Abuse of Antibiotics
In clinical practise
Dr. Hussein Fatehy
Abbassia Chest Hospital
Antibiotics are substances that
kill or inhibit the growth of microorganisms.
Bactericidal (Beta lactams,
Thanks to work by Alexander Fleming (1881-1955), Howard
Florey ( 1898-1968) and Ernst Chain (1906-1979), penicillin was
first produced on a large scale for human use in 1943. At this
time, the development of a pill that could reliably kill bacteria
was a remarkable development and many lives were saved
during World War II because this medication was available.
H. Florey BC Yang
Penicillin: an extensively studied
For lecture only
Social and economic impact
Antibiotics can cause severe reactions,
increasing hospitalization: in the United
States, this accounts for billions of dollars
of expense within the healthcare system.
Adverse effects from antibiotics account
for nearly 25% of all adverse drug
reactions amongst hospitalized patients
Beringer PM, Wong-Beringer A, Rho JP (January 1998). "Economic aspects
of antibacterial adverse effects". PharmacoEconomics 13 (1 Pt 1): 35–
ARE ALL ANTIBIOTICS ALIKE?
Many types of antibiotics are
available. Each works a little
differently and acts on different
bacteria. This is why you must have a
prescription to buy antibiotics. Your
doctor will decide which antibiotic
will work best for your infection
ARE ANTIBIOTICS SAFE?
Antibiotics are usually safe when taken
as directed by your doctor. However,
people may develop allergies to specific
antibiotics, and may have a reaction to
them. Your doctor will ask if you have
ever had allergic reactions to any
medicines. This is to make sure you
receive the right antibiotic.
PRINCIPLES OF ANTIMICROBIAL
Empiric therapy is a medical term referring to the
initiation of treatment (against an anticipated and
likely cause of infectious disease) prior to
determination of a firm diagnosis.
It is most often used when antibiotics are
given to a person before the specific
microorganism causing an infection is known.
Factors considered when selecting
empiric antimicrobial therapy
• Presumed source of infection.
• Presence of co-morbid conditions (i.e., recent surgery or trauma,
• Previous antibiotic administration history.
• Identification of the most likely pathogens and their unit-specific
• Pharmacologic factors
– Potential drug toxicity (i.e. aminoglycosides)
– Distribution to the site of infection.
Bad prescribing habits lead to:
–Ineffective and unsafe treatment,
–Exacerbation or prolongation of
–Distress and harm to the patient
–Increased mortality and morbidity
Antibiotics have no effect on viral infections such as
the common cold. They are also ineffective against
sore throats, which are usually viral and selfresolving. Most cases of bronchitis (90–95%) are
viral as well, passing after a few weeks—the use of
antibiotics such as ofloxacin against bronchitis is
superfluous and can put the patient at risk of
suffering adverse reactions .
Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL (August 1997)."Reattendance and
complications in a randomised trial of prescribing strategies for sore throat: the medicalising effect of
prescribing antibiotics". BMJ 315 (7104): 350–
2. doi:10.1136/bmj.315.7104.350. PMC 2127265. PMID 9270458.
Hueston WJ (March 1997). "Antibiotics: neither cost effective nor 'cough' effective". The Journal of
Family Practice 44 (3): 261–5. PMID 9071245
Reasons for unnecessary and
Expect to be cured
Need to return to work/school
Similar symptoms treated with
antibiotics in the past.
• Patient satisfaction
• Time pressures
• Diagnostic uncertainty
When parents demand
• Provide educational materials
and share your treatment rules
to explain when the risks of
antibiotics outweigh the
• Build cooperation and trust.
Antibiotic misuse, sometimes called antibiotic
abuse or antibiotic overuse, refers to the misuse or
overuse of antibiotics, with potentially serious
effects on health. It is a contributing factor to the
creation of multidrug-resistant bacteria, informally
called "super bugs": relatively harmless bacteria can
develop resistance to multiple antibiotics and cause
Harrison JW, Svec TA (April 1998). "The beginning of the end of the antibiotic era? Part
II. Proposed solutions to antibiotic abuse". Quintessence International 29 (4): 223–9.
Though antibiotics are required to
treat severe bacterial infections,
misuse has contributed to a rise in
bacterial resistance. The overuse of
fluoroquinolone and other
antibiotics fuels antibiotic resistance
in bacteria .
Neuhauser etal (February 2003). "Antibiotic resistance among gram-negative bacilli in US intensive care units: implications
for fluoroquinolone use". JAMA 289 (7): 885–8.doi:10.1001/jama.289.7.885. PMID 12588273
Bacteria can develop resistance to antibiotics in many ways:
Some doctors give patients antibiotics when they might not be helpful. For
example, a patient with a cold may pressure a doctor into prescribing an
antibiotic because the patient hopes to get a quick fix to his/her illness.
Antibiotics won't cure a cold because colds are caused by viruses, not
Antibiotics have no effect on viral infections. The treatment for a cold is
generally rest, plenty of fluids and medicines for fever and headache.
Antibiotics are misused because many patients do not take them
according to their doctor's instructions. They may stop taking their
antibiotics too soon, before their illness is completely cured. This allows
bacteria to become resistant by not killing them completely.
Some patients save unused medicine and take it later for another illness,
or pass it to other ill family members or friends.
These practices may result in the wrong antibiotics being used. They can
also lead to the development of resistant bacteria.
Reasons and causes of Antibiotic Resistance in
Less potent activity of Antibiotics ie.
generics,transportation,expired, and decreased potency.
Lack of diagnostic clinical microbiology labs.
Misuse of Antibiotics ie.failure to complete therapy,
skipping doses or reuse of leftovers.
Over the counter availability.
Use of antimicrobials in Vet.
CAUTION in antimicrobial
use for URTI
• Even a properly prescribed antibiotic can foster the
growth of one or more strains of antibiotic-resistant
bacteria for at least two to six months inside the
person taking the pills.
• "Carrying" a microbe also means that, during that
time, you're likely to "share" the resistant bug with
family, co-workers and others in your path.
• That particular strain may not make you sick. But if
you find yourself one day immune-suppressed,
those resistant strains of bacteria living inside you
increase the odds that any infection will be hard - or
even impossible - to beat.
Hay, J of Antimicrobial Chemotherapy , Jul 2005
Rhinitis and sinusitis
1. Antibiotics should not be given for viral rhinosinusitis.
2. Mucopurulent rhinitis (thick, opaque, or discolored nasal discharge)
frequently accompanies viral rhinosinusitis. It is not an indication for
antibiotic treatment unless it persists without improvement for more than
1. Diagnose as sinusitis only in the presence of:
- prolonged nonspecific upper respiratory signs and symptoms (e.g.
rhinorrhea and cough without improvement for > 10-14 days), or
- more severe upper respiratory tract signs and symptoms (e.g. fever
>39C, facial swelling, facial pain).
2. Initial antibiotic treatment of acute sinusitis should be with the most
narrow-spectrum agent which is active against the likely pathogens
American Academy of Pediatrics and American Academy of Family Physicians, Pediatrics
Sore throat – the evidence base
• Most sore throats are viral and selflimiting
• Strep is isolated in 30% of sore throats
• Asymptomatic carriage can be as high as
• Typical features only present in 15% of
patients with strep throat
• Recent studies do not support antibiotics
as preventative of non-suppurative
complications which are rare anyway
Cough needs to be
diagnosed by doctor.
cough can be caused
by GERD, post-nasal
drip or a combination
of factors. All of these
Cough illness & Bronchitis
1. Cough illness/bronchitis in children rarely warrants
2. Antibiotic treatment for prolonged cough (>10 days)
may occasionally be warranted:
- Pertussis should be treated according to established
- Mycoplasma pneumoniae infection may cause
pneumonia and prolonged cough (usually in children > 5
years); a macrolide agent (or tetracycline in children ≥ 8
years) may be used for treatment.
- Children with underlying chronic pulmonary disease
(not including asthma) may occasionally benefit
from antibiotic therapy for acute exacerbations.
Guidelines do not recommend antibiotics for asthma
attacks. The worse the symptoms, the more often this
practice seems to occur.
Unless there is a coexisting bacterial infectious such
as pneumonia or sinusitis, antibiotics should not be
Over use can cause drug resistant bacterial
In adults, bacterial infections are almost never the
cause of asthma exacerbations, and antibiotics are
rarely needed. The most common triggers of an
asthma attack in adults are viral infections, allergens,
and irritants, non of which responds to an antibiotics.
Empirical antibiotic treatment of CAP
– Previously healthy and no antibiotic treatment in past 3
• A macrolide or doxycyclin or amoxicillin/clavulanate
– Comorbidities or antibiotics in past 3 months
• A respiratory fluoroquinolone p.o. or β-lactam + macrolide
– Respiratory fluroquinolone p.o. or iv., or β-lactam +
• Special concerns
– Pseudomonas is a consideration (antistreptococcal,
antipseudomonas β-lactam (piperacillin/tazobactam,
imipenem plus ciprofloxacin or levofloxa
– MRSA is a consideration: add linezolid or vancomycin iv.
Switch IV to Oral Therapy
1. Cough and shortness of air are improving
2. Patient is afebrile for at least 8 hours
3. White blood cell count is normalizing
4. PO intake and GI absorption are adequate
ATS Guidelines 2004
Switching from IV to Oral
• Step-down therapy:
Conversion of an IV antibiotic to another oral
• Transitional therapy:
Conversion from same IV antibiotic to oral but
not of same dosage or strength
• Sequential therapy:
Conversion from same IV antibiotic to oral of
same dosage and strength
•Viruses cause most
•Viral illness needs time to
heal, antibiotic can not
Taking antibiotics for viral
illnesses will not:
*cure the infection.
*keep others from getting the
*make the patient feels better.
But it will make it more likely to
Clinical differentiation is possible between
bacterial and viral infection most of the times.
* Viral infection is disseminated
throughout the system (URT/LRT). Fever is
usually high at onset, settles by day 3-4.
* Bacterial infection is localized to one
part of the system ( acute tonsillitis does
not present with running nose or chest
signs ). Fever is generally moderate at the
onset and peaks by day 3-4.
So there is no
need to hurry
Mr: Don’t forget to take one
of our antibiotics free
sample before you leave the
Restrict antibiotic availability
Don'ts about antibiotics
DO NOT...pressure your doctor to prescribe an antibiotic .
DO NOT...take antibiotics that have been sitting around
the house unless prescribed by your doctor for a current
DO NOT...give your antibiotics to other people. Their
illness is probably different than yours, and so your
antibiotics will not help them to get well. Also, they might
even be harmed by your medicine.
DO NOT...take antibiotics simply because you were
exposed to someone with a disease. You are only
increasing your chances of picking up a resistant
infection. If you are exposed to an infectious disease, seek
Do's about antibiotics
• DO...ask your doctor whether your infection or your family
member's infection will respond to antibiotics.
• DO...ask your doctor about antibiotic-resistant bacteria and
what you can do to help prevent its occurrence. .
• DO...follow the instructions for taking your
antibiotic. Always take the exact amount specified on the
label at a specified time. Take the medicine for the entire
time that your doctor has prescribed. Even if you feel
better, take all of the medicine!