Irrational use of antibiotics

Introduction

• Antibiotics also known as antibacterial medications that inhibits or

slows down the growth of bacteria. Bacteria are microscopic
organisms that cause many types of infection in the human beings.

• Antibiotic resistance is an outcome of irrational use of antibiotics

therefore it’s very important to know the right and rational use of
antibiotics.

1) Jodi Vanden Eng, Ruthanne Marcus, James L. Hadler, Beth Imhoff, Duc J. Vugia, Paul R. Cieslak, Elizabeth Zell, Valerie Deneen, Katherine Gibbs Mccombs, Shelley M. Zansky,
Marguerite A. Hawkins, And Richard E. Besser 2003 ( Consumer Attitudes And Use Of Antibiotics) Emerging Infectious Diseases • Vol. 9, No. 9, September.
2) Available from: Http://Publichealth.Lacounty.Gov/Acd/Docs/Lahealth092003_Antib.Pdf
 Antimicrobial action and spectrum
• In severe infections and / or immunocompromised patients, it’s customary to use
bactericidal agents rather than bacteriostatic agents .
• Empiric antibiotics therapy is selected to treat a clinical syndrome (eg: meningitis)
before microbiological diagnosis has been made.

• Targeted antibiotic therapy is aimed at the pathogen of known antimicrobial sensitivity.

• Ideally broad spectrum of antibiotics is used in empiric therapy, and narrow-spectrum
antibiotic is used in targeted therapy.
• Combination therapy is usually used in 3 situations as following:

a. To increase efficacy ( eg: enterococcal endocarditis )

b. When no single antibiotic covers all potential pathogens (eg: sepsis)

c. To reduce antibiotic resistance (eg: T.B)

1) Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, 2) Harvey RA, Clark MA, Finkel R, Rey JA, Whalen K. Lippincott’s illustrated reviews:
Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients. Pharmacology. Philadelphia: Wolters Kluwer; 2012.
Cochrane Database Syst Rev. 2013 Jan 1;4(4).
What is Antimicrobial resistance
(AMR)?

Antimicrobial resistance (AMR) is the ability of a microorganism to stop an

antimicrobial from working against it.

• Microorganisms include bacteria, viruses, fungi and parasites.

• Antimicrobials include antibiotics, antivirals, antifungals and

antimalarials.

As a result of AMR, standard treatments become ineffective, infections

persist and may spread to others.

https://www.who.int/antimicrobial-resistance/en/ as accessed on 30th August 2019

How Antimicrobial Resistance Happens ?

https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf
 Causes of antimicrobial resistance
Factors Contribution
Poor drug Sales of counterfeit, adulterated and poor
quality quality antibiotics
Regulators While most developed countries have
developed AMR action plans, this is still lacking regarding the manufacture and distribution of
in many developing countries especially in
Africa
Prescribers Excessive clinical use and misuse is partially
responsible for increased rate of resistance
Dispensers Drug vendors usually have little or no
knowledge of the required dosage regimen,
indication, or contraindications
Users High rate of self- medication and lack of
(patients) treatment compliance
Animal The use of antimicrobial drugs in agriculture or
industry industrial settings, exerts a selection pressure
which can favor the survival of resistant strains
(or genes) over susceptible ones, leading to a
relative increase in resistant bacteria within
microbial communities
Example
These poor quality antibiotics can produce sub-
inhibitory concentration in vivo, which increases the
selection of resistant strains
Most countries lack the resources to enforce policies
substandard drugs
Variation in prescription practice among health care
providers. Sometimes there is prescription of a wrong
drug, wrong doses, or an antimicrobial not necessary at
all
Medications are usually purchased in small aliquots
from roadside stall and storage and distribution is
usually done under inadequate conditions
Patients fail to adhere to dosage regimens and
discontinue treatment when symptoms subside before
pathogen is eliminated
Resistant bacteria in animals can be transferred to
humans through the consumption of food or through
direct contact with food-producing animals or through
environmental spread
Ayukekbong et al. Antimicrobial Resistance and
Infection Control (2017) 6:47
 Patterns of irrational use of antibiotics
Leading to AMR
1.Self-prescription which means the selection and use of medicines by individuals to treat self-
recognized illnesses or symptoms (Eg: using antibiotics for viral infections)
2.The use of wrong drug, which is either the doctor’s mistake or the pharmacist’s mistake but it also
can be the nurse’s mistake. (Eg: use of methionine instead of ORS in case of viral diarrhea )
3.The use of the correct drug on the appropriate patient but with incorrect doses, this problem can be
caused by anyone of the health care staff, and sometimes the patient himself thinks that taking a
higher dose would be better when it’s actually worse .
4.The use of the correct drug but with wrong duration, (eg: some patients take the drug for short
periods and when the feel slightly better they stop taking the drug and this what will cause antibiotics
resistance).

5. The use of unnecessary expensive drugs, thinking it’s better for them !

6. Overuse of antibiotics
7.Multiple drug presentation, which in some cases cause harmful drug-drug interactions (Eg: taking
multiple antibiotics with the same effect at the same time )
8.Self antibiotics use (using antibiotic leftovers), or in some cases sharing the drug prescription with
other patients.
Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, Ramsay CR, Wiffen PJ, Wilcox M. Interventions to improve antibiotic prescribing practices for hospital inpatients.
Cochrane Database Syst Rev. 2013 Jan 1;4(4).
Examples of How Antibiotic Resistance
Spreads

https://www.cdc.gov/drugresistance/pdf/ar-threats-2013-508.pdf
 WHO multi-country survey

The 2015 WHO multi-country survey revealed widespread public

misunderstanding about antibiotic usage and resistance
Three quarters (75%) of
respondents think, More than three quarters (76%)
incorrectly, of respondents report having
that colds and flu can be taken antibiotics within the past 6
treated
with antibiotics.
Highlights from months.

India
Only 58% know that
72% of respondents believe
they should stop taking
experts will solve the
antibiotics only when
problem before it becomes
they finish the course
too serious.
as directed.

www.searo.who.int/india/topics/antimicrobial_resistance/Combating_Antimicrobial_
Resistance_in_India/en/ as accessed on 30th August 2019
 Consequences of AMR

 Increases in the cost of health care

 Lengthier stays in hospitals
More consumption of health-care resources
Worse clinical outcomes
Increases mortality rate

https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance as accessed on 30th August 2019

 Mortality due to AMR

Two million deaths are projected to occur in India due to AMR by the year 2050
https://www.weforum.org/agenda/2018/03/india-s-war-on-antimicrobial-resistance as accessed on 30th August,
http://www.ijcm.org.in as accessed on 31st August 2019
Strategies to contain and minimize the development of
antimicrobial resistance

Ayukekbong et al. Antimicrobial Resistance and Infection Control (2017) 6:47

Antimicrobial Stewardship- A way to Combat AMR
• Antimicrobial stewardship refers to coordinated interventions designed to
improve and measure the appropriate use of antimicrobials by promoting
the selection of the optimal antimicrobial drug regimen, dose, duration of
therapy, and route of administration.

• Purpose:

– Limit inappropriate and excessive antibiotic use

– Improve and optimize therapy and clinical outcomes for the

individual infected patient

Clin Infect Dis, 2009, 49(8):1175-1184

Antimicrobial Stewardship Programme

Information Microbiology
Technology Lab

Monitoring of
Supplemental Process and
Strategies outcome
measurement

Effective
Active Team
Strategies antimicrobial Approach
Stewardship

IDSA (Infectious Diseases Society of America) Practice Guidelines for antimicrobial Stewardship Programs, 17th Annual seminar, 2013
Antibiotic Stewardship Improves Clinical
Outcomes
Optimal antibiotic use- Advise for Patients

https://www.who.int/docs/default-source/antibiotic-awareness-week/2018-waaw-how-to-guide final.pdf?Status=Temp&sfvrsn=b3e4d84c_12
https://www.healthinfi.com/how-do-antibiotics-work/
 Conclusion
• An antimicrobial stewardship programme is essential to promote the

judicious use of antibiotics.

• An understanding of the pharmacodynamics is essential to optimize

the use of antibiotics based on individual patient characteristics.

• Change from intravenous to oral and de-escalation need to be

addressed and implemented.