The document discusses antimicrobial stewardship and its importance. It provides 3 key goals of antimicrobial stewardship programs: [1] Ensuring each patient receives the most appropriate antimicrobial, [2] Preventing overuse, misuse and abuse of antimicrobials, and [3] Minimizing the development of resistance. It also outlines some core strategies for antimicrobial stewardship programs, including formulary restrictions, preauthorization requirements, and prospective audit and feedback of antimicrobial usage.
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
FLOW OF THE SEMINAR
1. Definition – antibiotic resistance, Multi-resistance, cross-resistance in antibiotics
2. Evolution of resistance
3. Impact of resistance
4. The scenario of resistance: Global, India
5. Factors causing resistance
6. Mechanisms of resistance: Intrinsic and Acquired
7. Acquired mechanism of resistance
8. Quorum sensing
9. Mechanism of resistance in commonly used antibiotics
10. Methods for determining the resistance
11. Strategies to contain resistance
12. Antibiotic stewardship
13. Role of Pharmacologist
14. Initiatives undertaken by India to control resistance
Role of PK PD in Antibiotic Stewardship Program with case study. This presentation gives an comprehensive overview about role of PK PD in antibiotic stewardship program.
Antibiotic Stewardship: A National and International ImperativePYA, P.C.
J. Michael Keegan, MD, an infectious disease specialist who leads the antibiotic stewardship team at PYA, discussed antibiotic stewardship at the South Dakota Pharmacists Association’s (SDPHA) Annual Convention in Deadwood, South Dakota.
Mechanism Antibiotic Resistance
Intrinsic (Natural)
Acquired
Chromosomal
Extra chromosomal
Intrinsic Resistance
Lack target : No cell wall; innately resistant to penicillin
2. Drug inactivation: Cephalosporinase in Klebsiella
3. Innate efflux pumps:
It is an active transport mechanism. It requires ATP.
Eg. E. coli, P. aeruginosa
Altered target sites
PBP alteration
Ribosomal target alteration
Decreased affinity by target modification
Beta-lactamase
Beta-lactamases are enzymes produced by bacteria that provide resistance to β-lactam antibiotics such as penicillins, cephamycins, and carbapenems
Major resistant Pathogen
1. PRSP- Penicillin resistant Streptococcus pneumoniae2. MRSA/ORSA- Methicillin-resistant Staphylococcus Aureus (Super bug)3. VRE -Vancomycin-Resistant Enterococci4. Carbapenem resistant pseudomonas aeruginosa5. Carbapenem resistant Carbapenem resistant 6. Extended spectrum beta-lactamase (ESBL)-producing bacteria
Dr.sherin elsherbiny
Senior registrar clinical microbiology
AMR coordinator
Infection control auditor
Riyadh region
Meeqat General Hospital ,Madina,KSA
updated statistics about antimicrobial resistance,causes and mechanism of antimicrobial resistances, national antimicrobial policy, national antimicrobial surveillance, new delhi b metallo-lactamase-1 bacteria
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Infection Control and Antibiotic Stewardship Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
FLOW OF THE SEMINAR
1. Definition – antibiotic resistance, Multi-resistance, cross-resistance in antibiotics
2. Evolution of resistance
3. Impact of resistance
4. The scenario of resistance: Global, India
5. Factors causing resistance
6. Mechanisms of resistance: Intrinsic and Acquired
7. Acquired mechanism of resistance
8. Quorum sensing
9. Mechanism of resistance in commonly used antibiotics
10. Methods for determining the resistance
11. Strategies to contain resistance
12. Antibiotic stewardship
13. Role of Pharmacologist
14. Initiatives undertaken by India to control resistance
Role of PK PD in Antibiotic Stewardship Program with case study. This presentation gives an comprehensive overview about role of PK PD in antibiotic stewardship program.
Antibiotic Stewardship: A National and International ImperativePYA, P.C.
J. Michael Keegan, MD, an infectious disease specialist who leads the antibiotic stewardship team at PYA, discussed antibiotic stewardship at the South Dakota Pharmacists Association’s (SDPHA) Annual Convention in Deadwood, South Dakota.
Mechanism Antibiotic Resistance
Intrinsic (Natural)
Acquired
Chromosomal
Extra chromosomal
Intrinsic Resistance
Lack target : No cell wall; innately resistant to penicillin
2. Drug inactivation: Cephalosporinase in Klebsiella
3. Innate efflux pumps:
It is an active transport mechanism. It requires ATP.
Eg. E. coli, P. aeruginosa
Altered target sites
PBP alteration
Ribosomal target alteration
Decreased affinity by target modification
Beta-lactamase
Beta-lactamases are enzymes produced by bacteria that provide resistance to β-lactam antibiotics such as penicillins, cephamycins, and carbapenems
Major resistant Pathogen
1. PRSP- Penicillin resistant Streptococcus pneumoniae2. MRSA/ORSA- Methicillin-resistant Staphylococcus Aureus (Super bug)3. VRE -Vancomycin-Resistant Enterococci4. Carbapenem resistant pseudomonas aeruginosa5. Carbapenem resistant Carbapenem resistant 6. Extended spectrum beta-lactamase (ESBL)-producing bacteria
Dr.sherin elsherbiny
Senior registrar clinical microbiology
AMR coordinator
Infection control auditor
Riyadh region
Meeqat General Hospital ,Madina,KSA
updated statistics about antimicrobial resistance,causes and mechanism of antimicrobial resistances, national antimicrobial policy, national antimicrobial surveillance, new delhi b metallo-lactamase-1 bacteria
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
Infection Control and Antibiotic Stewardship Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Presentation from the 3rd Joint Meeting of the Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) Networks, organised by the European Centre of Disease Prevention and Control - Stockholm, 11-13 February 2015
Dr. Lonnie King - Antibiotic Use and Resistance: Moving Forward Through Share...John Blue
Antibiotic Use and Resistance: Moving Forward Through Shared Stewardship - Dr. Lonnie King, Dean of College of Veterinarian Medicine at The Ohio State University, from the 2014 NIAA Symposium on Antibiotics Use and Resistance: Moving Forward Through Shared Stewardship, November 12-14, 2014, Atlanta, Georgia, USA.
More presentations at http://www.swinecast.com/2014-niaa-antibiotics-moving-forward-through-shared-stewardship
Dr. Steve Solomon - Metrics and Decision-Making for Antibiotic Stewardship in...John Blue
Metrics and Decision-Making for Antibiotic Stewardship in Human Medicine - Dr. Steve Solomon, Centers for Disease Control & Prevention, Currently serves as Director of the Office of Antimicrobial Resistance in the Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, in the Office of Infectious Diseases at CDC., from the 2014 NIAA Symposium on Antibiotics Use and Resistance: Moving Forward Through Shared Stewardship, November 12-14, 2014, Atlanta, Georgia, USA.
More presentations at http://www.swinecast.com/2014-niaa-antibiotics-moving-forward-through-shared-stewardship
•Describe the role of antibiotic use in the development of resistance
•Review toxicity of commonly used antibiotics
•Understand the prevalence and clinical impact of carbapenem resistant enterobacteriaceae
•State the prognosis antimicrobial resistant Staph aureus infections
Les différentes situations d’expertises
Expertise amiable
Expertise judiciaire
Le cadre médico-légal
Accident de circulation (AC)
Coups et blessure volontaire (CBV)
Responsabilité médicale
Accident du travail (AT)
Notion d’Incapacité
Réduction par les séquelles de la capacité physiologique
Évaluation barémique
AT : Art.38 alinéa 3 de la loi n°94/28 du 21/2/1994
AC : Art. 131 alinéa 2 de la loi n°2005-86 du 15/8/2005
More than half of all hospital patients are treated with antibiotics and prescribing practices vary widely, even within hospitals. Efforts to rationalize antibiotic use have been stymied by delays in obtaining specific diagnoses, by the volume of prescriptions written each day and by the difficulty of extracting meaningful data from scattered clinical, laboratory and pharmacy records. But the push is on – from the White House, the CDC, infectious disease specialists, the industry – for more judicious use of antibiotics through antibiotic stewardship programs.
Hear how leading health care institutions have moved from education to active surveillance to intervention, reducing infections and lowering costs.
Fighting the growing threat of antimicrobial resistance webinar4 All of Us
Lord Jim O’Neill, the UK Commercial Secretary to the Treasury and Chair of the Review on Antimicrobial Resistance, recently released a report laying out recommendations to fight the global threat of antimicrobial resistance (AMR).
Overuse of antibiotics, especially of broad spectrum antibiotics rather than targeted narrow spectrum therapies, has led to an increase in drug-resistant bacterial infections. This emerging health issue is poised to have devastating global consequences, making it impossible to treat previously curable diseases. AMR already contributes to 700,000 deaths a year, and the report warns that it could cause 10 million deaths a year and $100 trillion in lost global productivity by 2050 if nothing is done to stop its spread.
In recent years, advances in diagnostic technology have made rapid point-of-care testing possible for many diseases – enabling providers to immediately prescribe the most appropriate therapy during the course of a patient’s visit.
This webinar will focused on the importance of understanding the need for diagnostics, what is being done in development and the solutions that are available now.
Presentation from the 3rd Joint Meeting of the Antimicrobial Resistance and Healthcare-Associated Infections (ARHAI) Networks, organised by the European Centre of Disease Prevention and Control - Stockholm, 11-13 February 2015
Viral Challenge Studies: An Innovative Way to Speed Up Vaccine Development; A...SGS
In order to effectively fight influenza, the development of new, higher performing and universal vaccines is essential. However, clinical development is a lengthy and very expensive process, making it difficult for researchers to design vaccines for rapidly mutating viruses such as influenza. Assessing efficacy of a new influenza vaccine as early as possible in the development, to make a first selection and an early ‘go – no go’ decision, is key. Viral Challenge studies are an important tool to aid in the swift development of effective influenza vaccines particularly for potential pandemics like the avian influenza (bird flu).
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Antibiotic resistance is one of the biggest threats facing us today.
Why it is relevant to you: without effective antibiotics many routine treatments will become increasingly dangerous. Setting broken bones, basic operations, even chemotherapy and animal health all rely on access to antibiotics that work.
What we want you to do: To slow resistance we need to cut the unnecessary use of antibiotics. We invite the public, students and educators, farmers, the veterinary and medical communities and professional organisations, to become Antibiotic Guardians.
Call to action: Choose one simple pledge about how you’ll make better use of antibiotics and help save these vital medicines from becoming obsolete.
Global cancer vaccine market & clinical trial insightKuicK Research
“Global Cancer Vaccine Market & Clinical Trial Insight” Report Highlights:
Global Cancer Market Overview
Emergence of Personalized Cancer Vaccines
Platforms for Cancer Vaccines Delivery
Mechanism of Cancer Vaccines
Global Cancer Vaccines Clinical Pipeline by Phase, Indication, Company & Country
Global Cancer Vaccine Clinical Pipeline: 298 Vaccines
Marketed Cancer Vaccines: 15 Vaccines
Regulatory Framework for Cancer Vaccines Development & Marketing
Dr. Jeff Bender - Companion Animal Antimicrobial StewardshipJohn Blue
Companion Animal Antimicrobial Stewardship - Dr. Jeff Bender, Co-Director for the Upper Midwest Agricultural Safety and Health Center and Professor College of Veterinary Medicine and School of Public Health at the University of Minnesota, Chair for the AVMA Task Force for Antimicrobial Stewardship in companion Animal Practice, from the 2014 NIAA Symposium on Antibiotics Use and Resistance: Moving Forward Through Shared Stewardship, November 12-14, 2014, Atlanta, Georgia, USA.
More presentations at http://www.swinecast.com/2014-niaa-antibiotics-moving-forward-through-shared-stewardship
Advisor Live: Antimicrobial Stewardship - Why Now and How?Premier Inc.
This 90-minute webinar discusses strategies and tools for implementing antimicrobial stewardship programs, including methods for measuring antimicrobial use and resistance.
Join Premier’s free Advisor Live® webinar series for a special Get Smart About Antibiotics Week presentation on Thursday, November 19 from 12-1:30 p.m. EST. The panel for this 90-minute webinar will discuss strategies and tools for implementing antimicrobial stewardship programs, including methods for measuring antimicrobial use and resistance.
EXPERT PRESENTERS:
- Gina Pugliese, RN, MS, vice president, Premier Safety Institute®, moderator
- Arjun Srinivasan, MD, (CAPT, USPHS) medical director of the CDC’s Get Smart for Healthcare program, will highlight the national focus on antibiotic stewardship and reasons for the current urgency
- Michael Postelnick, RPh, BCPS AQ- Infectious Diseases, clinical manager and senior infectious diseases pharmacist for Northwestern Memorial Hospital, will share lessons learned from implementing their antibiotic stewardship program
- Craig Barrett, Pharm.D., BCPS, director safety solutions for Premier, Inc. will share strategies from Premier member hospitals striving for antimicrobial stewardship
Antibiotic Guardian London Workshop 20164 All of Us
Antibiotic resistance is one of the biggest threats facing us today.
Why it is relevant to you: without effective antibiotics many routine treatments will become increasingly dangerous. Setting broken bones, basic operations, even chemotherapy and animal health all rely on access to antibiotics that work.
What we want you to do: To slow resistance we need to cut the unnecessary use of antibiotics. We invite the public, students and educators, farmers, the veterinary and medical communities and professional organisations, to become Antibiotic Guardians.
Call to action: Choose one simple pledge about how you’ll make better use of antibiotics and help save these vital medicines from becoming obsolete.
Anthropology is a fascinating field that delves into the study of humans, encompassing their biological evolution, cultural development, social behavior, and linguistic diversity. It's essentially the exploration of what it means to be human across time and space.
Within anthropology, there are several subfields:
Cultural Anthropology: This branch focuses on the study of contemporary human cultures, their beliefs, practices, and social institutions. Cultural anthropologists often conduct fieldwork, immersing themselves in different societies to understand their customs, traditions, and social dynamics.
Physical Anthropology: Also known as biological anthropology, this area concentrates on the biological aspects of human beings, including their evolution, genetics, primatology, and forensic anthropology. Physical anthropologists study human variation and adaptation over time.
Linguistic Anthropology: Linguistic anthropologists explore the role of language in human societies. They investigate how language shapes cultural identities, social interactions, and thought processes. This field also encompasses the study of language evolution and linguistic diversity.
Archaeology: Archaeologists study past human societies through the analysis of material remains, such as artifacts, structures, and environmental data. They reconstruct ancient cultures, economies, and technologies to understand human history and prehistory.
Applied Anthropology: Applied anthropologists use anthropological methods and theories to address contemporary social issues. They work in various settings, including development projects, public health initiatives, and cultural resource management.
Overall, anthropology offers a holistic perspective on humanity, examining the interconnectedness of biological, cultural, and social dimensions of human existence.
In today’s healthcare environment, there is an increasing emphasis on antimicrobial stewardship programs (ASP) and their impact on patient and community health and hospital financials. There are now new regulatory standards from The Joint Commission (TJC) that require hospitals to implement ASPs, and the Centers for Medicare and Medicaid Services (CMS) has proposed making it mandatory that hospitals implement an ASP in order to participate in Medicare and Medicaid. Regardless, a solid ASP is critically important to patient wellbeing, public health, and a hospital’s bottom line. This webinar will focus on how to bring a successful ASP to life in your hospital with a business plan and buy in from key stakeholders across the organization.
Dr. Michael D. Apley - Antibiotic Resistance: A One Health PerspectiveJohn Blue
Antibiotic Resistance: A One Health Perspective - Dr. Michael D. Apley, Professor, Production Medicine/Clinical Pharmacology, Frick Professorship, Kansas State University, from the 2018 NIAA Antibiotic Symposium: New Science & Technology Tools for Antibiotic Stewardship, November 13-15, 2018, Overland Park, KS, USA.
More presentations at https://www.youtube.com/playlist?list=PL8ZKJKD9cmEffjOrjbBvQZeN2_SZB_Skc
Similar to Antibiotic stewardship programme hiht final 3nov2012 (20)
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Best Ayurvedic medicine for Gas and IndigestionSwastikAyurveda
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Antibiotic stewardship programme hiht final 3nov2012
1. Vikas KesarwaniVikas Kesarwani MD FICM FCCPMD FICM FCCP
Asstt. Professor & In-charge,Asstt. Professor & In-charge,
Department of Critical care medicineDepartment of Critical care medicine
ANTIMICROBIAL STEWARDSHIP:ANTIMICROBIAL STEWARDSHIP:
A CONCERN FOR ALL PRACTITIONERSA CONCERN FOR ALL PRACTITIONERS
2. Guideline ResourcesGuideline Resources
• IDSA and SHEAIDSA and SHEA
– Guidelines for Developing an Institutional ProgramGuidelines for Developing an Institutional Program
to Enhance Antimicrobial Stewardshipto Enhance Antimicrobial Stewardship
• ASMASM
– Antimicrobial Resistance Prevention Initiative—AnAntimicrobial Resistance Prevention Initiative—An
UpdateUpdate
IDSA: Infectious Disease Society of AmericaIDSA: Infectious Disease Society of America
SHEA: Society of Heathcare Epidemiology of AmericaSHEA: Society of Heathcare Epidemiology of America
ASM: American Society of MicrobiologyASM: American Society of Microbiology
4. Why Stewardship is Needed
– Up toUp to 50% antimicrobial50% antimicrobial prescribingprescribing inappropriateinappropriate**
– Causal relationshipCausal relationship betweenbetween antimicrobial useantimicrobial use andand
emergence ofemergence of resistanceresistance
– IDSA’s:IDSA’s: Bad Bugs, No Drugs task forceBad Bugs, No Drugs task force to call forto call for
a global commitment from stakeholders to supporta global commitment from stakeholders to support
thethe development of 10 new drugs indevelopment of 10 new drugs in novelnovel classesclasses
by the year 2020by the year 2020:: 10 × 20 initiative10 × 20 initiative
*Dellit TH et al. IDSA and SHEA guidelines. Clin inf dis 2007;44(2):159-177.
IDSA: Infectious Diseases Society of America
5. Those of us not developing new drugsThose of us not developing new drugs
have another job:have another job:
Conserve the antibiotics byConserve the antibiotics by
Antibiotic stewardshipAntibiotic stewardship
6. What is Antimicrobial Stewardship?What is Antimicrobial Stewardship?
• ““The optimalThe optimal selectionselection,, dosagedosage, and, and
durationduration ofof antimicrobial treatmentantimicrobial treatment thatthat
results in theresults in the best clinical outcome”best clinical outcome” oror
““TreatmentTreatment andand prevention of infectionprevention of infection,,
withwith minimal toxicityminimal toxicity to the patient andto the patient and
minimal impactminimal impact on subsequenton subsequent
resistanceresistance.”.”
Dellit TH, et al. CID 2007;44:159-77,Dellit TH, et al. CID 2007;44:159-77,
Hand K, et al. Hospital Pharmacist 2004;11:459-64Hand K, et al. Hospital Pharmacist 2004;11:459-64
Paskovaty A, et al IJAA 2005;25:1-10Paskovaty A, et al IJAA 2005;25:1-10
7. 3 Goals of Antimicrobial Stewardship3 Goals of Antimicrobial Stewardship
• 11stst
Goal:Goal: each patient receive the mosteach patient receive the most
appropriateappropriate antimicrobialantimicrobial
• 2nd Goal:2nd Goal: preventprevent antimicrobialantimicrobial
overuse, misuse, and abuse.overuse, misuse, and abuse.
• 3rd Goal :3rd Goal : minimizeminimize the development ofthe development of
resistance.resistance.
• Secondary goalSecondary goal
ReduceReduce healthcarehealthcare costscosts without adversely impactingwithout adversely impacting
quality of carequality of care
8. Goals of Antimicrobial StewardshipGoals of Antimicrobial Stewardship
11stst
Goal:Goal: each patient receive the mosteach patient receive the most
appropriate antimicrobialappropriate antimicrobial
““4 D’s4 D’s of optimal antimicrobial therapy”:of optimal antimicrobial therapy”:
-- RightRight DrugDrug,,
--RightRight DoseDose,,
-- De-escalationDe-escalation to pathogen-directed therapy,to pathogen-directed therapy,
-- RightRight DurationDuration of therapy.of therapy.
9. Goals of Antimicrobial StewardshipGoals of Antimicrobial Stewardship
• 22ndnd
Goal: prevent antimicrobialGoal: prevent antimicrobial
overuse, misuse, and abuse.overuse, misuse, and abuse.
Overuse:Overuse:
Antibiotics toAntibiotics to patients withpatients with viral infectionsviral infections,,
noninfectious processes (noninfectious processes (pancreatitispancreatitis), infections), infections
that do not require antibiotics (that do not require antibiotics (small skin abscessessmall skin abscesses
that willthat will resolve with I & Dresolve with I & D), and), and
bacterial colonizationbacterial colonization (positive urine culture result in(positive urine culture result in
catheterized patient.).catheterized patient.).
10. Goals of Antimicrobial StewardshipGoals of Antimicrobial Stewardship
• 22ndnd
Goal: prevent antimicrobialGoal: prevent antimicrobial
overuse, misuse, and abuse.overuse, misuse, and abuse.
• Misuse:Misuse: use ofuse of broad-spectrum antibioticsbroad-spectrum antibiotics that coverthat cover
MDR organisms in a patient withMDR organisms in a patient with community acquiredcommunity acquired
infectioninfection or theor the failure to adjust antibiotics accordingfailure to adjust antibiotics according
to culture.to culture.
• Abuse:Abuse: use of oneuse of one particular antibiotic preferentiallyparticular antibiotic preferentially
over othersover others as a result ofas a result of aggressive detailing byaggressive detailing by
pharmaceutical representativepharmaceutical representative or worse becauseor worse because ofof
financial interest.financial interest.
11. Goals of Antimicrobial StewardshipGoals of Antimicrobial Stewardship
• 33rdrd
Goal :Goal : minimizeminimize the development ofthe development of resistance.resistance.
Antimicrobial resistance is associated withAntimicrobial resistance is associated with
increased morbidity and mortalityincreased morbidity and mortality
12. Building the Stewardship teamBuilding the Stewardship team
Infectious DiseasesInfectious Diseases
SpecialistsSpecialists
AntimicrobialAntimicrobial
ControlControl
Infection ControlInfection ControlAdministrationAdministration
ClinicalClinical
PharmacistsPharmacists
ID trainedID trained
NursingNursing
Surgical InfectionSurgical Infection
Experts/SurgeonsExperts/Surgeons
OT PersonnelOT Personnel
MicrobiologistMicrobiologist
IntensivistIntensivist
13. The stewardship team does notThe stewardship team does not
have to fit a particular mold.have to fit a particular mold.
14. Building the Stewardship teamBuilding the Stewardship team
Hospitalist interested inHospitalist interested in
infectious diseaseinfectious disease
AntimicrobialAntimicrobial
ControlControl
Infection ControlInfection ControlAdministrationAdministration
NursingNursing
Surgical InfectionSurgical Infection
Experts/SurgeonsExperts/Surgeons
OT PersonnelOT Personnel
MicrobiologistMicrobiologist
IntensivistIntensivist
InfectionInfection
preventionistpreventionist
16. IDSA Grading System for RankingIDSA Grading System for Ranking
Recommendations in Clinical GuidelinesRecommendations in Clinical Guidelines
Kish MA et al. CID 2001; 32: 851 - 4Kish MA et al. CID 2001; 32: 851 - 4
Category, GradeCategory, Grade DefinitionDefinition
Strength ofStrength of
recommendationrecommendation
AA Good evidence to supportGood evidence to support
BB Moderate evidence to supportModerate evidence to support
CC Poor evidence to supportPoor evidence to support
Quality of evidenceQuality of evidence
II ≥≥ 1 randomized, controlled trials1 randomized, controlled trials
IIII ≥≥ 1 clinical trial unrandomized, cohort1 clinical trial unrandomized, cohort
or case-controlled studies, dramaticor case-controlled studies, dramatic
results from uncontolled experimentsresults from uncontolled experiments
IIIIII Opinion of experts, clinical experience,Opinion of experts, clinical experience,
descriptive studiesdescriptive studies
17. Antimicrobial Stewardship Core StrategiesAntimicrobial Stewardship Core Strategies
• Front endFront end (pre-prescription approach):(pre-prescription approach):
Formulary restrictionFormulary restriction andand preauthorizationpreauthorization
(expert approval) leading to reductions in(expert approval) leading to reductions in
antimicrobial use and cost .antimicrobial use and cost . (A II)(A II)
• Back endBack end (Post prescription approach):(Post prescription approach):
Interventions after antimicrobials have beenInterventions after antimicrobials have been
prescribedprescribed. (A II). (A II)
• Prospective audit with intervention and feedbackProspective audit with intervention and feedback ofof
antimicrobial use and resistance patternsantimicrobial use and resistance patterns to reduceto reduce
inappropriate antimicrobial useinappropriate antimicrobial use (A I)(A I)
Dellit TH, et al. CID 2007;44:159-77Dellit TH, et al. CID 2007;44:159-77
Hand K, et al Hospital Pharmacist 2004;11:459-64Hand K, et al Hospital Pharmacist 2004;11:459-64
Paskovaty A, et al IJAA 2005;25:1-10Paskovaty A, et al IJAA 2005;25:1-10
18. Core strategy “The Front End”Core strategy “The Front End”
• Restrictive prescriptive authorityRestrictive prescriptive authority::
- Certain- Certain antimicrobialsantimicrobials requirerequire prior authorizationprior authorization
for use by all except a select group of clinicians.for use by all except a select group of clinicians.
- Approved- Approved for a specificfor a specific durationduration, thereby, thereby
prompting reviewprompting review after cultureafter culture data obtained.data obtained.
-- TargetTarget aa specific diseasespecific disease or indication withor indication with
specific antimicrobialsspecific antimicrobials associated withassociated with highhigh ratesrates
ofof resistance and costresistance and cost..
Advantage:Advantage:
--PreventsPrevents overuse, misuseoveruse, misuse andand abuseabuse..
- Significant- Significant reduction in cost.reduction in cost.
19. Core Strategy “The Back end”Core Strategy “The Back end”
• Post prescription restriction: Uses prospective review andPost prescription restriction: Uses prospective review and
feedback.feedback.
• Specific AntimicrobialsSpecific Antimicrobials areare reviewed at specified intervalsreviewed at specified intervals
after initiation. Adviced toafter initiation. Adviced to continue, adjust, change, orcontinue, adjust, change, or
discontinuediscontinue the therapythe therapy based on microbiology resultsbased on microbiology results andand
clinical featuresclinical features of the case.of the case.
AdvantageAdvantage
Focus is onFocus is on De-escalation.De-escalation.
-- changing achanging a broad-spectrumbroad-spectrum antibiotic toantibiotic to narrow spectrumnarrow spectrum
- changing from- changing from combinationcombination therapy totherapy to monotherapymonotherapy, or, or
-- stopping antibioticstopping antibiotic therapy altogether as it becomes moretherapy altogether as it becomes more
apparent that these drugs areapparent that these drugs are not needednot needed..
20. Supplemental AntimicrobialSupplemental Antimicrobial
Stewardship Strategies/TechniquesStewardship Strategies/Techniques
– Education: clinical guidelines, infectionEducation: clinical guidelines, infection
control.control.
– Antimicrobial order formsAntimicrobial order forms
– IV-PO switchIV-PO switch
– Dose optimization via PK-PDDose optimization via PK-PD
– Antimicrobial cyclingAntimicrobial cycling
21. Educational StrategiesEducational Strategies
• Educational programs, active interventionEducational programs, active intervention
(A-III, B-II)(A-III, B-II) Guideline & algorithm dissemination.Guideline & algorithm dissemination.
• Guidelines and clinical pathways –Guidelines and clinical pathways – seek multi-seek multi-
disciplinary involvement and approvaldisciplinary involvement and approval (A-I)(A-I)
– Incorporate local antimicrobial resistanceIncorporate local antimicrobial resistance patternspatterns
(A-I)(A-I)
– ProvideProvide education and feedbackeducation and feedback to practitionersto practitioners
(A-III)(A-III) idea ?idea ? Microbiology Newsletter.Microbiology Newsletter. Questions of theQuestions of the
week/monthweek/month
22. Antimicrobial order forms (B-II)Antimicrobial order forms (B-II)
Shown to be effective component of the programShown to be effective component of the program
and canand can facilitate planningfacilitate planning intointo practice.practice.
HelpsHelps auditaudit andand feedback.feedback.
– ensuresensures guideline-basedguideline-based appropriateappropriate empiricempiric
antibioticantibiotic ordering.ordering.
– Day 3 reviewDay 3 review bundlebundle based on investigations andbased on investigations and
clinical profile.clinical profile.
– Streamlining orStreamlining or de-escalationde-escalation therapytherapy (A-II)(A-II)
Antimicrobial order formsAntimicrobial order forms
23. Day 3 Antibiotic Review BundleDay 3 Antibiotic Review Bundle
Pulcini et al, JAC, 2008Pulcini et al, JAC, 2008
24. Parenteral to Enteral conversionParenteral to Enteral conversion (A-I)(A-I)
– As soon as the patient’s condition allowsAs soon as the patient’s condition allows
• Reduces length of stayReduces length of stay && healthcare costshealthcare costs
I.V. to oral switch overI.V. to oral switch over
Dose optimization via PK-PDDose optimization via PK-PD
Dose optimizationDose optimization (A-II)(A-II)
Based onBased on Organ dysfunctionOrgan dysfunction..
Patient characteristicsPatient characteristics (wt, age, sex,(wt, age, sex,
ethnicity),ethnicity),
CausativeCausative organismorganism ((virulencevirulence),),
SiteSite of infection (drug delivery to that site)of infection (drug delivery to that site)
25. – Hypothesis:Hypothesis: byby removing specific classesremoving specific classes ofof
antimicrobialsantimicrobials on a regular basison a regular basis, the, the
development of resistance can be avoided.development of resistance can be avoided.
Antimicrobial cycling – isAntimicrobial cycling – is not recommendednot recommended
because ofbecause of insufficient datainsufficient data (no ranking)(no ranking)
Antimicrobial cyclingAntimicrobial cycling
………………………………….
26. Barriers to Implementing AntibioticBarriers to Implementing Antibiotic
stewardship programmestewardship programme
27. The Vicious Spiral:
The Prescriber’s dilemma
--Must get right at allMust get right at all
cost.cost.
-Blanket cover is less-Blanket cover is less
stressful.stressful.
-Lack of faith in tests-Lack of faith in tests
-Defensive medicine-Defensive medicine
↑↑ use of newuse of new
drugsdrugs
↑↑ Use of broadUse of broad
spectrum drugsspectrum drugs
↑↑ C.difficleC.difficle
↑↑ costcost
↑ResistanceResistance
28. Barriers to Implementing AntibioticBarriers to Implementing Antibiotic
stewardship programmestewardship programme
Lack of understanding of problem…Who cares..Lack of understanding of problem…Who cares..
– Staff may not want to assume “added”Staff may not want to assume “added”
responsibility.responsibility. (No compensation)(No compensation)..
– The paradoxThe paradox:: higherhigher thethe antibiotic demandantibiotic demand moremore
earning,earning, happierhappier thethe beneficiariesbeneficiaries..
– ““ManyMany clinicians might feel offendedclinicians might feel offended to their rightto their right
to prescribe antibiotics freely (unrestricted)”to prescribe antibiotics freely (unrestricted)”
-Sunenshine RH, et al.-Sunenshine RH, et al. Clin Infect DisClin Infect Dis 2004;38:934-38.2004;38:934-38.
-Arvind Kejriwal-Arvind Kejriwal IACIAC
29. We can still do much without problem.
Every ounce of stewardship countsEvery ounce of stewardship counts
– start small,– start small, think bigthink big!!
30. We can still do a lot…..We can still do a lot…..
• Form anForm an Antibiotic stewardship teamAntibiotic stewardship team withwith
Hospitalists interested in infectiousHospitalists interested in infectious
diseasedisease..
• Educate:Educate: clinical guidelines, algorithms,clinical guidelines, algorithms,
infection control techniques.infection control techniques.
• Day 3 Antibiotic Review form.Day 3 Antibiotic Review form.
31. Day 3 Antibiotic Review form
Pulcini et al, JAC, 2008
-IV-PO switch.IV-PO switch.
-De-escalation.De-escalation.
-Audit and feedback.Audit and feedback.
32. We can still do a lot…..We can still do a lot…..
• Form anForm an Antibiotic stewardship teamAntibiotic stewardship team withwith
Hospitalists interested in infectious diseaseHospitalists interested in infectious disease..
• Educate:Educate: clinical guidelines, algorithms, infectionclinical guidelines, algorithms, infection
control techniques.control techniques.
• Day 3 Antibiotic Review form.Day 3 Antibiotic Review form.
-- IV-PO switch.IV-PO switch.
- De-escalation.- De-escalation.
- Audit and feedback.- Audit and feedback.
• PosterPoster ofof empiric treatment guidelineempiric treatment guideline..
• Microbiology newsletterMicrobiology newsletter with microbial resistancewith microbial resistance
review and feedback.review and feedback.
………………………….
33.
34. A Disturbing Trend
1930 1940 1950 1960 1970 1980 1990 2000 2010
Sulfa, BL, AG,
Chloramphenicol
TCN, MAC, Vanc,
RIF, FQ, TMP
No new classes.
Modification of existing agents.
LZD,
DAP,
TIG
CBP; DAL;
New Entities
Limited
PCN-resistant S. aureus
MRSA
VRE
VISA in 7 states
VRSA
LZD-R S. aureus
MDR Pseudomonas and Acinetobacter, metallo-beta-lactamases, carbapenemases
Half of US and Japanese companies END
drug discovery
Recommendation from the Infectious Disease Society of America (IDSA) Endorsed by the ASHP Board of Directors in March of 2006 Includes the IDSA Ranking System for Clinical Guidelines Official journal of the IDSA - Clinical Infectious Diseases Much recent support to institute management services in your institution Historically non-pharmacy friendly organization
Not another disease treatment where you must weigh your current patient’s treatment, with how that impacts future patients in your HC system Mortality affected when tx in inappropriate Resistance increases with broad spectrum agents needed, negative impact on outcomes
Clear association between resistance and increased morbidity/mortality and cost Inappropriate use is rampant—reason is that it is REALLY COMPLEX and DIFFICULT 10 × 20 initiative has been likened to John F. Kennedy’s dream of walking on the moon.
OK, we are back to our definition Remember infection control and its importance Mandatory infection control compliance plus antimicrobial management Appropriate antimicrobial selection, dosing, route, and duration Selection of antimicrobials that cause the least collateral damage (emergence of resistance, adverse drug events, and cost) MRSA ESBLs Clostridium difficille Stable derepression Metallo-beta-lactamases and other carbapenemases VRE
Do not include outpatient recommendations Financially self-supporting Improve patient care Should be evidence based
Do not include outpatient recommendations Financially self-supporting Improve patient care Should be evidence based
Do not include outpatient recommendations Financially self-supporting Improve patient care Should be evidence based
Do not include outpatient recommendations Financially self-supporting Improve patient care Should be evidence based
Do not include outpatient recommendations Financially self-supporting Improve patient care Should be evidence based
Infectious diseases specialists are one important resource for providing input, but many other professionals also contribute to optimal care for patients with infections. Like all patient safety endeavors, multidisciplinary collaboration is key! ESSENTIAL COLLABORATION Hospital administration Medical staff Infection Control Committee Pharmacy and Therapeutics Committee Approval of pathways Review of budgetary issues Approval of restriction policies and procedures Review of yearly antibiogram
Infectious diseases specialists are one important resource for providing input, but many other professionals also contribute to optimal care for patients with infections. Like all patient safety endeavors, multidisciplinary collaboration is key! ESSENTIAL COLLABORATION Hospital administration Medical staff Infection Control Committee Pharmacy and Therapeutics Committee Approval of pathways Review of budgetary issues Approval of restriction policies and procedures Review of yearly antibiogram
In some hospitals, the pharmacy will not dispense certain antimicrobial agents without the approval of a physician trained in ID. This practice reduces both the use and costs of these agents. In several studies, this practice and other methods used to restrict antimicrobial use have decreased the incidence of certain drug-resistant organisms in healthcare settings. IDSA’s Emerging Infections Network (EIN) surveyed its members to characterize antimicrobial restriction policies in their hospitals and the involvement of ID consultants in this process. 502 responded to the survey. Almost all respondents agreed that inappropriate use of antibiotics is the most important factor contributing to increased antibiotic resistance. Nearly all respondents agreed that ID consultants should be directly involved in the approval process of selected antimicrobials. However, there are many barriers to the involvement of ID consultants in this process. Primary among these barriers are Time and effort required to maintain an approval program Lack of compensation for such a role Fear of antagonizing colleagues from other specialties and consequent loss of income due to reduced consultations In the editorial comment on this paper, John E McGowan, Jr identifies several stakeholder groups that must be included in efforts to deal with resistance in the healthcare setting. These groups include: Prescribers Patients Healthcare administrators Institutional thought leaders Pharmacists, nurses, and laboratory personnel Antimicrobial use improvement and quality assurance groups Professional societies and the government
Illustrate antimicrobial eras during which new agents with new MOA came out Last breakthru drug of a new class (and not even a new MOA) in 1980s—carbapenem (imipenem) much more resistant to hydrolysis by PCNases/Cephalosporinases But, now this is changing IDSA/ICAAC posters for future agents: in phase III clinical trials = 0 Not much on the 10 year horizon Ceftibiprole=4 th gen ceph with MRSA coverage Dalpovancin=glycopeptide antibiotic 30 years with no new PA drugs 30 years with 1 new drug for other G- (tig) $1B investment, not much return, orgs pursuading congress to provide incentives to companies Drug on for short duration