Abstract Search board and discussion: Rational use of drugs Antimicrobial action and spectrum Patterns of irrational use of antibiotics Mechanisms of antibiotic resistance Etiological factors of irrational use of antibiotics Impacts and complications of irrational use of drugs in general Examples of common misused antibiotics Solutions and Recommendations

1. Irrational use of antibiotics
Principles of pharmacology Module
ALI QAIS HASSAN

2. 1
Contents
1. Abstract ………..……………………………………………………….. 2
2. Introduction ...…………...……………………………………………… 3
3. Search board and discussion:
 Rational use of drugs..……………………………………………... 6
 Antimicrobial action and spectrum ……………………………...… 5
 Patterns of irrational use of antibiotics…………………………...... 7
 Mechanisms of antibiotic resistance ……………………………..... 9
 Etiological factors of irrational use of antibiotics …….…………. 14
 Impacts and complications of irrational use of drugs in general … 15
 Examples of common misused antibiotics ………………………. 16
 Solutions and Recommendations …..…………………………..... 18
1- Summary ……………………………………………………………..... 19
2- References ………………………………………………………...…… 20

3. 2
Abstract
The use of antibiotic drugs triggers a complex interaction involving many
biological, sociological and psychological determinants.
Drugs in general and antibiotics especially should be used rationally by
following the instructions of the doctor who diagnosed the disease (in case if the
doctor was right).
In some cases the drugs are misused or overused and it’s a serious problem in
the community that has complications , most common complication is antibiotic
resistance
Resistance to antibiotics is a serious worldwide problem which is increasing and
has implications for morbidity, mortality and health care both in hospitals and in
the community.
figure 1

4. 3
Introduction
The discovery of antibiotics existed one of the significant events in medical
history and said to have added a decade to the life expectancy of human beings.
(1)
Antibiotics also known as antibacterial medications that inhibits or slows down
the growth of bacteria. Bacteria are microscopic organisms that cause many
types of infection in the human beings.
We have special white blood cells that attack the harmful bacteria and this is the
main function of our immune system. In some cases the body can’t defend itself
and needs the help of antibiotics with the immune system to attack the harmful
bacteria.
Children and infants represents a large part of population in the developing
nations and those groups are usually prone to recurrent attacks of gastrointestinal
and respiratory infections of viral origin and usually misuse of antibiotics in
these groups have been reported (2)
Antibiotic resistance is an outcome of irrational use of antibiotics therefore it’s
very important to know the right and rational use of antibiotics. (3)
The infectious diseases society of America had identified six organisms as being
the major agent that cause bacterial resistance to antibiotics (4) .

5. 4Rational use of drugs (in general)
The term rational or appropriate means that the patient receives a drug that suits
his/her clinical illness and in doses that meets his requirements and for adequate
period of time and with lowest cost to patient and community . (15)
So rational use of drugs especially antibiotics must meet the following criteria:
a. appropriate indication
b. appropriate drug
c. appropriate patient
d. appropriate dose of drug
e. appropriate duration of use
f. appropriate information about use of the drug should be provided for
the patients
g. Appropriate cost that meets the economic status of the deferent
patients
h. appropriate monitoring of the patient after taking the drug to avoid
side effects (5)
figure 2

6. 5Antimicrobial action and spectrum
Antimicrobial agents play a role in killing bacterial microorganisms by
inhibiting, damaging or destroying a target that is a required component of the
organism (11).
Every antimicrobial agent is able to kill specific range of microorganisms and
this must be considered in selecting appropriate antimicrobial therapy .
In sever infections and / or immunocompromised patients, it’s customary to use
bactericidal agents rather than bacteriostatic agents .
Empiric antibiotics therapy is selected to treat a clinical syndrome (ex;
meningitis) before microbiological diagnosis has been made.
Targeted antibiotic therapy is aimed at the casual pathogen of known
antimicrobial sensitivity (15).
Ideally broad spectrum of antibiotics is used in empiric therapy , and narrow-
spectrum antibiotic is used in targeted therapy .
figure 4

7. 6Combination therapy is usually used in 3 situations as
following:
a. To increase efficacy ( ex; enterococcal endocarditis )
b. When no single antibiotic covers all potential pathogens (ex; sepsis)
c. To reduce antibiotic resistance (Ex; T.B) ((12))
figure 5

8. 7Patterns of irrational use of antibiotics
1. Self-prescription which means the selection and use of medicines by
individuals to treat self-recognized illnesses or symptoms (12)
(Ex;using antibiotics for viral infections)
2. The use of wrong drug, which is either the doctor’s mistake or the
pharmacist’s mistake
but it also can be the nurse’s mistake .
(Ex; use of methionine instead of ORS in case of viral diarrhea )
3. The use of the correct drug on the appropriate patient but with incorrect doses,
this problem can be caused by anyone of the health care staff, and sometimes the
patient himself thinks that taking a higher dose would be better when it’s actually
worse .
4. The use of the correct drug but with wrong duration , (ex; some patients take
the drug for short periods and when the feel slightly better they stop taking the
drug and this what will cause antibiotics resistance)
5. The use of unnecessary expensive drugs, thinking it’s better for them !
6. Overuse of antibiotics
7. Multiple drug presentation, which in some cases cause harmful drug-drug
interactions (Ex; taking multiple antibiotics with the same effect at the same
time )
8. Prophylactic use of antibiotics (14)
9. Self antibiotics use ( using antibiotic leftovers ) , or in some cases sharing the
drug prescription with other patients

9. 8
figure 3

10. 9Mechanisms of antibiotic resistance
1. Adaptation of organisms physiology to the new environment after receiving
a signal to change their physiological state. The signal usually arrives from the
new environment, the change in physiological state occurs uniformly when the
new environment is not lethal to the organism ( ex ; low dose antibiotic )
2. Organism production of enzymes that degrades the antibiotics before it even
try to kill the organism (ex; B-lactamase )
3. Gene mutation of the organism or transfer of genetic materials from another
organisms (16)
4. Impermeability to the antibiotics (ex; resistance of pseudomonas bacteria to
many antibiotics)
5. Absence of antimicrobial target , in simpler words it means the science
haven’t made any antibiotic that can attack this certain microorganism (ex;
resistance of cryptococcus organism)
6. Active efflux of antimicrobial agent , so when the antibiotic gets inside the
bacteria it ejects the antibiotic before it works
(Ex; tetracycline resistance in gram (+) and gram(-) bacteria (7)
figure 6

11. 10How bacteria spread resistance
against antibiotics?
There are 2 processes that play a role in transferring resistance against antibiotics
between bacterial cells (16).
a. Transformation:- engulfment of free DNA by bacterial cells with it’s
genetic information as resistance to antibiotics.
figure 7

12. 11Bacterial conjugation:- sharing of DNA with its genetic information between
living bacteria
There is a third way of sharing bit it’s less common and it depends on
bacteriophages (10)
figure 8

13. 12How does antibiotic resistance transmit
from animals to humans?
Antibiotics now are
used widely in animals
to treat or prevent
diseases of animals.
Antibiotics are either
given as sub therapeutic
concentration or full
therapeutic
concentration inside the
food of the animals.
Irrational use of
antibiotics is not only in
humans it can be used
irrationally in animals
too,
Because of the bad
environments that farm
animals live in so these
animals are given
antibiotics
continuously along
with other drugs to
prevent them from
being sick , this
irrational use of
antibiotics produce
resistant bacteria inside
the body of animals
(11).
figure 9

14. 13As a consequence this antibiotic resistant bacteria are transmitted to humans via
eating contaminated meat if not cooked well or through faeces of animals.
Examples of resistant bacteria transmitted from animals to humans are:
a) Salmonella
b) E.coli
c) Campylobacter
d) Staphylococcus aureus (14)
figure 10

15. 14Etiological factors of irrational
use of antibiotics
1. Deficiency of knowledge and education of the community about the risks of
antibiotics if it’s not used in the right way
2. Lack of education and training of drug prescribers ( doctors , pharmacists and
other health providers)
3. Self use of drugs by community.
4. Heavy patients load in primary health centers , which cause making mistakes
5. Defect in drug supply system (especially antibiotics)
(Drug shortage, expired drugs supplied)
6. Defect in drug regulation (non-essential drugs available)
7. Defect in industry policy (16)
8. Low cost of some types of drugs such as (amoxicillin) ، Which makes the drug
affordable for a wide range of people in the community so they buy the drug
every time they get sick and use it irrationally
9. Defect of country policy to prevent selling of drugs without prescription
10. Reusing old prescriptions many times or sharing it with other people without
asking a doctor ((8))
figure 11

16. 15 Impacts and complications of
irrational use of drugs in general
1. Reduction in the quality of drug therapy on the long term use leading to
increased morbidity and mortality
2. Waste of resources leading to reduced availability of other viral drugs and
increased costs
3. Increased risk of unwanted effects like drug resistance
4. Psychological impacts because the patient will not be satisfied by the
treatment. ((9))
figure 12

17. 16Examples of common misused
antibiotics
1. Amoxicillin capsule : commonly used in upper respiratory tract infections
and tonsillitis and sinusitis , it’s usually misused because it’s too cheap
(15).
2. sulfamethoxazole/trimethoprim suspension: commonly used to treat
chronic diarrhea in children under 5 years who had viral gastroenteritis
(Rota virus)
figure 13
figure 14

18. 173. Ciprofloxacin tablets : this drug usually used in urinary tract infections
(15).
figure 15

19. 18Solutions and Recommendations
1. Educational programs : for the medical staff ( doctors, health
providers, pharmacists, drug dispenser ) The education programs are about the
rational use of antibiotics and drugs in general and the right indications and doses
and duration of therapy and side effects of drugs (11)
2. Managerial approaches : This is done by the manager of public
health and district and hospitals through supervision and monitoring the health
centers .
3. Economic solutions: This is done by increasing the cost of drugs that
are usually misused
4. Education programs : For the community through health centers , Tv
channels , and internet.
The advantages of such programs is to increase the base of knowledge in drugs,
diseases and risks of misuse in the community (16)
5. Policy solutions: Drugs should only be sold by prescription of the
doctors
6. Other solutions: Such as using of national standard treatment guidelines
in primary health centers (12)
figure 16

20. 19
Summary
The issues of antibiotic misuse are of global concern because of the spreading
and developing resistance of most common bacteria to most inexpensive
generic antibiotics.
Therefore methods to improve their use in sustainable and cost-effective way
are of crucial importance.
Intervention and solutions must be used to improve the problem and this needs
interventions of the government and ministry of health and community..
figure 17

21. 20
References
1) Larissa Grigoryan, Johannes G. M. Burgerhof, Flora M. Haaijer-Ruskamp, John E. Degener,
Reginald Deschepper, Dominique L. Monnet, Antonella Di Matteo, Elizabeth A. Scicluna, Ana-
Claudia Bara, Cecilia Stalsby Lundborg And Joan Birkin On Behalf Of The Sar Group 2006 (Is
Self-Medication With Antibiotics In Europe Driven By Prescribed Use? ) Journal Of
Chemotherapy Published November 22. Antimicrobial Advance Access
2) Jodi Vanden Eng, Ruthanne Marcus, James L. Hadler, Beth Imhoff, Duc J. Vugia, Paul R.
Cieslak, Elizabeth Zell, Valerie Deneen, Katherine Gibbs Mccombs, Shelley M. Zansky,
Marguerite A. Hawkins, And Richard E. Besser 2003 ( Consumer Attitudes And Use Of
Antibiotics) Emerging Infectious Diseases • Vol. 9, No. 9, September.
3) L.A.CountyBoardOfSupervisors:GloriaMolina,FirstDistrict,YvonneBrathwaiteBurke,Second
District;Zev Yaroslavsky, Third District;Don Knabe, Fourth District;Michael D. Antonovich,
Fifth District 2003(Antibiotic Misuse) Http://Publichealth.Lacounty.Gov/Acd
/Docs/Lahealth092003_Antib.Pdf
4) Dr. Gerome Manhattan's Weiss(Medicine: Antibiotics) Http://Www.Time.Com/Time/Magazin
e/Article/0,9171,866656,00.Html
5) Ross-Degnan D, Laing R, Quick J, Ali HM, Ofori-Adjei D, Salako L, Santoso B. A strategy for
promoting improved pharmaceutical use: the International Network for Rational Use of Drugs.
Social science & medicine. 1992 Dec 1;35(11):1329-41.
6) Vance MA, Millington WR. Principles of irrational drug therapy. International Journal of
Health Services. 1986 Jul;16(3):355-62.
7) Walker BR, Colledge NR. Davidson's Principles and Practice of Medicine E-Book. Elsevier
Health Sciences; 2013 Dec 6.
8) Vance MA, Millington WR. Principles of irrational drug therapy. International Journal of
Health Services. 1986 Jul;16(3):355-62.
9) Ross-Degnan D, Laing R, Quick J, Ali HM, Ofori-Adjei D, Salako L, Santoso B. A strategy for
promoting improved pharmaceutical use: the International Network for Rational Use of Drugs.
Social science & medicine. 1992 Dec 1;35(11):1329-41.
10)Morse SA, Butel JS, Brooks BG. Medical microbiology. MacGraw-Hill, New York. 2005.
11)Finch RG, Greenwood D, Whitley RJ, Norrby SR. Antibiotic and chemotherapy e-book.
Elsevier Health Sciences; 2010 Nov 30.
12)Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ,
Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients.
Cochrane Database Syst Rev. 2013 Jan 1;4(4).
13)Aarestrup FM, Wegener HC, Collignon P. Resistance in bacteria of the food chain:
epidemiology and control strategies. Expert review of anti-infective therapy. 2008 Oct
1;6(5):733-50.
14)Bager F, Aarestrup FM, Madsen M, Wegener HC. Glycopeptide resistance in Enterococcus
faecium from broilers and pigs following discontinued use of avoparcin. Microbial Drug
Resistance. 1999;5(1):53-6.
15)Harvey RA, Clark MA, Finkel R, Rey JA, Whalen K. Lippincott’s illustrated reviews:
Pharmacology. Philadelphia: Wolters Kluwer; 2012.
16) Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, Pharmacotherapy 3rd A. K: A
Pathophysiologic Approach. DiPiro JT, editor. Appleton & Lange; 1997.

22. 21
Figures' References:
1- http://intranet.tdmu.edu.ua/data/kafedra/internal/magistr/classes_stud/English/F
irst%20year/Clinical%20Pharmacology/08_Cl_%20Pharm_antibiotics.htm
2- https://commons.wikimedia.org/wiki/File:Antibiotic_resistance_mechanisms.jpg
3- https://www.healthinfi.com/how-do-antibiotics-work/
4- https://www.nature.com/articles/nrd4675
5- http://nptel.ac.in/courses/102103015/module7/lec9/4.html

23. 22