DIAGNOSTIC MICROBIOLOGY

IN

ANTIBIOTIC POLICY
Dr.T.V.Rao MD

Improving the Use of Antibiotics a Priority

Improving the use of antibiotics is an important patient safety and public health issue as well as a national priority

Why take antibiotics?

William Osler, MD (1849 - 1919)

"The

desire to take medicine is perhaps the greatest feature which distinguishes man from animals." "One of the first duties of the physician is to Educate the masses not to take medicine"

H. Cushing, Life of Sir William Osler (1925)

Antibiotics Changed the Human Survival

Antibiotics have transformed the practice of medicine, making once lethal infections readily treatable and making other medical advances, like cancer chemotherapy and organ transplants, possible.

Fleming Nobel Prize Speech identifies

In his Nobel Prize acceptance speech, Fleming identified the risk of bacteria becoming resistant to antibiotics. If a bacterium carries several resistance genes, it is called multiresistant or, informally, a

"superbug."

A Changing Landscape for Numbers of Approved Antibacterial Agents

18

Number of agents approved

16 14 12 10 8 6 4 2

Resistance

0
1983-87 1988-92 1993-97 1998-02 2003-05 2008

Bars represent number of new antimicrobial agents approved by the FDA during the period listed.
Infectious Diseases Society of America. Bad Bugs, No Drugs. July 2004; Spellberg B et al. Clin Infect Dis. 2004;38:1279-1286; New antimicrobial agents. Antimicrob Agents Chemother. 2006;50:1912

Scarcity of New Antibiotics

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.

Pharmaceutical Industry Pushes

Commercial interests of Pharmaceutical industry pushing the Antibiotics, more so Broad spectrum and Newer Generation antibiotics. as every Industry has become profit oriented

Poverty and Drug Resistance

Poverty encourages drug resistance due to under utilization of appropriate Antibiotics.

ANTIMICROBIAL RESISTANCE:

The role of animal feed antibiotic additives

48% of all antibiotics by weight is added to animal feeds to promote growth. Results in low, sub therapeutic levels which are thought to promote resistance.

Farm families who own chickens feed tetracycline have an increased incidence of tetracycline resistant fecal flora

Inappropriate use of antibiotics is a worldwide problem

More than 50% of all medicines are prescribed, dispensed or sold inappropriately, and half of all patients fail to take

medicines correctly.
The overuse, underuse or misuse of medicines harms people and wastes resources. More than 50% of all countries do not implement basic policies to promote rational use of medicines.

Creation of SUPERBUGS
Antimicrobial resistance is a serious global challenge. Every continent and country faces the menace of antibiotic resistant super bugs, though the extent and the severity of the problem varies. There could be a return to the preantibiotic era, where many people could suffer or die from untreatable bacterial

infections

Settings that Foster Drug Resistance

Intensive care units Oncology units

Dialysis units
Rehab units

Transplant units
Burn units

Treated Without Coordination

When the patients to be treated by several specialists, multiple antibiotics prescribed
Drug Antagonism

Our Indian Hospitals

Indian hospitals have reported very high Gramnegative resistance rates, with very high prevalence of ESBL (Extended Spectrum Beta Lactamases) producers and also high carbapenem

resistance rates.

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. Misuse of antibiotics is also associated with an increased incidence of Clostridium difficle infections.

Pan Drug Resistant Infections

Increasing carbapenem resistance will invariably result in increased usage of colistin, currently the last line of defence, with a potential for colistinresistant and Pan Drug

Resistant bacterial infections

Can we tackle the Problem

India, with more than 20,000 hospitals, more than a billion population, wide cultural diversity, socio-economic disparity, and a large medical community of more than three-fourths of a million doctors, will find the resistance problem an issue very difficult to tackle

Why is an antibiotic policy necessary?

An antibiotic policy will:
Improve patient care by promoting the best practice in antibiotic prophylaxis and therapy,

Make better use of resources by using cheaper drugs where possible

Retard the emergence and spread of multiple antibioticresistant bacteria. Improve education of junior doctors by providing guidelines for appropriate therapy

Eliminate the use of unnecessary or ineffective antibiotics and restrict the use of expensive or unnecessarily powerful ones

An antibiotic policy will:

Improve patient care by promoting the best practice in antibiotic prophylaxis and therapy,
Make better use of resources by using cheaper drugs where possible Retard the emergence and spread of multiple antibioticresistant bacteria.

*Improve education of junior doctors by providing guidelines for appropriate therapy

Eliminate the use of unnecessary or ineffective antibiotics and restrict the use of expensive or unnecessarily powerful ones

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

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.

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 )

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.

The 3 Stratagecies Will it Work ? Complete ban on OTC sale of antibiotics without
prescription throughout the country?. Complete ban of OTC sale of antibiotics without prescription in metros and larger cities with a more liberal approach in smaller cities and villages. A liberal approach throughout the country to start with, with an initial list of antibiotics under restriction and addition of other drugs to the list in a phased manner.

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

Role of Microbiology Departments

Microbiology labs should issue hospital Antibiogram at predefined intervals. Those hospitals without good laboratory support should be willing to outsource samples to better laboratories.

Role of Microbiology Departments

The system of notification of communicable diseases is a popular, established, though not strictly followed system in the country. Multidrug-resistant bacteria, especially pandrug resistant bacteria, must be considered as a notifiable entity. Such a reporting system should complement national antimicrobial resistance surveillance studies.

Better services from Microbiology Departments.

Basic infrastructure should be updated for detection of MRSA and ESBL and Carbapenamase producers.

Documentation of all Opportunistic infections. and Hospital infection outbreaks

Carbapenemases
Ability to hydrolyze penicillins, cephalosporins, monobactams, and carbapenems Resilient against inhibition by all commercially viable -lactamase inhibitors
Subgroup 2df: OXA (23 and 48) carbapenemases Subgroup 2f : serine carbapenemases from molecular class A: GES and KPC

Subgroup 3b contains a smaller group of MBLs that preferentially hydrolyze carbapenems

IMP and VIM enzymes that have appeared globally, most frequently in nonfermentative bacteria but also in Enterobacteriaceae

Notifying Pan Resistant Microbes Superbugs

Pan-drug-resistant Gram-negatives, carbapenemresistant GramNegatives, Vancomycinresistant Enterococcus and MRSA should be made notifiable

Curriculum change
Structured training in antibiotic usage and infection control should be introduced in both UG and PG curriculum.

Infectious Diseases training in UG and PG curriculum in all specialties.

Antibiotic stewardship and infection control one week rotation-3rd, 4th, and final year MBBS.

WHONET
Documentation Why We Need It

What is WHONET
WHONET is a free software developed by the
WHO Collaborating Centre for Surveillance of Antimicrobial Resistance for laboratory-based surveillance of infectious diseases and antimicrobial resistance. The principal goals of the software are: 1 to enhance local use of laboratory data; and 2 to promote national and international collaboration through the exchange of data.

Whonet helps us in
The understanding of the local epidemiology of microbial populations; the selection of antimicrobial agents; the identification of hospital and community outbreaks; and the recognition of quality assurance problems in laboratory testing.

All the Documented results are analyzed in WHONET

The heart of WHONET is a software package designed to collect the results of antibiotic resistance tests. Researchers / Microbiologists feed the results into a computer and look for trends

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.

Physicians Can Impact

Patients
Other clinicians

Optimize patient evaluation Optimize consultations with Adopt judicious antibiotic other clinicians prescribing practices Use infection control measures Immunize patients Educate others about judicious use of antibiotics

Best way to keep the matters in Order

Every Hospital should have a policy which is practicable to their circumstances. The *Seniors physician in the respective departments will make the best policy

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)

Our minimal Targets

List of available antibiotics agreed by all clinicians, indicating dosages, routes of administration and toxicities. Guidelines for therapy and prophylaxis. A regimen selection algorithm also might be included in an antibiotic policy.
CLSI guidelines are already followed

IMAGINE A WORLD WITHOUT ANTIBIOTICS

A world without effective antibiotics is a terrifying but real prospect. Overuse of antibiotics has led to dangerous outbreaks of drug resistant disease, and puts us in very real danger of a global pandemic. In future we have to use ???

Collect microbiology Specimens Before Antibiotic Therapy

Nurses and Resident doctors can assure that cultures are performed before starting antibiotics. In addition, nurses review medications as part of their routine duties and can prompt discussions of antibiotic treatment, indication, and duration

Never Forget Optimal Specimen Collection a Top Priority

STOP MISUSE OF Antibiotics and Start Washing Hands

Programme Created by Dr.T.V.Rao MD for Medical Microbiologists for the Improvements in Global Health care
Email

doctortvrao@gmail.com