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Dr.T.V.Rao MD   Dr.T.V.Rao MD   1
Antimicrobial Resistance                     of antimicrobialThe emerging clinical impact resistance, urgent implementat...
Antibiotics and Mechanisms of               Resistance                                   ß-lactams B-lactamases,        ...
Genetics of Antimicrobial        Resistance                            Genetic diversity – nucleotide substitution, DNA...
Why Are Resistant      Infections Happening?                          Enormous biomass of microorganisms • Genetic plas...
How Much Antibiotics ? 22,000 t                                11,000 t dispensed to humans (50%)      in 150 million p...
Drugs for Human Treatment   are Excreted into Sewage                      Some drugs excreted in metabolized amounts via...
Metabolism of Antibiotics                      Dr.T.V.Rao MD     8
Veterinary Medicines in the       Environment                        Dr.T.V.Rao MD      9
Antimicrobial Prescribing Facts                         1/3 of all hospitalised inpatients at any given time  receive an...
Why So Many Mistakes High number and                                complexity of drugs High number and  complexity of ...
Hospital acquired infections     cause of many DeathsEvery year, many                       lives are lost because of th...
The spectrum of health research Biomedical research         Health policy and systems         Social sciences and      Ope...
What is Antimicrobial Stewardship                      Ongoing effort by a health care institution to optimize antimicro...
What Can We Do?Strengthen our Microbiology Departments ?Keep aware                     National/Provin cial Surveillanc...
What Can We Do?                    –Expect rapid              turn around              times             – Appropriate ...
What Can We Do?                      Infection Control in the office & hospital• Decrease antibiotic prescriptions for ...
Hand Washing a must for Safety of our Patients                             Proper hand washing is                   the ...
Preventive Measures …. Covering coughs and                           sneezes Staying up-to-  date with  immunizations Us...
Organize your ClinicalMicrobiology Laboratory Bench               Microbiologists                            should brin...
What most Proficiency Testing  does not tend to look at:                            Are negative samples reported as neg...
CDC Report   PT providers should publish scientifically             credible reports in peer-reviewed journals.April 2008...
Does Proficiency Testing       improve quality? Probably yes, but hard to                             prove.   Accredit...
Medical laboratory proficiency           testing                           Medical laboratory proficiency testing has be...
What is Antimicrobial Stewardship? A marriage of infection control and antimicrobial  management                         ...
Objectives for Starting       Antibiotic Stewardship                    A.Be able to list the recommended components of ...
Why Develop an Antimicrobial       Stewardship Program      From an Infection Preventionist Perspective: Track and Reduce...
WORKSTREAMS        1. INFORMATION MANAGEMENT (HPS AND ISD)2. EDUCATION (NES)3.ORGANISATION AND ACCOUNTABILITY (NQIS)  ...
WORKSTREAMS                   4.INFECTION MANAGEMENT (SPA,NQIS,NES,HPS-ISD, Professional Organisations) All the work-st...
INFECTION MANAGMENT           PHILOSOPHY                 HIGH BURDEN, HIGH IMPACT CONDITIONSEVIDENCE OF BENEFIT FOR INT...
Goals of Committee                          Assist providers in appropriate use of antimicrobial  therapy with improved ...
Clean Hands Saves   Many Lives                Dr.T.V.Rao MD   32
Follow me for more topics ofInterest on Infectious Diseases                            Dr.T.V.Rao MD        33
Programme Created by Dr.T.V.Rao MD for     Awareness on Use and Misuse of    Antibiotics by Medical Professionals       ...
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Antibiotic resistance What can we do ?

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Antibiotic resistance What can we do ?

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  1. 1. Dr.T.V.Rao MD Dr.T.V.Rao MD 1
  2. 2. Antimicrobial Resistance  of antimicrobialThe emerging clinical impact 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 2
  3. 3. Antibiotics and Mechanisms of Resistance  ß-lactams B-lactamases, altered PBP, efflux Macrolides MLS, efflux Aminoglycosides AME, permeability Fluoroquinolones altered topoisomerases, efflux Tetracyclines 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 3
  4. 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 4
  5. 5. Why Are Resistant Infections 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 5
  6. 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 AquacultureDr.T.V.Rao MD (1%) 6
  7. 7. Drugs for Human Treatment are Excreted into Sewage Some drugs excreted in metabolized amounts via the urine and fecesSome yield bioactive metabolites.Some excreted as Dr.T.V.Rao MD 7 conjugates
  8. 8. Metabolism of Antibiotics  Dr.T.V.Rao MD 8
  9. 9. Veterinary Medicines in the Environment  Dr.T.V.Rao MD 9
  10. 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 10
  11. 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 11
  12. 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 12
  13. 13. The spectrum of health research Biomedical research Health policy and systems Social sciences and Operational research behavioral research research  Basic research: Research on Research on Research onphysical and biological policy formulation, relationship social and behavioural factors sciences including to evidence, factors influencing health affecting chemistry, prioritization, etc and their relation to functioning of pharmacology, equity, access, programs, toxicology, Research on lifestyle and health- effectiveness of genetics, etc health systems management, seeking behaviours, targeting, functions, efficiency, etc impact on R&D for drugs, effectiveness, system factors behavior, vaccines, affecting access disease diagnostics, scale-up, monitoring and burdens and appliances, etc evaluation, etc public health, etc Understanding the biological nature of Understanding how to test, scale-up and follow through the introduction of diseases; creating interventions and optimize their benefitsproducts to prevent or treat disease states Innovation Impact MD Dr.T.V.Rao 13
  14. 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 14
  15. 15. What Can We Do?Strengthen our Microbiology Departments ?Keep aware National/Provin cial Surveillance Programs Get to know your microbiology laboratory Dr.T.V.Rao MD 15
  16. 16. What Can We Do?  –Expect rapid turn around times – Appropriate susceptibility test reporting Dr.T.V.Rao MD 16
  17. 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 17
  18. 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, dont be afraid to remind friends, family and health care providers to wash their hands before getting close to you. Dr.T.V.Rao MD 18
  19. 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 19
  20. 20. Organize your ClinicalMicrobiology 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 20
  21. 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 21
  22. 22. CDC Report PT providers should publish scientifically credible reports in peer-reviewed journals.April 2008 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. Dr.T.V.Rao MD Develop innovative 22 approaches to PT.
  23. 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 23
  24. 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 24
  25. 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 25 Dellit TH et al Clin Infect Dis 2007; 44: 159-177
  26. 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 26
  27. 27. Why Develop an Antimicrobial Stewardship Program From 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 27
  28. 28. WORKSTREAMS 1. INFORMATION MANAGEMENT (HPS AND ISD)2. EDUCATION (NES)3.ORGANISATION AND ACCOUNTABILITY (NQIS) Dr.T.V.Rao MD 28
  29. 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 29
  30. 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 30
  31. 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 31
  32. 32. Clean Hands Saves Many Lives  Dr.T.V.Rao MD 32
  33. 33. Follow me for more topics ofInterest on Infectious Diseases  Dr.T.V.Rao MD 33
  34. 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 34
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