Upload
drtv-rao
View
5.224
Download
1
Embed Size (px)
DESCRIPTION
Rationalism of antibiotic therapy
Citation preview
Dr.T.V.Rao MD 1
GUEST TALK AT CHENNAI MEDICAL COLLEGE, HOSPITAL AND RESEARCH CENTRE
TIRUCHIRAPALLI-TAMILNADU
RATIONALSIM OF ANTIBIOTIC THERAPY
DR.T.V.RAO MD
Fleming and Penicillin
Dr.T.V.Rao MD 2
Dr.T.V.Rao MD 3
• The greatest possibility of evil in self-medication is the use of too small doses so that instead of clearing up infection, the microbes are educated to resist penicillin and a host of penicillin-fast organisms is bread out which can be passed to other individuals and from them to other until they reach someone who gets a septicemia or a pneumonia which penicillin cannot save.
Sir AlexanderFlemming
Self Medication
Dr.T.V.Rao MD 4
• 50 penicillin's• 71 cephalosporins• 12 tetracycline's• 8 aminoglycosides• 1 monobactam• 5 Carbapenems
• 9 macrolides• 2 streptogramins• 3 dihydrofolate
reductase inhibitors
• 1 oxazolidinone• 5.5 quinolones
Antibiotic brands
Dr.T.V.Rao MD 5
Evolution of b-LactamasePlasmid-Mediated TEM and SHV Enzymes
AmpicillinThird-GenerationCephalosporins
1963
1965
TEM-1E coliS paratyphi
1970s
TEM-1Reported in28 Gram-NegativeSpecies
1980s1983
ESBLinUnitedStates
1987
ESBL inEurope
2000
>120 ESBLsWorldwide
1920 1930 1940 1950 1960 1970 1980 1990 2000
ertapenem
tigecyclin daptomicin linezolid
telithromicin quinup./dalfop. cefepime ciprofloxacin aztreonam norfloxacin imipenem cefotaxime clavulanic ac. cefuroxime gentamicin cefalotina nalidíxico ac. ampicillin methicilin vancomicin rifampin chlortetracyclin streptomycin pencillin G prontosil
The development
of anti-infectives …
Development of anti-microbials
Dr.T.V.Rao MD 6
Dr.T.V.Rao MD 7
1962 and 2000, no major classes of antibiotics were introduced
Fischbach MA and Walsh CT Science 2009
A Changing Landscape forNumbers of Approved Antibacterial Agents
Bars represent number of new antimicrobial agents approved by the FDA during the period listed.
00
2
4
6
8
10
12
14
16
18
Num
ber o
f age
nts
appr
oved
1983-87 1988-92 1993-97 1998-02 2003-05 2008
Infectious Diseases Society of America. Bad Bugs, No Drugs. July 2004; Spellberg B et al. Clin Infect Dis. 2004;38:1279-1286;New antimicrobial agents. Antimicrob Agents Chemother. 2006;50:1912
Resistan
ce
Dr.T.V.Rao MD 9
Dr.T.V.Rao MD 10
Antibiotics• Biology and Society
About 50% of the antibiotics produced today are used in the livestock industry.
What impact does this have on the treatment of human diseases?
Dr.T.V.Rao MD 11
ANTIMICROBIAL RESISTANCE:The role of animal feed antibiotic additives
• 48% of all antibiotics by weight is added to animal feeds to promote growth. Results in low, sub therapeutic levels which are thought to promote resistance.
• Farm families who own chickens feed tetracycline have an increased incidence of tetracycline resistant fecal flora
Dr.T.V.Rao MD 12
Prescribing an antibiotic Is an antibiotic necessary ? What is the most appropriate
antibiotic ? What dose, frequency, route and
duration ? Is the treatment effective ?
Dr.T.V.Rao MD 13
How are antibiotics overused or Misused?
• Seven out of ten Americans receive antibiotics when they seek treatment for a common cold! Only one-third of patients use antibiotics the way doctors tell them.
• This allows bacteria to become resistant by not killing them completely.
Dr.T.V.Rao MD 14
Antibiotic PrescribingChildren are real Concern
• Antibiotics were prescribed in 68% of acute respiratory tract visits – and of those, 80% were unnecessary according to CDC guidelines
• Children are of particular concern because they have the highest rates of antibiotic use.
Dr.T.V.Rao MD 15
We too Contribute for Creating Drug Resistance
• Every time a person takes antibiotics, sensitive bacteria are killed, but resistant microbes may be left to grow and multiply. Repeated and improper uses of antibiotics are primary causes of the increase in drug-resistant bacteria.
Dr.T.V.Rao MD 16
The consequences of antibiotic resistance
• Increased morbidity & mortality– “best-guess” therapy may fail with the patient’s
condition deteriorating before susceptibility results are available
– no antibiotics left to treat certain infections
• Greater health care costs– more investigations– more expensive, toxic antimicrobials required– expensive barrier nursing, isolation, procedures, etc.
• Therapy priced out of the reach of some third-world countries
Dr.T.V.Rao MD 17
Costs Associated withIncreased Bacterial
Resistance• ↑Treatment failures• ↑Morbidity and mortality• ↑Risk of hospitalization• ↑Length of hospital stays• ↑Need for expensive and broad
spectrum antibiotics
Dr.T.V.Rao MD 18
Social factors fuelling resistance
• Poverty encourages the development of resistance through under use of drugs– Patients unable to afford the full course of
the medicines – Sub-standard & counterfeit drugs lack
potency• Globalization, increased travel and
trade ensure that resistant strains quickly travel elsewhere. So does excessive promotion.
Dr.T.V.Rao MD 19
Developed countries Overuse
• In wealthy countries, resistance is emerging for the opposite reason – the overuse of drugs.
• Unnecessary demands for drugs by patients are often eagerly met by health services and stimulated by pharmaceutical promotion
• Overuse of antimicrobials in food production is also contributing to increased drug resistance.
Classification of Pencillins• Natural Benzyl penicillin Phenoxymethyl penicillin Penicillin v Semi synthetic and pencillase resistant 1 Methicillin 2 Nafcillin 3 Cloxacillin 4 Oxacillin 5 Floxacillin
Dr.T.V.Rao MD 20
• Contain macro cyclic lactone ring Erythromycin. Is popularly used drug
• Other drugs Roxithromycin,Azithromycin
• Inhibits the protein synthesis.
• Used as alternative to pencillin allergy patients.
Macrolides,Azalides,Ketolides
Dr.T.V.Rao MD 21
Dr.T.V.Rao MD 22
• Like penicillin acts similar
• Products of the molds of genus Cephalosporium except cefoxilin
• Divided into 4 generation of Cephalosporins depending on the spectrum of activity.
Cephalosporins
Dr.T.V.Rao MD 23
Dr.T.V.Rao MD 24
Major generations of Cephalosporins
• Cephalosporins are divided into 3 generations:• 1st generation: Cephalexin, cefadroxil,
cephradine • 2nd generation: Cefuroxime, cofactor • 3rd generation: cefotaxime, Ceftazidime,
cefepime - these give the best CNS penetration • 4th generation Cephalosporins are already
available
• Cephalosporins are grouped into "generations" based on their spectrum of antimicrobial activity. The first Cephalosporins were designated first generation while later, more extended spectrum Cephalosporins were classified as second generation Cephalosporins.
Different Generations of Cephalosporins
Dr.T.V.Rao MD 25
Dr.T.V.Rao MD 26
5th Generation Cephalosporins
• Ceftaroline is a new intravenous (IV) cephalosporin that was FDA-approved October 2010. It is labelled for the treatment of adults with infections caused by susceptible bacteria, specifically skin and skin structure infections (SSSIs) caused by methicillin-sensitive
Dr.T.V.Rao MD 27
5th Generation Cephalosporins
• Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), Streptococcus pyogenes, Streptococcus agalactiae, Escherichia coli, Klebsiella pneumoniae, or Klebsiella oxytoca; and community acquired pneumonia (CAP) caused by Streptococcus pneumoniae (with or without concurrent bacteraemia), MSSA, E coli, Haemophilus influenza, K.pneumoniae, or K oxytoca
Dr.T.V.Rao MD 28
Ceftaroline is effective …
• Ceftaroline is a fifth generation cephalosporin with excellent activity against GPCs including MRSA & DRSP Affinity for all PBPs including PBP 2’ and PBP 2X Not ESBL stable, Not active against Non fermenters
Dr.T.V.Rao MD 29
• Several studies have demonstrated that patterns of antibiotic usage greatly affect the number of resistant organisms which develop. Overuse of broad-spectrum antibiotics, such as second- and third-generation Cephalosporins, generate resistant strains.
Irrational Use of Third Generation Cephalosporins
Dr.T.V.Rao MD 30
Advantages with Newer generations
• Each newer generation of cephalosporins has significantly greater gram-negative antimicrobial properties than the preceding generation, in most cases with decreased activity against gram-positive organisms. Fourth generation cephalosporins, however, have true broad spectrum activity
Dr.T.V.Rao MD 31
Other Beta-lactams include• Other beta-lactams include:• Aztreonam: a monocytic beta-
lactam, with an antibacterial spectrum which is active only against Gram negative aerobes, including Pseudomonas aeruginosa, Neisseria meningitides and N. gonorrhoea.
Dr.T.V.Rao MD 32
How are Carbapenems Used?
Uses by Clinical Syndrome• Bacterial meningitis• Hospital-associated
sinusitis• Sepsis of unknown origin• Hospital-associated
pneumonia
Use by Clinical Isolate Acinetobacter spp. Pseudomonas aeruginosa Alcaligenes spp. Enterobacteriaceae
Mogenella spp. Serratia spp. Enterobacter spp. Citrobacter spp. ESBL or AmpC + E. coli
and Klebsiella spp.
Reference: Sanford Guide
Spectrum of ActivityDrug
Strep spp. &MSSA
Entero-bacteriaeae
Non-fermentors
Anaerobes
Imipenem + + + +
Meropenem + + + +
Ertapenem + + Limited activity +
Doripenem + + + +
Dr.T.V.Rao MD 34
Emerging Carbapenem Resistance in Gram-Negative Bacilli
• Significantly limits treatment options for life-threatening infections
• No new drugs for gram-negative bacilli • Emerging resistance mechanisms,
carbapenemases are mobile, • Detection of carbapenemases and
implementation of infection control practices are necessary to limit spread
Daptomycin (Cubicin®)• New drug class (lipopeptide)• Rapidly bactericidal• New mechanism of action: acts by
binding to cell membrane and disrupting the cell membrane potential
• No cross resistance• Dose: 4-6 mg/kg once daily
• Imipenem: a carbapenem with a broader spectrum of activity against Gram positive and negative aerobes and anaerobes. Needs to be given with cilastatin to prevent inactivation by the kidney.
Other drugs
Dr.T.V.Rao MD 36
• Quinolones are the first wholly synthetic antimicrobials. The commonly used Quinolones.
• Act on the DNA gyrase which prevents DNA polymerase from proceeding at the replication fork and consequently stopping synthesis.
Quinolones
Dr.T.V.Rao MD 37
• Aminoglycosides are group of antibiotics in which amino sugars liked by glycoside bonds
• Eg Streptomycin, • Act at the level of Ribosome's
and inhibits protein synthesis• Other Aminoglycosides –
Gentamycin, neomycins,paromomycins,tobramycins Kanamycins and
spectinomycins
Aminoglycosides
Dr.T.V.Rao MD 38
Dr.T.V.Rao MD 39
• Broad spectrum antibiotic produced by Streptomyces species
• 1. Oxytetracycle, chlortetracycle and tetracycline
• Tetracyclnes are bacteriostatic drugs inhibits rapidly multiplying organisms
• Resistance develops slowly and attributed to alterations in cell membrane permeability to enzymatic inactivation of the drug
Tetracycline's
Dr.T.V.Rao MD 40
• Lincomycins Clindamycin
resembles Macrolides in biting site and antimicrobial activity.
Streptogramins Quinpristin /
dalfopristin useful in gram
positive bacteria
Other Antimicrobial agents
Dr.T.V.Rao MD 41
• Major anaerobes – Anaerobic cocci, clostridia and Bactericides are susceptible to Benzyl pencillin
• Bact.fragilis as well as many other anaerobes are treatable with Erythromycin,Lincomycin, tetracycline and Chloramphenicol
• Clindamycin is effective against many strains of Bacteroides
Antibiotics in Anaerobes
Dr.T.V.Rao MD 42
• Since the discovery of Metronidazole in 1973 since then it was identified as leading agent anaerobes.
• But also useful in treating parasitic infections
Trichomonas, Amoebiasis and other protozoan infections.
Metronidazole in Anaerobic Infections
Dr.T.V.Rao MD 43
Treatment of N. gonorrhoea
• Only current CDC-recommended options for treating N. gonorrhoea infections are from a single class of antibiotics, the cephalosporins. – Ceftriaxone, available only as an injection, is the
recommended treatment for all types of gonorrhea infections (i.e., urogenital, rectal, and pharyngeal).
– Cefixime is the only oral agent recommended for treatment of uncomplicated urogenital or rectal gonorrhea
Reduced susceptibility to cefixime being described in Japan and other countries
• In spite discovery of several antibiotics several microorganisms attained resistance.
• The major factor contributing to persistence of infectious disease has been the tremendous capacity of microorganisms for circumventing the action of inhibitory drugs.
• The drug resistance continues to be a threat for usefulness of the chemotherapeutic agents.
Drug Resistance
Dr.T.V.Rao MD 45
< Use of antibiotics with no clinical indication (eg, for viral infections)
< Use of broad spectrum antibiotics when not indicated
< Inappropriate choice of empiric antibiotics
Inappropriate Antibiotic Use
Dr.T.V.Rao MD 46
• If a bacterium carries several resistance genes, it is called multiresistant or, informally, a superbug. The term antimicrobial resistance is sometimes use to explicitly encompass organisms other than bacteria
Multi Drug resistant pathogens
Dr.T.V.Rao MD 47
Extended-Spectrum β-Lactamases
• β-lactamases capable of conferring bacterial resistance to
– the penicillins– first-, second-, and third-generation
cephalosporins– aztreonam – (but not the cephamycins or carbapenems)
• These enzymes are derived from group 2b β-lactamases (TEM-1, TEM-2, and SHV-1)
– differ from their progenitors by as few as one AA
Dr.T.V.Rao MD 48
• Antibiotic resistance has become a serious problem in both developed and underdeveloped nations. By 1984 half of those with active tuberculosis in the United States had a strain that resisted at least one antibiotic. In certain settings, such as hospitals and some childcare location
Antibiotic Resistance Threat to Humans and Animals
Dr.T.V.Rao MD 49
Carbapenemases• Ability to hydrolyze penicillins, cephalosporins,
monobactams, and carbapenems• Resilient against inhibition by all commercially viable ß-
lactamase inhibitors– Subgroup 2df: OXA (23 and 48) carbapenemases– Subgroup 2f : serine carbapenemases from molecular class
A: GES and KPC – Subgroup 3b contains a smaller group of MBLs that
preferentially hydrolyze carbapenems• IMP and VIM enzymes that have appeared globally, most
frequently in non-fermentative bacteria but also in Enterobacteriaceae
Dr.T.V.Rao MD 50
• KPCs are the most prevalent of this group of enzymes, found mostly on transferable plasmids in K. pneumonia
• Substrate hydrolysis spectrum includes
cephalosporins and carbapenems
K. pneumonia carbapenemases)
Dr.T.V.Rao MD 51
Dr.T.V.Rao MD 52
Consequences of Antibiotic drug Resistance
• People infected with drug-resistant organisms are more likely to have longer and more expensive hospital stays, and may be more likely to die as a result of the infection. They require treatment with second- or third-choice drugs that may be less effective, more toxic, and more expensive. This means that patients with an antimicrobial-resistant infection may suffer more and pay more for treatment. (Issues with Insurance)
Dr.T.V.Rao MD 53
Emerging Trends in Antibiotic Resistance
• Reports of methicillin-resistant Staphylococcus aureus (MRSA)—a potentially dangerous type of staph bacteria that is resistant to certain antibiotics and may cause skin and other infections—in persons with no links to healthcare systems have been observed with increasing frequency in the United States and elsewhere around the globe.
Dr.T.V.Rao MD 54
Gram negative bacteria a great threat
• Multi-drug resistant Klebsiella species and Escherichia coli have been isolated in hospitals throughout the United States.
• It is a Universal phenomenon
Dr.T.V.Rao MD 55
WHAT NEXT • Indian hospitals have reported very high
Gram-negative resistance rates, with very high prevalence of ESBL (Extended Spectrum Beta Lactamases) producers and also high carbapenem resistance rates. Increasing carbapenem resistance will invariably result in increased usage of colistin, currently the last line of defence, with a potential for colistin-resistant and Pan Drug Resistant bacterial infections.
Dr.T.V.Rao MD 56
Fungi too becoming resistant
• Antimicrobial resistance is emerging among some fungi, particularly those fungi that cause infections in transplant patients with weakened immune systems.
Dr.T.V.Rao MD 57
Resistance in Virus• Antimicrobial
resistance has also been noted with some of the drugs used to treat human immunodeficiency virus (HIV) infections and influenza.
Dr.T.V.Rao MD 58
Parasites too are Problematic• The development of
antimicrobial resistance to the drugs used to treat malaria infections has been a continuing problem in many parts of the world for decades. Antimicrobial resistance has developed to a variety of other parasites that cause infection.
•
Dr.T.V.Rao MD 59
Identification of The Etiological Agent
Laboratory diagnosis Interpretation of the report What is isolated is not necessarily the
pathogen Was the specimen properly collected ? Is it a contaminant or colonizer ? Sensitivity reports are at best a guide
Dr.T.V.Rao MD 60
• The role of combination antimicrobial therapy for the prevention of resistance is limited to those situations in which there is
A high organism load A high frequency of
mutational resistance during therapy.
• Classic examples are tuberculosis or HIV infection.
Limitations of combination of antibiotics
Dr.T.V.Rao MD 61
Problems With Improper Use of Antibiotics
• They don’t help the patient at all• Expense: 75% of outpatient antibiotics are used for
respiratory infections• Patient expectations: why no better?• Side effects: diarrhea, rash, allergy
• Development of resistance: the antibiotic won’t work when you really DO need it for a bacterial infection
Dr.T.V.Rao MD 62
WHO global strategy on reducing the antibiotic resistance
• The WHO Global Strategy for Containment of Antimicrobial Resistance identifies the establishment and support of microbiology laboratories as a fundamental priority in guiding and assessing intervention efforts.
Dr.T.V.Rao MD 63
Importance of local antibiotic Resistance data
Resistance patterns vary From country to country From hospital to hospital in the same country From unit to unit in the same hospital
Regional/Country data useful only for looking at trends NOT guide empirical therapy
Dr.T.V.Rao MD 64
Streamlining or De-Escalation of Therapy
–On the basis of culture and sensitivity reports we can more effectively target the causative pathogens, by elimination of redundant combination therapy
–Resulting in decreased Ab exposure and substantial cost savings
Dr.T.V.Rao MD 65
• Training and educating health care professionals on the appropriate use of antibiotics must include appropriate selection, dosing, route, and duration of antibiotic therapy. To ensure that training and education is working, there should be extensive collaboration between the antibiotic stewardship and hospital infection prevention and control teams.
Continuous Medical Education a Must ..
Dr.T.V.Rao MD 66
Antibiotic Pressure and Resistance in Bacteria What factors promote their development and
spread ?
< Alteration of normal flora
< Practices contributing to misuse of antibiotics
< Settings that foster drug resistance
< Failure to follow infection control principles
Dr.T.V.Rao MD 67
< Inappropriate specimen selection and
collection
< Inappropriate clinical tests
< Failure to use stains/smears
< Failure to use cultures and susceptibility tests
Practices Contributing to Misuse of Antibiotics
Dr.T.V.Rao MD 68
Hospital < Intensive care units
< Oncology units
< Dialysis units
< Rehab units
< Transplant units
< Burn units
Settings that Foster Drug Resistance
Dr.T.V.Rao MD 69
What Is Antimicrobial Stewardship?
• A combination of infection control and antimicrobial management• Mandatory infection control compliance• Selection of antimicrobials from each class of drugs that doesthe least collateral damage• Collateral damage issues include– MRSA– ESBLs– C difficile– Stable derepression– MBLs and other carbapenemases– VRE• Appropriate de-escalation when culture results are availableDellit TH, et al. Clin Infect Dis. 2007;44:159-177.
Dr.T.V.Rao MD 70
IDSA Guidelines – Definition ofAntimicrobial Stewardship
• Antimicrobial stewardship is an activity that promotes
– The appropriate selection of antimicrobials
– The appropriate dosing of antimicrobials
– The appropriate route and duration of antimicrobial therapy
Dr.T.V.Rao MD 71
The Primary Goal ofAntimicrobial Stewardship
• The primary goal of antimicrobial stewardship is to
– Optimize clinical outcomes while minimizing unintendedconsequences of antimicrobial use
• Unintended consequences include the following– Toxicity
– The selection of pathogenic organisms, such as C difficile
– The emergence of resistant pathogens
Dr.T.V.Rao MD 72
< Inappropriate specimen selection and collection
< Inappropriate clinical tests
< Failure to use stains/smears
< Failure to use cultures and susceptibility tests
Practices Contributing to Misuse of Antibiotics
Identification of The Etiological Agent
Laboratory diagnosis Interpretation of the report What is isolated is not necessarily the
pathogen Was the specimen properly collected ? Is it a contaminant or colonizer ? Sensitivity reports are at best a guide
Dr.T.V.Rao MD 74
Implementation of WHONET CAN HELP TO MONITOR RESISTANCE
• Legacy computer systems, quality improvement teams, and strategies for optimizing antibiotic use have the potential to stabilize resistance and reduce costs by encouraging heterogeneous prescribing patterns and use of local susceptibility patterns to inform empiric treatment.
Growing importance of WHONET
• World over antimicrobial resistance is a major public health problem. The WHONET software program puts each laboratory data into a common code and file format, which can be merged for national or global collaboration of antimicrobial resistance surveillance
Dr.T.V.Rao MD 75
Dr.T.V.Rao MD 76
Whonet helps us in ……
• The understanding of the local epidemiology of microbial populations; the selection of antimicrobial agents; the identification of hospital and community outbreaks; and the recognition of quality assurance problems in laboratory testing.
Dr.T.V.Rao MD 77
Drugs Under DevelopmentPRSP, MRSA,VISA,VRE
• Lipopetides (Daptomycin: narrow therapeutic index)
• Glycyclines• Glycopeptides (Vancomycin analogues)• Fluoroquinolones • Macrolides/Ketolides• Evernimicin (trials on hold)
Physicians Can Impact
O th e r clin ician s
Patients
Optimize patient evaluation Adopt judicious antibioticprescribing practicesImmunize patients
Optimize consultations with other cliniciansUse infection control measuresEducate others about judicious use of antibiotics
Dr.T.V.Rao MD 78
Dr.T.V.Rao MD 79
• Treatment should be limited to bacterial infections, using antibiotics directed against the causative agent, given in optimal dosage, interval and length of treatment, with steps taken to ensure maximum patient compliance with the treatment regimen and only when the benefit of treatment outweighs the individual and global risks
A good clinical practice saves antibiotics
Dr.T.V.Rao MD 80
• Training and educating health care professionals on the appropriate use of antibiotics must include appropriate selection, dosing, route, and duration of antibiotic therapy. To ensure that training and education is working, there should be extensive collaboration between the antibiotic stewardship and hospital infection prevention and control teams
Continuous Medical Education a Must ..
Dr.T.V.Rao MD 81
Chennai Declaration • The Chennai Declaration wants India to take urgent
initiatives to formulate an effective national policy to control the rising trend of antimicrobial resistance and to ban on over-the-counter sale of antibiotics.
• Chennai: ‘The Chennai Declaration: A roadmap to tackle the challenge of antimicrobial resistance’ published in the latest edition of Indian Journal of Cancer has recommended to make it mandatory to set up an Infection Control Team (ICT) in all hospitals.
Dr.T.V.Rao MD 82
Educating the Educated
• The recommendations include offering Post-MD/DNB (internal medicine) sub-specialisation in Infectious Diseases at all post-graduate centres that offer sub-speciality training, compulsory training in infection control and infectious diseases training in under-graduate and post graduate curriculum in all specialities. The Medical Council of India should introduce one-week antibiotic stewardship and infection control training in the third, fourth and final year of MBBS and two-week training at the PG level.
Dr.T.V.Rao MD 83
Creating a Task force
• Recommending the setting up of a National Task Force to guide and supervise the regional and State infection control committees, the paper suggests that the National Accreditation Board for Hospitals & Healthcare Providers (NABH) insist on strict implementation of hospital antibiotic and infection control policy, during hospital accreditation and re-accreditation processes.
Are we overusing Antibiotics
Dr.T.V.Rao MD 84
Dr.T.V.Rao MD 85
Good hand washing practices still reduces antibiotic resistance and spread
Dr.T.V.Rao MD 86
Conclusions Antibiotic resistance is a major
problem world-wide Resistance is inevitable with use No new class of antibiotic introduced
over the last two decades Appropriate use is the only way of
prolonging the useful life of an antibiotic
Dr.T.V.Rao MD 87
Antibiotics save LivesSave Antibiotics from Misuse
Dr.T.V.Rao MD 88