The document discusses the importance of developing an antibiotic policy to improve antibiotic use and combat antibiotic resistance. It notes that overuse and misuse of antibiotics in various healthcare, agricultural, and community settings has contributed significantly to the rise of antibiotic-resistant bacteria. An antibiotic policy aims to standardize and promote best practices for antibiotic prophylaxis and treatment. It also seeks to improve education, optimize resource use, and slow the emergence and spread of resistant bacteria. Developing effective antibiotic stewardship requires coordinated efforts between clinicians, microbiologists, pharmacists, and other stakeholders. Ongoing monitoring of resistance patterns and prudent prescribing guided by local susceptibility data are also emphasized.

1. DIAGNOSTIC MICROBIOLOGY
IN
ANTIBIOTIC POLICY
Dr.T.V.Rao MD

2. Improving the Use of
Antibiotics a Priority
Improving the use
of antibiotics is an
important patient
safety and public
health issue as well
as a national
priority

3. Why take antibiotics?
William Osler, MD (1849 - 1919)
"The desire to take
medicine is perhaps
the greatest feature
which distinguishes
man from animals."
"One of the first duties
of the physician is to
Educate the masses
not to take medicine"
H. Cushing, Life of Sir William Osler (1925)

4. Antibiotics Changed the
Human Survival
Antibiotics have
transformed the
practice of
medicine, making
once lethal infections
readily treatable and
making other medical
advances, like cancer
chemotherapy and
organ
transplants, possible.

5. Fleming Nobel Prize
Speech identifies
In his Nobel Prize
acceptance speech,
Fleming identified the
risk of bacteria
becoming resistant to
antibiotics. If a
bacterium carries
several resistance
genes, it is called
multiresistant or,
informally, a
"superbug."

6. A Changing Landscape for
Numbers 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
Numberofagentsapproved
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
Resistance

7. Scarcity of New
Antibiotics

8. What went wrong with
Antibiotic Usage
Treating trivial infections / viral
Infections with Antibiotics has become
routine affair.
Many use Antibiotics without knowing
the Basic principles of Antibiotic
therapy.
Many Medical practioners are under
pressure for short term solutions.

9. Pharmaceutical Industry
Pushes
Commercial
interests of
Pharmaceutical
industry pushing the
Antibiotics, more so
Broad spectrum and
Newer Generation
antibiotics. as every
Industry has become
profit oriented

10. Poverty and Drug
Resistance
Poverty
encourages
drug resistance
due to under
utilization of
appropriate
Antibiotics.

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

12. Inappropriate use of antibiotics
is a worldwide problem
More than 50% of all medicines are
prescribed, dispensed or sold inappropriately,
and half of all patients fail to take
medicines correctly.
The overuse, underuse or misuse of
medicines harms people and wastes
resources.
More than 50% of all countries do not
implement basic policies to promote rational
use of medicines.

13. Creation of SUPERBUGS
Antimicrobial resistance is a serious
global challenge. Every continent and
country faces the menace of antibiotic
resistant “super bugs,” though the extent
and the severity of the problem varies.
There could be a return to the pre-
antibiotic era, where many people could
suffer or die from untreatable bacterial
infections

14. Settings that Foster Drug
Resistance
Intensive care units
Oncology units
Dialysis units
Rehab units
Transplant units
Burn units

15. Treated Without
Coordination
When the
patients to be
treated by
several
specialists,
multiple
antibiotics
prescribed
Drug Antagonism

16. Our Indian Hospitals
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.

17. Misuse of Antibiotics Drives
Antibiotic Resistance
Studies prove that misuse of antibiotics may
cause patients to become colonized or infected
with antibiotic-resistant bacteria, such as
methicillin-resistant Staphylococcus aureus
(MRSA), vancomycin-resistant enterococci
(VRE) and highly-resistant Gram-negative
bacilli.
Misuse of antibiotics is also associated with an
increased incidence of Clostridium difficle
infections.

18. Pan Drug Resistant
Infections
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

19. Can we tackle the
Problem
India, with more than
20,000 hospitals, more
than a billion population,
wide cultural diversity,
socio-economic disparity,
and a large medical
community of more than
three-fourths of a million
doctors, will find the
resistance problem an
issue very difficult to
tackle

20. Why is an antibiotic policy necessary?
An antibiotic policy will:
Improve patient care by promoting the best practice in
antibiotic prophylaxis and therapy,
Make better use of resources by using cheaper drugs where
possible
Retard the emergence and spread of multiple antibiotic-
resistant bacteria.
Improve education of junior doctors by providing guidelines
for appropriate therapy
Eliminate the use of unnecessary or ineffective antibiotics and
restrict the use of expensive or unnecessarily powerful ones

21. An antibiotic policy will:
Improve patient care by promoting the best practice in
antibiotic prophylaxis and therapy,
Make better use of resources by using cheaper drugs where
possible
Retard the emergence and spread of multiple antibiotic-
resistant bacteria.
*Improve education of junior doctors by providing guidelines
for appropriate therapy
Eliminate the use of unnecessary or ineffective antibiotics and
restrict the use of expensive or unnecessarily powerful ones

22. Aim of Antibiotic Policy
Reduce the Antimicrobial resistance
Initiate best efforts in the hospital area as
many resistance Bacteria are generated in
Hospital areas and in particular critical
care areas.
Initiate good hygienic practices so these
bacteria do not spread to others
Practice best efforts, these resistance
strains do not spill into critically ill
patients in the Hospital

23. Objectives of Antibiotic
Policy.
Antibiotics should not be used casually
Policy emphasizes, avoiding the use of
powerful Antibiotics in the Initial treatments.
We should create awareness that we are
sparing the powerful Broad spectrum Drugs
for later treatment
Patient saves Money
Doctors save Lives.

24. Aims of the Antibiotic
Policy
Create awareness on Antibiotics as misuse is
counterproductive.
More effective treatments in serious
Infections.
Reduce Health care associated infections
spilling to society and increase of Community
associated Infections.
( A growing concern in Developing world )

25. Policy Deals on Broad
Basis
Clinicians /
Microbiologists /
Pharmacists and
Nurses do take part.
Policies are framed on
demands of the Clinical
areas, depending on
recent Infection
surveillance data
contributed from
Microbiology
Departments.

26. The 3 Stratagecies
Will it Work ?Complete ban on OTC sale of antibiotics without
prescription throughout the country?.
Complete ban of OTC sale of antibiotics without
prescription in metros and larger cities with a
more liberal approach in smaller cities and
villages.
A liberal approach throughout the country to
start with, with an initial list of antibiotics under
restriction and addition of other drugs to the list
in a phased manner.

27. Education On Antibiotic
policyActon plan for Education to all
concerned clinical staff on Antibiotic
prescriptions.
Evaluate the feed back of success and
failures of the policy.
Create Infection surveillance Data
Developing facilities in Microbiology
departments for auditing data and
guidance
Restrictions in prescribing and Antibiotic
availability.
A continuous education to Junior Doctors

28. Role of Microbiology
Departments
Microbiology labs
should issue hospital
Antibiogram at pre-
defined intervals.
Those hospitals
without good
laboratory support
should be willing to
outsource samples to
better laboratories.

29. Role of Microbiology
Departments
The system of notification of communicable
diseases is a popular, established, though
not strictly followed system in the country.
Multidrug-resistant bacteria, especially pan-
drug resistant bacteria, must be considered
as a notifiable entity. Such a reporting
system should complement national
antimicrobial resistance surveillance
studies.

30. Better services from Microbiology
Departments.
Basic infrastructure
should be updated for
detection of MRSA
and ESBL and
Carbapenamase
producers.
Documentation of all
Opportunistic
infections. and
Hospital infection
outbreaks

31. 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

32. Notifying Pan Resistant Microbes
Superbugs
Pan-drug-resistant
Gram-negatives,
carbapenem-
resistant Gram-
Negatives,
Vancomycin-
resistant
Enterococcus and
MRSA should be
made notifiable

33. Curriculum change
Structured training in antibiotic usage and
infection control should be introduced in
both UG and PG curriculum.
Infectious Diseases training in UG and PG
curriculum in all specialties.
Antibiotic stewardship and infection
control one week rotation-3rd, 4th,
and final year MBBS.

34. WHONET
Documentation
Why We Need It

35. What is WHONET
WHONET is a free software developed by the
WHO Collaborating Centre for Surveillance of
Antimicrobial Resistance for laboratory-based
surveillance of infectious diseases and
antimicrobial resistance.
The principal goals of the software are:
1 to enhance local use of laboratory data; and
2 to promote national and international
collaboration through the exchange of data.

36. 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.
Whonet helps us in
……

37. All the Documented results are
analyzed in WHONET
The heart of
WHONET is a
software package
designed to collect
the results of
antibiotic resistance
tests. Researchers /
Microbiologists feed
the results into a
computer and look
for trends

38. 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.
Implementation of WHONET CAN
HELP TO MONITOR RESISTANCE

39. Physicians Can Impact
Other clinicians
Patients
Optimize patient evaluation
Adopt judicious antibiotic
prescribing practices
Immunize patients
Optimize consultations with
other clinicians
Use infection control measures
Educate others about judicious
use of antibiotics

40. Best way to keep the matters
in Order
Every Hospital should have a policy which is
practicable to their circumstances.
The *Seniors physician in the respective
departments will make the best policy
Rigid guidelines without coordination will
lead to greater failures
The only way to keep Antimicrobial agents
useful is to use them appropriately and Judiciously
(Burke A.Cunha, MD,MACP Antimicrobial Therapy. Medical Clinics of North America
NOV 2006)

41. Our minimal Targets
List of available antibiotics agreed by all
clinicians, indicating dosages, routes of
administration and toxicities.
Guidelines for therapy and prophylaxis.
A regimen selection algorithm also
might be included in an antibiotic policy.
CLSI guidelines are already followed

42. IMAGINE A WORLD
WITHOUT ANTIBIOTICS
A world without effective antibiotics is a
terrifying but real prospect. Overuse of
antibiotics has led to dangerous
outbreaks of drug resistant disease, and
puts us in very real danger of a global
pandemic. In future we have to use ???

43. Collect microbiology Specimens
Before Antibiotic Therapy
Nurses and Resident doctors can
assure that cultures are performed
before starting antibiotics. In
addition, nurses review
medications as part of their routine
duties and can prompt discussions
of antibiotic treatment, indication,
and duration

44. Never Forget Optimal Specimen
Collection a Top Priority

45. STOP MISUSE OF
Antibiotics and Start Washing
Hands

46. Programme Created by Dr.T.V.Rao MD
for Medical Microbiologists for the
Improvements in Global Health care
Email
doctortvrao@gmail.com