BULETIN FARMASI

FEBRUARI 2013 KKB KOTA BHARU In this issue:

New antibiotic in the market, 2 Antimicrobial resistance, 4 Trends in antimicrobial resistance in health are, 5

How to prevent antimicrobial resistance, 7

Impact of antimicrobial resistance, 10

ADVISOR

NDM-1, 11 Superbug??, 13 Pendidikan pesakit , 14 Word search, 16 Laughter is the best medicine?, 16

EDITORIAL MEMBERS

Crossword puzzle, 17 Lensa KKB Kota Bahru,18

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Telavancin : New Antibiotic in the market

T stration (FDA) has approved

he US Food and Drug Admini-

telavancin injection (Vibativ, Theravance, Inc, and Astellas Pharma US, Inc) for the once-daily treatment of adults with complicated skin and skin structure infections (cSSSI) caused by susceptible Gram-positive bacteria, including methicillin-resistant and methicillin-susceptible strains of Staphylococcus aureus. The injectable lipoglycopeptide antibiotic is a synthetic derivative of vancomycin, the current standard of care for cSSSI. Telavancin and vancomycin both inhibit bacterial cell wall synthesis by interfering with the polymerization and cross-linking of peptidoglycan; telavancin also binds to the bacterial membrane, disrupting its barrier function. Approval of telavancin was based on data from 2 double-blind, randomized phase 3 studies (ATLAS I and II) of 1867 patients, showing that its use was statistically noninferior to vancomycin (1 g intravenously every 12 hours) for curing cSSSI caused by Gram-positive bacteria, including methicillin-resistant S aureus. "Vibativ has demonstrated its efficacy and safety in clinical trials for the treatment of Grampositive complicated skin and skin structure infections which included the largest cohort of patients with methicillin-resistant Staphylococcus aureus studied to date," said Ralph Corey, MD, professor of medicine at the Duke University Medical Center, Durham, North Carolina, and the principal investigator in the ATLAS program in a company news release. "I believe Vibativ will be a welcome addition for physicians treating this serious infection." The recommended dose of telavancin is 10 mg/kg administered by intravenous infusion once every 24 hours for 7 to 14 days. An infusion period of at least 60 minutes is recommended to reduce the risk for infusion reactions ("red man syndrome"). Women of childbearing potential should have a serum pregnancy test before treatment with telavancin; use during pregnancy should be avoided unless the potential benefit to the mother outweighs fetal risk.
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Because of the potential for new-onset or worsening renal impairment, renal function should be monitored during treatment; dose adjustments are recommended for those with creatinine clearance of 50 mL/min or less, and caution is advised when treating elderly patients. Although telavancin does not interfere with coagulation, it does affect laboratory tests such as prothrombin time, international normalized ratio, and activated partial thromboplastin time. Blood samples for these tests should be collected as closely as possible before the patient's next dose of telavancin. Because of the potential for QTc prolongation, caution is advised when treating patients taking other drugs known to have this effect. Adverse reactions most commonly reported with use of telavancin in clinical studies included taste disturbance, nausea, vomiting, and foamy urine.

Generic name Brand name Class Mechanism of action Adult dose Pediatric dose Dose adjustment Adverse effect Pregnancy category Breastfeeding

Telavancin Vibativ Glycopeptides Inhibit bacterial cell wall synthesis by interfering with the polymerization and cross-linking of peptidoglycan 10 mg/kg IV over 60 minutes once every 24 hours for 7 to 14 days Safety and effectiveness not established in pediatric patients Renal impairment: CrCl of 30 to 50 mL/min, 7.5 mg/kg IV every 24 h Renal impairment: CrCl of 10 to 30 mL/min, 10 mg/kg IV every 48 h Taste disturbance, nausea, vomiting, and foamy urine C Infant risk cannot be ruled out.

www.vibativ.com/
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HOW DOES IT HAPPEN?

The genetic alterations in bacteria cause resistance to antibiotics in one or more of four principal ways: The target molecules are structurally altered to prevent antibiotic binding Antibiotics are excluded from cell entry They are inactivated, e.g. through enzymatic degradation They are or pumped out of the cell (efflux)

Antibacterial drug resistance Per Nordberg MD, Dominique L. Monnet PharmD, Otto Cars MD, PhD

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Februari 2013 TRENDS IN ANTIMICROBIAL RESISTANCE IN HEALTH CARE ASSOCIATED PATHOGENS AND EFFECT ON TREATMENT

GRAM-POSITIVE ORGANISMS

The increasing prevalence of MRSA in hospitals has led to the increased use of vancomycin for treatment VISA appears to adapt to the presence of vancomycin through a series of mutations, resulting in strains that can overproduce cell-wall components that bind vancomycin and limit its penetration into the cell. Linezolid and trimethoprim-sulfamethoxazole have been used successfully in the treatment of VISA infections VRE are, cause of bloodstream, wound, and urinary tract infections in immunosuppressed and other severely ill inpatient populations. By 1993, the prevalence of VRE had increased 20fold in the ICUs between 2001 and 2004. Although rates of resistance appear to be stable in ICUs, VRE may be emerging as a cause of occasional infection in new patient populations, such as patients receiving hemodialysis and patients in pediatric hematology/oncology departments.

Evolution of antimicrobial-resistant Staphylococcus aureus as a cause of nosocomial and community-acquired infections.

Black squares, nosocomial infection; Gray squares, community-acquired infection.

Trends in Antimicrobial Resistance in Health CareAssociated Pathogens and Effect on Treatment. L. Clifford McDonald. Centers for Disease Control and Prevention, Clin Infect Dis. (2006) 42 (Supplement 2): S65-S71.

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MULTIDRUG-RESISTANT GRAM-NEGATIVE BACTERIA

Enterobacteriaceae
Increased utilization of cephalosporins as

Data collected between 1994 and 2002 at one tertiary care center in the United States showed the emergence: Pseudomonas aeruginosa (prevalence1% 16%) Klebsiella species (prevalence, 0.5%17%) The most common resistance pattern was coresistance to quinolones, third-generation cephalosporins, and aminoglycosides.

Acinetobacter baumannii
Emerged worldwide as an important patho

gen in hospitalized patients, causing high mortality rates

Cause many infections, including pneumonia,

bacteremia, meningitis, urinary tract infection, and skin and soft-tissue infections
Prevalence

of Acinetobacter organisms among gram-negative pathogens causing pneumonia in ICUs has increased from 4.2% in 1986 to 7.0% in 2003, with resistance to imipenem (increase in prevalence, from 0% to 42%) and ceftazidime (increase in prevalence, from 18% to 68%) increasing substantially during the same period

workhorse antimicrobial agents has coincided with the emergence of Enterobacteriaceae, primarily Klebsiella pneumoniae, that possess extended-spectrum b-lactamases Carbapenems have been used for the treatment of serious infections caused by isolates possessing extended-spectrum b-lactamases cause recent emergence of carbapenemresistant Klebsiella species Three carbapenem hydrolyzing b-lactamase variants (KPC-1KPC-3) have been reported. These enzymes confer moderate- to high-level resistance to all agents in the carbapenem class Many of these isolate also carry determinants of resistance to aminoglycosides and are fluoroquinolone resistant, making these strains resistant to multiple classes of antimicrobial agents There has been resurgence in the use of the polymyxins, which, although highly active against gram-negative bacteria, were abandoned in the 1970s because of toxicity, especially nephrotoxicity. However, recent experiences suggest that polymyxins can be used to treat serious infections due to multidrugresistant gram-negative bacteria without causing significant associated adverse events, perhaps on the basis of the use of lower doses, avoidance of concurrent use of nephrotoxins, and improved fluid supplementation and supportive treatment.

Resistance to antimicrobials (imipenem, ciprofloxacin, and third-generation cephalosporins) in Pseudomonas aeruginosa isolates recovered from intensive care unit patients (National Nosocomial Infections Surveillance System, unpublished data)
Trends in Antimicrobial Resistance in Health CareAssociated Pathogens and Effect on Treatment. L. Clifford McDonald. Centers for Disease Control and Prevention, Clin Infect Dis. (2006) 42 (Supplement 2): S65-S71.

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Februari 2013 HOW TO PREVENT ANTIMICROBIAL RESISTANCE
1) Vaccinate
Predischarge influenza and pneumococcal vaccination of at-risk hospital patients and influenza vaccination of healthcare personnel will prevent infections give influenza/S. pneumonia vaccine to at-risk patients before discharge get influenza vaccine annually

2) Get the catheters out

Catheters and other invasive devices are the exogenous cause of hospital-acquired infections Intravenous catheters, arterial catheters, urinary tract catheters, endotracheal tubes, and many other devices increase the risk of hospital-acquired infection in all patient populations The estimated attributable mortality for catheter-associated bloodstream infections ranges from 0% to 35%, depending on study design The estimated attributable cost per bloodstream infection ranges from $34,508 to $56,000, and the annual cost of caring for infected patients between $296 million and $2.3 billion ACTIONS use catheters only when essential use the correct catheter use proper insertion and catheter-care protocols remove catheters when not essential

3) Access the experts

Optimal Patient Care

Campaign to Prevent Antimicrobial Resistance, Centers for Disease Control and Prevention http://www.cdc.gov/drugresistance/healthcare

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4) Target the pathogen

Clinicians dilemma of empiric therapy Appropriate antimicrobial therapy (correct regimen, timing, dosage, route, and duration) saves lives.

ACTIONS culture the patient target empiric therapy to likely pathogens and local antibiogram target definitive therapy to known pathogens and antimicrobial susceptibility test results

5) Practice antimicrobial control

Methods to Improve Antimicrobial Use Passive prescriber education Standardized antimicrobial order forms Formulary restrictions Prior approval to start/continue Pharmacy substitution or switch Multidisciplinary drug utilization evaluation (DUE) Interactive prescriber education Provider/unit performance feedback Computerized decision support/online ordering

6) Treat infection,not contamination

A major cause of antimicrobial overuse is treatment of contaminated cultures.

Campaign to Prevent Antimicrobial Resistance, Centers for Disease Control and Prevention http://www.cdc.gov/drugresistance/healthcare

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7) Stop treatment when infection is cured or unlikely

Contributes to overuse and resistance STOP!!! when infection is cured when cultures are negative and infection is unlikely when infection is not diagnosed

8) Contain your contagion

Healthcare personnel can spread antimicrobial-resistant pathogens from patient to patient Improved Patient Outcomes Associated With Proper Hand Hygiene

Ignaz Philipp Semmelweis (1818-1865) introduced antiseptic hand hygiene techniques Chlorinated lime hand antiseptic

9) Know when to say no to vanco

Vancomycin overuse promotes emergence, selection, and spread of resistant pathogens

Campaign to Prevent Antimicrobial Resistance, Centers for Disease Control and Prevention http://www.cdc.gov/drugresistance/healthcare

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Februari 2013 IMPACT OF ANTIMICROBIAL RESISTANCE

Public health impact

The increasing health impact of resistance is most visible in the critical care area

The economic costs of antibiotic resistance

The increasing prevalence of MRSA and vancomycinresistant enterococci described in previous sections inevitably drives changes to empirical and prophylactic regimens. This shift in therapy would increase the total antibiotic budget by 100%. Increased length of hospitalization, increased risks of complications and mortality

Increased use of broad spectrum antibiotics as empirical therapy of many common bacteria infections. However, development of new drugs were seriously reduced Discovery of new classes of antibacterial drugs Discovery of new antibacterial drugs

The consequences for the patient

Prolonged disease or increased mortality Infections caused by antimicrobial-resistant organisms also may require more toxic therapy that can lead to adverse outcomes. The use of colistin for highly resistant Pseudomonas or Acinetobacter infections is associated with a high risk of renal dysfunction
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The Impact of Antimicrobial Resistance on Health and Economic Outcomes. George M. Eliopoulos, Sara E. Cosgrove1 and Yehuda Carmeli. Clin Infect Dis. (2003) 36 (11): 1433-1437

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NDM1 enzyme-containing superbugs struck in India, Pakistan and the United Kingdom in 2010
NDM1 is an enzyme that confers resistance to one of the most potent classes of antibiotics, known as carbapenems. This new resistance pattern has been reported in many different types of bacteria compared to previously and at least one in 10 of these NDM1-containing strains appear to be panresistant. Pan resistance refers to pathogens that are specifically resistant to 7 antimicrobial agents (cefepime, ceftazidime, imipenem, meropenem, piperacillin-tazobactam, ciprofloxacin, and levofloxacin) which mean that there is no known antibiotic that can treat it. A second concern is that there is no significant new drug development for antimicrobials. Third, this particular resistance pattern is governed by a set of genes that can move easily from one bacterium to another. Fourth, NDM1 has been found in the most commonly encountered bacterium in the human population, E. coli, which is the most common cause of bladder and kidney infections. A further concern is that of the two drugs potentially capable of treating an infection due to one of these new multiresistant strains, one of them, colistin, causes toxic effects to the kidney in about a third of people.
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How can we educate patients to understand that antibiotics have no effect on viral infections, like the common cold?

Doctors will face a terrible dilemma when a pregnant woman develops a kidney infection that spills over into the bloodstream with a pan-resistant strain containing NDM1 and there are no treatment options. We are essentially back to an era with no antibiotics. By early September 2010, the United States of America (USA) had reported cases in three states and Canada, in three provinces. Australia, Belgium, Japan, Sweden and Viet Nam have all reported cases, so its outside of India, Pakistan and the United Kingdom of Great Britain and Northern Ireland, where it was initially described. Antimicrobial resistance is concern in countries where prescription of antimicrobials is unregulated and where you can buy antibiotics over the counter. This is the case in many countries, including those with large populations such as China and India, where antibiotic sales appear to have increased, consistent with the growth of a more affluent middle class, as well as many countries in Africa and Central and South America. But the usage in humans pales in comparison with the use of antibiotics in the agri-food industry in cattle, poultry and hog farming, fish farming, honeybee hives where these agents are used as growth promoters. Some estimates suggest that antibiotic use in animals and fish is at least 1000-fold greater in terms of absolute tonnage compared with use in humans. How can we educate patients to understand that antibiotics have no effect on viral infections, like the common cold? That is a very important message. Behavioral analyses show that doctors and other prescribers often give in to pressure from patients and prescribe antibiotics because they are afraid they will lose their patients
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http://www.who.int/bulletin/volumes/88/11/10-031110/en/index.html

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Superbug????....
Utusan Malaysia,28/10/2012 Seorang pesakit wanita datang ke Hospital Sungai Buluh, Selangor kerana sakit perut dan demam yang telah berlarutan lebih dua minggu. Sebelum itu wanita berusia 31 tahun itu telah berulang-alik ke klinik yang berhampiran dengan rumahnya. Apabila demam dan sakitnya masih berterusan, dia ke hospital untuk mendapatkan pemeriksaan lanjut. Malangnya semasa sampai ke hospital, keadaannya telah parah dan dia terpaksa diletakkan di bawah mesin sokongan hayat. Lebih mengerikan nanah keluar dengan banyak daripada mulutnya dan perlu disedut menggunakan tiub. Pemeriksaan menunjukkan bisul yang terdapat di dalam hatinya telah pecah dan masuk ke dalam paru-paru. Wanita malang itu akhirnya meninggal dunia. Kajian menunjukkan tubuhnya dijangkiti bakteria yang telah rintang dengan pelbagai jenis antibiotik. New England Journal of Medicine pada 2011 telah menerbitkan kajian mengenai bakteria yang kebal terhadap antibiotik dengan tajuk AntibioticResistant Bugs in the 21st Century a Clinical Super Challenge. Kisah wanita di Hospital Sungai Buloh ini seakan-akan sama dengan insiden sebelum antibiotik yang dinamakan penicillin ditemui pada 1940-an. Sejarah antibiotik bermula apabila Alexander Fleming menemui kulat Penicillium notatum pada 1928. Penemuan itu membolehkannya memenangi Hadiah Nobel dalam bidang fisiologi pada 1945 bersama Howard Florey dan Ernst Boris Chain. Tarikh itu menandakan bermulanya sejarah antibiotik moden yang banyak digunakan dalam mengawal jangkitan bakteria. Sejak itu kajian dilakukan bagi mencari pelbagai jenis antibiotik yang baru untuk mengawal jangkitan bakteria berbahaya. Pakar Runding Penyakit Berjangkit Hospital Sungai Buloh, Dr. Benedict Sim berkata, insiden yang berlaku pada wanita berkenaan bukanlah kes yang terpencil. "Kejadian berkenaan bukan saja berlaku di negara ini malah telah dan sedang berlaku di seluruh dunia akibat kerintangan bakteria terhadap antibiotic." Beberapa akhbar luar negara telah menerbitkan kisah mengenai bakteria rintang ini atau digelar suberbug yang telah mengorbankan banyak nyawa," katanya kepada pemberita pada bengkel sempena Kempen Kebangsaan Antimicrobial Resistance 2012 di Putrajaya, baru-baru ini. Menurutnya, rawatan terhadap jangkitan superbug menyebabkan kos perubatan pesakit semakin meningkat. Ini berlaku kerana harga ubat yang digunakan adalah mahal serta pesakit perlu tinggal lama di dalam wad. "Tetapi apa yang paling ditakuti, superbug membunuh pesakit," katanya.

(Artikel Penuh: http://www.utusan.com.my/utusan/Kesihatan/20121028/kn_04/Elak-kekebalan-superbug#ixzz2I6Dtmj3u Utusan Melayu (M) Bhd )

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PENDIDIKAN PESAKIT: Tahukah Anda?

Berapa ramai antara kita menghabiskan antibiotik, seperti diarah doktor setiap kali mengalami masalah kesihatan akibat jangkitan? Biarpun doktor menekankan antibiotik perlu dihabiskan, biasanya ramai berhenti makan antibiotik berkenaan apabila berasa semakin sihat walaupun baki antibiotik masih banyak. Destinasi akhir baki antibiotik itu mungkin di rak peti sejuk atau lebih buruk, di dalam tong sampah. Namun di sebalik pembaziran ini, kita masih segera bergegas ke klinik untuk mendapatkan antibiotik setiap kali demam, sakit tekak, batuk atau selesema, sedangkan batuk dan selsema biasanya tidak memerlukan antibiotik dan akan pulih dengan pengambilan air dan rehat secukupnya. Ada pesakit, terutama ibu bapa, merasakan set ubat mereka tidak lengkap tanpa antibiotik sehingga mendesak diberi ubat berkenaan, walaupun ia sebenarnya tidak perlu. Malah, ada pesakit atau ibu bapa pesakit kecil yang hampa jika pulang dengan tangan kosong. Pengambilan antibiotik yang tidak diperlukan pada umumnya tidak memberi kesan sampingan, tetapi untuk jangka masa panjang, tindakan ini dikhuatiri boleh menyebabkan masalah kerintangan antibiotik.

APA ITU ANTIBIOTIK?

Antibiotik membunuh atau merencatkan pertumbuhan kuman bakteria. Antibiotik adalah rawatan anti mikrob yang khusus untuk jangkitan bakteria dan digunakan sejak 1940-an. Ia sangat penting kerana tanpa antibiotik, keadaan individu yang mendapat jangkitan bakteria boleh menjadi teruk dan membawa kepada kematian. Pun begitu, ia hanya untuk jangkitan bakteria dan ia tidak memberi kesan kepada masalah kesihatan akibat jangkitan virus. Kebanyakan masalah kesihatan disebabkan jangkitan bakteria dan virus. Walaupun keduaduanya boleh menjangkiti dan menyebabkan masalah kesihatan, cara ia membiak dan merebak tidak sama. Bakteria ialah mikro organisma satu sel yang sentiasa ada di keliling kita. Kebanyakannya tidak berbahaya dan ada yang sangat berguna kepada manusia seperti Lactobacillus yang hidup dalam usus untuk membantu proses pencernaan makanan. Antibiotik sangat berkesan membunuh bakteria kerana ia bertindak ke atas organisma hidup dengan menghentikan proses pembahagian dan pertumbuhan sel. Sebaliknya, virus pula bukan organisma hidup dan tidak boleh hidup sendiri. Ia adalah partikel yang mempunyai bahan genetik dan diselaputi kot protein. Virus hanya hidup dan membiak apabila ada dalam badan perumah seperti manusia dan haiwan. Ini sebabnya antibiotik tidak memberi kesan ke atas virus.

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Februari 2013 APA ITU KERINTANGAN ANTIBIOTIK?
Kerintangan antibiotik adalah satu keadaan apabila bakteria menjadi kebal kepada antibiotik atau tidak berkesan dengan antibiotik berkenaan. Bakteria yang kebal atau mengalami kerintangan antibiotik menyebabkan jangkitan menjadi lebih teruk dan tidak boleh disembuhkan dengan antibiotik biasa. Penyembuhan memerlukan antibiotik yang lebih kuat. Bagaimana kerintangan antibiotik boleh berlaku? Setiap kali anda mengambil antibiotik, bakteria yang sensitif akan dimusnahkan tetapi bakteria yang kebal akan terus berkembang sehingga hampir kesemua bakteria tersebut menjadi kebal kepada antibiotik. Keadaan ini dinamakan kerintangan antibiotik Mengapa perlu menghabiskan antibiotik?

Untuk memusnahkan bakteria sepenuhnya seterusnya mengelak daripada jangkitan semula. Untuk mengelakkan kerintangan antibiotik.

CARA PENGAMBILAN ANTIBIOTIK YANG BETUL?

1. Baca, fahami dan patuhi arahan : * kuantiti/sukatan (dos) yang perlu * masa pengambilan 2. Cara pengambilan antibiotik bergantung kepada jenis antibiotic yang diambil : * sebelum makan (satu jam sebelum makan) * selepas makan 3. Simpan antibiotik mengikut arahan. 4. Habiskan semua antibiotik walaupun anda berasa sihat. 5. Jangan gandakan dos walaupun terlupa mengambil dos sebelumnya. 6. Jangan berkongsi antibiotik dengan orang lain. 7. Ambil ubat dan antibiotik bersama air kosong; bukan teh, kopi, minuman berkarbonat atau beralkohol. Sesetengah antibiotik boleh bertindak balas dengan alkohol dan mendatangkan kesan sampingan yang tidak diingini

www.myhealth.gov.my

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Bacteria WORD SEARCH

Microscopic Living Infection Cell wall Membrane Germ Good Bad Tiny Rounded Sick Antibiotic

Laughter is the best medicine? Think TWICE!!

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Bacteria, Viruses and Antibiotics Crossword Puzzle

Across 4 5 8 9 10 12 14 17 18 19 Don't use antibiotics unless you are very, very What do antibiotics fight against, or kill? Viruses are living/non-living? (choose one) Viruses are responsible for us getting sick, like when we get a? Washing your hands can prevent ______ from making you sick If you have the ____ you should NOT use antibiotics to fight it You can find lots of antibiotics here 'Anti' means? Antibiotics are often used in _____ form You cannot see viruses or bacteria with your naked _____?

Down 1 2 3 6 7 9 11 13 15 16 These drugs kill bad bacteria living inside our bodies? Always use antibiotics until they are all _______. A super-bug we talked about today is? (abbreviation) These bacteria make their own food What is something that an antibiotic cannot kill? Your body is made up of? Using too many hand sanitizers can help create ______-bugs All living organisms have genetic material called? 'Biotic' means? Bacteria are essential to all ________. Answer: Across: 4. Sick 5. Bacteria 8. Nonliving 9. Cold 10. Germs 12. Flu 14. Hospitals 17. Against 18. Pill 19. Eye Down: 1. Antibiotics 2. Gone 3. MRSA 6. Autotrophes 7. Virus 9. Cell 11. Super 13. DNA 15. Living 16. Life 17

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LENSA KKB KOTA BHARU 2012

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Pantai Sri Tujoh

Pantai Melawi, Bachok

Karaoke di PCB

Bowling di KB Mall

Jamuan perpisahan Sze Mun Jamuan perpisahan pelatih

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