This document discusses rational antibiotic use and antibiotic policy. It covers topics like antimicrobial resistance, irrational antibiotic use, general principles for antibiotic use, and antibiotic stewardship programs. The key points are that irrational antibiotic use can lead to antimicrobial resistance, there are many factors that influence rational use like clinical guidelines and resistance patterns, and programs like CARAT aim to promote evidence-based antibiotic selection and use.
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
Dr.sherin elsherbiny
Senior registrar clinical microbiology
AMR coordinator
Infection control auditor
Riyadh region
Meeqat General Hospital ,Madina,KSA
This PDF deals with important guidelines, with respect to usage of antibiotics. This PDF outlines the important strategies involved while using antibiotics, and important factors involving antibiotic selection.
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.
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
Dr.sherin elsherbiny
Senior registrar clinical microbiology
AMR coordinator
Infection control auditor
Riyadh region
Meeqat General Hospital ,Madina,KSA
This PDF deals with important guidelines, with respect to usage of antibiotics. This PDF outlines the important strategies involved while using antibiotics, and important factors involving antibiotic selection.
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.
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
overuse and misuse of antibiotic put all of us at danger, and help to develop drug-resistant bacteria, so-called superbugs. which ultimately increase the cost of health care. so the third world countries are facing a burden of an extra charge of expenditure and unusual death
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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
- 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
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
1. Rational use of
antibiotics &
antibiotic policy
By –
Dr. Vikas S. Sharma
Dept. Of Pharmacology
GMC, Nagpur
1 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
2. Overview
i. Introduction
ii. Antimicrobial resistance & Antimicrobial resistance cycle
iii. Rational use of drugs
iv. Irrational use of antimicrobial
v. General principles in use of antibiotics
vi. The Council for Appropriate & Rational Antibiotic
Therapy (CARAT)
vii. Promoting rational prescription
viii.National antibiotic policy
ix. Antimicrobial stewardship
x. Summary
2 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
3. “Medicines are nothing in themselves,
if not properly used, but the very
hands of Gods, if employed with
reason and prudence.”
- Herophilus, Greek Physician
3 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
4. History of chemotherapy
• Chemotherapy:
• Pre-Ehrlich era: Before 1891
E.g. - Mouldy curd by Chinese in boils
Cinchona bark in malaria
Mercury in syphilis
Use of chemical compounds in treatment of
infectious diseases, so as to destroy
offending organisms & parasites without
damaging host tissues
4 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
5. • Period of Paul Ehrlich (1891-1935):
Dyes and organometallic compounds – “magic
bullets”
E.g. methylene blue for malaria
Arsenic for syphilis
• Period after 1935:
Discovery of sulfonamides and antibiotics
5 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
6. Antibiotic Era
• Antibiotics - “miracle drugs” in 1940s
• Penicillin, wonder drug, saved millions of lives in
World war II & many mothers were saved from
puerperal sepsis
• Their widespread availability & success led to
dramatic reduction in morbidity & mortality
6 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
7. Antibiotic Resistance
• As if proving the saying –
“What doesn’t kill you,
only makes you stronger”
Bacteria underwent a rapid unprecedented
evolution to circumvent this menace to their
survival
• WHO –
7 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
Microorganism’s resistance to an antibiotic drug that
was once able to treat an infection by that
microorganism
8. Mechanism of resistance and its
transfer
1. Enzymatic alteration
2. Decreased permeability
3. Efflux
4. Alteration of target site
5. Protection of target site- Tetracycline, quinolones
6. Overproduction of target- Sulphonamides,
trimethoprim, glycopeptide
7. Bypass of inhibited process- Sulphonamides,
trimethoprim
8. Bind up antibiotic- Glycopeptide
β Lactams,
Aminoglycosides,
Macrolides,
Quinolones,
Chloramphenicol
8 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
9. 9 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
10. What is Rational Use of Drugs?
10 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
Requires that patients receive medicines
appropriate to their clinical needs, in doses
to meet individual requirements, for an
adequate period of time, at the lowest
cost to them & the community
– WHO (1985)
11. What is causing antimicrobial
resistance ?
• Irrational use –
• Irrational prescribing -
Taking antibiotics without prescription
Skipping doses of antibiotics
Taking antibiotics at irregular intervals
Saving antibiotics to use them later
Unnecessary prescription of antibiotics
Wrong selection of antibiotics
Inappropriate dose or duration of antibiotics
11 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
12. What is causing antimicrobial
resistance ???
• Indiscrimate use of
Antibiotics in Animals
• R plasmids spread among co-
inhabiting bacterial flora in
animals ( in gut )
• R plasmids may be mainly
involved in animals spread to
human commensal - E. coli
followed by spread to more
important human pathogens
Eg Shigella spp.
12 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
13. Irrational prescribing =
"pathological" prescribing
• Use of drugs when no drug therapy is indicated
• Use of wrong drug for specific condition
• Use of drugs with doubtful or unproven efficacy
• Use of drugs of uncertain safety status
• Failure to provide available, safe & effective drugs
• Use of correct drugs with incorrect administration,
dosages & duration
• Use of unnecessarily expensive drugs
13 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
14. Examples of inappropriate
prescribing practices
• Overuse of antibiotics & antidiarrheals for nonspecific
childhood diarrhea
• Indiscriminate use of injections, e.g. in malaria treatment
• Multiple or over-prescription
• Excessive use of antibiotics for treating minor acute
respiratory tract infections
14 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
15. Factors Underlying Irrational Use
of Drugs
• Patients:
Drug misinformation
Misleading beliefs
Patient demands/expectations
Marketing pressures
Economic considerations
Lack of access to proper health care
15 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
16. Factors Underlying Irrational Use of Drugs...
• Prescribers:
Lack of education and training
Inappropriate role models
Lack of objective drug information
Generalization of limited experience
Misleading beliefs about drugs efficacy
Delayed lab results, fear of clinical failure
Inappropriate peer norms
Local medical culture
Economic incentives
Patient demand of “quick fix”
16 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
17. Factors Underlying Irrational Use of Drugs...
• Workplace:
• Drug Supply System:
Heavy patient load
Pressure to prescribe
Lack of adequate lab capacity
Insufficient staffing
Unreliable suppliers
Drug shortages
Expired drugs supplied
17 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
18. Factors Underlying Irrational Use of Drugs...
• Drug Regulation:
• Industry:
Nonessential drugs available
Informal prescribers
Lack of rational drug policy
Lack of infrastructure
Lack of regulation enforcement
Promotional activities
Misleading claims
18 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
19. Consequences of irrational use
of antibiotics
• Reduction in quality of drug therapy - ↑ morbidity &
mortality
• Waste of resources - ↓ availability of other vital drugs & ↑
costs
• ↑ risk of unwanted effects - ADRs & emergence of
antimicrobial resistance
• Psychosocial impacts - “a pill for every ill” - apparent ↑
demand for drugs
• ↑ Treatment failures
19 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
20. General principles in use of antibiotics
• Appropriate Antibiotic Therapy:
1. Perception of need
Is an antibiotic necessary?
2. Choice of antibiotic
What is the most appropriate antibiotic?
3. Choice of regimen
What dose, route, frequency & duration are needed?
4. Monitoring efficacy
Is the treatment effective?
20 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
21. General principles
I. Host factors:
1. Age
– Some drugs are contraindicated in children like
tetracycline - discolor teeth
– Renal function and creatinine clearance ↓ elderly -
↓ doses
2. Renal and hepatic function:
– Aminoglycosides and glycopeptides - carefully even
in mild renal failure
– Macrolides, metronidazole, rifampicin & INH - doses
↓ in liver failure
21 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
22. Host factors…
3. Pregnancy & lactation
– Aminoglycosides & tetracyclines should be avoided
– Penicillins, cephalosporins & erythromycin appear to
be safe
– Drugs like trimethoprim, metronidazole & macrolides
enter breast milk
4. Site of infection
– Antibiotics need to achieve sufficient local conc.
– Abscesses will require drainage, necrotic material to
be debrided
22 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
23. Host factors…
5. Immune status
– AIDS, hematological malignancies; influence both
likelihood of infection & its likely etiology
6. Presence of prosthetic material
– Rarely respond to antibiotic therapy
– Usually require removal of device
7. Allergy
– Determination of previous allergic drug reactions
– Drug of choice for syphilis in patient allergic to
penicillin is tetracycline
23 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
24. II. Likely infecting agent:
Clinical assessment may allow likely source of infection
Empirical treatment is aimed at these organisms
Bacteriological examination supports to establish definitive
microbiological diagnosis
(a) Bacteriological services are not available
(b) Bacteriological services are available, but treatment
cannot be delayed
(c) Bacteriological services are available & treatment can
be delayed for a few days
24 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
25. III. Drug related factors
1. Spectrum of activity:
For definitive therapy - narrow-spectrum drug
For empirical therapy - broad-spectrum drug
2. Type of activity:
Severe acute infections - cidal than a static drug
Bactericidal antibiotic - superior (impaired host defence,
life-threatening infections, infections at less accessible
sites or when carrier state is possible)
25 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
26. Drug related factors...
3. Sensitivity of the organism:
Assessed on basis of MIC values & postantibiotic effect
4. Relative toxicity:
Less toxic antibiotic is preferred
e.g. β-lactam over aminoglycoside
5. Pharmacokinetic profile:
For optimum action antibiotic has to be present at site
of infection in sufficient conc. for adequate length of
time
26 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
27. Drug related factors...
For many organisms, aminoglycosides, fluoroquinolones &
metronidazole - ‘concentration-dependent inhibition’
For many organisms, β-lactams, glycopeptides & macrolides
- ‘time-dependent inhibition’
Penetration to site of infection - drug which penetrates
better & attains higher conc. at site of infection
6. Cost:
Less expensive drugs are to be preferred
27 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
28. Drug related factors...
7. Routes of administration:
Parenteral therapy:
• Seriously ill patient, where effective drug conc.
are required rapidly at site of infection
• Drugs not orally absorbed e.g. aminoglycosides
• Oral route is contraindicated
Oral therapy
Topical therapy
• Superficial skin infections, mucosal candidiasis,
middle ear & superficial ocular infections
28 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
29. Drug related factors...
8. Dosage regimens:
– Dose influenced by severity of infection, age & weight
– Standard treatment guidelines should be followed
9. Encouraging compliance:
– Less frequency improves compliance
10. Length of treatment:
– Depends upon site & severity of infections, causative
organisms & patient’s response to treatment
29 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
30. Combination therapy
• Objectives:
1. To achieve synergism:
Manifests in terms of ↓ in MIC of one antimicrobial
agents in presence of another or MICs of both may be ↓
• General guidelines:
(a) Two bacteriostatic agents are often additive, rarely
synergistic
(b) Two bactericidal drugs are frequently additive &
sometime synergistic if organism is sensitive to both
30 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
31. Combination therapy…
(c) Combination of a bactericidal with bacteriostatic drug
may be synergistic or antagonistic depending on organism
If organism is highly sensitive to cidal drug—response to
combination is equal to static drug given alone (apparent
antagonism)
If organism has low sensitivity to cidal drug—synergism
31 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
32. Combination therapy…
2. To reduce severity or incidence of adverse effects:
Possible only if combination is synergistic - doses can be ↓
3. To prevent emergence of resistance:
Principle of using two or more antimicrobial agents
together is valid primarily for chronic infections needing
prolonged therapy
If incidence of resistant mutants of bacillus infecting
individual for drug A is 105 and for drug B is 107, then only
one out of 1012 bacilli will be resistant to both
32 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
33. Combination therapy…
4. To broaden spectrum of antimicrobial action
(a) Treatment of mixed infection - aerobic & anaerobic
organisms sensitive to different drugs are often
involved
(b) Initial treatment of severe infections - drugs
covering gram-positive and gram-negative (in certain
situations anaerobes as well)
(c) Topically - AMAs which are not used systemically,
are poorly absorbed from local site & cover broad
range of bacteria
33 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
34. Disadvantages of combinations
• Foster casual rather than rational outlook in diagnosis of
infections & choice of antimicrobial agents
• ↑ incidence & variety of ADRs. Toxicity of one agent may
be enhanced by another
• ↑ chances of superinfections
• If inadequate doses of non-synergistic drugs are used—
emergence of resistance
• Higher cost of therapy
34 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
35. The Council for Appropriate and Rational
Antibiotic Therapy (CARAT)
• CARAT is independent, multidisciplinary panel
of healthcare professionals, clinicians as well
as scientists, established to advocate
appropriate & accurate use of antibiotics
35 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
36. CARAT criteria
Evidence based results
Therapeutic benefits
Safety
Cost-Effectiveness
Optimal drug dose and duration
36 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
37. Evidence based results
• In choosing an antibiotic, clinicians should consider
clinical evidence –
Drug is clinically and microbiologically appropriate
Efficacy of drug in well-designed clinical trials
Antibiotic resistance pattern of local region
• Well conducted, randomized, controlled clinical trials
provide highest quality information for making
decisions
37 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
38. Therapeutic Benefits
• Key to applying evidence-based results & making
appropriate therapeutic choices for each patient
involves determining correct diagnosis & analyzing
therapeutic benefits of possible treatments
• To maximize patient health & reduce unnecessary
prescribing, therapeutic benefits of each drug should
be considered relative to status of patient’s infection
38 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
39. Therapeutic Benefits…
• Clinician must consider any evidence that particular
antibiotic can result in clinical & microbiologic cure as
well as treatment failures associated with absence of
drug treatment
• If possible, clinician should identify causative pathogen
& use surveillance data on regional antibiotic resistance
patterns in selecting optimal therapeutic agent
39 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
40. Safety
• Clinically applicable treatment strategies should be chosen
to maximize efficacy while minimizing side effects
• In study, between 1975 and 2000, 548 new chemical
entities were approved for use in US; 45 of these (8.2%)
acquired new black-box warnings & 16 (2.9%) were
withdrawn from market during this time
• Of 16 withdrawn from market, 8 were withdrawn within
2 years after their introduction
• E.g. Temafloxacin was withdrawn 0.3 years after
introduction and grepafloxacin was withdrawn 2.0 years
after introduction
40 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
41. Cost effectiveness
• Choosing inappropriate therapy is associated with
increased costs, including cost of antibiotic & increases
in overall costs of medical care
Due to treatment failures and adverse events
• Using optimal course of antibiotics can have economic
as well as clinical advantages
• Outpatients may experience faster return to their
normal daily routine & earlier return to work
41 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
42. Optimal Drug for Optimal Duration
• Optimal drug selection requires finding antimicrobial class
& specific member of that class
• Because empiric therapy is used in most cases:
- Etiologic agent - gram +VE or gram –VE ?
- Narrow or broad-spectrum agent ?
- Resistance patterns of likely pathogen to this drug, both
nationally and regionally &
- Individual patient’s medical history, including
recent antibiotic exposure
42 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
43. Optimal Drug for Optimal Duration…
• Optimal duration:
Prescribing selected drug for shortest amount of
time required for clinical & microbiologic efficacy
– Decreased side effects
– Increased patient adherence
– Decreased promotion of resistance
– Decreased cost
43 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
44. The pipeline is drying up!
US FDA approval of new
antibacterials down 56% from
1983 to 2002
Infectious diseases are still
most common cause of death
worldwide
We are effectively living in
post-antibiotic era
Therefore, we must manage
carefully and responsibly what
we have
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45. Science magazine; July 18, 2008
The last decade has seen inexorable proliferation
of a host of antibiotic resistant bacteria, or bad
bugs, not just MRSA, but other insidious players
as well… For these bacteria, the pipeline of new
antibiotics is verging on empty. 'What do you do
when you're faced with an infection, with a very
sick patient, and you get a lab report back and
every single drug is listed as resistant?' asked
Dr. Fred Tenover, Centers for Disease Control
and Prevention (CDC). 'This is a major blooming
public health crisis.’
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46. Best way to keep the matters in order
• Nearly 50% of hospitalized patients receive
antimicrobial agents
• Every hospital should have a policy which is
practicable to their circumstances
• Rigid guidelines without coordination will lead to
greater failures
• Only way to keep antimicrobial agents useful is to
use them appropriately & judiciously
46 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
47. National Policy
• Government of India - National policy for containment of
antimicrobial resistance in 2011
• Aims & objectives:
1. Understanding emergence & spread of antimicrobial
resistance & the factors influencing it
2. Establish nationwide well coordinated antimicrobial
program with well defined & interlinked responsibilities
& functions of different arms of program
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48. National policy for containment of antimicrobial
resistance in 2011...
3. Rationalizing usage of available antimicrobials
4. Reducing antibiotic selection pressures by appropriate
control measures
5. Promotion of discovery of newer & effective
antimicrobials based on current knowledge of
resistance mechanisms
6. Rapid and accurate diagnosis of infections &
infectious diseases
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49. Antibiotic policy
• A corporate document that is designed to
further the aim of the hospital to provide a
high standard of patient care
• Principles of antibiotic policy were laid down
in 1980s
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50. Antibiotic policy…
• Educational programs designed to improve antibiotic uses
• Controls operated through Pharmacy department
– Creation of hospital pharmacopeia
– Written justification for costlier & broader spectrum
antibiotics
– Introduction of concept of stop orders
– Automatic changes from IV to oral antibiotic therapy
– Sponsoring of antibiotics according to their usage e.g.
prophylaxis, specific therapy, therapeutic trials etc.
50 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
51. Antibiotic policy…
• Controls through laboratory in form of reporting,
regular issue of resistance / susceptibility patterns &
active consultations
• Establishment of antibiotic advisory service in hospitals
• Publication of consensual antibiotic policy for special
use e.g. prophylaxis & specialized clinical units
• Audit of antibiotic usage; antibiotics as a class of drugs
accounts for largest expenditure in health care system
51 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
52. Antibiotic policy…
• Promotion of ethical relationship between the
pharmaceutical companies, prescribers and pharmacists
• Regulation of antibiotic usage in veterinary practices. All
veterinary antibiotics should need prescription
• Monitoring of antibiotic residues in food of animal origin
• Encourage research to develop new molecules
Infectious Disease Society of America’s
“10 × ‘20 initiative”
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53. What can we do ?
53 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
54. Promoting rational prescribing
• Standard treatment guidelines - when evidence-
based, developed with end-users, with active
dissemination & follow-up
• Essential medicines lists - when linked to
treatment guidelines & used for training & supply
• Hospital Drugs & Therapeutic Committees
• Undergraduate training
• Comprehensive approach, with all components
54 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
55. Possible interventions in private sector
• Regulation:
Market approval, re-licensing, re-evaluation per
therapeutic category, regulation of promotion, ban
over-the-counter (OTC) sale of antimicrobials
• Training:
Basic training, national clinical guidelines, CMEs
by universities & professional bodies, re-licensing
of professionals on basis of education points,
medical audit, patient information leaflets, public
education
55 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
56. Possible interventions in private sector...
• Financial incentives:
Separate prescribing from dispensing,
dispensing fee (flat or tiered), price controls
on generic / brand drugs, contracting out
• Insurance:
Reimbursement limited to essential
medicines, reference pricing
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57. Educating Practitioners
• Seminars
• Panel discussion
• Updates
57 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
58. Don’t let the advertisements block
our intelligence !!!
***Read the fine prints
The drug is 10 times more potent
but may cause renal damage in some
The most effective antibiotic
For what?
At what cost?
What duration?
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59. Educating Consumers
No self medication No own antibiotic kit Emphasis on dose
and duration
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60. Standard Treatment Guidelines
A systematically developed statement to
assist practitioners in making decisions about
appropriate health care for specific clinical
conditions
These guidelines should be tailored to local
situations and specific to levels of care
From national level to hospital level
60 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
61. Key features of standard
treatment guidelines
• Simplicity
• Credibility
• Same standard for all levels
• Drug supply based on standard treatment guidelines
• Introduce in pre-service training
• Dynamic (regular updates)
• Handy pocket books
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62. Increasing use of diagnostic tests
• Lack of adequate, well equipped laboratory facilities
• Under-utilization of microbiological labs
• Ministry of Health & Family Welfare recommends for
increase in utilization of diagnostic tests in clinical practice
• Newer rapid molecular diagnostic tests –
Peptide nucleic acid technology
Matrix-assisted laser desorption/ionization technology
rapid polymerase chain reaction
62 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
63. Surveillance
• Two complementary types of surveillance -
– Surveillance for antibiotic resistance
– Surveillance for antibiotic use
• Knowing resistance levels & tracking them over period of
time is powerful tool to support real changes
• Once link between resistance & antibiotic is accepted,
tracking antibiotic use can be used as surrogate for
changes in antibiotic resistance
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64. Surveillance…
Sentinel surveillance for antimicrobial
resistance:
• Provides only indicative data, but the same can be
extrapolated to rest of population
• Suitable mode of surveillance when prolonged &
detailed data is needed
• Best approach for our country
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65. WHONET Software
• Free Windows-based database software
• Developed for management & analysis of microbiology
laboratory data with special focus on analysis of
antimicrobial susceptibility test results
• Used by clinical, public health, veterinary & food
laboratories in over 90 countries to support local &
national surveillance programs
65 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
66. Proposed care bundles for antibiotic
prescribing
• Acute care: initiation of therapy
Document clinical rationale for antibiotic initiation
Collect & send appropriate specimens to microbiology
laboratory
Select antibiotic therapy according to local policies (i.e.,
local antimicrobial susceptibilities) & risk group (exclude
drug allergy)
Consider removal of foreign body/drainage of
pus/surgical intervention
66 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
67. Proposed care bundles for antibiotic
prescribing...
• Acute care: continuation of therapy
On daily basis, consider de-escalation, parenteral-to-oral
conversion, or discontinuation of antibiotic therapy
based on clinical signs & symptoms and laboratory test
results
Monitor serum antibiotic conc. in accordance with local
policies
67 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
68. Proposed care bundles for antibiotic
prescribing...
• Surgical prophylaxis:
Select antibiotic therapy based on local guidelines
(i.e., local antimicrobial susceptibilities) & type of
surgery (exclude drug allergy)
Give first dose within guideline-defined time before
incision
Discontinue antibiotic therapy within guideline defined
time after first preoperative dose or surgical end time
68 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
69. Infection prevention & control methods for
controlling antimicrobial resistance in
hospitals
• Hand hygiene
• Contact (i.e. barrier) precautions
• Active surveillance for and decolonization (i.e.
eradication) of multidrug-resistant organisms
• Preoperative antimicrobial prophylaxis
69 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
70. Infection prevention & control methods for controlling
antimicrobial resistance in hospitals...
• Implementation of best practices for invasive
procedures & devices (e.g., removal of
unnecessary central catheters)
• Disinfection & sterilization of medical devices
• Environmental cleaning
70 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
71. Antimicrobial stewardship
• Definition –
The optimal selection, dosage & duration
of antimicrobial treatment that results in
the best clinical outcome for the
treatment or prevention of infection,
with minimal toxicity to the patient and
minimal impact on subsequent resistance
71 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
72. Goals of antimicrobial stewardship
• To work with health care practitioners to help
each patient receive most appropriate
antimicrobial with correct dose and duration
• To prevent antimicrobial overuse, misuse & abuse
• To minimize development of resistance
• Reduction of health care costs without adversely
impacting quality of care
72 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
73. Antibiotic stewardship team
Collaboration between antimicrobial stewardship team,
hospital infection control, pharmacy, therapeutics
committees & hospital administration is essential
Infectious Disease Physician
Clinical Pharmacist with infectious disease training
Clinical Microbiologist
Information system specialist
Infection control professional
Hospital epidemiologist (Optional)
73 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
74. Antibiotic stewardship team…
• Functions-
– Providing high standard of patient care
– Improving rational utilization of antibiotic
– Pharmacovigilance of antimicrobial
– Effective utilization of financial resources in purchase
of antimicrobials
– Curbing emergence of microbial resistance
74 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
75. The Antibiotic Resistance
Declaration
• May 2014, Antibiotic Resistance Coalition -
‘Declaration on Antibiotic Resistance’ to advocate for
policy change & action to prevent post-antibiotic era
from becoming a bleak reality
• Chennai Declaration: December 2012
A document, prepared by representatives of
various stakeholders and eminent experts in India, to
tackle the challenge of anti-microbial resistance from
an Indian perspective
75 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
76. Use of antibiotics wisely
- The only solution
• Before taking any antibiotic ask your physician if it is
required & beneficial
• Always take antibiotics as prescribed by physician
• Take antibiotics to treat only bacterial infections
• Don’t take antibiotics in viral infections such as cold,
cough or flu
• Don’t repeat same antibiotic for next time you get sick
76 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
77. Use of antibiotics wisely - The only solution...
• Don’t stop antibiotic before complete prescribed
course of treatment
• Don’t skip doses
• Don’t copy antibiotic with same diseases which is
prescribed for someone else
• Educate yourself & talk to your physician about
antibiotic resistance
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78. 78 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
79. 79 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
80. “The public will demand [the drug and] … then will begin
an era … of abuses. The microbes are educated to resist
penicillin and a host of penicillin-fast organisms is bred
out which can be passed to other individuals and perhaps
from there to others until they reach someone who gets
a septicemia or a pneumonia which penicillin cannot save.
In such a case the thoughtless person playing with
penicillin treatment is morally responsible for the death
of the man who finally succumbs to infection with the
penicillin-resistant organism. I hope the evil can be
averted.”
- Alexander Fleming, 1945
80 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
81. Summary
• Infectious diseases are still serious problem,
compounded by development of antibiotic resistance
in many bacteria & relative lack of newer
antimicrobial agents to combat these multi-resistant
organisms
• Appropriate aggressive short-course treatment is
recommended for ensuring clinical & microbiologic
cure, optimal patient adherence & minimal generation
of antibiotic resistance
81 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
82. • Ideally, institution of 5 CARAT criterias will optimize
safe & well-tolerated treatment regimens, curb
unnecessary prescribing of antibiotics, decrease
treatment costs & increase adherence
• By making antimicrobial stewardship part
of our daily practice, we can improve patient safety &
care, reduce unnecessary use of valuable resources &
reduce resistance
• Thus, antibiotic prescribing should be prudent,
thoughtful & rational
82 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
83. References
• Goodman & Gilman’s The Pharmacological Basis of
Therapeutics 12th Edition
• R.S. SATOSKAR. PHARMACOLOGY AND
PHARMACOTHERAPEUTICS 24th EDITION
• Bertram G. Katzung & Anthony J. Trevor’s Basic & Clinical
Pharmacology 13th Edition
• National policy for containment of antimicrobial
resistance, India 2011.
1 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
84. References...
• Vance MA, Millington WR. Principles of irrational drug
therapy. Int J Health Serv. 2010;16(3):355–61.
• National Nosocomial Infections Surveillance (NNIS)
System Report, data summary from January 1992
through June 2003, issued August 2003. Am J Infect
Control. 2003;31(8):481-498
• Dellit TH, Owens RC, McGowan JE Jr, et al. IDSA and
SHEA guidelines for developing an institutional program
to enhance antimicrobial stewardship. Clin Infect Dis.
2007;44(2):159-177
Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
85. References...
• Gerding DN. The search for good antimicrobial
stewardship. Jt Comm J Qual Improv. 2001;27(8):403-
404
• Thomas G. Slama et al. A clinician’s guide to the
appropriate and accurate use of antibiotics: the Council
for Appropriate and Rational Antibiotic Therapy (CARAT)
criteria. doi:10.1016/j.amjmed.2005.05.007
• “Chennai Declaration” Team. “Chennai Declaration”: 5-year
plan to tackle the challenge of anti-microbial resistance.
IJMM, (2014) 32(3): 221-2281
Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
86. Thank you !!!
Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017