Rational Use of Antibiotics in Hospital- and Community-Acquired Infections

Iman M. Fawzy; MD, MSc, PhDConsultant of Clinical PathologyANTIBIOTICPOLICY

Rational Use of AntibioticsThe conference of experts on the rational use of drugs, by the WHO in 1985 defined that

Rational use of drugs requires that patients receive medications appropriately to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, at the lowest cost to them and their community

Reasons for Patient ConcernsWant clear explanationGreen nasal dischargeNeed to return to workPhysician ConcernsPatient expects antibioticDiagnostic uncertaintyTime pressure

Antibiotic Prescription

Antibiotic Overuse

Antibiotic Resistance

New Resistant Bacteria

MutationsXXEmergence of Antibiotic ResistanceSusceptible Bacteria

Resistant Bacteria

Resistance Gene Transfer

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Resistant StrainsRare

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Resistant Strains DominantAntimicrobial Exposure

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Selection for Antibiotic-Resistant Strains

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

Emergence of antibiotic resistance5. Pray LA Insight Pharma Reports 2008, in Looke D The Real Threat of Antibiotic Resistance 2012

The time it takes for bacteria to develop resistance is decreasing.Start of line = time of antibiotic discovery, End of line = when resistance reportedMore recently the time between discovery and development of resistance has become much shorter.

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Resistance spreads rapidly

11Once resistance develops it spreads rapidly. This graph from the Center of Disease Control in the US demonstrates how quickly resistant strains of MRSA, VRE and fluoroquinolone resistant Pseudomonas aeruginosa have spread.

Impact of resistanceUntreatable infections

Excess length of stay Increased morbidity/ mortalityIncreased costsInterference with patients normal flora.

Selection of drug resistant organisms

Increased side effects

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Settings that favor antimicrobial resistanceImmune compromised patients e.g.ICUOncology unitDialysis unitRehabilitation unitTransplantation unitBurn unit

Antibiotic policy

Aim of Antibiotic Policy

Objectives of Antibiotic Policy

Scope of hospital antibiotic policyprophylaxis, empirical and definitive therapy. high-risk/special groups e.g. immune compromised hosts; hospital-associated infections and community-associated infections.The hospital antibiotic policy shall be based upon:spectrum of antibiotic activitypharmacokinetics/pharmacodynamics of antibiotic sadverse effectspotential to select resistancecostspecial needs of individual patient groups.

Surveillance of antimicrobialresistanceUse standardsGenerate reliable numerator: only the first positive culture from the patient for each disease episode should be reported for surveillance purposes.Express resistance as incidence rateParticipate in external quality assessment schemesPrediction of evolution of antimicrobial resistanceSurveillance 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 or infection site, by nursing unit or site of care, by organisms resistance characteristics, by clinical service or patient population.Reviewing the cumulative antibiogram data if clinical failure occurs after empiric therapy.Comparing the cumulative antibiogram with national data.

Development of standard treatment guidelines

Should be based on local antibiograms.Should be syndrome/diseased based.Should specify type of clinical setting Outpatient clinics, Inpatient units, ICU setting.Should involve treating physicians to bring ownership to the guidelines

Direction of antibiotic policyFrame the hospital own list of therapeutic antibiotic categories: First-line Reserved agents Restricted agents Withdrawn agentsfor example, first choice antibiotics can be prescribed by all doctors while restricted choice antibiotics can only be prescribed after consulting the head of the department or the antimicrobial team (AMT) representative. Reserve antibiotics, are prescribed only by designated experts.

Minimizing selection of resistant organismsWhat should not be doneTreat 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 activity not indicated.

InterventionsContinuous surveillance of bacterial infections.

InterventionsProhibiting the sale of antibiotics without medical prescription. Development of regulations by Ministries of Health regarding responsible prescription of antibiotics.Prohibition of advertising of antibiotics in the community by industry and pharmaceutical representatives.

Community pharmacistPharmacist should be able to prescribe certain antibiotics in appropriate circumstances to patients needing treatment for particular conditions Advice to patients to ensure that the patient understands that:Antibiotic must be used properly Help and encourage Health Authorities. Ensure the implementation of the policies

Prevent Antimicrobial Resistance

12 Contain your contagion 11 Isolate the pathogen 10 Stop treatment when cured 9 Know when to say no to antibiotic 8 Treat infection, not colonization 7 Treat infection, not contamination 6 Use local data 5 Practice antimicrobial control 4 Access the experts3 Target the pathogen 2 Get the catheters out 1 Vaccinate

Prevent Transmission

Use Antimicrobials Wisely

Diagnose and Treat Effectively

Prevent InfectionClinicians hold the solution

32Clinicians hold the solution to antimicrobial resistanceThe 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults is one of the new tools to encourage clinicians to engage in actions that will promote patient safety and prevent antimicrobial-resistant infections The evidence-based action steps are designed to optimize the care of individual patients in the era of widespread antimicrobial resistanceAdditional 12 Steps to Prevent Antimicrobial Resistance programs addressing other target patient populations, including children, geriatric patients, dialysis patients, surgical patients, etc, will be available soon!

Antimicrobial Resistance: Key Prevention Strategies

Optimize Use

PreventTransmission

PreventInfectionEffectiveDiagnosisand Treatment

Pathogen

Antimicrobial-Resistant Pathogen

Antimicrobial Resistance

Antimicrobial Use

InfectionSusceptible Pathogen

33Once a pathogen produces infection, antimicrobial treatment may be essentialHowever, antimicrobial use promotes selection of antimicrobial-resistant strains of pathogensAs the prevalence of resistant strains increases in a population, subsequent infections are increasingly likely to be caused by these resistant strainsFortunately, this cycle of emerging antimicrobial resistance/multidrug resistance can be interruptedPreventing infections in the first place will certainly reduce the need for antimicrobial exposure and the emergence and selection of resistant strainsEffective diagnosis and treatment will benefit the patient and decrease the opportunity for development and selection of resistant microbes; this requires rapid accurate diagnosis, identification of the causative pathogen, and determination of its antimicrobial susceptibility Optimizing antimicrobial use is another key strategy; optimal use will ensure proper patient care and at the same time avoid overuse of broad-spectrum antimicrobials and unnecessary treatment Finally, preventing transmission of resistant organisms from one person to another is critical to successful prevention efforts

ANTIMICROBIAL PRESCRIBING: GOOD PRACTICESSend for appropriate investigations in all infections. All antibiotic initiations would be done after sending appropriate culturesFollow Hospital policy when choosing antimicrobial therapy whenever possible. Check for factors which will affect drug choice, eg, renal function, interactions, allergy.Check that the appropriate dose is prescribed. The need for antimicrobial therapy should be reviewed on a daily basis. Once culture reports are available, the physician shall step down to the narrowest spectrum, most efficacious and most cost effective option.

Empiric TherapyWhere delay in initiating therapy to await microbiological results would be life threatening or risk serious morbidity, antimicrobial therapy based on a clinically defined infection is justified.

Where empiric therapy is used, the accuracy of diagnosis should be reviewed regularly and treatment altered/stopped when microbiological results become available.

Empiric TherapySide effects empirical antibiotics :Development of resistance in pathogens infecting the patient.Risk for spread of resistance.Suppression of normal flora.Development of resistance in normal flora.Risk for super infection.

Hand Washing is Important BecauseHand hygiene compliance rates of 10%-40% have been observed in the developed countries.

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