Iman M. Fawzy; MD, MSc, PhD

Consultant of Clinical Pathology

Rational Use of Antibiotics

The conference of experts on the rational use of drugs, by the WHO in 1985defined that

“Rational use of drugs requires that patientsreceive medications appropriately to theirclinical needs, in doses that meet their ownindividual requirements for an adequate periodof time, at the lowest cost to them and theircommunity”

Reasons for

Patient Concerns

• Want clear explanation

• Green nasal discharge

• Need to return to work

Physician Concerns

• Patient expects antibiotic

• Diagnostic uncertainty

• Time pressure

Antibiotic Prescription

Antibiotic Overuse

What is inappropriate use ?

Unnecessary prescription of antibiotics, such as for viral infections or for prolonged prophylaxis

Using broad-spectrum antibiotics when narrow-spectrum antibiotics are effective

Prescribing too low or too high dose

Continuing treatment for longer than necessary

What is inappropriate use ?

Not prescribing according to microbiology results

Omitting or delaying administration of doses

Prescribing intravenous therapy when oral therapy is known to be effective and clinically safe

Not taking antibiotics as prescribed

Antibiotic Resistance

New Resistant Bacteria

Emergence of Antibiotic Resistance

Susceptible

Bacteria

Resistant Bacteria

Resistance Gene Transfer

Resistant StrainsRare

Resistant Strains Dominant

Antimicrobial Exposure

Selection for Antibiotic-Resistant Strains

Antimicrobial resistance has emerged as a major public health problem all over the world

Infections by resistant microbes treatment fail↑morbidity ↑mortality.

Treatment failure longer infectivity, ↑infected people in community.

exposes general population to risk of resistant strains

Resistant to first-line antimicrobials, high cost of the second-line drugs treatment failure

Most alarming caused by multidrug-resistant microbes, which are virtually non-treatable and thereby create a “post-antibiotic era” scenario

Emergence of antibiotic resistance

5. Pray LA Insight Pharma Reports 2008, in Looke D ‘The Real Threat of Antibiotic Resistance’ 2012

Resistance spreads rapidly

Impact of resistance

Untreatable infections

Excess length of

stay

Increased morbidity/

mortality

Increased costs

Interference with patient’s normal flora.

Selection of drug resistant organisms

Increased side effects

Settings that favor antimicrobial resistance

Immune compromised patients e.g.

– ICU

– Oncology unit

– Dialysis unit

– Rehabilitation unit

– Transplantation unit

– Burn unit

Acute otitis

media

Respiratory tract

infection

AB resistance problem

Not only in hospitals

Urinary tract

infection

DiarrheaDental manipulation

we have to fight against the irrational use

save these important discoveries of man

Inappropriate use of antibiotics (life-saving (many problems

not many new antimicrobials

have been discovered since

the 1980th

funding on antimicrobial research is on

the decline

Antibiotic policy

Aim of Antibiotic Policy↓↓ morbidity and

mortality due to antimicrobial-resistant

infection

Preserve the effectiveness of antimicrobial agents in

treatment

Prevention of communicable diseases

Detect resistant microorganisms

Ensure effective treatment

Recognize trends in antimicrobial resistance within the institution

Assure infection control procedures

Plan for identifying,transferring, discharging andreadmitting patientscolonized with specificantimicrobial resistantpathogens

Incorporate the detection,prevention and control ofantimicrobial resistanceinto institutional strategicgoals

Rational use of antimicrobials

Objectives of Antibiotic Policy

Organizational structure of

antibiotic policy

Clinicians

Microbiologists

Pharmacists

Nurses

ANTIBIOTIC COMMITTEE

infection control

committee

Scope of hospital antibiotic policy

prophylaxis, empirical and definitive therapy.

high-risk/special groups e.g. immune compromised hosts;hospital-associated infections and community-associatedinfections.

The hospital antibiotic policy shall be based upon:

– spectrum of antibiotic activity

– pharmacokinetics/pharmacodynamics of antibiotic s

– adverse effects

– potential to select resistance

– cost

– special needs of individual patient groups.

Cumulative antibiogram (Hospital/Community)

Antibiotic policy

Standard treatment guidelines

Antimicrobial stewardship

Hospital acquired infection

Surveillance of antimicrobial resistance/ Antibiotic consumption

Surveillance of antimicrobialresistance

• Use standards

• Generate reliable numerator: only the first positive culture from the patient for each disease episode should be reported for surveillance purposes.

• Express resistance as incidence rate

• Participate in external quality assessment schemes

• Prediction of evolution of antimicrobial resistance

• Surveillance of antimicrobial consumption

Cumulative antibiogram

• Analyses of data regularly, at least annually.

• Inclusion of diagnostic isolates.

• It is useful to stratify results by specimens type orinfection site, by nursing unit or site of care, byorganism’s resistance characteristics, by clinicalservice or patient population.

• Reviewing the cumulative antibiogram data if clinicalfailure occurs after empiric therapy.

• Comparing the cumulative antibiogram with nationaldata.

Development of standard treatment guidelines

• Should be based on local antibiograms.

• Should be syndrome/diseased based.

• Should specify type of clinical setting – Outpatientclinics, Inpatient units, ICU setting.

• Should involve treating physicians to bring ownershipto the guidelines

Direction of antibiotic policy

Frame the hospital own list of therapeutic antibioticcategories:• First-line• Reserved agents• Restricted agents• Withdrawn agentsfor example, first choice antibiotics can be prescribed by alldoctorswhile restricted choice antibiotics can only be prescribed afterconsulting the head of the department or the antimicrobialteam (AMT) representative.Reserve antibiotics, are prescribed only by designated experts.

Minimizing selection of resistant organisms

What should not be done• Treat non-infectious or nonbacterial

syndrome.

• Treat colonization or contamination.

• Treat longer than necessary.

• Fail to make adjustment in a timely manner.

• Prescribe antibiotic with spectrum of activitynot indicated.

Interventions

Continuous surveillance of bacterial infections.

Hospital acquired infection

Community acquired infection

Interventions

• Prohibiting the sale of antibiotics withoutmedical prescription.

• Development of regulations by Ministries ofHealth regarding responsible prescription ofantibiotics.

• Prohibition of advertising of antibiotics in thecommunity by industry and pharmaceuticalrepresentatives.

Community pharmacist

• Pharmacist should be able to prescribe certainantibiotics in appropriate circumstances topatients needing treatment for particularconditions

• Advice to patients to ensure that the patientunderstands that:– Antibiotic must be used properly

– Help and encourage Health Authorities.

– Ensure the implementation of the policies

Prevent Antimicrobial Resistance

12 Contain your contagion11 Isolate the pathogen

10 Stop treatment when cured9 Know when to say “no” to antibiotic

8 Treat infection, not colonization7 Treat infection, not contamination

6 Use local data5 Practice antimicrobial control

4 Access the experts3 Target the pathogen

2 Get the catheters out1 Vaccinate

Prevent Transmission

Use Antimicrobials Wisely

Diagnose and Treat Effectively

Prevent Infection

Clinicians hold the solution…

Antimicrobial Resistance:

Key Prevention Strategies

Optimize

Use

Prevent

Transmission

Prevent

Infection

Effective

Diagnosis

and Treatment

Pathogen

Antimicrobial-Resistant

Pathogen

Antimicrobial Resistance

Antimicrobial Use

Infection

Susceptible Pathogen

Antibiotic prescribing

Indication for use (definitive, empirical,

prophylaxis)

Route of administration,

dosage regimen, duration of

treatment, adverse effects

If the drug was on a

reserved list

Drug combinations

Whether it was approved by a microbiologist

Was culture and sensitivity

performed

Development of treatment

guidelines

ANTIMICROBIAL PRESCRIBING: GOOD PRACTICES

• Send for appropriate investigations in all infections.

• All antibiotic initiations would be done after sendingappropriate cultures

• Follow Hospital policy when choosing antimicrobial therapywhenever possible.

• Check for factors which will affect drug choice, eg, renalfunction, interactions, allergy.

• Check that the appropriate dose is prescribed.

• The need for antimicrobial therapy should be reviewed on adaily basis.

• Once culture reports are available, the physician shall stepdown to the narrowest spectrum, most efficacious and mostcost effective option.

Empiric Therapy

Where delay in initiating therapy to awaitmicrobiological results would be life threatening or riskserious morbidity, antimicrobial therapy based on aclinically defined infection is justified.

Where empiric therapy is used, the accuracy ofdiagnosis should be reviewed regularly and treatmentaltered/stopped when microbiological results becomeavailable.

Empiric Therapy

Side effects empirical antibiotics :

• Development of resistance in pathogens infecting thepatient.

• Risk for spread of resistance.

• Suppression of normal flora.

• Development of resistance in normal flora.

• Risk for super infection.

Hand Washing is Important Because…

Hand hygiene compliance rates of 10%-40% have been observed in the developed

countries.

• Policy should be reviewed by expertswho are not the members of thepolicy development group, but areexperts in the relevant field.

Revise policy

• Policy is not static. It is a livingdocument. It should be reviewed atperiodic intervals, updated accordingto current medical knowledge, clinicalpractice and local circumstances.

Revise policy

THANK YOU