ANTIBIOTICS• We didn’t have antibiotics before the 1940s.• Alexander Fleming helped to develop the first antibiotic from a mold.• Antibiotics work to kill infecting bacteria.• Natural variations exist within bacterial populations that make some bacteria resistant to antibiotics.• Abuse of antibiotics promotes the development of antibiotic-resistant bacteria.
A DISCOVERY BY ACCIDENT • A fungal spore that the wind might have blown into his lab while Fleming was on vacation in 1928, forever changed the course of medicine... • A. Fleming named the substance Penicillin, after the mould Pencillium notatum – but was unable to isolate the substance • In the late 1930s and early 1940s, E. Chain & H. Florey managed to produce larger amounts of penecillin, and ran successful trials on mice • Nobel prize in 1945
Development of anti-microbials ertapenem tigecyclin daptomicin linezolid telithromicinThe development quinup./dalfop. cefepime ciprofloxacin of anti-infectives … aztreonam norfloxacin imipenem cefotaxime clavulanic ac. cefuroxime gentamicin cefalotina nalidíxico ac. ampicillin methicilin vancomicin rifampin chlortetracyclin streptomycin pencillin G prontosil 1920 1930 1940 1950 1960 1970 1980 1990 2000 DR.T.V.RAO MD 5
ANTIBIOTIC USE AND MISUSE• During the 1940s and 1950s antibiotics were extremely effective• They were (and still are) widely prescribed, often for medical conditions that did not require them• Antibiotics started to be used in agriculture: dosing cattle with antibiotics increases yield, and battery farming relies on antibiotics to control infection• By the 1970s the World was awash with antibiotics.
EVOLUTION OF RESISTANCE• Antibiotic use represents a strong selection pressure• If a population of bacteria with a few resistant individuals is exposed to a lethal antibiotic, the susceptible bacteria will die, but the resistant bacteria will survive• In an environment with a lot of antibiotic use, resistance alleles spread rapidly• The problem is compounded by horizontal gene transfer and by cross-resistance
ANTIBIOTICS• Biology and SocietyAbout 50% of the antibiotics produced today are used in the livestock industry. What impact does this have on the treatment of human diseases?
ANTIMICROBIAL RESISTANCE:THE ROLE OF ANIMAL FEED ANTIBIOTIC ADDITIVES• 48% of all antibiotics by weight is added to animal feeds to promote growth. Results in low, sub therapeutic levels which are thought to promote resistance.• Farm families who own chickens feed tetracycline have an increased incidence of tetracycline resistant fecal flora
CHRONOLOGY OF DEVELOPMENT OF ANTIBIOTIC RESISTANCEAntibiotic Year introduced Resistance identifiedPenicillin 1942 1940Streptomycin 1947 1947Tetracycline 1952 1956Erythromycin 1955 1956Gentamicin 1967 1970Vancomycin 1956 1987
PRESCRIBING AN ANTIBIOTIC Is an antibiotic necessary ? What is the most appropriate antibiotic ? What dose, frequency, route and duration ? Is the treatment effective ?
ANTIBIOTIC PRESCRIBING CHILDREN REAL CONCERN• Antibiotics were prescribed in 68% of acute respiratory tract visits – and of those, 80% were unnecessary according to CDC guidelines• Children are of particular concern because they have the highest rates of antibiotic use.
WE TOO CONTRIBUTE FORCREATING DRUG RESISTANCE • Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper uses of antibiotics are primary causes of the increase in drug- resistant bacteria.
ANTIBIOTIC PRESSURE AND RESISTANCE IN BACTERIA WHAT HAPPENED TO S. AUREUS ?• Reports of increasing use of third gen cephalosporins and quinolones related to emergence of MRSA.• Some data suggest that quinolones enhance expression of methicillin resistance in SA in vitro• Outbreaks of MRSA have been reduced by curbing antibiotic use: especially of cephalosporins
CONSEQUENCES OF ANTIBIOTIC DRUG RESISTANCE• People infected with drug-resistant organisms are more likely to have longer and more expensive hospital stays, and may be more likely to die as a result of the infection. They require treatment with second- or third-choice drugs that may be less effective, more toxic, and more expensive. This means that patients with an antimicrobial-resistant infection may suffer more and pay more for treatment.
ANTIBIOTIC PRESSURE AND RESISTANCE IN BACTERIA WHAT FACTORS PROMOTE THEIR DEVELOPMENT AND SPREAD ? Alteration of normal flora Practices contributing to misuse of antibiotics Settings that foster drug resistance Failure to follow infection control principles
Practices Contributing to Misuse of Antibiotics Inappropriate specimen selection and collection Inappropriate clinical tests Failure to use stains/smears Failure to use cultures and susceptibility tests
Settings that Foster Drug Resistance HOSPITAL Intensive care units Oncology units Dialysis units Rehab units Transplant units Burn units
EMERGING TRENDS IN ANTIBIOTIC RESISTANCE• Reports of methicillin-resistant Staphylococcus aureus (MRSA)—a potentially dangerous type of staph bacteria that is resistant to certain antibiotics and may cause skin and other infections—in persons with no links to healthcare systems have been observed with increasing frequency in the United States and elsewhere around the globe.
GRAM NEGATIVE BACTERIA A GREAT THREAT • Multi-drug resistant Klebsiella species and Escherichia coli have been isolated in hospitals throughout the United States. • It is a Universal phenomenon
FUNGI TOO BECOMING RESISTANCE• Antimicrobial resistance is emerging among some fungi, particularly those fungi that cause infections in transplant patients with weakened immune systems.
RESISTANCE IN VIRUS • Antimicrobial resistance has also been noted with some of the drugs used to treat human immunodeficiency virus (HIV) infections and influenza.
PARASITES TOO ARE PROBLEMATIC• The development of antimicrobial resistance to the drugs used to treat malaria infections has been a continuing problem in many parts of the world for decades. Antimicrobial resistance has developed to a variety of other parasites that cause infection.•
Identification of The Etiological Agent Laboratory diagnosis Interpretation of the report What is isolated is not necessarily the pathogen Was the specimen properly collected ? Is it a contaminant or colonizer ? Sensitivity reports are at best a guide
WHO GLOBAL STRATEGY ON REDUCING THE ANTIBIOTIC RESISTANCE• The WHO Global Strategy for Containment of Antimicrobial Resistance identifies the establishment and support of microbiology laboratories as a fundamental priority in guiding and assessing intervention efforts.DR.T.V.RAO MD 26
IMPORTANCE OF LOCAL ANTIBIOTICRESISTANCE DATA Resistance patterns vary From country to country From hospital to hospital in the same country From unit to unit in the same hospital Regional/Country data useful only for looking at trends NOT guide empirical therapy
ADOPTION OF WHONET• To enhance the local use of data for local needs: clinical decision support, antimicrobial use policy, infection control and outbreak detection, identifying laboratory test performance, and characterization of local microbial and resistance epidemiology• To promote local, national, regional, and global collaborations through the exchange of data and sharing of experiences
WHAT IS WHONET• WHONET is a free software developed by the WHO Collaborating Centre for Surveillance of Antimicrobial Resistance for laboratory-based surveillance of infectious diseases and antimicrobial resistance.• The principal goals of the software are:• 1 to enhance local use of laboratory data; and• 2 to promote national and international collaboration through the exchange of data. DR.T.V.RAO MD 30
GROWING IMPORTANCE OF WHONET• World over antimicrobial resistance is a major public health problem. The WHONET software program puts each laboratory data into a common code and file format, which can be merged for national or global collaboration of antimicrobial resistance surveillance DR.T.V.RAO MD 31
WHONET SUPPORTS SURVEILLANCE IN OVER 90 COUNTRIES INDICATED BELOW IN RED.DR.T.V.RAO MD 32
US – NEW ANTIBACTERIAL AGENTSYear No. Approved Agents1991 20± Multiple agents1992 3 Temafloxacin, lomefloxacin, cefpodoxime1993 1 Piperacillin/Tazobactam1994 0 Lowest number of new agents (22) since 19881995 2 Dirithromycin, ceftibutin1996 4 Meropenem, levofloxacin, sparfloxacin, Cefepime1997 2 Grepafloxacin, Trovafloxacin1998 0 Rivaled 19941999 3 Dalfopristin/quinupristin, gatifloxacin, moxifloxacin2000 1 Linezolid2001 2 Ertapenem, ceftidoren2002 0 89 drugs approved, no antibacterial agents2003 2 Daptomycin, gemifloxacin
WHONET HELPS US IN ……• The understanding of the local epidemiology of microbial populations; the selection of antimicrobial agents; the identification of hospital and community outbreaks; and the recognition of quality assurance problems in laboratory testing.DR.T.V.RAO MD 34
CLINICIANS AND MICROBIOLOGIST CAN DO ANALYSIS OF THE DATA THEMSELVES• WHONET has a user-friendly interface permitting many types of analysis. Options include isolate line-listings and summaries, such as organism frequencies over time, antimicrobial susceptibility test statistics, zone diameter antibiotic scatterplots and regression curves, and antibiotic resistance and MIC histograms, profile line listings and summaries. WHONET also has a number of alert features which permit the detection of unlikely or important results as well as possible community outbreaks of bacterial or non-bacterial species. DR.T.V.RAO MD 35
ALL THE DOCUMENTED RESULTS ARE ANALYZED IN WHONET• 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.T.V.RAO MD 36
CLINICIANS CAN ACCESS DATA OF THEIR PATIENTS ANYTIME IN THE COMPUTER JUST WITH CLICK OF THE MOUSEDR.T.V.RAO MD 37
OUR LABORATORY REPORTS ARE DOCUMENTED IN DIGITAL FORMAT WITH WHONET
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.DR.T.V.RAO MD 39
ANTIBIOTICS SAVE LIVES SAVE ANTIBIOTICS FROM MISUSEDR.T.V.RAO MD 40
PHYSICIANS CAN IMPACT Other cliniciansPatientsOptimize patient evaluation Optimize consultations with Adopt judicious antibiotic other clinicians prescribing practices Use infection control measures Immunize patients Educate others about judicious use of antibiotics
CONCLUSIONS Antibiotic resistance is a major problem world-wide Resistance is inevitable with use No new class of antibiotic introduced over the last two decades Appropriate use is the only way of prolonging the useful life of an antibiotic
• Programme Created by Dr.T.V.Rao MD for Medical, Paramedical and Health Care Workers in the Developing World • Email • firstname.lastname@example.org