Preventive Measures …. • Covering coughs and sneezes Staying up-to-date with immunizations Using gloves, masks and protective clothing Making tissues and hand cleaners available Following hospital guidelines when dealing with blood or contaminated items Dr.T.V.Rao MD

20. Organize your Clinical Microbiology Laboratory Bench • Microbiologists should bring in change with dedication to bench work, and Proficiency Testing to improve the quality to services in Health care Dr.T.V.Rao MD

21. What most Proficiency Testing does not tend to look at: • Are negative samples reported as negative? • Are contaminated samples reported as contaminated? • Are complex samples submitted for referral? • Are pre-analytic factors addressed? • Improper containers and transport • Outdated samples. • Mislabeled samples. • Rejection criteria • Are post-analytic factors addressed? • Interpretive commentary included Dr.T.V.Rao MD

22. CDC Report April 2008 • PT providers should publish scientifically credible reports in peer-reviewed journals. • Ensure all clinical laboratories participate in PT, including waved tests. • Develop a methodology-based approach for PT (one material for many assays). • Samples should mimic patient samples with a minimum of matrix effect. • Small adjunct studies with fresh frozen samples in conjunction with “routine” PT. • Evaluate alternatives to current CLIA requirements for frequency and scoring. • Develop innovative approaches to PT. Dr.T.V.Rao MD

23. Does Proficiency Testing improve quality? • Probably yes, but hard to prove. • Accredited programs do better on PT • Laboratories with consistently high PT performance do better with accreditation • Clinical Error? • Clinical error detection? • OFIs and Continual Improvement? Dr.T.V.Rao MD

24. Medical laboratory proficiency testing • Medical laboratory proficiency testing has been around for 60 years • Respected as a valued monitoring tool • Inter-laboratory comparisons • Internal audit • Inter-technologist education • Starting to show its age • Testing the wrong thing in the wrong way • Falling behind laboratory reality Dr.T.V.Rao MD

25. What is Antimicrobial Stewardship? • A marriage of infection control and antimicrobial management • Mandatory infection control compliance • Selection of antimicrobials from each class of drugs that does the least collateral damage • Collateral damage issues include- MRSA- ESBLs- C.difficile- stable DE repression- MBLs and other carbapenemases- VRE • Appropriate de-escalation when culture results are available Dr.T.V.Rao MD Dellit TH et al Clin Infect Dis 2007; 44: 159-177

26. Objectives for Starting Antibiotic Stewardship • A. Be able to list the recommended components of an antibiotic stewardship program • B. Be able to detect antibiotic use improvement opportunities from the analysis of utilization data • C. Be able to explain the barriers for successful implementation of such a program Dr.T.V.Rao MD

27. Why Develop an Antimicrobial Stewardship ProgramFrom an Infection Preventionist Perspective: • Track and Reduce antimicrobial resistance • Encourage appropriate treatment patterns ~ The right antibiotic, for the right duration • Develop a collaborative practice between MDs/LIPs, Pharmacy, Laboratories and Infection Preventionists’ with best patient outcome in mind. Dr.T.V.Rao MD

28. WORKSTREAMS • 1. INFORMATION MANAGEMENT (HPS AND ISD) • 2. EDUCATION (NES) • 3.ORGANISATION AND ACCOUNTABILITY (NQIS) Dr.T.V.Rao MD

29. WORKSTREAMS • 4.INFECTION MANAGEMENT (SPA,NQIS,NES,HPS-ISD, Professional Organisations) • All the work-streams work in parallel but with vertical integration • Work stream work underpinned by an AMT Clinical Network Dr.T.V.Rao MD

30. INFECTION MANAGMENT PHILOSOPHY • HIGH BURDEN, HIGH IMPACT CONDITIONS • EVIDENCE OF BENEFIT FOR INTERVENTION • ALSO TARGET SYSTEMS CHANGE TO BRING ABOUT DESIRED BENEFIT • INTEGRATE, DEVELOP AND IMPLEMENT EXISITING AND NEW PROJECTS OVER 3 YEAR TIME FRAME: WORK CLOSELY WITH WORK PROGRAMMES OF KEY STAKEHOLDERS (e.g HPS, SPA) • IMMEDIATE OPPORTUNITIES AROUND SNAP-CAP, C.difficle and Surgical Prophylaxis. Dr.T.V.Rao MD

31. Goals of Committee • Assist providers in appropriate use of antimicrobial therapy with improved patient outcomes • Slow the development of antimicrobial resistance • Develop evidence- based appropriate use guidelines • Educate providers and staff regarding guidelines • Track resistance patterns and report back to medical and hospital staff • Report committee progress and outcomes to P&T, and Executive Committees Dr.T.V.Rao MD

32. Clean Hands Saves Many Lives Dr.T.V.Rao MD

33. Follow me for more topics of Interest on Infectious Diseases Dr.T.V.Rao MD

34. Programme Created by Dr.T.V.Rao MD for Awareness on Use and Misuse of Antibiotics by Medical Professionals Email doctortvrao@gmail.com Dr.T.V.Rao MD