Dr.T.V.Rao MD
Dr.T.V.Rao MD 1

Discovery Of Penicillin changes
the History of Medicine
Dr.T.V.Rao MD 2

Why we Need Antibiotics
Nearly One half of the Hospitalized
patients receive antimicrobial agents.
 Antibiotics are val...

What went wrong with
Antibiotic Usage
 Treating trivial infections / viral Infections with
Antibiotics has become routi...

Introduction
 ‚The end of infectious diseases‛ was a
popular idea in the 1970s
Infectious diseases are still important...
 The last decade has seen the inexorable proliferation
of a host of antibiotic resistant bacteria, or bad
bugs, not just...

Four main groups of Bacteria a
Concern for Antibiotic Resistance
Gram positive
Gram negative
Anaerobes
Atypical
Dr.T.V.R...

Gram +ve
Skin, Bone &
Respiratory
Gram -ve
GI-tract, GU &
RespiratoryAnaerobes
Mouth, teeth, th
roat, sinuses &
lower bo...
Why inappropriate
use of antibiotics
contributes to
antibiotic resistance
– the “why”
Dr.T.V.Rao MD 9

Misuse of antibiotics in hospitals is one
of the main factors that drive
development of antibiotic resistance.
Patient...

 Studies prove that misuse of antibiotics may cause
patients to become colonized or infected with
antibiotic-resistant ...

Basis of Antibiotic
Resistance
The antibiotic resistance is guided by Genomic
changes
Spread of R plasmids among the B...
Plasmids played a Major Role in
spread of Antibiotic resistance.
Dr.T.V.Rao MD 13

Multiple Mechanism of
Drug Resistance
Dr.T.V.Rao MD 14

Spread of Antibiotic Resistance
 Indiscrimate use of
Antibiotics in Animals and
Medical practice
 R plasmids spread am...

Why Everyone worried about
Antibiotic ( misuse ) Use.
Drug resistance can reverse Medical progress
The following disease...
Misuse of antibiotics can include any of the following
When antibiotics are prescribed unnecessarily;
When antibiotic a...
Dr.T.V.Rao MD 18

Aim of Antibiotic
Policy
Reduce the Antimicrobial resistance
Initiate best efforts in the hospital area as many
resist...

Objectives of Antibiotic Policy.
Antibiotics should not be used casually
Policy emphasizes, avoiding the use of
powerf...

Aims of the Antibiotic
Policy
Create awareness on Antibiotics as misuse is
counterproductive.
More effective treatment...

Policy Deals on Broad
Basis
 Clinicians /
Microbiologists /
Pharmacists and
Nurses do take part.
 Policies are framed ...

Antibiotic working Group
Monitors
Formulate Optimal guidelines in
Treatment of Infections with minimal
risk of Health ca...

Education On Antibiotic policy
Acton plan for Education to all concerned
clinical staff on Antibiotic prescriptions.
 ...

Ideal Sample Collection is
Essential Requirement
Proper specimen collection is combined
responsibility of Clinical and ...
Pitfalls in Specimen
collection
A proper specimen
collection is most
neglected area of
Microbiology.
Scientific approach...
Microbiology Services
Constant up
graduation of
Microbiology
departments is good
investment.
Quality control
methods in ...

Role of Microbiology
Department
 Microbiology
departments asses trends
in development of
antimicrobial resistance.
 Th...
Better services from
Microbiology Departments.
 Basic infrastructure
should be updated for
detection of MRSA and
ESBL pro...
 Measures that guide antibiotic prescribing are likely to
decrease antibiotic resistance in hospitals.32-34 Such
measure...

 The ESKAPE Pathogens: The so-called ESKAPE
Pathogens (Enterococcus faecium, Staphylococcus
aureus, Klebsiella pneumoni...

Advantages of
Antibiotic Policy
Saves the Lives
Reduces the
morbidity
Saves Health related
costs
Reduces the
Antibio...

Staff Education on Antibiotic
Policy
Staff education is most Important principle in
success
Draw your own plans accord...

Training in rational prescribing has
expanded in universities throughout
the world
 Problem-based
pharmacotherapy
 In ...

Patient Education on Antibiotic
Policy
Education of the patients and society is
important in Developing world.
Educate...

Proved success of Antibiotic
Policies
Studies Prove
1 Rapid reversal of major clinical problems of
resistance to Chloram...

Make your conclusions and
contribute to Antibiotic Policy
It is true to say that there is no absolute proof
of causativ...

Antibiotic resistance –
a problem in the present and the
future
Antibiotic resistance
is an increasingly
serious public...

CDC reports
CDC reports that
nearly 2 million
health care-associated
infections (HAIs) and
90,000 HAI-related
deaths oc...

New Innovations in
Diagnostic Microbiology
 New rapid diagnostic tests
would greatly facilitate
clinical trials of crit...

Infection Control Team
Leadership and
dedicated staff;
training and
education;
mechanisms that
serve to improve
antibio...

Best way to keep the matters
in Order
Every Hospital should have a policy which is
practicable to their circumstances.
R...

Prudent prescribing to reduce
antimicrobial resistance
• Only use an antimicrobial when clearly indicated.
• Select an a...

 Antibiotic prescribing practices and decreasing
antibiotic resistance can be addressed through
multifaceted strategies...

 Training and educating health care professionals on
the appropriate use of antibiotics must include
appropriate select...

Dr.T.V.Rao MD 46
Computerized Decisions
a Emerging Need …..
 Computerized decision
support can preserve
physician auton...

Dr.T.V.Rao MD 47
Implementation of WHONET CAN
HELP TO MONITOR RESISTANCE
 Legacy computer
systems, quality
improvement ...

Hand Washing Reduces the
Spread of Antibiotic Resistant
Strains
Dr.T.V.Rao MD 48

The Programme created by
Dr.T.V.Rao MD for ‘e’ Learning
resources for Medical Professionals
in Developing World.
 Emai...
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  1. 1. Dr.T.V.Rao MD Dr.T.V.Rao MD 1
  2. 2.  Discovery Of Penicillin changes the History of Medicine Dr.T.V.Rao MD 2
  3. 3.  Why we Need Antibiotics Nearly One half of the Hospitalized patients receive antimicrobial agents.  Antibiotics are valuable Discoveries of the Modern Medicine.  All current achievements in Medicine are attributed to use of Antibiotics  Life saving in Serious infections. Dr.T.V.Rao MD 3
  4. 4.  What went wrong with Antibiotic Usage  Treating trivial infections / viral Infections with Antibiotics has become routine affair.  Many use Antibiotics without knowing the Basic principles of Antibiotic therapy.  Many Medical practioners are under pressure for short term solutions.  Commercial interests of Pharmaceutical industry pushing the Antibiotics, more so Broad spectrum and Newer Generation antibiotics. as every Industry has become profit oriented. Poverty encourages drug resistance due to under utilization of appropriate Antibiotics.Dr.T.V.Rao MD 4
  5. 5.  Introduction  ‚The end of infectious diseases‛ was a popular idea in the 1970s Infectious diseases are still important in the 21st century 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. 6.  The last decade has seen the inexorable proliferation of a host of antibiotic resistant bacteria, or bad bugs, not just MRSA, but other insidious players as well. ...For these bacteria, the pipeline of new antibiotics is verging on empty. 'What do you do when you're faced with an infection, with a very sick patient, and you get a lab report back and every single drug is listed as resistant?' asked Dr. Fred Tenover of the Centers for Disease Control and Prevention (CDC). 'This is a major blooming public health crisis.'" Science magazine; July 18, 2008 Dr.T.V.Rao MD 6
  7. 7.  Four main groups of Bacteria a Concern for Antibiotic Resistance Gram positive Gram negative Anaerobes Atypical Dr.T.V.Rao MD 7
  8. 8.  Gram +ve Skin, Bone & Respiratory Gram -ve GI-tract, GU & RespiratoryAnaerobes Mouth, teeth, th roat, sinuses & lower bowel Generally. Infecting Microbes.. Atypicals Chest and genito-urinary Peritonitis Biliary infection Pancreatitis UTI PID CAP/HAP/VAP Sinusitis Cellulitis Wound infection Line infection Osteomyelitis Pneumonia Sinusitis Dental infection Peritonitis Appendicitis Abscesses Pneumonia Urethritis PID Dr.T.V.Rao MD 8
  9. 9. Why inappropriate use of antibiotics contributes to antibiotic resistance – the “why” Dr.T.V.Rao MD 9
  10. 10.  Misuse of antibiotics in hospitals is one of the main factors that drive development of antibiotic resistance. Patients in hospitals have a high probability of receiving an antibiotic and 50% [adapt to national figure where available] of all antibiotic use in hospitals can be inappropriate. In-patients are at high risk of antibiotic-resistant infections Dr.T.V.Rao MD 10
  11. 11.   Studies prove that misuse of antibiotics may cause patients to become colonized or infected with antibiotic-resistant bacteria, such as methicillin- resistant Staphylococcus aureus (MRSA), vancomycin- resistant enterococci (VRE) and highly-resistant Gram- negative bacilli.13-14  Misuse of antibiotics is also associated with an increased incidence of Clostridium difficile infections.15-17 Misuse of Antibiotics Drives Antibiotic Resistance Dr.T.V.Rao MD 11
  12. 12.  Basis of Antibiotic Resistance The antibiotic resistance is guided by Genomic changes Spread of R plasmids among the Bacteria Do remember Antibiotics are used in Animal husbandry apart from Medical use The discovery of antibiotic resistance was discovered with spread of R plasmids from animal sources The Human gut forms the interconnecting area in R plasmids transmission leading ultimately to antibiotic resistance Dr.T.V.Rao MD 12
  13. 13. Plasmids played a Major Role in spread of Antibiotic resistance. Dr.T.V.Rao MD 13
  14. 14.  Multiple Mechanism of Drug Resistance Dr.T.V.Rao MD 14
  15. 15.  Spread of Antibiotic Resistance  Indiscrimate use of Antibiotics in Animals and Medical practice  R plasmids spread among co-inhabiting Bacterial flora in Animals ( in gut )  R plasmids may be mainly evolved in Animals spread to Human commensal, - Escherichia coli followed by spread to more important human pathogens Eg Shigella spp. Dr.T.V.Rao MD 15
  16. 16.  Why Everyone worried about Antibiotic ( misuse ) Use. Drug resistance can reverse Medical progress The following diseases are already in the list of attaining the drug resistance, and Medical profession will find difficult to cure in future. 1. Tuberculosis 2. Malaria 3. Sore throat and Ear Infections. Dr.T.V.Rao MD 16
  17. 17. 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. What is Misuse of Antibiotics? Dr.T.V.Rao MD 17
  18. 18. Dr.T.V.Rao MD 18
  19. 19.  Aim of Antibiotic Policy Reduce the Antimicrobial resistance Initiate best efforts in the hospital area as many resistance Bacteria are generated in Hospital areas and in particular critical care areas. Initiate good hygienic practices so these bacteria do not spread to others Practice best efforts, these resistance strains do not spill into critically ill patients in the Hospital To prevent spill into Society, as they present as community associated infections.. Dr.T.V.Rao MD 19
  20. 20.  Objectives of Antibiotic Policy. Antibiotics should not be used casually Policy emphasizes, avoiding the use of powerful Antibiotics in the Initial treatments. We should create awareness that we are sparing the powerful Broad spectrum Drugs for later treatment Patient saves Money Doctors save Lives. Dr.T.V.Rao MD 20
  21. 21.  Aims of the Antibiotic Policy Create awareness on Antibiotics as misuse is counterproductive. More effective treatments in serious Infections. Reduce Health care associated infections spilling to society and increase of Community associated Infections. ( A growing concern in Developing world ) Dr.T.V.Rao MD 21
  22. 22.  Policy Deals on Broad Basis  Clinicians / Microbiologists / Pharmacists and Nurses do take part.  Policies are framed on demands of the Clinical areas, depending on recent Infection surveillance data contributed from Microbiology Departments. Dr.T.V.Rao MD 22
  23. 23.  Antibiotic working Group Monitors Formulate Optimal guidelines in Treatment of Infections with minimal risk of Health care associated Infections. Create a plan for monitoring the Use of Antibiotics across the Hospital Dr.T.V.Rao MD 23
  24. 24.  Education On Antibiotic policy Acton plan for Education to all concerned clinical staff on Antibiotic prescriptions.  Evaluate the feed back of success and failures of the policy. Create Infection surveillance Data Developing facilities in Microbiology departments for auditing data and guidance Restrictions in prescribing and Antibiotic availability. A continuous education to Junior Doctors Dr.T.V.Rao MD 24
  25. 25.  Ideal Sample Collection is Essential Requirement Proper specimen collection is combined responsibility of Clinical and Microbiological Departments. Continuous training of junior staff on sample collection, and is most neglected necessity A good clinical history is greatly helpful in differentiating community acquired infections from hospital acquired infections. Dr.T.V.Rao MD 25
  26. 26. Pitfalls in Specimen collection A proper specimen collection is most neglected area of Microbiology. Scientific approaches in Sample collection is concern for successful Microbiological evaluations, Dr.T.V.Rao MD 26
  27. 27. Microbiology Services Constant up graduation of Microbiology departments is good investment. Quality control methods in testing of antibiotic resistance pattern is a top priority. Dr.T.V.Rao MD 27
  28. 28.  Role of Microbiology Department  Microbiology departments asses trends in development of antimicrobial resistance.  The results of sensitivity/resistance patterns should be correlated with Antimicrobial agents currently used in the Hospital.  Identify and forecast that nature of relation between antibiotic use and resistance. Dr.T.V.Rao MD 28
  29. 29. Better services from Microbiology Departments.  Basic infrastructure should be updated for detection of MRSA and ESBL producers.  Documentation of all Opportunistic infections. and Hospital infection outbreaks Dr.T.V.Rao MD 29
  30. 30.  Measures that guide antibiotic prescribing are likely to decrease antibiotic resistance in hospitals.32-34 Such measures include:  Obtaining cultures  Take appropriate and early cultures before initiating empiric antibiotic therapy,  and streamline antibiotic treatment based on the culture results35  Monitoring local antibiotic resistance patterns  Being aware of local antibiotic resistance patterns (Antibiograms) enables  appropriate selection of initial empiric antibiotic therapy Measures that can decrease antibiotic resistance Dr.T.V.Rao MD 30
  31. 31.   The ESKAPE Pathogens: The so-called ESKAPE Pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and ESBL positive bacteria, such as E. coli and Enterobacter species) represent a grouping 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. PRIORITY ANTIBIOTIC-RESISTANT BACTERIA PATHOGENS Dr.T.V.Rao MD 31
  32. 32.  Advantages of Antibiotic Policy Saves the Lives Reduces the morbidity Saves Health related costs Reduces the Antibiotic related toxicity. Patients are satisfied. Dr.T.V.Rao MD 32
  33. 33.  Staff Education on Antibiotic Policy Staff education is most Important principle in success Draw your own plans according to nature of patients, your past experiences Induction training for new staff Continuing Medical Education to both Junior and Senior Doctors Include nursing staff, pharmacists for the success of the Programme Dr.T.V.Rao MD 33
  34. 34.  Training in rational prescribing has expanded in universities throughout the world  Problem-based pharmacotherapy  In 18 languages  For medical students, clinical officers  Measurable improvement in prescribing  Now also: Teacher’s Guide to Good Prescribing Achievements Dr.T.V.Rao MD 34
  35. 35.  Patient Education on Antibiotic Policy Education of the patients and society is important in Developing world. Educate the patients many infections are trival,viral, Do not need Antibiotics If they understand Unnecessary consumption of Antibiotics kills the Normal flora, and reduces the Immunity and makes them potential victims in future. A difficult task in Developing countries. Dr.T.V.Rao MD 35
  36. 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. 37.  Make your conclusions and contribute to Antibiotic Policy It is true to say that there is no absolute proof of causative association between antibiotic use and resistance, But many authorities believe the association to be virtually certain. It is pragmatic and essential approach to control of antibiotic resistance with control of antibiotic use. Make every one a partner in prevention of Antibiotic resistance, and success will follow. Dr.T.V.Rao MD 37
  38. 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. 39.  CDC reports CDC reports that nearly 2 million health care-associated infections (HAIs) and 90,000 HAI-related deaths occur annually in the U.S. Many of these infections and deaths are caused by antibiotic-resistant infections. Dr.T.V.Rao MD 39
  40. 40.  New Innovations in Diagnostic Microbiology  New rapid diagnostic tests would greatly facilitate clinical trials of critically needed new antibiotics. The tests would enable investigators to identify potential study subjects more easily, which would permit smaller and less expensive studies of antibiotics as they move through development Dr.T.V.Rao MD 40
  41. 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. 42.  Best way to keep the matters in Order Every Hospital should have a policy which is practicable to their circumstances. Rigid guidelines without coordination will lead to greater failures The only way to keep Antimicrobial agents useful is 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. 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. 44.   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 Multifaceted strategies can address and decrease antibiotic resistance in hospitals Dr.T.V.Rao MD 44
  45. 45.   Training and educating health care professionals on the appropriate use of antibiotics must include appropriate selection, dosing, route, and duration of antibiotic therapy. To ensure that training and education is working, there should be extensive collaboration between the antibiotic stewardship and hospital infection prevention and control teams. Without benchmarks, it is difficult to track successes and weaknesses Continuous Medical Education a Must .. Dr.T.V.Rao MD 45
  46. 46.  Dr.T.V.Rao MD 46 Computerized Decisions a Emerging Need …..  Computerized decision support can preserve physician autonomy and has been shown to improve antibiotic use by a number of different measures: fewer susceptibility mismatches, allergic reactions and other adverse events, excess dosages, and overall amount and cost of antibiotic therapy
  47. 47.  Dr.T.V.Rao MD 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.
  48. 48.  Hand Washing Reduces the Spread of Antibiotic Resistant Strains Dr.T.V.Rao MD 48
  49. 49.  The Programme created by Dr.T.V.Rao MD for ‘e’ Learning resources for Medical Professionals in Developing World.  Email doctortvrao@gmail.com Dr.T.V.Rao MD 49
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