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Antimicrobial Stewardship                                 1. Antibiotic Policy                            2. Infection Con...
Discovery & Development ofAnti-bacterials is one of the most  important discovery of the          20th Century            ...
Power of antibioticsDisease                              Pre Antibiotic era                    Deaths with    Change in de...
Introductions of New Antibiotic Classes1940       1950     1960        1970 1980 1990 2000 2002 2004 2006 2007 2008 2010  ...
Mankind has always hadthe benefit of “good” advice    “By the year 2000, nearly all    experts agree that bacterial and   ...
Increasing Incidence of Resistance in the US                        MRSE, MRSA, VRE, PRSP, GISA                           ...
Bad bugs, no drugs: No ESKAPE                    CID 2009; 48: 1 - 12E   nterococcus faeciumS   taphylococcus aureusK   le...
We have a basic problem   We must make the best use of what we have                                               8
Consequences of antibiotic use                   •Inhibition of non pathogenic bacteria                   •Selection of re...
Antimicrobial Stewardship                •Inhibition of non pathogenic bacteria                 •Selection of resistant mu...
Antimicrobial StewardshipEffective antimicrobial stewardship Comprehensive infection control      Audit & feedback        ...
Empiric treatmentBroad spectrum antibioticNo sample collected                            Prolonged                        ...
Empiric treatmentBroad spectrum antibioticNo sample collected                            Prolonged                        ...
Knowledge of local ecologyOPDIPDICU                             14
PK/PD terminology    32                               C max/ MIC    16                                     AUC / MIC      ...
PK/PD correlation with efficacyT > MIC                   AUC or Cmax/MICTarget: >40 % of dosing     100            10  Pen...
De Escalation strategy                         17
Short duration of therapyAutomatic stop orders                            18
Antibiotic Use BundleInitiation bundle:1.    1. Clinical rationale for antibiotic initiation documented2.    2. Appropriat...
Lewisham Empirical Antimicrobial Prescribing (LEAP) Initiation Care Bundle            [Complete this section for all Commu...
21
Day 3 bundle:1.    1. Was an antibiotic plan documented     1.   (name, dose, route, frequency & planned duration ?)2.    ...
Lewisham Empirical Antimicrobial Prescribing (LEAP) Initiation Care Bundle            [Complete this section for all Commu...
Gram +ve problemNailed down Vancomycin & Teicoplanin                                              Tigecycline             ...
Hand washing is an important strategy to            control MRSA                                           25
Surveillance culture is an important strategy to               control MDR GNB                                            ...
Rapid diagnostic tests would help                TAT 20 min to 4 hoursProcalcitonin for initiation of antibacterial  thera...
Extinction of MDR Bacteria is             not an achievable GoalBacteria have inhabited the Earth longer than humans  and ...
Our innovations must stay ahead of         bacterial adaptationNew strategies may include  Discovery & Development of new ...
Current Crisis of MDR InfectionsAct of GOD (nature) Act of Man Kind  Spread of resistant gene    Selection of resistant   ...
but we CAN         31
Dennis Maki, IDSA Meeting 1998Developing new antibiotics without having mechanismsto insure their appropriate use is much ...
33
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Tackling MDR bacteria

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Antimicrobial stewardship involves prudent use of antibiotics and infection control.

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Transcript of "Tackling MDR bacteria"

  1. 1. Antimicrobial Stewardship 1. Antibiotic Policy 2. Infection Control ManualDr. Ashok Rattan,Chairman : Laboratory Medicine
  2. 2. Discovery & Development ofAnti-bacterials is one of the most important discovery of the 20th Century 2
  3. 3. Power of antibioticsDisease Pre Antibiotic era Deaths with Change in deaths due deaths antibiotics to antibioticsCAP (1) 35% 10% - 25%HAP (2) 60% 30% - 30%Heart Infection (3) 100% 25% - 75%Brain Infections (4) > 80% < 20% - 60%Skin Infection (5) 11% < 0.5% -10%By comparison…. Treatment of heart attacks with aspirin or clot busting drugs (6) - 3% Ref.: (1) IDSA Position Paper. Clin Infect Dis 2008; 47 (S3): S 249 – 65 (2) IDSA/ACCP/ATS/SCCM position paper. CID 2010; 51 (S1): 51 – 3 (3) Kerr AJ. SABE Lancet 1935; 226: 383 – 4 (4) Waring et al. Am J Med 1948; 5: 402 – 18 (5) Spellberg et al CID 2009; 49: 383 – 91 (6) Lancet 1998; 351 : 233 – 41. 3
  4. 4. Introductions of New Antibiotic Classes1940 1950 1960 1970 1980 1990 2000 2002 2004 2006 2007 2008 2010 Ceftaroline 2010 Doripenem 2007 Tigecycline 2006 Telithromycin 2004 Quinolones 1962 Daptomycin 2003 Streptogramin 1962 Ertapenem 2001 Oxazolidinone 2000 Glycopeptides 1958 Macrolides 1952 Aminoglycosides 1950 Tetracycline 1949 Me too drugs Different Generations Penicillin 1940Sulfas 1936 4
  5. 5. Mankind has always hadthe benefit of “good” advice “By the year 2000, nearly all experts agree that bacterial and viral diseases will have been virtually wiped out…” The futurists: looking toward year 2000 (Time magazine, february 25, 1966) US surgeon general William Stewart:“ The time has come to close the book on infectious diseases” (1969) 5
  6. 6. Increasing Incidence of Resistance in the US MRSE, MRSA, VRE, PRSP, GISA 1980-2006 100Percentage MRSEof 80PathogensResistant toAntibiotics 60 MRSA PRSP 40 VRE 20 VRSA VISA 0 1975 1980 1985 1990 1995 2000 2006 1997 6
  7. 7. Bad bugs, no drugs: No ESKAPE CID 2009; 48: 1 - 12E nterococcus faeciumS taphylococcus aureusK lebseilla pneumoniaeA cinetobacter baumaniiP seudomonas aeruginosaE nterobacter species Clostridium difficile & E. coli 7
  8. 8. We have a basic problem We must make the best use of what we have 8
  9. 9. Consequences of antibiotic use •Inhibition of non pathogenic bacteria •Selection of resistant mutants •Toxicity / side effects •Clinical cure 9
  10. 10. Antimicrobial Stewardship •Inhibition of non pathogenic bacteria •Selection of resistant mutants •Toxicity / side effectsClinical cure 10
  11. 11. Antimicrobial StewardshipEffective antimicrobial stewardship Comprehensive infection control Audit & feedback Managing data and information Guidelines & algorithms Policies & procedures Antibiotic order form Regulatory requirements Combination Employee health De escalation Prevent transmission, investigate outbreaks Dose optimization Education & training Parentral  oral Mobilize resources: human & Cycling financial 11
  12. 12. Empiric treatmentBroad spectrum antibioticNo sample collected Prolonged treatment Selection of MDR Mutant bacteria 12
  13. 13. Empiric treatmentBroad spectrum antibioticNo sample collected Prolonged treatment Reward Selection of MDR Mutant bacteria 13
  14. 14. Knowledge of local ecologyOPDIPDICU 14
  15. 15. PK/PD terminology 32 C max/ MIC 16 AUC / MIC t > MIC 8SerumConc. 4 C max(ug/ml) 2 1 0.5 MIC 0.25 0.12 Time > MIC 0.06 0 15
  16. 16. PK/PD correlation with efficacyT > MIC AUC or Cmax/MICTarget: >40 % of dosing 100 10 Penicillin Aminoglycosides Cephalosporins Fluoroquinolones Carbapenems Metronidazole Daptomycin Monobactam Ketolides Macrolides Azithromycin Clindamycin Streptogramin Oxazolidinones Glycopeptides Glycylcyclines Amphotericin Flucytosine Fluconazole 16
  17. 17. De Escalation strategy 17
  18. 18. Short duration of therapyAutomatic stop orders 18
  19. 19. Antibiotic Use BundleInitiation bundle:1. 1. Clinical rationale for antibiotic initiation documented2. 2. Appropriate samples for smear & culture collected & submitted to the laboratory3. 3. Antibiotic selected according to local policy & risk group4. 4. Antibiotic ordered as per plan 1. (name, dose, route, frequency & tentative duration)5. 5. Removal of foreign body or ID, as appropriate, considered 19
  20. 20. Lewisham Empirical Antimicrobial Prescribing (LEAP) Initiation Care Bundle [Complete this section for all Community or Hospital Acquired Infections] Care Bundle Element Evident Comments Yes / No1 Clinical signs of infection documented in medical notes2 Appropriate clinical specimens sent to microbiology / blood samples requested3 Antimicrobial prescription in accordance with local guidelines and appropriate for individual patient4 Antibiotic plan documented ?5 Foreign body removed or pus drained, as appropriateTotal no. care bundle elements evident % Compliance 20
  21. 21. 21
  22. 22. Day 3 bundle:1. 1. Was an antibiotic plan documented 1. (name, dose, route, frequency & planned duration ?)2. 2. Review of diagnosis after lab reports ?3. 3. If positive microbiology results, was there any adaptation : streamlining or discontinuation4. 4. Was IV -> oral switch considered & implemented5. 5. Were all four above mentioned steps followed ? 22
  23. 23. Lewisham Empirical Antimicrobial Prescribing (LEAP) Initiation Care Bundle [Complete this section for all Community or Hospital Acquired Infections] Care Bundle Element Evident Comments Yes / No1 Was an antibiotic plan documented (name, dose, route, frequency & planned duration ?)2 Review of diagnosis after lab reports ?3 If positive microbiology results, was there any adaptation : streamlining or discontinuation4 Was IV -> oral switch considered & implemented5 Were all four above mentioned steps followed ?Total no. care bundle elements evident % Compliance 23
  24. 24. Gram +ve problemNailed down Vancomycin & Teicoplanin Tigecycline & ColistinLinezolidDaptomycinCeftaroline Gram –ve infections may leave us exposed 24
  25. 25. Hand washing is an important strategy to control MRSA 25
  26. 26. Surveillance culture is an important strategy to control MDR GNB 26
  27. 27. Rapid diagnostic tests would help TAT 20 min to 4 hoursProcalcitonin for initiation of antibacterial therapyPOCT for infectious markers Lateral flow Immunological tests Real time PCR; Multiplex PCR for Sepsis MALDI TOF MSEmergent indications for antibiotic use Sever sepsis or septic shock Infections known to have fulminant course 27
  28. 28. Extinction of MDR Bacteria is not an achievable GoalBacteria have inhabited the Earth longer than humans and in far greater numberHumans have capability of causing extinction of other species, mostly unintentional (Dodo, ? Tiger) However, Extinction of MDR bacteria is not an achievable goal by Man Kind 28
  29. 29. Our innovations must stay ahead of bacterial adaptationNew strategies may include Discovery & Development of new antimicrobials Antimicrobial stewardship and appropriate guidelines for use of older drugs Rapid point of care diagnostic tests Biomarkers for diagnostic & prognostic accuracy Strict Infection control 29
  30. 30. Current Crisis of MDR InfectionsAct of GOD (nature) Act of Man Kind Spread of resistant gene Selection of resistant from antibiotic mutants by use & over producing bacteria to use of antibiotics pathogens Spread of MDR strains Acquisition of resistance from one patient to to available drugs by another by non mutation application of Infection Control policies 30
  31. 31. but we CAN 31
  32. 32. Dennis Maki, IDSA Meeting 1998Developing new antibiotics without having mechanismsto insure their appropriate use is much like supplyingyour alcoholic patients with a finer brandy. 32
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