Dr.T.V.

Rao MD

Dr.T.V.Rao MD 1
Discovery Of Penicillin changes the
History of Medicine

Dr.T.V.Rao MD 2
 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


 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
Dr.T.V.Rao MD
Antibiotics. 4
 Introduction


 “The end of infectious diseases” was a popular
idea in the 1970s

Infectious diseases are still important in the 21st

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.'"
Dr.T.V.Rao MD 6
 Four main groups of Bacteria a
Concern for Antibiotic Resistance


Gram positive

Gram negative

Anaerobes

Atypical
Dr.T.V.Rao MD 7
 Generally. Infecting Microbes..
Gram -ve
GI-tract, GU &
Anaerobes Respiratory
Mouth, teeth,
throat, sinuses &
lower bowel
Peritonitis
Biliary infection
Pancreatitis
Dental infection UTI
Peritonitis PID
Appendicitis CAP/HAP/VAP
Abscesses Sinusitis

Gram +ve
Skin, Bone & Atypicals
Respiratory Chest and genito-
Cellulitis urinary
Wound infection Pneumonia
Line infection Urethritis
Osteomyelitis PID
Pneumonia Dr.T.V.Rao MD 8
Sinusitis
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.
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

Dr.T.V.Rao MD 11
 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.

Dr.T.V.Rao MD 13
Multiple Mechanism of Drug
Resistance

Dr.T.V.Rao MD 14
 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.


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.

Dr.T.V.Rao MD 17
Dr.T.V.Rao MD 18
 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.


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


 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


 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


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


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


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
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

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


 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.
 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 results35

 Monitoring local antibiotic resistance patterns

 Being aware of local antibiotic resistance patterns (Antibiograms)
enables
 appropriate selection of initial empiric antibiotic therapy

Dr.T.V.Rao MD 30
 PRIORITY ANTIBIOTIC-RESISTANT
BACTERIA PATHOGENS


 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.

Dr.T.V.Rao MD 31
 Advantages of
Antibiotic

Policy
 Saves the Lives
 Reduces the morbidity
 Saves Health related
costs
 Reduces the Antibiotic
related toxicity.
 Patients are satisfied.

Dr.T.V.Rao MD 32
 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 hasAchievements

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

Dr.T.V.Rao MD 34
 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
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
rd
and
role played by reducing the prescription of 3
.
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


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 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 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 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


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


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


• 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

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

Dr.T.V.Rao MD 45
 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 46
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.

Dr.T.V.Rao MD 47
Hand Washing Reduces the Spread
of Antibiotic Resistant Strains

Dr.T.V.Rao MD 48


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

Dr.T.V.Rao MD 49