Though antibiotics are required to treat severe bacterial infections, misuse has contributed to a rise in bacterial resistance

1. ANTIBIOTIC MISUSE
Dr Ramadan Hamad-MMSC
Assistant Professor Sirte University-libya.
sr. consultant
Paediatric & Paediatic cardiology
Benghazi Medical Center ( previously )

2. Declaration of Conflict of Interest of Speaker
I do not have an affiliation (financial or
otherwise) with a pharmaceutical, medical
device or communications organization.

3. Q1. Did you ingest any type of
Antibiotic in the following periods ?
A. Within the last 3 days
B. Within the last week
C. Within the last month
D. Within the last 3 months
E. Within the last 6 months

5. 7180 ÷ 20 = 359 patients / month
= 17.95 / day
MMSC

6. MMSC
6772 ÷20 = 336 patient÷20 =

7. 39.50%
20%
18.70%
0.07% 0.01%
% of antibiotics consumption for April 2017
in MMSC
augmentin claithromycin cefroxime amoxil penicillin V

8. A study of non-prescription usage of antibiotics in
the URTI in the urban population22-Feb-2013
Sangeeta Bhanwra
Department of Pharmacology, Government Medical
College and Hospital, Chandigarh, India

10. Drug name December 2017 January 2018 February
amoxacillin250mg 100 440 220
Amoxacillin 500mg 5249 7105 5650
Amox-amoclave625 7600 8400 6391
Ciprofloxcin250mg 150 590 458
Ciprofloxcin500 1450 1690 2438
Difloconazole 140 134 129
Metronidazole 250mg 460 1434 440
Metronidazole500mg 1754 2687 2587
Cephalexin250mg 0 760 190
Claithromycin 250mg 2928 4191 3328
Tetracycline 100mg 1792 2189 1892
Cefuroxime 250mg 3750 3970 3650
Azithromycin250mg 132 136 84
Amox-amoclave457mg/5ml 34 86 49
Amoxacillin 250mg/5ml 36 79 72
Cefuroxime 250mg/5ml 39 45 49

11. 440
7105
8400
590
1690
760
4191
2189
3970
136
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
Jan-18
amoxacillin250mg Amoxacillin 500mg Amox-amoclave625 Ciprofloxcin250mg Ciprofloxcin500
Cephalexin250mg Claithromycin 250mg Tetracycline 100mg Cefuroxime 250mg Azithromycin250mg

15. "Inappropriate use of antibiotics for ARTIs is an
important factor contributing to the spread of
antibiotic-resistant infections, which is a public
health threat," said ACP President Wayne . J. Riley.
Philadelphia, January 19, 2016 -- In a paper published today in
Annals of Internal Medicine, the American College of Physicians
(ACP) and the Centers for Disease Control and Prevention (CDC)

16. by the American College of Physicians (ACP)
and the Centers for Disease Control and
Prevention ( CDC )
1. In the United States, at least 2 million
antibiotic-resistant illnesses and 23 000(
in UK 12,000 ) deaths occur each year, at
a cost to the U.S. economy of at least $30
billion/year.
2. Increased community use of antibiotics is
highly correlated with emerging antibiotic-
resistant infections.

17. 3. An estimated 50% of antibiotic prescriptions
may be unnecessary or inappropriate in the
outpatient setting .
4. 72% of the patients in USA expect to
receive antibiotic during doctor visits

18. 5. In places with greater prescribing of
broad-spectrum antibiotics, specifically
extended-spectrum cephalosporins and
macrolides, rates of multidrug-resistant
pneumococcal disease are higher
6. Antibiotics are also responsible for the
largest number of medication-related
adverse events, implicated in 1 of every 5
visits to emergency departments for adverse
drug reactions

19. Reducing overuse of antibiotics for ARTIs in
adults is a clinical priority and a High Value
Care way to
1. improve quality of care.
2. lower health care costs.
3. slow and/or prevent the continued rise in
antibiotic resistance.

20. One of commonest drugs side effect is
Clostridium difficile diarrhea, which can be life-
threatening and is usually a result of antibiotic
treatment, causes nearly 500 000 infections and
29 300 deaths in the United States each year,
leading to an estimated $1 billion in extra
medical costs.
The antibiotics that most often lead to C. difficile
infections include fluoroquinolones,
cephalosporins, penicillins and clindamycin.

21. J Infect Dev Ctries. 2011 May 28;5(5):396-9.
The sale of antibiotics without prescription in pharmacies in Damascus, Syria.
Al-Faham Z1, Habboub G, Takriti F
Non prescribed sale of antibiotics in Riyadh, Saudi Arabia: 2011 Bin abdulhak

23. Just imagine before 1941 ( before
discovering of the penicillin )
How the Doctors can help the patients
Or how the hospital can help the patients

29. CNN News Superbug Resistant to Every Antibiotic in the U.S.
Killed Nevada Woman. Sep 2016
A CDC report concludes that the woman,
who died last August (2016) succumbed
to a Klebsiella pneumoniae infection that
was resistant to 26 different antibiotics
which all antibiotics available in USA.
Including colistin ( a so called last
resort antibiotic )

31. Inappropriate antibiotic use :
• Use of antibiotic with no clinical indications
(e.g. for viral infections )
• Use of broad spectrum antibiotics when
not indicated.
• Inappropriate choice of empiric antibiotics
• Inappropriate Drug Regimen

32. Inappropiate Drug Regimen
1. Inappropiate dose- ineffective
concentration of antibiotic at site of
infections
2. Inappropiate route- ineffective
concentration of antibiotic at site of
infections
3. Inappropiate duration.

33. It is not random shooting

34. Empirical initiation of antibiotic therapy
Empirical antibiotic therapy MEANS against
the MOST probable pathogen
NOT against all microorganism

37. the human Microbiome
has troubled researchers since the term was
coined by Joshua Lederberg in 2001.
Definition of Microbiome:
the microorganisms or its genetic
material in a particular environment
(including the body or a part of the
body).

38. The human Microbiota consists of the
10-100 trillion symbiotic microbial cells
harbored by each person.
% of human cells to microbiome cells in
human body.
1 cell human / 10 cells microbiome

39. Grice, E. A. and J. A. Segre (2012). "The human
microbiome: our second genome." Annu Rev
Genomics Hum Genet 13: 151-170.
The “ecological community of
…microorganisms that
literally share our body
space”
90% of all the cells
associated with the human
body; the other 10% are
human cells
Disruption of the microbiome
leads to:
Short-term and long-term
adverse events, including
C. difficile disease
Greater likelihood of
resistant infection
The microbiome

40. The Human Microbiome Project :
Project was a United States National Institutes of
Health (NIH) initiative with the goal of identifying
and characterizing the microorganisms which
are found in association with both healthy and
diseased humans
 The first phase of HMP (2007-2012 )
 The second phase of HMP (2013-2015 )
 The cost of the project 115$ million for1st stage.
 The ultimate goal of this projects was to test
how changes in the human microbiome are
associated with human health or disease. This
topic is currently not well understood.

41. The human microbiome has an
influence on the following four broad
areas of importance to our health:
1. Nutrition.
2. Immunity.
3. Behavior .
4. The disease.

42. Some e.g. of the diseases
Asthma
Autism
Cancer
Celiec disease
Colitis
Diabetes
Eczema
Heart disease
Malnutrition
Multiple Sclerosis
Obesity.

43. Some scientists, such as Dr Juliette C. Madan,
assistant professor of paediatrics&
epidemiology at the Geisel School of Medicine at
Dartmouth, think that the mother ‘seeds’ the
baby with bacteria during pregnancy. Their
evidence include finding bacteria in the amniotic
fluid of healthy babies.

44. Research | 16 February 2018 |
Delayed gut microbiota development in high-
risk for asthma infants is temporarily
modifiable by Lactobacillus supplementation

45. How long the intestinal microflora return to
normal after single episode of antibiotic
associated diarrhea ?
Latest study shows no return of intestinal
microflora to normal even after 6 months,
this indicate that it could permanently
influence the gut microflora.

46. Researchers from Tulane University School of
Public Health and Tropical Medicine and
Harvard T.H. Chan School of Public Health
recently uncovered an alarming connection
between long-term antibiotic use and heart
disease.

47. Q1. Did you ingest any type of
Antibiotic in the following periods ?
A. Within the last 3 days
B. Within the last week
C. Within the last month
D. Within the last 3 months
E. Within the last 6 months

49. When you see such a chicken you should not feel hungry but angry

50. Antibiotics in animal foods
and Agriculture

51. We’ve played chicken with food
safety … and we’ve lost
Felicity Lawrence
Felicity Lawrence is an award-winning journalist and editor
who has been writing on food-related issues for over twenty
years. She is a special correspondent for the Guardian and
lives in London.

52.  Baytril is used by poultry growers to protect
chickens and turkeys from E. coli infection.
 Ciprofloxcin and Baytril belong to a class of
drugs known as fluoroquinolone, among the
most powerful antibiotics currently available.
 Physicians have used fluoroquinolones to
treat food-borne illness since 1986, but
fluoroquinolone-resistant bacteria were rare
until 1995, when the FDA approved the use
of these drugs in drinking water for poultry.

53. said FDA officials, fluoroquinolones should
be used in patients with
1. Acute bacterial sinusitis
2. Acute bacterial exacerbation of chronic
bronchitis
3. Uncomplicated UTI
only when no other treatment options are
available, "because the risk of serious side
effects generally outweighs the benefits in
these patients."

57.  Some meat labels for antibiotics only apply to specific antibiotic categories.
CR photo

58. Burger King, KFC and others fail in study on antibiotic use at fast food
chains in USA
Report. Published September 22, 2016
Burger King, KFC and more than a dozen other big fast food chains are
still earning failing grades (F) for their antibiotics policies, according to
a new report compiled by various groups including the Consumers
Union and the Natural Resources Defense Council.
‫الطبيعية‬ ‫الموارد‬. ‫الدفاع‬ ‫ومجلس‬ ‫المستهلكين‬ ‫اتحاد‬‫عن‬
But most big chains, including Burger King, KFC, Dunkin’ Donuts,
Sonic, Jack in the Box, Denny’s, Starbucks, Olive Garden, Dominos,
Arby’s and IHOP, all failed. Although some of those with “F” grades
earned points for being transparent about their lack of antibiotics
policies, others didn’t register a single point. Those include Buffalo
Wild Wings, Burger King, Chili’s, Domino’s, IHOP and Little Caesars.

62. 1. WHO level
2. National level
3. Hospital/clinic level
4. Doctors level
5. Patients/ community level

63. Strategic objectives of WHO
Alert to this crisis, in May 2015 WHO
Assembly adopted a global action plan on
antimicrobial resistance,
which outlines five objectives:
1. Improve Awareness and education through
communication, Education & training.
Surveillance of antimicrobial resistance.2
3. Reduce the incident of Infection through
effective sanitation, hygiene & infection
prevention measure.

64. 4.Optimize the use of antimicrobial
medicines in human and animal health &
agriculture.
5. Develop the economic case for sustainable
investment that takes account of the needs
of all countries, and increase investment in
new medicines, diagnostic tool, vaccines and
other intervention.

65. Examples : How to reduce misuse of
antiobiotic ?
. Two of the best campaign
1.National campaign in France
which had the highest antibiotic
consumption
2. National campaign in Belgium

66.  The government in France launched
awareness campaign called <<Antibiotic
are not automatic >> and reduced the
antibiotic misuse to 27% in 5 years.
 Most campaign in higher- income countries
focus on eliminating antibiotic use in
respiratory infection.
 In France & Belgium after the campaign notice
reduction in penicillin and macrolids resistance

67.  CRE
◦ Success in Israel
 MRSA
◦ “Search and destroy” in the
Netherlands
◦ Invasive MRSA reduction in the US
 C. difficile
◦ Success in England

70. Antibiotics AMR--
The “Resistome”People
Bacteria
Animals
Plants
Soil
Water
Air

71. For essential treatments before prescribe an
antibiotic REMEMBER the following 7 Right :
1. Right patient
2. Right antibiotic
3. Right dose
4. Right route
5. Right concentration
6. Right time
7. Right cost

72. steps of a scientific method can be
applied for improving antibiotic
implementation policies :
(1) Asking a question;
(2) Carrying out background
research;
(3) Constructing a hypothesis;
(4) Testing the hypothesis through
an experiment;
(5) Analyzing data and drawing a
conclusion;
(6) Communicating the result

73. Right time !
Certain antibiotics, such as phenoxymethylpenicillin
(penicillin V), are best taken on an empty stomach as
they can be less effective after prolonged exposure to
acidic conditions.
Dairy products should be avoided within two hours of
taking antibiotics such as ciprofloxacin or norfloxacin
however they can be eaten at other times.

74. Some causes of developing AMR

75. Case 1
46 year old young man known to be healthy, presented
2days history of with fever 38,5, sore throat ,no cough,
O/E : sick , follicular exudate over both tonsils ,
anterior cervical lymph nodes palpable < 5mm and none
tender , no meningeal signs, chest clear, ears normal
1.What is the diagnosis ?
2.How many Centor scores , he has ?
3. Is any investigation needed for confirmation of the
diagnosis ?
4. What is the drug of the choice ?

76. Case 2:
16 year old young boy presented with 6 days
history of purulent nasal discharge, fever38.5 c˚,
fatigability, associated with 2 days history of
maxillary tooth pain and facial pressure.
1. What is the diagnosis ?
2. Is any investigation needed for confirmation
Of the diagnosis ?
3. What is the drug of choice ?

77. Case 3 :
Swabs Culture of middle ear of 6years old child
shows significant growth of alpha hemolytic
streptococcus , with sensitivity report as following:
Amoxacillin++ , Amoxacillin- clauvonate +++,
CLarithromycin +++ , Penicillin +++ . Which of
the following is the best choice ?
A. Amoxicillin
B. Amoxicillin- clauvonate
C. Penicillin
D. clarithromycin
E. None of the above

78. Take home massage:
1. Take care of the patient microbiome
2. Spend 5 mins more with patient for Education. Or
give him Augmencin !!!!! Rather than Augmentin
3. Think a lot before prescribe an antibiotic.
(Is needed ? and if , narrow spectrum)
blc you may disturb the normal percentage
Of microbiome
4. 90% of sore throat does not need antibiotic .
5. Be aware if what you eat.
6. Be global thinker i.e safer guard for the
international community

79. Do not think about a Patient
alone
But
Think about The Community as
whole
RAMADAN HAMAD

80. Thanks