Dr Gan

Antibiotics-most commonly used group of drugs Antibiotic resistance-worlds most pressing public health problems Studies worldwide has shown a high incidence of inappropriate use

 Although

many countries have been successful in reducing primary care prescribing of antimicrobials, primary care is still responsible for the majority of antibiotics prescribed to people To combat antimicrobial resistance effectively, information is needed on antibiotic use

Avoid adverse effects on the patient Avoid emergence of antibiotic resistance ecological or societal aspect of antibiotics Avoid unnecessary increases in the cost of health care

Antibiotics differ from other classes of drugs The way in which a physician and other professionals use an antibiotic can affect the response of future patients Responsibility to society Antibiotic resistance can spread from

bacteria to bacteria patient to patient animals to patients

Is an antibiotic necessary ? What is the most appropriate antibiotic ? What dose, frequency, route and duration ? Is the treatment effective ?

 Useful only for the treatment of bacterial infections Not all fevers are due to infection Not all infections are due to bacteria

There is no evidence that antibiotics will prevent secondary bacterial infection in patients with viral infection

Meta-analysis of 9 randomised placebo controlled trials involving 2249 patients

Conclusions: There is not enough evidence of important benefits from the treatment of upper respiratory tract infections with antibiotics and there is a significant increase in adverse effects associated with antibiotic use.

 Aetiological

agent Patient factors Antibiotic factors

In most instances the optimum duration is unknown Duration varies from a single dose to many months depending on the infection Shorter durations, higher doses For certain infections a minimum duration is recommended

Infection Tuberculosis Empyema/lung abscess Endocarditis Osteomyelitis Atypical pneumonia Pneumococcal meningitis Pneumococcal pneumonia

Minimum duration 4 - 6 months 4 - 6 weeks 4 weeks 4 weeks 2 - 3 weeks 7 days 5 days

 Lower

threshold for antibiotics in immunocompromised hosts or those with multiple comorbidities; consider culture and seek advice
an antibiotic only when there is likely to be a clear clinical benefit NO antibiotic strategy for acute self-limiting upper respiratory tract infections

Prescribe

Consider

 Use

narrow spectrum antibiotics when possible Avoid broad spectrum antibiotics eg coamoxiclav, quinolones and cephalosporins Avoid widespread use of topical antibiotics e.g. fusidic acid Where a best guess therapy has failed or special circumstances exist, seek advice from Physicians/ID/Clinical Microbiologists.

 Enterobacter Staphylococcus

aureus (MRSA) Klebsiella ( ESBL , CRE ) Acinetobacter (MDR,XDR ,PDR) Pseudomonas aeruginosae Enterococcus (VRE)

Boucher HW et al, Clin Infect Dis 2009 ;48:1-12

MRSA = methicillin-resistant Staphylococcus aureus; VRE = Vancomycin-resistant enteroccoci FQRP = Fluoroquinolone-resistant Pseudomonas aeruginosa

Susceptibility of members of the family Enterobacteriaceae and bacteria that were not members of the Enterobacteriaceae to imipenem and ciprofloxacin from 2002 to 2008.

Hoban D J et al. Antimicrob. Agents Chemother. 2010;54:3031-3034

Percentage

Acinetobacter species resistance : IMR (%)

90 80 70 60 50 40 70

ICU
60
50 40 30 20 10 0

MEDICAL
80 70 60 50 40 30 20 10 0

SURGICAL

30
20 10 0

Common among Acinetobacter spp.

Usually encountered in ICU

Resistance Profile 2008 2009 2010 2011

% Acinetobacter Amikacin, Ceftazidime, sp resistant Cefepime, Cefoperazone / sulb, Ciprofloxacin, Meropenem

7.4

11.8

15.2

17.7

Predicted mortality for patients with and without antimicrobial-resistant infection (ARI)

Roberts R R et al. Clin Infect Dis. 2009;49:1175-1184

Source: US CDC 2010

Spellberg, CID 2004

Approvals

Strengthen Infection Control measures to Rationalize the use of available antimicrobial

reduce spread of resistant organisms
agents

Prevent emergence of resistance by reducing Promote discovery, development and

selection pressure by appropriate control measures dissemination of new antimicrobial agents

Projected cost savings if antimicrobial-resistant infection (ARI) rates were reduced from 13.5% to 10%.

Roberts R R et al. Clin Infect Dis. 2009;49:1175-1184

 Purpose

To

remove dirt, debris & reduce microbes from hand reduce cross contamination / infection

To

To

interrupt mode of transmission by contact

of cleanliness, credibility of HCW

Image

Prevent infection Vaccinate Get the catheter out Diagnose and treat infection effectively Target the pathogen Access the expert Use antimicrobial wisely Practice antimicrobial control Use local data

Treat infection, not contamination Treat infection, not colonization Know when to say no to vancomycin Stop treatment when infection is cured or unlikely Prevent transmission Isolate the pathogen Break the chain of contagion