DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
Rational use of antibiotics & antibiotic policy
1. Rational use of
antibiotics &
antibiotic policy
By –
Dr. Vikas S. Sharma
Dept. Of Pharmacology
GMC, Nagpur
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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
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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
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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
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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
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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
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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 –
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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
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9. 9 of 82 Rational use of antibiotics & antibiotic policy – Dr. Vikas S. Sharma 11th January 2017
10. What is Rational Use of Drugs?
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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
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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.
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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
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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
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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
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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”
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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
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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
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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
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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?
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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36. CARAT criteria
Evidence based results
Therapeutic benefits
Safety
Cost-Effectiveness
Optimal drug dose and duration
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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 ?
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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.
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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