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Dr.T.V.Rao MD Dr.T.V.Rao MD 1Antimicrobial Resistance: T he emerging clinical impact of antimicrobial resistance, urgent implementation of the Global Strategy for the Containment of Antimicrobial Resistance is a Priority . However, at the same time, a clear research agenda highlighting the most important current knowledge gaps needs to be defined to guide the direction of future research efforts. Antimicrobial Resistance Dr.T.V.Rao MD 2Antibiotics and Mechanisms of Resistance: ß-lactams B-lactamases, altered PBP, efflux Macrolides MLS , efflux Aminoglycosides AME , permeability Fluoroquinolones altered topoisomerases, efflux Tetracycline's efflux , altered target Chloramphenicol CAT , efflux Sulfonamides altered dihydropteroate synthase Trimethoprim altered dihydrofolate reductase Vancomycin bypass pathway Streptogramins MLS , efflux, enzyme modification Rifampicin altered target Antibiotics and Mechanisms of Resistance Dr.T.V.Rao MD 3Genetics of Antimicrobial Resistance: Genetic diversity – nucleotide substitution, DNA rearrangements and gene acquisition • Gene acquisition – transformation, transduction and conjugation • Mobile genetic elements – gene cassettes – integrons – insertion sequence elements and transposons – plasmids Genetics of Antimicrobial Resistance Dr.T.V.Rao MD 4Why Are Resistant Infections Happening?: Enormous biomass of microorganisms • Genetic plasticity • Antibiotics are microbial products, organisms have seen them before! • * Excessive antibiotic use • World wide travel • *Lax infection control practices Why Are Resistant Infections Happening? Dr.T.V.Rao MD 5How Much Antibiotics ? 22,000 t: How Much Antibiotics ? 22,000 t 11,000 t dispensed to humans (50%) in 150 million prescriptions written annually by physicians 8 -10,000 t given to animals (40%) to treat or prevent infections mixed into feed to promote growth of agricultural animals 20-30 t Plant (0.1%) 30-200 t Aquaculture (1%) Dr.T.V.Rao MD 6Drugs for Human Treatment are Excreted into Sewage: Drugs for Human Treatment are Excreted into Sewage Some drugs excreted in metabolized amounts via the urine and feces Some yield bioactive metabolites. Some excreted as conjugates Dr.T.V.Rao MD 7Metabolism of Antibiotics: Metabolism of Antibiotics Dr.T.V.Rao MD 8Veterinary Medicines in the Environment: Veterinary Medicines in the Environment Dr.T.V.Rao MD 9Antimicrobial Prescribing Facts: Antimicrobial Prescribing Facts 1/3 of all hospitalised inpatients at any given time receive antibiotics ~ up to 1/3 to ½ are inappropriate ~ up to 30% of all surgical prophylaxis in inappropriate Antimicrobials account for upwards of 30% of hospital pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets. Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences , increased morbidity, mortality,increased cost, increased litigation and reduce quality of life Dr.T.V.Rao MD 10Why So Many Mistakes: Why So Many Mistakes High number and complexity of drugs High number and complexity of syndromes and pathogens Poor training in antibiotic use Variability over time and place in - pathogen prevalence - antibiotic susceptibilities - antibiotic formularies Dr.T.V.Rao MD 11Hospital acquired infections cause of many Deaths: Hospital acquired infections cause of many Deaths Every year, many lives are lost because of the spread of infections in hospitals. Health care workers can take steps to prevent the spread of infectious disease Dr.T.V.Rao MD 12PowerPoint Presentation: Biomedical research Health policy and systems research Social sciences and behavioral research Operational research Basic research: physical and biological sciences including chemistry, pharmacology, toxicology, genetics, etc Research on policy formulation, relationship to evidence, prioritization, etc R&D for drugs, vaccines, diagnostics, appliances, etc Research on health systems management, functions, efficiency, effectiveness, system factors affecting access scale-up, monitoring and evaluation, etc Research on social and behavioural factors influencing health and their relation to equity, access, lifestyle and health-seeking behaviours, etc Research on factors affecting functioning of programs, effectiveness of targeting, impact on behavior, disease burdens and public health, etc Understanding the biological nature of diseases; creating products to prevent or treat disease states Understanding how to test, scale-up and follow through the introduction of interventions and optimize their benefits Innovation Impact The spectrum of health research Dr.T.V.Rao MD 13What is Antimicrobial Stewardship: O ngoing effort by a health care institution to optimize antimicrobial use among hospitalized patients to ... - Improve patient outcomes - Ensure cost-effective therapy, and - Reduce adverse sequelae of antimicrobial use ( including antimicrobial resistance). What is Antimicrobial Stewardship Dr.T.V.Rao MD 14What Can We Do? Strengthen our Microbiology Departments ?: What Can We Do ? Strengthen our Microbiology Departments ? Keep aware National/Provincial Surveillance Programs Get to know your microbiology laboratory Dr.T.V.Rao MD 15What Can We Do?: What Can We Do? –Expect rapid turn around times – Appropriate susceptibility test reporting Dr.T.V.Rao MD 16What Can We Do?: What Can We Do? Infection Control in the office & hospital • Decrease antibiotic prescriptions for viral URI’s by half! • Improve communication with patients Dr.T.V.Rao MD 17Hand Washing a must for Safety of our Patients: Hand Washing a must for Safety of our Patients Proper hand washing is the most effective way to prevent the spread of infections in hospitals. If you are a patient, don't be afraid to remind friends, family and health care providers to wash their hands before getting close to you. Dr.T.V.Rao MD 18Preventive Measures ….: Preventive Measures …. C overing coughs and sneezes Staying up-to-date with immunizations Using gloves, masks and protective clothing Making tissues and hand cleaners available Following hospital guidelines when dealing with blood or contaminated items Dr.T.V.Rao MD 19Organize your Clinical Microbiology Laboratory Bench: Organize your Clinical Microbiology Laboratory Bench Microbiologists should bring in change with dedication to bench work, and Proficiency Testing to improve the quality to services in Health care Dr.T.V.Rao MD 20What most Proficiency Testing does not tend to look at:: What most P roficiency T esting does not tend to look at: Are negative samples reported as negative? Are contaminated samples reported as contaminated? Are complex samples submitted for referral? Are pre-analytic factors addressed? Improper containers and transport Outdated samples. Mislabeled samples. Rejection criteria Are post-analytic factors addressed? Interpretive commentary included Dr.T.V.Rao MD 21PowerPoint Presentation: PT providers should publish scientifically credible reports in peer-reviewed journals. Ensure all clinical laboratories participate in PT, including waved tests. Develop a methodology-based approach for PT (one material for many assays). Samples should mimic patient samples with a minimum of matrix effect. Small adjunct studies with fresh frozen samples in conjunction with “routine” PT. Evaluate alternatives to current CLIA requirements for frequency and scoring. Develop innovative approaches to PT. CDC Report April 2008 Dr.T.V.Rao MD 22Does Proficiency Testing improve quality?: Does Proficiency Testing improve quality? Probably yes, but hard to prove. Accredited programs do better on PT Laboratories with consistently high PT performance do better with accreditation Clinical Error? Clinical error detection? OFIs and Continual Improvement? Dr.T.V.Rao MD 23Medical laboratory proficiency testing : Medical laboratory proficiency testing Medical laboratory proficiency testing has been around for 60 years Respected as a valued monitoring tool Inter-laboratory comparisons Internal audit Inter-technologist education Starting to show its age Testing the wrong thing in the wrong way Falling behind laboratory reality Dr.T.V.Rao MD 24What is Antimicrobial Stewardship?: What is Antimicrobial Stewardship? A marriage of infection control and antimicrobial management Mandatory infection control compliance Selection of antimicrobials from each class of drugs that does the least collateral damage Collateral damage issues include - MRSA - ESBLs - C.difficile - stable DE repression - MBLs and other carbapenemases - VRE Appropriate de-escalation when culture results are available Dellit TH et al Clin Infect Dis 2007; 44: 159-177 Dr.T.V.Rao MD 25Objectives for Starting Antibiotic Stewardship: A . Be able to list the recommended components of an antibiotic stewardship program B. Be able to detect antibiotic use improvement opportunities from the analysis of utilization data C . Be able to explain the barriers for successful implementation of such a program Objectives for Starting Antibiotic Stewardship Dr.T.V.Rao MD 26Why Develop an Antimicrobial Stewardship Program From an Infection Preventionist Perspective: : Why Develop an Antimicrobial Stewardship Program From an Infection Preventionist Perspective: Track and Reduce antimicrobial resistance Encourage appropriate treatment patterns ~ The right antibiotic, for the right duration Develop a collaborative practice between MDs/LIPs, Pharmacy, Laboratories and Infection Preventionists’ with best patient outcome in mind. Dr.T.V.Rao MD 27 WORKSTREAMS: WORKSTREAMS 1. INFORMATION MANAGEMENT (HPS AND ISD) 2. EDUCATION (NES) 3.ORGANISATION AND ACCOUNTABILITY (NQIS) Dr.T.V.Rao MD 28WORKSTREAMS: 4.INFECTION MANAGEMENT (SPA,NQIS,NES,HPS-ISD , Professional Organisations) All the work-streams work in parallel but with vertical integration Work stream work underpinned by an AMT Clinical Network WORKSTREAMS Dr.T.V.Rao MD 29 INFECTION MANAGMENT PHILOSOPHY: INFECTION MANAGMENT PHILOSOPHY HIGH BURDEN, HIGH IMPACT CONDITIONS EVIDENCE OF BENEFIT FOR INTERVENTION ALSO TARGET SYSTEMS CHANGE TO BRING ABOUT DESIRED BENEFIT INTEGRATE, DEVELOP AND IMPLEMENT EXISITING AND NEW PROJECTS OVER 3 YEAR TIME FRAME: WORK CLOSELY WITH WORK PROGRAMMES OF KEY STAKEHOLDERS (e.g HPS, SPA) IMMEDIATE OPPORTUNITIES AROUND SNAP-CAP, C.difficle and Surgical Prophylaxis. Dr.T.V.Rao MD 30Goals of Committee: Assist providers in appropriate use of antimicrobial therapy with improved patient outcomes Slow the development of antimicrobial resistance Develop evidence- based appropriate use guidelines Educate providers and staff regarding guidelines Track resistance patterns and report back to medical and hospital staff Report committee progress and outcomes to P&T, and Executive Committees Goals of Committee Dr.T.V.Rao MD 31Clean Hands Saves Many Lives : Dr.T.V.Rao MD 32 Clean Hands Saves Many LivesFollow me for more topics of Interest on Infectious Diseases : Dr.T.V.Rao MD 33 Follow me for more topics of Interest on Infectious DiseasesPowerPoint Presentation: Programme Created by Dr.T.V.Rao MD for Awareness on Use and Misuse of Antibiotics by Medical Professionals Email firstname.lastname@example.org Dr.T.V.Rao MD 34 You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.