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emerging antibiotic resistance

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indiscriminate use of antibiotics in animal husbandry as well as human medicine is leading to ever increasing multi-drug resistance even pan-drug resistance. the situation is getting even grimmer in face of hardly any antibiotic developed in the last 25 years. WHO has published guidelines on infection control. it is the duty of every clinician to take situation in their hand, get oriented in judicious antibiotic usage and use sanitation in their clinical practice. principles of surgical antibiotic prophylaxis must be known to every surgeon and be adhered to strictly.

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emerging antibiotic resistance

  1. 1. ​Dr Mayank Mohan Agarwal MBBS, MS, MRCS(Ed), ​DNB, MCh (PGIMER, Chandigarh) ​VMMF and IAUA Fellowships Uro-Oncology, Pelvic Floor Reconstruction (MSKCC, NY; UCLA, LA; WFUBMC, NC)​ Formerly Associate Professor of Urology PGIMER, Chandigarh Formerly Consultant & Head of Urology, NMC specialty hospital, Abu Dhabi Senior Consultant and Head of Urology Aster Ramesh Hospital Guntur (AP), India <mayank.mohan@rameshhospitals.com> ANTIBIOTIC RESISTANCE Are we treating patients or our own fears
  2. 2. The road to destruction Dr Tom Frieden, CDC
  3. 3. The road to destruction
  4. 4. Europe: E coli (R) to cephalosporins da Costa ME, Machado HS. J Allerg Ther 2017
  5. 5. Kumar SG et al. J Nat sc Biol med 2013
  6. 6. Kumar SG et al. J Nat sc Biol med 2013
  7. 7. Where is it coming from? • INAPPROPRIATE USAGE OF ANTIBIOTICS • IN ANIMALS • IN HUMANS
  8. 8. VETERINARY
  9. 9. • Livestock animals are fed antibiotics to “prevent” diseases  “promote” growth • Poor regulation leading to antibiotic usage in their food instead of restricting to therapeutic usage
  10. 10. • Livestock animals are fed antibiotics to “prevent” diseases  “promote” growth • Poor regulation leading to antibiotic usage in their food instead of restricting to therapeutic usage
  11. 11. Human medicine • Similar thing happens in human medicine • Inappropriate diagnosis – • Contaminated sample • Not performing gram staining • Not performing culture • Not performing sensitivity PERCEIVED WELL-WISH FOR PATIENT INCOMPLETE KNOWLEDGE PRESSURE FROM PATIENT PRESSURE FROM INDUSTRY PRESSURE FROM COLLEAGUES
  12. 12. • Inappropriate treatment – • Unindicated prescription – e.g. for viral illness • Broad spectrum antibiotics even when avoidable • Low dose • Incomplete duration • Over-duration (e.g. surgical prophylaxis) • Poor quality supply
  13. 13. • Not giving importance to hygiene and supportive measures – • Hand hygiene • Improving immunity in viral illness • Trying to replace need for hygiene with higher antibiotics
  14. 14. OUR ROLE : practice
  15. 15. Hand hygiene Semmelweis's reference to "cadaverous particles" were (in German) "an der Hand klebende Cadaverth Hand hygiene with chlorinated water
  16. 16. Endourology – a clean contaminated surgery • Just imagine – • Sterilization is recommended • Minimum High level disinfection is an absolute must • There is no short cut to mechanical cleaning • Enzymatic detergent
  17. 17. Sterilization and disinfection Vegetative Bacteria Fungi Enveloped viruses Mycobacteria Nonenveloped viruses spores Sterilizant + + + + + + HL Disinfectant + + + + + - IL Disinfectant + + + + - - LL disinfectant + +/- + - - - Rutala et al. CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
  18. 18. Cidex ® Cidex-OPA ® Perasafe ® Level of disinfection HLD HLD HLD / Sterilizant Contact time for HLD 20 min 10 min 10 min Contact time for sterilization 10 hours 24 hours 10-20 min Specialized ventilation Required Required Not required Toxic to environment +++ + - Rutala et al. CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
  19. 19. Antibiotic prophylaxis in surgery • Choose well – based on organism encountered, antibiogram, immunity level of patient • Avoid the one often used for ‘treatment’ • Long half life • Loading dose – iv, double dose • Within 60 minutes of incision / insertion (except vanco, FQ 120min) • Repeat if procedure is long or blood loss significant • Stop within 24 hours • Don’t continue till drain / catheter removal Haun et al. JAMA surg 2013
  20. 20. Antibiotic prophylaxis in surgery • Choose well – based on organism encountered, antibiogram, immunity level of patient • Avoid the one often used for ‘treatment’ • Long half life • Loading dose – iv, double dose • Within 60 minutes of incision / insertion (except vanco, FQ 120min) • Repeat if procedure is long or blood loss significant • Stop within 24 hours • Don’t continue till drain / catheter removal Haun et al. JAMA surg 2013
  21. 21. Antibiotic prophylaxis in urology Grabe M. Int J antimicrob ag 2004
  22. 22. TRANSURETHRAL RESECTION OF PROSTATE • The most studied entity w.r.t antibiotics – over 32 RCT’s • Antibiotics – yes or no? DEFINITELY YES 0 2 4 6 8 10 12 UTI sepsis placebo antibiotic Berry A, Barratt A. J urol 2002
  23. 23. TRANSURETHRAL RESECTION OF PROSTATE • The most studied entity w.r.t antibiotics – over 32 RCT’s • Antibiotics – yes or no? DEFINITELY YES • How long? VARIABLE • Single dose • Upto 72 hours • Extended 50 55 60 65 70 75 80 85 90 RRR all RRR ceph single <72hr >72hr Berry A, Barratt A. J urol 2002
  24. 24. TRANSURETHRAL RESECTION OF PROSTATE • The most studied entity w.r.t antibiotics – over 32 RCT’s • Antibiotics – yes or no? DEFINITELY YES • How long? VARIABLE • Single dose • Upto 72 hours • Extended • Which antibiotic? Berry A, Barratt A. J urol 2002
  25. 25. PERCUTANEOUS NEPHROSTOLITHOTOMY • STONE score • Low risk - <2cm, single stone, sterile culture – antibiotic ≡ no antibiotic • Others with sterile culture – single dose antibiotic > no antibiotic • Infected case – preop 3-7 days  continue for 7 days Treatment, not prophylaxis Lai WS, Assimos D. Rev Urol 2016
  26. 26. URETEROSCOPY • Similar to PCNL • Systematic review and Meta-analysis • Low risk, lower ureteric calculi - antibiotic ≡ no antibiotic • Anything more - single dose antibiotic > no antibiotic Pyuria Bacteruria Bacteremia Lo et al. Surg Inf 2015
  27. 27. Kidney transplantation • N = 212 • SD = cefazolin just preop (after 2015) • MD = pip-taz x 7 days sulbacin x 3d 0 5 10 15 20 25 30 35 40 45 50 SD MD COST SAVING 97.5% 8 € vs 387 € Bachmann et al. World J urol 2018
  28. 28. Antibiotic Prophylaxis and the Risk of SSI following Total Hip Arthroplasty: Timely Administration Is the Most Important Factor • 1900+ patients undergoing hip arthroplasty
  29. 29. CONCLUSION • SO IT TURNS OUT THAT MOST OF THE TIME WE ARE TREATING OUR OWN FEARS
  30. 30. CONCLUSION • SO IT TURNS OUT THAT MOST OF THE TIME WE ARE TREATING OUR OWN FEARS • DON’T WAIT FOR SOMEBODY ELSE TO TAKE ACTION • ACT BEFORE IT’s TOO LATE • THINK BEFORE WRITING / TAKING NEXT ANTIBIOTIC
  31. 31. THANK YOU

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