2. Overview
• Antibiotics are vital life-saving medicines
• Antimicrobial resistance is both a global and
local problem
• The link between antibiotic use and resistance
• Addressing antimicrobial resistance
• Antimicrobial stewardship (AMS)
4. Narrow spectrum antibiotics work against a
limited group of bacteria
Broad spectrum antibiotics work against a
larger group of bacteria
Overuse of unnecessarily broad spectrum
antibiotics can drive antimicrobial resistance
Broad vs Narrow Spectrum
5. Why antibiotics are important?
• Modern medicine, especially surgery and cancer
treatments, depends on effective antibiotics to
minimise the risk of infection
• Currently, antibiotics reduce post-operative
infection rates to below 2.0%
• Without effective antibiotics, this could increase
to around 40% to 50%. Up to 30% of these
patients could die from resistant bacterial
infections.
• The risk of mortality without access to effective
antibiotics may make some treatments and
surgical procedures too risky to continue.
7. • Antimicrobial resistance (AMR) occurs when
bacteria, parasites, viruses or fungi change to
protect themselves from the effects of
antimicrobial drugs designed to destroy them.
• This means previously effective antimicrobial
drugs (e.g. antibiotics) used to treat or prevent
infections may no longer work.
• The World Health Organization (WHO) has
identified AMR as ‘one of the biggest threats to
global health’.
What is AMR
8. What has led to resistance?
• Increased use of antibiotics
• Prescriptions taken incorrectly
• Sold without medical supervision
• Prophylactic use before surgery
• Antibiotics used for viral infection
• Spread of resistant microbes in hospitals due to
lack of hygiene
• Antibiotics in animal feeds
14. Antimicrobial Stewardship
(AMS)
— Stewardship means to protect something
— AMS is a systematic approach to optimising the use of
antimicrobials
— Goals of AMS are to:
—improve patient outcomes / patient safety
—reduce antimicrobial resistance
—reduce costs.
— AMS works hand-in-hand with infection prevention
and control strategies
15. Multi disciplinary approach
• Core strategy
– Prospective audit, feedback
– Formulary restriction
• Supplementary strategy
– Education, training & teaching activities
– Antibiotic audit & order form
17. The scenario
• A patient attends the ED with fever for 5 days looks
sick.
• Widal is positive
• The PGMO diagnoses as Enteric fever advices
Ciprofloxacin IV and admits
• Next day: Medicine Specialist in round
• What does the guideline say?
21. Ideal local Antibiotic Guideline
• Based on Antibiogram
– Based on AIIMS Antibiotic policy 2019
– Antibiogram from other Medical Colleges ?
• Dynamic:
– With your feedback
22. Ask yourself 5 D
Before writing Antibiotic
• Diagnosis
• Drug
• Dose
• Duration
• De-escalation (When to stop)
24. Mind it…
• Not always right but right most often
• Important for public health
• Patient in SIRS:
– Any 2 among
• Temp >100.4 / <96.8
• Tachycardia>90
• SBP < 90
• TLC >12000 or < 4000
28. Fever up to 3 days
• If Malaria Parasite RDT negative
– Only PCM 650 mg 6-8 hourly
29. Fever 3-5 days
• CBC
– TLC = Bacterial
• May add Doxycyclin 100mg BD for 5 days
• (Azithromycin in pregnancy )
– TLC = Viral
• Dengue
– Hematocrit
– May be with TPC (Don’t chase platelet)
– Only PCM 650 8 -6 hourly
– Judicious IV Fluids
30. Fever 7-10 days
• Thorough history
• Can treat as Typhoid if
– Widal test
• O>160
• H>320
– Blood culture is more sensitive in 1st wk
– Azithromycin 500 BD for 5 days
– Ceftriaxone 1 Gm BD / Cefixime 400 mg BID -14 days
• If Widal is negative & CBC normal: Doxy for 5 days
31. Fever > 14 days
• Need thorough investigations
– CBC, PS Comment, ESR
– Urine R & M
– Blood and Urine Culture
– Imaging
• Xray chest PA
• USG whole abdomen
• Refer to higher center
33. Urinary Tract Infections (UTI)
Urinary tract Genital
• Nitrofurantoin 100mg BD
• 5-7days for females
• 10-14 days for males
• Ulcer over the Ext Gen
• STI Kit
35. Skin & Soft tissue infections
• Amoxy-Clav 625 tid for 5-7 days
• Diabetic foot
– Neuropathy
– Vasculopathy
– Infection
• May add Clindamycin 300 mg tid 7-10 days
36. Acute Encephalitis Syndrome
(AES)
• Mortality is highPyogenic / Viral/ Tubercular
– Acute and generalized Pyogenic / Viral
– Chronic and Focal signTubercular
– Epidemic Viral
• Ceftriaxone 2 Gm BID for 14 days
• May add Acyclovir 500mg 8 hourly
• May give a dose of IV steroid along with Antibiotic
• Refer to higher center with facility for CSF study and
imaging
38. Take home message
• All acute fever does not need antibiotics
– AUF / Upper RTI / GIT / Diabetic foot
• In Typhoid, UTI, RTI, GITI: No Cipro
• Typhoid: 5-7 days Azi or 14 dy Cephalosporin
• RTI: Amoxy if Sputum production
• ORS and patience for GITI
• UTI:Nitrofurantoin 5-7 days for females or 10-14
days for male
• Ceftriaxone 2 Gm BD in CNS infection
In an interview shortly after winning the Nobel Prize in 1945 for discovering penicillin, Alexander Fleming said: “The thoughtless person playing with penicillin treatment is morally responsible for the death of the man who succumbs to infection with the penicillin-resistant organism.”
Antimicrobial use is a key factor in the development of antimicrobial resistance – the more antimicrobials are used, the more likely it is that resistance will develop.
Streptococcus pneumoniae
Streptococcus pneumoniae causes otitis media (middle ear infections), sinusitis, acute exacerbation of chronic obstructive pulmonary disease, pneumonia, meningitis and septicaemia.
This slide shows the occurrence of penicillin non-susceptible Streptococcus pneumoniae (PNSP) plotted against outpatient use of penicillins in 20 industrialised countries. It is a representation which clearly demonstrates the relationship of antibiotic usage with the development of penicillin resistance (as antibiotic usage has increased so has resistance).
