Antibiotic Pharmacy Initiative

1
Antibiotic Resistance prevention
2
Content

• History of Antibiotic resistance
• The consequences of Antibiotic resistance
• Reasons for Antibiotic resistance
• Prevention

3
The start of antibiotic resistance Penicillin
Florey Chain1940
Fleming1928
4
History of resistance
5
There are two major effects of an antibiotic
therapeutically, it treats the invading
infectious organism, but it also eliminates
other, or non-disease producing, bacteria in its
wake. The latter do, in fact, contribute to the
diversity of the ecosystem and the natural
balance between susceptible and resistant
strains.
6
The consequence of antibiotic use is, therefore,
the disruption of the natural microbial ecology.
This alteration may be revealed in the emergence
of types of bacteria which are very different
from those previously found there, or drug
resistant variants of the same ones that were
already present. Levy, 1997
7
"... the mounting use of antibiotics, not only in
people, but also in animals and in agriculture,
has delivered a selection unprecedented in the
history of evolution." Levy, 1997
8
DRUG RESISTANCE THREATENS TO REVERSE MEDICAL
PROGRESS Curable diseases from sore throats and
ear infections to TB and malaria -- are in danger
of becoming incurable A new report warns that
increasing drug resistance could rob the world of
its opportunity to cure illnesses and stop
epidemics.
9
The consequences of antibiotic resistance

• Increased morbidity mortality
• best-guess therapy may fail with the patients
  condition deteriorating before susceptibility
  results are available
• no antibiotics left to treat certain infections
• Greater health care costs
• more investigations
• more expensive, toxic antimicrobials required
• expensive barrier nursing, isolation, procedures,
  etc.
• Therapy priced out of the reach of some
  third-world countries

10
Therapy priced out of the reach of the poor

• A decade ago in New Delhi, India, typhoid could
  be cured by three inexpensive drugs. Now, these
  drugs are largely ineffective in the battle
  against this life-threatening disease.
• Likewise, ten years ago, a shigella dysentery
  epidemic could easily be controlled with
  cotrimoxazole a drug cheaply available in
  generic form. Today, nearly all shigella are
  non-responsive to the drug.
• The cost of treating one person with
  multidrug-resistant TB is a hundred times greater
  than the cost of treating non-resistant cases.
  New York City needed to spend nearly US1 billion
  to control an outbreak of multi-drug resistant TB
  in the early 1990s a cost beyond the reach of
  most of the world's cities.

11
Bacterial evolution vs mankinds ingenuity

• Adult humans contains 1014 cells, only 10 are
  human the rest are bacteria
• Antibiotic use promotes Darwinian selection of
  resistant bacterial species
• Bacteria have efficient mechanisms of genetic
  transfer this spreads resistance
• Bacteria double every 20 minutes, humans every 30
  years
• Development of new antibiotics has slowed
  resistant microorganisms are increasing

12
Antibiotic Failures are NOT all due to Resistance

• Lack of effectiveness in vivo may not be due to
  bacterial resistance the antibiotic may
• not be able to reach the microorganisms cannot
  go through blood brain barrier
• be too toxic at doses required to be effective
  against targeted microorganisms
• ...

13
Sustained Antibiotic Use Contributes to Resistance

• initial 3-month use of AMI restricted, TOB GEN
  unrestricted
• then 12 months when AMI was primary
  aminoglycoside

Muscato JJ1991. An evaluation of the
susceptibility patterns of gram-negative
organisms isolated in cancer centres with
aminoglycoside usage. Journal of Antimicrobial
Chemotherapy. 27 Suppl C1-7.
14
Antibiotics overuse creates Superbugs
50 million tons antibiotics per year Superbugs
resistant to most antibiotics Example
Tuberculosis 2.5 million deaths
Mycobacterium tuberculosis increasingly
resistant
15
Resistance Seems to Develop Mostly in ICU

• Project ICARE (Intensive Care Antibiotic
  Resistance Epidemiology) by CDC and Emory U SPH
  to collect data on 8 US hospitals
• For 8/10 pathogens considered, resistance was
  higher among in hospital isolates

16
How does animal use of antibiotics contribute to
resistance?

• Animals consume and excrete antibiotics
  (approximately 2 trillion lbs of manure generated
  in USA annually)
• Animals can transmit resistant bacteria in food
• Food of animal origin most common cause of
  food-borne infections due to
• Salmonella
• Campylobacter
• Yersinia
• E Coli 0157,H7
• Genetic transfer to human specific organisms
  (avoparcin in pigs and chickens). This can also
  occur with plant bacteria.

17
Social factors fuelling resistance

• Poverty encourages the development of resistance
  through under use of drugs
• Patients unable to afford the full course of the
  medicines
• Sub-standard counterfeit drugs lack potency
• In wealthy countries, resistance is emerging for
  the opposite reason the overuse of drugs.
• Unnecessary demands for drugs by patients are
  often eagerly met by health services and
  stimulated by pharmaceutical promotion
• Overuse of antimicrobials in food production is
  also contributing to increased drug resistance.
  Currently, 50 of all antibiotic production is
  used in animal husbandry and aquiculture
• Globalization, increased travel and trade ensure
  that resistant strains quickly travel elsewhere.
  So does excessive promotion.

18
Prevention
19
1-Vaccinate

• Influenza vaccine
• S.pneumoniae vaccine
• 7 vaccine serotypes are also most resistant
• So vaccine reduces incidence of infections due to
  the 7 serotypes and incidence of resistant strains

20
2- Diagnose Treat Infection Effectively

• Target the pathogen
• Target empiric therapy to likely pathogens
• Culture the patient
• Target definitive therapy to known pathogens
• Optimize timing, regimen, dose, route and
  duration
• Monitor response and adjust treatment when needed

21
3- Treat infection, not contamination

• Blood cultures
• Use proper antisepsis for blood cultures
• Avoid culturing vascular catheter tips
• Avoid culturing through temporary vascular
  catheters

22
4-Treat infection, not colonization

• Treat pneumonia
• not the tracheal aspirate
• not endotracheal tube
• Treat urinary tract infection
• not the indwelling catheter
• not simple bacteriuria
• Treat bacteremia
• not the catheter tip or hub
• Treat bone infection
• not the skin flora

23
5- Follow Established Guidelines
Consult Specialist
Follow Guidelines
24
6-Use Local Data

• Know your antibiogram
• Know your formulary
• Know your patient population

25
7-Stop Antimicrobial Treatment

• When infection is treated
• When infection is not diagnosed
• When infection is unlikely

26
8-Prevent Person to Person Transmission

• Health Care Facility
• Use standard infection control precautions
• Follow airborne, droplet and contact precautions
• When in doubt, consult infection control experts
• Community Setting
• Stay home when you are sick
• Keep your hands clean
• Set an example

27
9-Prevent Transmissionfrom Environment

• Get the Catheters out
• Use catheters only when essential
• Use the correct catheter
• Use proper insertion and catheter-care protocols
• Remove catheters when they are no longer
  essential
• Follow disinfection protocols
• From stethoscopes
• to endoscopes

28
10- Use Hospital Controls

• Educational Persuasive Approachesminor effect
• Facilitative Strategies
• clinical specialist or pharmacy clinician to
  advise
• computer help screens when ordering
• Power Strategies
• Formulary Control
• Monitor usage with time limits on prophylactic,
  empiric, therapeutic uses
• Restriction of Drugs classified as
• Uncontrolled available for all physicians,
• Monitored usage monitored thru system
• Restricted ID specialist only

29
Hospital Control Power

• 1-Formulary Control
• most common method
• pharmacy and therapeutics committee
• selects ab in hospital formulary
• based on the ab medical usefulness, cost,
  relevance to epidemiologic situation
• no duplication
• constant revision

30
Hospital Control Monitor

• 2-Monitor and evaluate empiric, therapeutic
  prophylactic use
• prescriptions include type of rx E/T/P
• Time limits
• Empiric 3 days
• Prophylactic 2 days
• Therapeutic 7 days
• extension requires justification written by the
  prescribing physician
• requiring MD to justify prescriptions ? proper
  usage.

31
Hospital Control Restrict

• 3-Restriction of Drugs classified as
• Uncontrolled available for rx by all physicians
• Monitored available but usage monitored through
  system
• Restricted available only after consultation
  with ID specialist or limited list of MD

32
Hospital Control

• 4- Antimicrobial form
• forms consume time to be filled
• act as a deterrent for casual prescriptions
• information obtained on form used to monitor
  proper usage
• 5- Laboratory reporting
• focus on formulary
• non formulary abS reported when multiple
  resistance occurs
• reporting of abS prompt to allow rapid switching
  to more appropriate and narrow spectrum ab
• 6- Concurrent control
• most beneficial to patient care, not
  retrospective
• easier implemented when rx thru computer system

33

• Thank you!