Antibiotic policy


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Antibiotic policy and trends in antibiotic policy,

Infection control: Basic concepts and practices, 2nd edn.
Antibiotics guide: choices for common infections
Chennai Declaration

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Antibiotic policy

  1. 1. ANTIBIOTIC POLICY Dr Md Ashraf Ali
  3. 3. “But I would like to sound one note of warning. Penicillin is to all intents non-poisonous so there is no need to worry about giving an overdose and poisoning the patient.There may be a danger, though, in underdosage. The time may come when penicillin can be bought by anyone in shops, an ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug, makes them resistant.” Sir Alexander Fleming Dr Md Ashraf Ali
  4. 4. Introduction “Over the counter” antibiotics • Improper use/misuse of antibiotics • Inappropriate prescription • Sale not restricted to medical prescription only. Dr Md Ashraf Ali
  5. 5. What is Misuse of Antibiotics? • DOSAGE: Incorrect dosage • DURATION: too short or too long • DELAY: antibiotic administration in critically ill patients • DATA: treatment if not streamlined as per culture and DST results. 5 Dr Md Ashraf Ali
  6. 6. Inappropriate prescription • >40% of all antimicrobials prescribed in teaching hospitals were considered inappropriate • Prescribing antibiotics for viral infections • broad-spectrum antibiotics are used too generously prior to first choice drugs Dr Md Ashraf Ali
  7. 7. • This unnecessary use / inappropriate use of antibiotics encourages the selection and proliferation of resistant bacterial strains. • These Spread to other patients (cross infection). • Transferred between bacterial species Dr Md Ashraf Ali
  8. 8. • Drug resistance- evolutionary phenomenon • Not possible to completely eliminate it • Possible to modify or slow it down by prudent antibiotic usage. • Hence importance of inclusion of an antibiotic policy in the infection control program. Dr Md Ashraf Ali
  9. 9. A solution to the evolutionary phenomen ANTIBIOTIC POLICY Dr Md Ashraf Ali
  10. 10. Definition • An antibiotic policy consists of written guidance that recommends antibiotics and their dose for treating and preventing specific infections. Dr Md Ashraf Ali
  11. 11. • In general a hospital antibiotic policy covers empirical treatment, specific treatment and also agents for prophylaxis. • It constitutes one of the most important aspects of Infection Control program. • It is evidence based and is drafted by a committee “The Hospital Infection Control Committee” or “Hospital Antibiotic Committee” Dr Md Ashraf Ali
  12. 12. Aims and objectives • Improve patient care • Better use of resources • Retard the emergence & spread of drug resistant bacteria. • Improve education of junior doctors • Avoid wasteful expenditure of government/ NGOs. Dr Md Ashraf Ali
  13. 13. Indian scenario Dr Md Ashraf Ali
  14. 14. Government hospitals • Nosocomial infection rate is as high as 40-50%. • There is an URGENT NEED or a concerted effort to control and prevent development of drug resistance within hospital setting.
  15. 15. NABH DATA on Indian Hospitals As per data available from NABH assessors “most accredited hospitals, though having a well written antibiotic policy on paper, are not compliant in practice.” 108
  17. 17. Hospital antibiotic committee Formation:  Medical director / Hospital superintendent should ensure formation of this committee.  Implementation of policies drafted by this committee throughout the hospital.  Stand alone or subcommittee of Hospital Infection Control Committee Dr Md Ashraf Ali
  18. 18. Key members of antibiotic committee • Physician • Clinical microbiologist • Clinical Pharmacologist • Pharmacist • Member of hospital management • Member of Infection Control Committee Dr Md Ashraf Ali
  19. 19. Functions of Antibiotic committee 1. To advice on antibiotic use & audit prescribing 2. Formulary restriction and preauthorization 3. Make rational choices amongst “equivalent drugs” & classes of drugs “least expensive and most effective”. Patient saves Money Doctors save Lives.
  20. 20. How to choose the antibiotics ? • Written by national experts • Regularly updated every 2 years • Recommendations concerning the treatment of choice for common clinical problems Dr Md Ashraf Ali
  22. 22. Policy for EMPERICAL treatment • Simple, clear and clinically relevant • Should include optimal dosage, route of administration, duration, ALTERNATIVES for patients allergic to first line drugs • May be ward specific • Should include levels of prescription Dr Md Ashraf Ali
  23. 23. Levels of prescription 1. First choice drugs: can be prescribed by all clinicians working in that hospital. 2. Restricted list of antibiotics: only after permission from Head of department, clinical microbiologist, Antibiotic committee representative 3. Reserve antibiotics: only after permission from Hospital Antibiotic Committee. Dr Md Ashraf Ali
  24. 24. 1. First choice antibiotics • Also called Unreserved antibiotics • Directed against specific diseases
  25. 25. Typhoid fever First choice: 3rd generation cephalosporin or Azithromycin Alternatives • Cotrimoxazole • Chloramphenicol Dr Md Ashraf Ali
  26. 26. Respiratory tract infections Disease First choice drug COPD • mild exacerbations • if assoc. with purulent sputum, dyspnea Not necessary (Viral origin) Doxycycline 100mg OD Amoxicillin 500mg TID PERTUSIS Azithromycin 500mg OD Erythromycin Pneumonia (adult) Amoxicillin Roxithromycin Doxycycline Levofloxacin Pneumonia (child) Amoxicillin Erythromycin
  27. 27. Ear, nose, throat infections INFECTION DRUG TO BE USED OTITIS EXTERNA •Topical ACETIC ACID 2% (mild cases) •Ciprofloxacin 500mg BD oral OTITIS MEDIA •Antibiotics not advised •If associated with perforation and otorrhea Amoxicillin-clavulinic acid PHARYNGITIS •Erythromycin 400mg SINUSITIS •Doxycycline 100mg OD •Amox-clav
  28. 28. Urinary tract infection First line • Norfloxacin • Nalidixic acid Alternatives • Cotrimoxazole • Cefpodoxime E. coli Dr Md Ashraf Ali
  29. 29. Eye infections Conjunctivitis ( Allergic, Viral / bacterial infection) If bacterial cause suspected (mucopurulent discharge) • Gentamicin 2% eye drops • Chloramphenicol eye drops Dr Md Ashraf Ali
  30. 30. CNS infections • Meningoencephalitis- viral origin • Bacterial meningitis  Ceftriaxone and Amikacin combination Dr Md Ashraf Ali
  31. 31. Skin infections Disease Drug Bites (Human / animal) • Augmentin • Metronidazole + Doxycycline • Metronidazole + co-trimoxazole Boils, Cellulitis • Flucloxacillin • Augmentin • Cotrimoxazole Diabetic foot • Augmentin • Cephelexin + Metronidazole • Cotrimoxazole + clindamycin Impetigo • Fusidic acid cream 2% • Oral Cotrimoxazole Recurrent skin infections • Fusidic acid cream 2% • Mupirocin
  32. 32. Gastrointestinal tract infections Disease Drug Diarrhea No antibiotics Dysentery Ofloxacin + ornidazole/tinidazole Dr Md Ashraf Ali
  33. 33. Policy for EMPERICAL treatment Levels of prescription 1. First choice drugs: can be prescribed by all Dr. 2. Restricted list of antibiotics: only after permission from Head of Department, clinical microbiologist, Antibiotic committee representative 3. Reserve antibiotics: only after permission from hospital antibiotic committee. Dr Md Ashraf Ali
  34. 34. 2. Restricted list 1. Imipenem/Meropenem : • Used for empirical in very sick patients • Stop after culture and sensitivity report is available, if it shows a susceptible pathogen to other classes of Antibiotics & if patient condition improves. 2. Piperacillin-Tazobactam: • These have a broad spectrum as carbapenems . • Used for empirical in very sick patients. Dr Md Ashraf Ali
  35. 35. 3. Vancomycin/Teicoplanin: • Use as empirical in sick patients may be allowed where MRSA is prevalent. • After 48-72hrs culture and sensitivity report shows no staph aureus or MSSA then they have absolutely no role and should be discontinued. Dr Md Ashraf Ali
  36. 36. Policy for EMPERICAL treatment Levels of prescription 1. First choice drugs: can be prescribed by all Dr. 2. Restricted list of antibiotics: only after permission from HOD, clinical microbiologist, Antibiotic committee representative 3. Reserve antibiotics: only after permission from Hospital Antibiotic Committee. Dr Md Ashraf Ali
  37. 37. 3. Reserve drugs 1. Colistin: • last resort for managing gram negative MDRs and its use, dose and duration needs to be rationalized. • Liberal use should be restricted 2. Doripenem: (FDA approval 2007) • It is the last FDA approved carbapenem. • If Imipenem and Doripenem are working, we need to conserve Doripenem Dr Md Ashraf Ali
  38. 38. 3. Rifampicin: • Valuable drug for Tuberculosis. • The use of rifampicin in MDR Pseudomonas, Acinetobacter or MRSA should be restricted. 4. Linezolid: • Bacteriostatic and available as oral - more prone for misuse in VRSA / VRE. Dr Md Ashraf Ali
  39. 39. 5. Daptomycin: – Moreover for VRSA and VRE but still not a major cause of concern 6. Tigecycline: – Bacteriostatic, one of the most Broad spectrum drugs, has limited role in MDR infections 7. Sulbactam alone: – Reserved for PDR Acinetobacter. Dr Md Ashraf Ali
  40. 40. Policy for Prophylaxis • These antibiotics are given for short duration, free of side effects and inexpensive. • Not intended towards therapy. Example • Pre-op Kanamycin, neomycin oral antibiotics • The addition of perioperative gentamicin and clindamycin following oral antibiotic bowel preparation. Dr Md Ashraf Ali
  42. 42. Samples: • Physicians need to be advised on proper collection and transport of the most appropriate specimen. • Microbiological samples always be sent prior to initiating antimicrobial therapy. • Gram stain report, can help determine therapeutic choices when empiric therapy is required. • When resources are scarce, priority given to samples from nosocomial, life threatening cases or sent to referral hospital. Dr Md Ashraf Ali
  43. 43. • Reports of AST based on the drugs available in agreed formulary. • Doubtful pathogen isolated, susceptibility need not be reported. • Limited no. of antibiotics are selected to optimize patient care, cost effectiveness, encourage better prescription. E.g. Augmentin need not be reported if the organism is sensitive to ampicillin/amoxicillin Reports Dr Md Ashraf Ali
  44. 44. Basic infrastructure should be updated for detection of • MRSA • ESBL producers. Dr Md Ashraf Ali
  45. 45. Reports on drug resistance • Assess trends in development of antimicrobial resistance • Report should also indicate wherever organisms are invariably resistant e.g. MRSA are resistant to all beta-lactams • Send regular updates /alerts to Hospital Antibiotic committee, on emergence of resistance to antibiotics used in hospital. Dr Md Ashraf Ali
  46. 46. Notifications and documentation • Microbiology labs should issue Hospital Antibiogram at pre-defined intervals. • Notification of communicable diseases. • Multidrug-resistant bacteria, esp. pan-drug resistant bacteria, must be considered as a notifiable entity.. Dr Md Ashraf Ali
  47. 47. Hospital Antibiogram: Periodic summary of antimicrobial susceptibilities of local bacteria isolates submitted by the hospital’s clinical microbiology laboratory. Dr Md Ashraf Ali
  48. 48. Documentation of all • Opportunistic infections • Hospital infection outbreaks • Emerging infections Dr Md Ashraf Ali
  49. 49. Education • Formal meeting, clinical rounds, formal lectures • Focus on new antibiotics, route of administration Surveillance • Antibiotic resistance • Antibiotic usage DDD (defined daily dose) • Prescription auditing Dr Md Ashraf Ali
  50. 50. WHONET Dr Md Ashraf Ali
  51. 51. What is WHONET • WHONET is a free software developed by the WHO Collaborating Centre for Surveillance of Antimicrobial Resistance. • Uses  laboratory-based surveillance of infectious diseases  antimicrobial resistance. Dr Md Ashraf Ali
  52. 52. The principal goals of the software are: 1. to enhance local use of laboratory data; 2. to promote national and international collaboration through the exchange of data.
  53. 53. Advantages • The understanding of the local epidemiology of microbial populations; • the selection of antimicrobial agents; • the identification of hospital and community outbreaks • the recognition of quality assurance problems in laboratory testing. Dr Md Ashraf Ali
  54. 54. How it works..?? • The heart of WHONET is a software package designed to collect the results of antibiotic resistance tests. • Researchers / Microbiologists feed the results into a computer and look for trends. Dr Md Ashraf Ali
  55. 55. Implementation of WHONET CAN HELP TO MONITOR RESISTANCE Dr Md Ashraf Ali
  56. 56. MONITORING TREATMENT Dr Md Ashraf Ali
  57. 57. • The need for antimicrobial therapy should be reviewed daily. • For most types of infection treatment should continue until the clinical signs and symptoms of infection have resolved. • Where treatment is apparently failing, advise from the microbiologist, pharmacologist and ID Physician should normally be sought rather than blindly changing to an alternative choice of antimicrobial agent. Dr Md Ashraf Ali
  59. 59. • One of the main reasons for the inappropriate antibiotic usage by Indian doctors is the lack of adequate training on the subject during undergraduate courses. • This deficit in the basic training can only be overcome if there is a change in the curriculum. • Prescriptions from RMP, Quacks, AYUSH doctors should be discouraged. Dr Md Ashraf Ali
  60. 60. Curriculum change • Structured training in antibiotic usage and infection control should be introduced in curriculum. • Infectious Diseases training in UG and PG curriculum in all specialties. Dr Md Ashraf Ali
  61. 61. Role of clinicians- Good practices • Send for the appropriate investigations, the minimum required for diagnosis of these infections. • All antibiotic initiations - after sending appropriate cultures • Follow the Hospital policy when choosing antimicrobial therapy. If alternatives chosen, document the reason in case sheets. • Check for factors which will affect drug choice & dose e.g., renal function, interactions, allergy. Dr Md Ashraf Ali
  62. 62. • Check that the appropriate dose is prescribed. If uncertain, contact Infectious disease committee, Pharmacy, or check in the formulary. • The need for antimicrobial therapy should be reviewed on a daily basis. • Empiric Therapy Where delay in initiating therapy would be life threatening. antimicrobial therapy based on a clinically defined infection is justified. • Once culture reports are available, step down to the narrowest spectrum. Dr Md Ashraf Ali
  63. 63. Antimicrobial Cycling or Rotation: Deliberate, scheduled removal and replacement of specific antimicrobials with in institutional environment to avoid the antimicrobial resistance. Dr Md Ashraf Ali
  64. 64. Research works: • Antimicrobial peptides(AMPs), Antimicrobial lipopeptides (AMLPs)  target bacterial membranes, making it nearly impossible to develop resistance • Phage therapy • Use of the lytic enzymes : in mucus and saliva • But they are a long way off, as the researches still in its infancy Dr Md Ashraf Ali
  65. 65. A WORLD WITHOUT ANTIBIOTICS- JUST IMAGINE • A world without effective antibiotics is a terrifying but real prospect. Overuse of antibiotics has led to dangerous outbreaks of drug resistant disease, and puts us in very real danger of a global pandemic. In future we have to use ??? Dr Md Ashraf Ali
  66. 66. • India needs “An implementable antibiotic policy” and NOT “A perfect policy” • Asking for a strict antibiotic policy in a country where there is currently no functioning antibiotic policy at all may not be an intelligent or immediately viable option without the political will to make such a drastic change.
  67. 67. SUMMARY
  68. 68. • Stop over the counter sale of drugs without prescription • Hospital antibiotic committee should be formed in every hospital, to draft an Antibiotic policy in hospitals. • Strict adherence to antibiotic policy- part of infection control • Microbiology labs- upgraded to detect MDR bacterias. • Encourage good practices among clinicians. • Implementation of “WHONET” for laboratory-based surveillance of infectious diseases and antimicrobial resistance. • Long term plans -MCI has a role. • 2011 WHO slogan on antibiotic resistance “no action today, no cure tomorrow”.
  69. 69. CONCLUSION
  70. 70. Microbiologist Bacterial sensitivity test and find out the Possible cause of development Clinician Treat infection
  71. 71. Sharing of expertise Microbiologist Bacterial sensitivity test and find out the Possible cause of development Physician Treat infection Antibiotic committee India needs “An implementable antibiotic policy” and NOT “A perfect policy”.
  72. 72. References • Infection control: Basic concepts and practices, 2nd edn. • • Antibiotics guide: choices for common infections • International Clinical Practice Guidelines for the treatment of urinary tract infections : An Update • Oxford handbook of infectious diseases
  73. 73. THANK YOU Dr Md. Ashraf Ali S N PG in Microbiology KIMS, Hubli