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Ama for BPH 2017
- 1. Principles of Antimicrobial Therapy and Public Health Implication of Antimicrobial Resistance - I For BPH 1st Year Dr. Pravin Prasad Resident 2nd Year, MD Clinical Pharmacology Maharajgunj Medical Campus 6th April, 2017 (Chaitra 24, 2073) Thursday
- 2. Antimicrobial Agents: Introduction • Antibiotics: • Substances produced by microorganisms, which selectively supress the growth or kill the microorganisms at very low concentrations • What does it excludes?
- 3. Antimicrobial Agents: Introduction • Chemotherapeutic agents and antimicrobial agents: • Synthetic compounds used to selectively supress the growth or kill the microorganisms at very low concentrations • Synthetic as well as naturally obtained drug that attenuate microorganisms
- 4. Antimicrobial Agents: Introduction •Chemotherapy: • Treatment of systemic infections with specific drugs that selectively supress the infecting micro-organism without significantly affecting the host. • Why is this term used for cancer therapy?
- 5. Choice of an Antimicrobial Agent Organism related Drug related Patient related
- 6. • Age • Renal or Hepatic Function • Local factors • Drug Allergy • Impaired Host Defence • Pregnancy • Genetic Factors Choice of an Antimicrobial Agent: Patient Related Factors
- 7. • Clinical Diagnosis itself directs the choice of the AMA • A good guess can be made • Choice based on bacteriological examination • Bacterial services are not available • Bacterial services are available but treatment cannot be delayed • Bacterial services are available and treatment can be delayed Choice of an Antimicrobial Agent: Organism Related Considerations
- 8. • Spectrum of activity • Type of activity • Sensitivity of organism • Relative toxicity • Pharmacokinetic profile • Route of administration • Evidence of clinical efficacy Choice of an Antimicrobial Agent: Drug Related Factors
- 9. Combined Use of Antimicrobial Agents • To achieve synergism • To reduce severity of adverse effects • To prevent emergence of resistance • To broaden the spectrum of antimicrobial action • Disadvantages?? Static Cidal Static Additive ? Cidal ? Additive
- 10. Prophylactic Use of Antimicrobials • Prophylaxis against specific organisms • Prevention of infection in high risk situations • Prevention of infection in general
- 11. Adverse Effects of AMA • Toxicity • Hypersensitivity reaction • Drug Resistance • Superinfection • Nutritional Deficiencies • Masking of an infection
- 12. Principles of Antimicrobial Therapy and Public Health Implication of Antimicrobial Resistance- II For BPH 1st Year Dr. Pravin Prasad Resident 2nd Year, MD Clinical Pharmacology Maharajgunj Medical Campus 13th April, 2017 (Chaitra 31, 2073) Thursday
- 13. Antimicrobial Resistance (AMR) AMR is resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it. -WHO
- 14. AMR: Global Status •Present in all parts of the world •2012: Gradual increase in resistance to HIV drugs (WHO) •2013: Multidrug-resistant tuberculosis (MDR-TB) and Extensively drug-resistant tuberculosis (XDR-TB) •Greater Mekong sub-region, resistance to the artemisinin- based combination therapies (ACTs) for falciparum malaria
- 15. AMR: Global Status •High proportions of antibiotic resistance in bacteria •Major number of Hospital-acquired infections: drug resistant organisms •Treatment failures for Gonorrhea •Infections caused by drug-resistant bacteria • At increased risk of worse clinical outcomes, death • Consumes more health-care resources
- 16. AMR: Why a Global Concern? •AMR kills •Hampers the control of infectious disease •Increases the costs of health care •Jeopardizes health care gains to society
- 17. Deaths Attributable to AMR every year Ref: Antimicrobial Resistance:Tackling a crisis for the health and wealth of nations; The Review on Antimicrobial Resistance Chaired by Jim O’Neill December 2014
- 18. AMR: Status in South East Asian Region Ref: Regional Report on Antimicrobial Resistance, Bangkok, Thailand 6-10 August, 2012, WHO Regional Office for South East Asia Tuberculosis Kala-azar Typhoid Fever ARI S. aureus A. baumannii
- 19. AMR: Status in Nepal • Started in Nepal in 1999 with technical assistance from ICDDR, Bangladesh. • National Public Health Laboratory (NPHL) is the focal point • Now supported by WHO. • Has conducted surveillance of 7 microorganisms: • Salmonella, Shigella, V. cholerae, S. pneumoniae, H. influenzae, N. gonorrhoeae and ESBL E.coli.
- 20. National Public Health Laboratory (NPHL) • Working in close coordination with 18 governmental hospitals, mission hospitals and private medical college hospitals • Receives, examines, stores local isolates from the participating laboratories • Sends the isolates for EQAS every three months • Participating laboratories send the testing reports to NPHL and the NPHL sends the feedback • Conducts quality assurance training, refresher training, workshop to enhance the diagnostic capacity of the participating laboratories.
- 21. AMR Resistance Patterns in Nepal •A total of 1346 isolates were reported in 2011. •Salmonella is the highest (1018). • Salmonella resistance against Nalidixic acid (S. paratyphi A 98%; S. typhi 91%). •Shigella, 75% were resistant to Cotrimoxazole, 70% resistant to amoxicillin and 44% to nalidixic acid.
- 22. AMR Resistance Patterns in Nepal •S. pneumoniae: 22% resistant to multiple drugs. •H. influenza: 53% resistant to co-trimoxazole (53%) • Included in the treatment guideline for ARI •ESBL E. coli: 100% resistance to the quinolones, 99% to ciprofloxacin and ceftriaxone. • Increasing resistance for combination of third generation cephalosporin (cefotaxime, ceftazidime) with clavulanic acid
- 23. • The Drug Act, 1978 and the rules thereunder: poor implementation • National Antibiotic Treatment Guidelines: drafted • Treatment Protocol for TB, leprosy, ARI, HIV/AIDS, malaria and childhood illness are available. • The National Health Laboratory Policy 2069 existent • Little importance to community empowerment for AMR • posters, pamphlets, publication of bulletin • No programme for school children for AMR awareness exists. AMR: Status in Nepal
- 24. AMR: Future Plans (GoN) National Steering Committee Drug Act, 1978 National Medicine Policy, 2007 Health Laboratory Act and Regulation Strengthening existing labs Strengthening existing labs National Antibiotic Policy Standard Treatment Guidelines Public AwarenessRestricted Use
- 28. What we have been doing…
- 29. Thank you!!! Effort from each one of us is imperative to keep the pre-antibiotic era at bay….
Editor's Notes
- Greatest contribution of 20th century to therapeutics Are one of the few drugs which can cure Most frequently used and misused drugs
- Other natural substance that inhibit microorganisms but are produced by higher forms (eg. Antibodies) or even those produced by microorganisms but are needed in high concentration (ethanol, lactic acid, H2O2)
- Designed to inhibit/kill the infecting organism and to have no/minimal effect on the recipient
- Is it necessary? Considerations: Patient factors Organism-related considerations Drug Factors
- Age: kinetics of AMA varies, age-related toxicity of AMA Chloramphenicol conjugation and excretion limited in newborn- gray baby syndrome Sulfonamides displaces bilirubin from proteins- kernicterus in babies Aminoglycoside T ½ prolonged in elderly, more prone to develop VIII nerve toxicity Tetracycline deposit in developing bones and teeth- weak and discoloured parts if given before 6 yrs Drug allergy: penicillin allergic syphilis pt- tetracycline. Lactams, sulphonamides, FQ, nitrofurantoin Host defence: neutropenic pts, AIDS Pregnancy safety: penicillins, many cephalosporins and erythromycin Tetracycline: acute yellow atrophy of liver, pancreatitis & KIDNEY DAMAGE to mother Aminoglycoside fetal ear damage FQ, CO-tri, Chloramphenicol, sulfonamides., nitrofurantoin showed fetal damage in animal studies.
- Highly sensitive to cidal drugs- response equal to static drug given alone (apparent antagonism) Low sensitive to cidal drugs – synergism may be seen To broaden the spectrum of antimicrobial action Treatment of mixed infection Initial treatment of severe infections Topically Disadvantages??
- Acquired resistance: mutation or gene transfer Natural resistance: cell wall arrangement of gram negative bacteria Drug tolerant Drug destroying Drug impermeable
- Greatest contribution of 20th century to therapeutics Are one of the few drugs which can cure Most frequently used and misused drugs
- 2013: about 480 000 new cases of multidrug-resistant tuberculosis (MDR-TB). Extensively drug-resistant tuberculosis (XDR-TB) has been identified in 100 countries.
- High proportions of antibiotic resistance in bacteria that cause common infections in all regions of the world. Major number of Hospital-acquired infections: methicillin-resistant Staphylococcus aureus (MRSA) or multidrug-resistant Gram-negative bacteria. Treatment failures for gonorrhea have been reported from 10 countries. Infections caused by drug-resistant bacteria are at increased risk of worse clinical outcomes and death, and consume more health-care resources than patients infected with the same bacteria that are not resistant.
- International Centre for Diarrhoeal Disease Research, Bangladesh
- External Quality Assurance Services