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ANTIBIOTIC POLICY an update Dr.T.V.Rao MD Dr.T.V.Rao MD 1

Discovery Of Penicillin changes the History of Medicine :

Discovery Of Penicillin changes the History of Medicine Dr.T.V.Rao MD 2

Why we Need Antibiotics:

Why we Need Antibiotics Nearly One half of the Hospitalized patients receive antimicrobial agents. Antibiotics are valuable Discoveries of the Modern Medicine. All current achievements in Medicine are attributed to use of Antibiotics Life saving in Serious infections. Dr.T.V.Rao MD 3

What went wrong with Antibiotic Usage:

What went wrong with Antibiotic Usage Treating trivial infections / viral Infections with Antibiotics has become routine affair. Many use Antibiotics without knowing the Basic principles of Antibiotic therapy. Many Medical practioners are under pressure for short term solutions. Commercial interests of Pharmaceutical industry pushing the Antibiotics, more so Broad spectrum and Newer Generation antibiotics. as every Industry has become profit oriented. Poverty encourages drug resistance due to under utilization of appropriate Antibiotics. Dr.T.V.Rao MD 4


Introduction “ The end of infectious diseases” was a popular idea in the 1970s Infectious diseases are still important in the 21 st century due to: Boundless nature Emergence of new infections Re-emergence of old infections Increase in drug - resistant infections Dr.T.V.Rao MD 5

Science magazine; July 18, 2008:

The last decade has seen the 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 of the Centers for Disease Control and Prevention (CDC). 'This is a major blooming public health crisis.'" Science magazine; July 18, 2008 Dr.T.V.Rao MD 6

Four main groups of Bacteria a Concern for Antibiotic Resistance:

Four main groups of Bacteria a Concern for Antibiotic Resistance Gram positive Gram negative Anaerobes Atypical Dr.T.V.Rao MD 7

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Gram +ve Skin, Bone & Respiratory Gram -ve GI-tract, GU & Respiratory Anaerobes Mouth, teeth, throat, sinuses & lower bowel Generally . Infecting Microbes.. Atypicals Chest and genito-urinary Peritonitis Biliary infection Pancreatitis UTI PID CAP/HAP/VAP Sinusitis Cellulitis Wound infection Line infection Osteomyelitis Pneumonia Sinusitis Dental infection Peritonitis Appendicitis Abscesses Pneumonia Urethritis PID Dr.T.V.Rao MD 8

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Why inappropriate use of antibiotics contributes to antibiotic resistance – the “why” Dr.T.V.Rao MD 9

In-patients are at high risk of antibiotic-resistant infections:

Misuse of antibiotics in hospitals is one of the main factors that drive development of antibiotic resistance. Patients in hospitals have a high probability of receiving an antibiotic and 50% [adapt to national figure where available] of all antibiotic use in hospitals can be inappropriate. In-patients are at high risk of antibiotic-resistant infections Dr.T.V.Rao MD 10

Misuse of Antibiotics Drives Antibiotic Resistance:

Studies prove that misuse of antibiotics may cause patients to become colonized or infected with antibiotic-resistant bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE) and highly-resistant Gram-negative bacilli . 13-14 Misuse of antibiotics is also associated with an increased incidence of Clostridium difficile infections. 15-17 Misuse of Antibiotics Drives Antibiotic Resistance Dr.T.V.Rao MD 11

Basis of Antibiotic Resistance:

Basis of Antibiotic Resistance The antibiotic resistance is guided by Genomic changes Spread of R plasmids among the Bacteria Do remember Antibiotics are used in Animal husbandry apart from Medical use The discovery of antibiotic resistance was discovered with spread of R plasmids from animal sources The Human gut forms the interconnecting area in R plasmids transmission leading ultimately to antibiotic resistance Dr.T.V.Rao MD 12

Plasmids played a Major Role in spread of Antibiotic resistance.:

Plasmids played a Major Role in spread of Antibiotic resistance . Dr.T.V.Rao MD 13

Multiple Mechanism of Drug Resistance:

Multiple Mechanism of Drug Resistance Dr.T.V.Rao MD 14

Spread of Antibiotic Resistance:

Spread of Antibiotic Resistance Indiscrimate use of Antibiotics in Animals and Medical practice R plasmids spread among co-inhabiting Bacterial flora in Animals ( in gut ) R plasmids may be mainly evolved in Animals spread to Human commensal, - Escherichia coli followed by spread to more important human pathogens Eg Shigella spp. Dr.T.V.Rao MD 15

Why Everyone worried about Antibiotic ( misuse ) Use.:

Why Everyone worried about Antibiotic ( misuse ) Use. Drug resistance can reverse Medical progress The following diseases are already in the list of attaining the drug resistance, and Medical profession will find difficult to cure in future. 1. Tuberculosis 2. Malaria 3. Sore throat and Ear Infections. Dr.T.V.Rao MD 16

What is Misuse of Antibiotics?:

Misuse of antibiotics can include any of the following When antibiotics are prescribed unnecessarily; When antibiotic administration is delayed in critically ill patients; When broad-spectrum antibiotics are used too generously, or when narrow-spectrum antibiotics are used incorrectly; When the dose of antibiotics is lower or higher than appropriate for the specific patient; When the duration of antibiotic treatment is too short or too long; When antibiotic treatment is not streamlined according to microbiological culture data results. What is Misuse of Antibiotics ? Dr.T.V.Rao MD 17

Why we Need Antibiotic Policy:

Why we Need Antibiotic Policy Dr.T.V.Rao MD 18

Aim of Antibiotic Policy:

Aim of Antibiotic Policy Reduce the Antimicrobial resistance Initiate best efforts in the hospital area as many resistance Bacteria are generated in Hospital areas and in particular critical care areas. Initiate good hygienic practices so these bacteria do not spread to others Practice best efforts, these resistance strains do not spill into critically ill patients in the Hospital To prevent spill into Society, as they present as community associated infections.. Dr.T.V.Rao MD 19

Objectives of Antibiotic Policy.:

Objectives of Antibiotic Policy . Antibiotics should not be used casually Policy emphasizes, avoiding the use of powerful Antibiotics in the Initial treatments. We should create awareness that we are sparing the powerful Broad spectrum Drugs for later treatment Patient saves Money Doctors save Lives . Dr.T.V.Rao MD 20

Aims of the Antibiotic Policy:

Aims of the Antibiotic Policy Create awareness on Antibiotics as misuse is counterproductive. More effective treatments in serious Infections. Reduce Health care associated infections spilling to society and increase of Community associated Infections. ( A growing concern in Developing world ) Dr.T.V.Rao MD 21

Policy Deals on Broad Basis:

Policy Deals on Broad Basis Clinicians / Microbiologists / Pharmacists and Nurses do take part . Policies are framed on demands of the Clinical areas, depending on recent Infection surveillance data contributed from Microbiology Departments . Dr.T.V.Rao MD 22

Antibiotic working Group Monitors:

Antibiotic working Group Monitors Formulate Optimal guidelines in Treatment of Infections with minimal risk of Health care associated Infections. Create a plan for monitoring the Use of Antibiotics across the Hospital Dr.T.V.Rao MD 23

Education On Antibiotic policy:

Education On Antibiotic policy Acton plan for Education to all concerned clinical staff on Antibiotic prescriptions. Evaluate the feed back of success and failures of the policy. Create Infection surveillance Data Developing facilities in Microbiology departments for auditing data and guidance Restrictions in prescribing and Antibiotic availability. A continuous education to Junior Doctors Dr.T.V.Rao MD 24

Ideal Sample Collection is Essential Requirement :

Ideal Sample Collection is Essential Requirement Proper specimen collection is combined responsibility of Clinical and Microbiological Departments. Continuous training of junior staff on sample collection, and is most neglected necessity A good clinical history is greatly helpful in differentiating community acquired infections from hospital acquired infections. Dr.T.V.Rao MD 25

Pitfalls in Specimen collection:

Pitfalls in Specimen collection A proper specimen collection is most neglected area of Microbiology. Scientific approaches in Sample collection is concern for successful Microbiological evaluations, Dr.T.V.Rao MD 26

Microbiology Services:

Microbiology Services Constant up graduation of Microbiology departments is good investment. Quality control methods in testing of antibiotic resistance pattern is a top priority. Dr.T.V.Rao MD 27

Role of Microbiology Department:

Role of Microbiology Department Microbiology departments asses trends in development of antimicrobial resistance. The results of sensitivity/resistance patterns should be correlated with Antimicrobial agents currently used in the Hospital. Identify and forecast that nature of relation between antibiotic use and resistance. Dr.T.V.Rao MD 28

Better services from Microbiology Departments.:

Better services from Microbiology Departments . Basic infrastructure should be updated for detection of MRSA and ESBL producers. Documentation of all Opportunistic infections. and Hospital infection outbreaks Dr.T.V.Rao MD 29

Measures that can decrease antibiotic resistance:

Measures that guide antibiotic prescribing are likely to decrease antibiotic resistance in hospitals. 32-34 Such measures include: Obtaining cultures Take appropriate and early cultures before initiating empiric antibiotic therapy, and streamline antibiotic treatment based on the culture results 35 Monitoring local antibiotic resistance patterns Being aware of local antibiotic resistance patterns (Antibiograms) enables appropriate selection of initial empiric antibiotic therapy Measures that can decrease antibiotic resistance Dr.T.V.Rao MD 30


The ESKAPE Pathogens: The so-called ESKAPE Pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa , and ESBL positive bacteria, such as E. coli and Enterobacter species) represent a grouping of antibiotic-resistant gram-positive and gram-negative bacteria that cause the majority of U.S. HAIs. The group is so-named because these bacteria effectively “escape” the effects of most approved antibacterial drugs. PRIORITY ANTIBIOTIC-RESISTANT BACTERIA PATHOGENS Dr.T.V.Rao MD 31

Advantages of Antibiotic Policy:

Advantages of Antibiotic Policy Saves the Lives Reduces the morbidity Saves Health related costs Reduces the Antibiotic related toxicity. Patients are satisfie d. Dr.T.V.Rao MD 32

Staff Education on Antibiotic Policy:

Staff Education on Antibiotic Policy Staff education is most Important principle in success Draw your own plans according to nature of patients, your past experiences Induction training for new staff Continuing Medical Education to both Junior and Senior Doctors Include nursing staff, pharmacists for the success of the Programme Dr.T.V.Rao MD 33

Training in rational prescribing has expanded in universities throughout the world:

Training in rational prescribing has expanded in universities throughout the world Problem-based pharmacotherapy In 18 languages For medical students, clinical officers Measurable improvement in prescribing Now also: Teacher’s Guide to Good Prescribing Achievements Dr.T.V.Rao MD 34

Patient Education on Antibiotic Policy :

Patient Education on Antibiotic Policy Education of the patients and society is important in Developing world. Educate the patients many infections are trival,viral, Do not need Antibiotics If they understand Unnecessary consumption of Antibiotics kills the Normal flora, and reduces the Immunity and makes them potential victims in future. A difficult task in Developing countries . Dr.T.V.Rao MD 35

Proved success of Antibiotic Policies:

Proved success of Antibiotic Policies Studies Prove 1 Rapid reversal of major clinical problems of resistance to Chloramphenicol ,Erythromycin, and Tetracycline in Staphylococcus aureus on withdrawal of antibiotics. 2 Out breaks of Erythromycin resistant Group A Streptococci and Penicillin resistant Pneumococci , can be controlled by major reduction in prescription of Erythromycin and Penicillin. 3 Control of multiple resistant Gram – ve bacteria and role played by reducing the prescription of 3 rd generation of Cephalosporins . ( I.M.Gould Review of the role of antibiotic policies in the control of antibiotic resistance, Journal of Antimicrobial Chemotherapy 1999 43, 459 – 465. ) Dr.T.V.Rao MD 36

Make your conclusions and contribute to Antibiotic Policy:

Make your conclusions and contribute to Antibiotic Policy It is true to say that there is no absolute proof of causative association between antibiotic use and resistance, But many authorities believe the association to be virtually certain. It is pragmatic and essential approach to control of antibiotic resistance with control of antibiotic use. Make every one a partner in prevention of Antibiotic resistance, and success will follow . Dr.T.V.Rao MD 37

Antibiotic resistance – a problem in the present and the future:

Antibiotic resistance – a problem in the present and the future Antibiotic resistance is an increasingly serious public health problem: resistant bacteria have become an everyday concern in hospitals across World Dr.T.V.Rao MD 38

CDC reports:

CDC reports CDC reports that nearly 2 million health care-associated infections (HAIs) and 90,000 HAI-related deaths occur annually in the U.S. Many of these infections and deaths are caused by antibiotic-resistant infections. Dr.T.V.Rao MD 39

New Innovations in Diagnostic Microbiology:

New Innovations in Diagnostic Microbiology New rapid diagnostic tests would greatly facilitate clinical trials of critically needed new antibiotics. The tests would enable investigators to identify potential study subjects more easily, which would permit smaller and less expensive studies of antibiotics as they move through development Dr.T.V.Rao MD 40

Infection Control Team:

Infection Control Team Leadership and dedicated staff; training and education; mechanisms that serve to improve antibiotic resistance Dr.T.V.Rao MD 41

Best way to keep the matters in Order:

Best way to keep the matters in Order Every Hospital should have a policy which is practicable to their circumstances. Rigid guidelines without coordination will lead to greater failures The only way to keep Antimicrobial agents useful is to use them appropriately and Judiciously (Burke A.Cunha, MD,MACP Antimicrobial Therapy. Medical Clinics of North America NOV 2006) Dr.T.V.Rao MD 42

Prudent prescribing to reduce antimicrobial resistance:

Prudent prescribing to reduce antimicrobial resistance Only use an antimicrobial when clearly indicated. Select an appropriate agent using local antimicrobial prescribing policy. Prescribe correct dose, frequency and duration. Limit use of broad spectrum agents and de-escalate or stop treatment if appropriate (Hospital). Dr.T.V.Rao MD 43

Multifaceted strategies can address and decrease antibiotic resistance in hospitals:

Antibiotic prescribing practices and decreasing antibiotic resistance can be addressed through multifaceted strategies including: 29-31 Use of ongoing education Use of evidence-based hospital antibiotic guidelines and policies Restrictive measures and consultations from infectious disease physicians, microbiologists and pharmacists Multifaceted strategies can address and decrease antibiotic resistance in hospitals Dr.T.V.Rao MD 44

Continuous Medical Education a Must ..:

Training and educating health care professionals on the appropriate use of antibiotics must include appropriate selection, dosing, route, and duration of antibiotic therapy. To ensure that training and education is working, there should be extensive collaboration between the antibiotic stewardship and hospital infection prevention and control teams. Without benchmarks, it is difficult to track successes and weaknesses Continuous Medical Education a Must .. Dr.T.V.Rao MD 45

Computerized Decisions a Emerging Need …..:

Dr.T.V.Rao MD 46 Computerized Decisions a Emerging Need ….. Computerized decision support can preserve physician autonomy and has been shown to improve antibiotic use by a number of different measures: fewer susceptibility mismatches, allergic reactions and other adverse events, excess dosages, and overall amount and cost of antibiotic therapy


Dr.T.V.Rao MD 47 Implementation of WHONET CAN HELP TO MONITOR RESISTANCE Legacy computer systems, quality improvement teams, and strategies for optimizing antibiotic use have the potential to stabilize resistance and reduce costs by encouraging heterogeneous prescribing patterns and use of local susceptibility patterns to inform empiric treatment.

Hand Washing Reduces the Spread of Antibiotic Resistant Strains:

Hand Washing Reduces the Spread of Antibiotic Resistant Strains Dr.T.V.Rao MD 48

Slide 49:

The Programme created by Dr.T.V.Rao MD for ‘e’ Learning resources for Medical Professionals in Developing World. Email Dr.T.V.Rao MD 49

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