ANTIBIOTICS IN RELATION TO INFECTION PREVENTION AND CONTROL Dr. T. B. Menge B. Pharm; M.Sc (Pharmacology & Toxicology) . DEPUTY CHIEF PHARMACIST, KENYATTA NATIONAL HOSPITAL .
WHY DO WE NEED TO BE CONCERNED ABOUT ANTIBIOTIC US E?
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Current Status Antimicrobials are among the most commonly used medicines More than 30% of all hospitalized patients are treated with one or more courses of antibiotics KNH Study: NBU: 48% medicines used; 75% patients on 1- 4 antibiotics ICU: 70% patients on antibiotics 22% medicines prescribed Antimicrobials among most MISUSED medicines 50% all viral infection treated with antibiotics
WHAT INFLUENCES A DOCTOR TO PRESCRIBE ANTIBIOTICS?
WHAT INFLUENCES A DOCTOR TO PRESCRIBE ANTIBIOTICS? The reasons driving unnecessary prescribing are complex, but include pressures from patients and parents, constraints on physician time, a lack of appreciation of the possible impact on resistance 1. Felmingham et al. J Antimicrob Chemother 2000; 45 :191–203 2. Macfarlane et al. BMJ 1997; 315 :1211–1214 3. Ball et al. J Antimicrob Chemother 2002; 49 :31–40
Pe e r g roups / pre sc ribing a nd pha rma c y a dvisors Pha rma c e utic a l Pa tie nts’ or re pre se nta tive s Pa re nt’s de ma nds Doc tor’s Re g ula tory a spira tions c ontrol me c ha nisms Hospita l e xpe rts, F ormula rie s a nd g uide line s
Acute respiratory infection Case: 40-year-old male with non-productive cough x 4 days; non-smoker; no comorbidity Exam: Afebrile; P-72; R-20; lungs – no localized findings Survey of PCPs: No Yes Should antibiotics be used? 90% 10% Would antibiotics be used? 12% 88% Tom File: Personal Communication
Relationship between pneumococcal resistance and beta-lactam usage 25 SPA 20 POR DDD/1000/day ITA 15 BEL LUX IRE 10 SWE FIN UK 5 GER NET 0 0 5 10 15 20 25 30 35 % Resistance Adapted from Bronzwaer et al . Emerg Infect Dis 2002; 8:278–282
Risk factors for the development of antibacterial resistance Low antibacterial dosages and long treatment duration are risks for carriage of penicillin- resistant S. pneumoniae Guillemot et al . JAMA 1998; 2 7 9 : 365–370 The risk of carrying penicillin-resistant S. pneumoniae increases by 4% for each additional day of antibacterial use in the previous 6 months Nasrin et al. BMJ 2001; 3 2 3 : 1–4 Short-course, high-dose amoxicillin therapy reduces pneumococcal carriage and minimizes the impact of therapy on drug-resistant pneumococci Schrag et al . JAMA 2001; 2 8 6 : 49–59
I m prove antibiotic use Monitor and provide feedback on occurrence of AMR Optim ize choice and duration of em piric antim icrobial therapy Optim ize antim icrobial prophylaxis I m plem ent form ulary restrictions for im portant types of antim icrobial use
I m prove antibiotic use Monitor and provide feedback on occurrence of AMR
Patient X, transferred from Kisum u | ( 1) x1 | ( 2) x1 | ( 3) x1 | ( 4) x1 | | ( 1) x1 | ( 2) x1 | ( 3) x1 | ( 4) x1 | ANTI BI O ANTI BI O G G RAM RAM M M ES | Aci net obact er | E. col i | S aur eus | ES | Aci net obact er | E. col i | S aur eus | | | | | | | | | - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Peni ci l l i ne G Peni ci l l i ne G | | | | RESI ST | | | | | RESI ST | Fl ucl oxaci l l i ne | | | | RESI ST | Fl ucl oxaci l l i ne | | | | RESI ST | Am Am oxi ci l l i ne | RESI ST | RESI ST | RESI ST | | oxi ci l l i ne | RESI ST | RESI ST | RESI ST | | Co- am Co- am oxi cl av | I NTERM oxi cl av | I NTERM | RESI ST | RESI ST | | | RESI ST | RESI ST | | I s this patient in your I CU? Pi per aci l l i ne | RESI ST | RESI ST | RESI ST | | Pi per aci l l i ne | RESI ST | RESI ST | RESI ST | | Pi per ac. +t azob | RESI ST | RESI ST | I NTERM Pi per ac. +t azob | RESI ST | RESI ST | I NTERM | | | | - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Can you treat his infection? Cef ur oxi m Cef ur oxi m e | RESI ST | RESI ST | RESI ST | RESI ST | e | RESI ST | RESI ST | RESI ST | RESI ST | Cef t azi di m Cef t azi di m e | I NTERM e | I NTERM | RESI ST | RESI ST | RESI ST | | RESI ST | RESI ST | RESI ST | Cef t r i axone | RESI ST | RESI ST | RESI ST | RESI ST | Cef t r i axone | RESI ST | RESI ST | RESI ST | RESI ST | Can you prevent cross-infection? Cef epi m Cef epi m e | I NTERM e | I NTERM | RESI ST | RESI ST | RESI ST | | RESI ST | RESI ST | RESI ST | I m I m i penem i penem | S | I NTERM | S | I NTERM | S | RESI ST | | S | RESI ST | Azt r eonam Azt r eonam | | | | RESI ST | | | | | RESI ST | - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + Am Am i kaci ne | RESI ST | S | RESI ST | I NTERM i kaci ne | RESI ST | S | RESI ST | I NTERM | | G G ent am ent am i ci ne | RESI ST | RESI ST | S | S | i ci ne | RESI ST | RESI ST | S | S | Tobr am Tobr am yci ne | | RESI ST | | S | yci ne | | RESI ST | | S | - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + Nor f l oxaci ne | RESI ST | RESI ST | S | RESI ST | Nor f l oxaci ne | RESI ST | RESI ST | S | RESI ST | Ci pr of l oxaci ne | | RESI ST | S | S | Ci pr of l oxaci ne | | RESI ST | S | S | - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + Cl i ndam Cl i ndam yci ne | | | | S | yci ne | | | | S | Er yt hr om Er yt hr om yci ne | | | | RESI ST | yci ne | | | | RESI ST | - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - + - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +
Antibiotic tre a tme nt without mic robiolog ic c ulture s in China (Hospita l) a nd Ne pa l (ICU) 1 0 0 9 0 8 0 7 0 % 6 0 5 0 No culture 4 0 3 0 Culture 2 0 1 0 0 China Ne pa l n=466 n=149 Suping Hu e t a l. J I nfe c t 2003; 46:161-63 Sha nkar e t a l. Am J I nfe c t Co ntro l 2003; 31: 410-14
I m prove antibiotic use Monitor and provide feedback on occurrence of AMR Optim ize choice and duration of em piric antim icrobial therapy
Surviva l Among 401 Pa tie nts with Nosoc omia l Pne umonia Assig ne d to Short (8 d) or L ong (15 d) Antimic robia l T re a tme nt 1.0 Proba bility of Surviva l 8- da y 0.8 15- da y 0.6 0.4 0.2 0.0 0 10 20 30 40 50 60 Da ys a fte r Bronc hosc opy Courtesy: J. Chastre, Paris JAMA 2003; 290: 2588-98
E me rg e nc e of multire sista nt pa thog e ns for pa tie nts who ha d pulmona ry infe c tion re c urre nc e 80% P = 0.04 60 62.3% 40 42.1% 20 0 “8-da y” “15-da y” (n=197) (n=204) Courtesy: J. Chastre, Paris JAMA 2003; 290: 2588-98
I m prove antibiotic use Monitor and provide feedback on occurrence of AMR Optim ize choice and duration of em piric antim icrobial therapy Optim ize antim icrobial prophylaxis
Common Misc onc e ptions in Surg ic a l Prophyla xis Bro a d-spe c trum is b e tte r L o ng e r a ntib io tic pro phyla xis is b e tte r Pro phyla xis sho uld b e c o ntinue d until a ll “tub e s” a re o ut
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