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Antibiotic policy


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Antibiotic policy

Antibiotic policy

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  • 1. Dr.T.V.Rao MD Dr.T.V.Rao MD 1
  • 2. Discovery Of Penicillin changes the History of Medicine Dr.T.V.Rao MD 2
  • 3. Why we Need Antibiotics Nearly One half of the Hospitalized patients receive antimicrobial agents.Antibiotics are valuable Discoveries of the ModernMedicine.All current achievements in Medicine are attributed touse of AntibioticsLife saving in Serious infections. Dr.T.V.Rao MD 3
  • 4. What went wrong with Antibiotic UsageTreating trivial infections / viral Infections withAntibiotics has become routine affair.Many use Antibiotics without knowing the Basicprinciples of Antibiotic therapy.Many Medical practioners are under pressure for shortterm solutions.Commercial interests of Pharmaceutical industry pushingthe Antibiotics, more so Broad spectrum and NewerGeneration antibiotics. as every Industry has becomeprofit oriented.Poverty encourages drug resistance due to underutilization of appropriate Antibiotics. Dr.T.V.Rao MD 4
  • 5. Introduction“The end of infectious diseases” was a popularidea in the 1970sInfectious diseases are still important in the 21stcentury due to: Boundless nature Emergence of new infections Re-emergence of old infections Increase in drug - resistant infections Dr.T.V.Rao MD 5
  • 6. Science magazine; July 18, 2008The last decade has seen the inexorable proliferation of ahost of antibiotic resistant bacteria, or bad bugs, not justMRSA, but other insidious players as well. ...For thesebacteria, the pipeline of new antibiotics is verging onempty. What do you do when youre faced with aninfection, with a very sick patient, and you get a labreport back and every single drug is listed as resistant?asked Dr. Fred Tenover of the Centers for Disease Control andPrevention (CDC). This is a major bloomingpublic health crisis." Dr.T.V.Rao MD 6
  • 7. Four main groups of Bacteria a Concern for Antibiotic ResistanceGram positiveGram negativeAnaerobesAtypical Dr.T.V.Rao MD 7
  • 8. Generally. Infecting Microbes.. Gram -ve GI-tract, GU & Anaerobes Respiratory Mouth, teeth, Peritonitisthroat, sinuses & Biliary infection lower bowel PancreatitisDental infection UTI Peritonitis PID Appendicitis CAP/HAP/VAP Abscesses Sinusitis Gram +ve Skin, Bone & Atypicals Respiratory Chest and genito- Cellulitis urinaryWound infection Pneumonia Line infection Urethritis Osteomyelitis PID Pneumonia Dr.T.V.Rao MD 8 Sinusitis
  • 9. Why inappropriate use of antibiotics contributes to antibiotic resistance – the “why” Dr.T.V.Rao MD 9
  • 10. In-patients are at high risk of antibiotic-resistant infectionsMisuse of antibiotics in hospitals is one ofthe main factors that drive development ofantibiotic resistance.Patients in hospitals have a highprobability of receiving an antibiotic and50% [adapt to national figure whereavailable] of all antibiotic use in hospitalscan be inappropriate. Dr.T.V.Rao MD 10
  • 11. Misuse of Antibiotics Drives Antibiotic ResistanceStudies prove that misuse of antibiotics may causepatients to become colonized or infected with antibiotic-resistant bacteria, such as methicillin-resistantStaphylococcus aureus (MRSA), vancomycin-resistantenterococci (VRE) and highly-resistant Gram-negativebacilli.13-14Misuse of antibiotics is also associated with an increasedincidence of Clostridium difficile infections.15-17 Dr.T.V.Rao MD 11
  • 12. Basis of Antibiotic ResistanceThe antibiotic resistance is guided by GenomicchangesSpread of R plasmids among the BacteriaDo remember Antibiotics are used in Animalhusbandry apart from Medical useThe discovery of antibiotic resistance was discoveredwith spread of R plasmids from animal sourcesThe Human gut forms the interconnecting area in Rplasmids transmission leading ultimately toantibiotic resistance Dr.T.V.Rao MD 12
  • 13. Plasmids played a Major Role inspread of Antibiotic resistance. Dr.T.V.Rao MD 13
  • 14. Multiple Mechanism of Drug Resistance Dr.T.V.Rao MD 14
  • 15. Spread of Antibiotic ResistanceIndiscrimate use ofAntibiotics in Animals andMedical practiceR plasmids spread among co-inhabiting Bacterial flora inAnimals ( in gut )R plasmids may be mainlyevolved in Animals spread toHuman commensal, -Escherichia coli followed byspread to more importanthuman pathogens EgShigella spp. Dr.T.V.Rao MD 15
  • 16. Why Everyone worried about Antibiotic ( misuse ) Use. Drug resistance can reverse Medical progress The following diseases are already in the list ofattaining the drug resistance, and Medical professionwill find difficult to cure in future. 1. Tuberculosis 2. Malaria 3. Sore throat and Ear Infections. Dr.T.V.Rao MD 16
  • 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 17
  • 18. Dr.T.V.Rao MD 18
  • 19. Aim of Antibiotic PolicyReduce the Antimicrobial resistanceInitiate best efforts in the hospital area as manyresistance Bacteria are generated in Hospital areasand in particular critical care areas.Initiate good hygienic practices so these bacteria donot spread to othersPractice best efforts, these resistance strains do notspill into critically ill patients in the HospitalTo prevent spill into Society, as they present ascommunity associated infections.. Dr.T.V.Rao MD 19
  • 20. Objectives of Antibiotic Policy.Antibiotics should not be used casuallyPolicy emphasizes, avoiding the use of powerfulAntibiotics in the Initial treatments.We should create awareness that we are sparingthe powerful Broad spectrum Drugs for latertreatment Patient saves Money Doctors save Lives. Dr.T.V.Rao MD 20
  • 21. Aims of the Antibiotic PolicyCreate awareness on Antibiotics as misuse iscounterproductive.More effective treatments in serious Infections.Reduce Health care associated infections spilling tosociety and increase of Community associatedInfections. ( A growing concern in Developing world ) Dr.T.V.Rao MD 21
  • 22. Policy Deals on Broad BasisClinicians /Microbiologists /Pharmacists and Nursesdo take part.Policies are framed ondemands of the Clinicalareas, depending onrecent Infectionsurveillance datacontributed fromMicrobiologyDepartments. Dr.T.V.Rao MD 22
  • 23. Antibiotic working Group Monitors Formulate Optimal guidelines inTreatment of Infections with minimal riskof Health care associated Infections. Create a plan for monitoring the Use of Antibiotics across the Hospital Dr.T.V.Rao MD 23
  • 24. Education On Antibiotic policyActon plan for Education to all concernedclinical staff on Antibiotic prescriptions. Evaluate the feed back of success and failuresof the policy.Create Infection surveillance DataDeveloping facilities in Microbiologydepartments for auditing data and guidanceRestrictions in prescribing and Antibioticavailability.A continuous education to Junior Doctors Dr.T.V.Rao MD 24
  • 25. Ideal Sample Collection is Essential RequirementProper specimen collection is combinedresponsibility of Clinical and MicrobiologicalDepartments.Continuous training of junior staff on samplecollection, and is most neglected necessityA good clinical history is greatly helpful indifferentiating community acquired infectionsfrom hospital acquired infections. Dr.T.V.Rao MD 25
  • 26. Pitfalls in Specimen collectionA proper specimencollection is mostneglected area ofMicrobiology.Scientific approaches inSample collection isconcern for successfulMicrobiologicalevaluations, Dr.T.V.Rao MD 26
  • 27. Microbiology ServicesConstant up graduationof Microbiologydepartments is goodinvestment.Quality controlmethods in testing ofantibiotic resistancepattern is a top priority. Dr.T.V.Rao MD 27
  • 28. Role of Microbiology DepartmentMicrobiology departmentsasses trends indevelopment ofantimicrobial resistance.The results ofsensitivity/resistancepatterns should becorrelated withAntimicrobial agentscurrently used in theHospital.Identify and forecast thatnature of relation betweenantibiotic use andresistance. Dr.T.V.Rao MD 28
  • 29. Better services from Microbiology Departments.Basic infrastructure shouldbe updated for detection ofMRSA and ESBLproducers.Documentation of allOpportunistic infections.and Hospital infectionoutbreaks Dr.T.V.Rao MD 29
  • 30. Measures that can decrease antibiotic resistanceMeasures that guide antibiotic prescribing are likely to decreaseantibiotic resistance in hospitals.32-34 Such measures include:Obtaining culturesTake appropriate and early cultures before initiating empiricantibiotic therapy,and streamline antibiotic treatment based on the culture results35Monitoring local antibiotic resistance patternsBeing aware of local antibiotic resistance patterns (Antibiograms)enablesappropriate selection of initial empiric antibiotic therapy Dr.T.V.Rao MD 30
  • 31. PRIORITY ANTIBIOTIC-RESISTANT BACTERIA PATHOGENSThe ESKAPE Pathogens: The so-called ESKAPEPathogens (Enterococcus faecium, Staphylococcus aureus,Klebsiella pneumoniae, Acinetobacter baumannii,Pseudomonas aeruginosa, and ESBL positive bacteria,such as E. coli and Enterobacter species) represent agrouping 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 31
  • 32. Advantages of Antibiotic PolicySaves the LivesReduces the morbiditySaves Health relatedcostsReduces the Antibioticrelated toxicity.Patients are satisfied. Dr.T.V.Rao MD 32
  • 33. Staff Education on Antibiotic PolicyStaff education is most Important principle insuccessDraw your own plans according to nature ofpatients, your past experiencesInduction training for new staffContinuing Medical Education to both Junior andSenior DoctorsInclude nursing staff, pharmacists for the successof the Programme Dr.T.V.Rao MD 33
  • 34. Training in rational prescribing hasAchievements expanded in universities throughout the worldProblem-basedpharmacotherapyIn 18 languagesFor medical students,clinical officersMeasurable improvement inprescribingNow also: Teacher’s Guide toGood Prescribing Dr.T.V.Rao MD 34
  • 35. Patient Education on Antibiotic PolicyEducation of the patients and society is importantin Developing world.Educate the patients many infections are trival,viral,Do not need AntibioticsIf they understand Unnecessary consumption ofAntibiotics kills the Normal flora, and reducesthe Immunity and makes them potential victimsin future.A difficult task in Developing countries. Dr.T.V.Rao MD 35
  • 36. Proved success of Antibiotic Policies 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 36
  • 37. Make your conclusions andcontribute to Antibiotic PolicyIt is true to say that there is no absolute proof ofcausative association between antibiotic use andresistance, But many authorities believe theassociation to be virtually certain.It is pragmatic and essential approach to controlof antibiotic resistance with control of antibioticuse.Make every one a partner in prevention ofAntibiotic resistance, and success will follow. Dr.T.V.Rao MD 37
  • 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 38
  • 39. CDC reportsCDC reports thatnearly 2 million healthcare-associatedinfections (HAIs) and90,000 HAI-relateddeaths occur annuallyin the U.S. Many ofthese infections anddeaths are caused byantibiotic-resistantinfections. Dr.T.V.Rao MD 39
  • 40. New Innovations in Diagnostic MicrobiologyNew rapid diagnostic testswould greatly facilitate clinicaltrials of critically needed newantibiotics. The tests wouldenable investigators to identifypotential study subjects moreeasily, which would permitsmaller and less expensivestudies of antibiotics as theymove through development Dr.T.V.Rao MD 40
  • 41. Infection Control Team Leadership and dedicated staff; training and education; mechanisms that serve to improve antibiotic resistance Dr.T.V.Rao MD 41
  • 42. Best way to keep the matters in OrderEvery Hospital should have a policy which is practicable to their circumstances. Rigid guidelines without coordination will lead to greater failuresThe only way to keep Antimicrobial agents usefulis 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 42
  • 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 43
  • 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 44
  • 45. Continuous Medical Education a Must ..Training and educating health care professionals on theappropriate use of antibiotics must include appropriateselection, dosing, route, and duration of antibiotictherapy. To ensure that training and education is working,there should be extensive collaboration between theantibiotic stewardship and hospital infection preventionand control teams. Without benchmarks, it is difficult totrack successes and weaknesses Dr.T.V.Rao MD 45
  • 46. Computerized Decisions a Emerging Need …..Computerized decisionsupport can preservephysician autonomy and hasbeen shown to improveantibiotic use by a numberof different measures: fewersusceptibility mismatches,allergic reactions and otheradverse events, excessdosages, and overall amountand cost of antibiotictherapy Dr.T.V.Rao MD 46
  • 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 47
  • 48. Hand Washing Reduces the Spread of Antibiotic Resistant Strains Dr.T.V.Rao MD 48
  • 49. The Programme created by Dr.T.V.Rao MD for ‘e’ Learningresources for Medical Professionals in Developing World. Email Dr.T.V.Rao MD 49