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Antibiotic policy
- 1. Iman M. Fawzy; MD, MSc, PhD Consultant of Clinical Pathology
- 2. Rational Use of Antibiotics The 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”
- 3. Reasons for Patient Concerns • Want clear explanation • Green nasal discharge • Need to return to work Physician Concerns • Patient expects antibiotic • Diagnostic uncertainty • Time pressure Antibiotic Prescription Antibiotic Overuse
- 4. What is inappropriate use ? Unnecessary prescription of antibiotics, such as for viral infections or for prolonged prophylaxis Using broad-spectrum antibiotics when narrow- spectrum antibiotics are effective Prescribing too low or too high dose Continuing treatment for longer than necessary
- 5. What is inappropriate use ? Not prescribing according to microbiology results Omitting or delaying administration of doses Prescribing intravenous therapy when oral therapy is known to be effective and clinically safe Not taking antibiotics as prescribed
- 7. New Resistant Bacteria Emergence of Antibiotic Resistance Susceptible Bacteria Resistant Bacteria Resistance Gene Transfer
- 8. Resistant Strains Rare Resistant Strains Dominant Antimicrobial Exposure Selection for Antibiotic-Resistant Strains
- 9. Antimicrobial resistance has emerged as a major public health problem all over the world Infections by resistant microbes treatment fail ↑morbidity ↑mortality. Treatment failure longer infectivity, ↑infected people in community. exposes general population to risk of resistant strains Resistant to first-line antimicrobials, high cost of the second-line drugs treatment failure Most alarming caused by multidrug-resistant microbes, which are virtually non-treatable and thereby create a “post-antibiotic era” scenario
- 10. Emergence of antibiotic resistance 5. Pray LA Insight Pharma Reports 2008, in Looke D ‘The Real Threat of Antibiotic Resistance’ 2012
- 13. Impact of resistance Untreatable infections Excess length of stay Increased morbidity/ mortality Increased costs Interference with patient’s normal flora. Selection of drug resistant organisms Increased side effects
- 14. Settings that favor antimicrobial resistance Immune compromised patients e.g. – ICU – Oncology unit – Dialysis unit – Rehabilitation unit – Transplantation unit – Burn unit
- 17. we have to fight against the irrational use save these important discoveries of man Inappropriate use of antibiotics (life-saving ( many problems not many new antimicrobials have been discovered since the 1980th funding on antimicrobial research is on the decline
- 19. Aim of Antibiotic Policy ↓↓ morbidity and mortality due to antimicrobial-resistant infection Preserve the effectiveness of antimicrobial agents in treatment Prevention of communicable diseases
- 20. Detect resistant microorganisms Ensure effective treatment Recognize trends in antimicrobial resistance within the institution Assure infection control procedures Plan for identifying, transferring, discharging and readmitting patients colonized with specific antimicrobial resistant pathogens Incorporate the detection, prevention and control of antimicrobial resistance into institutional strategic goals Rational use of antimicrobials Objectives of Antibiotic Policy
- 22. Scope of hospital antibiotic policy prophylaxis, 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 activity – pharmacokinetics/pharmacodynamics of antibiotic s – adverse effects – potential to select resistance – cost – special needs of individual patient groups.
- 23. Cumulative antibiogram (Hospital/Community) Antibiotic policy Standard treatment guidelines Antimicrobial stewardship Hospital acquired infection Surveillance of antimicrobial resistance/ Antibiotic consumption
- 24. Surveillance of antimicrobial resistance • Use standards • Generate reliable numerator: only the first positive culture from the patient for each disease episode should be reported for surveillance purposes. • Express resistance as incidence rate • Participate in external quality assessment schemes • Prediction of evolution of antimicrobial resistance • Surveillance of antimicrobial consumption
- 25. 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 organism’s 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.
- 26. 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
- 27. Direction of antibiotic policy Frame the hospital own list of therapeutic antibiotic categories: • First-line • Reserved agents • Restricted agents • Withdrawn agents for 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.
- 28. Minimizing selection of resistant organisms What should not be done • Treat 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.
- 29. Interventions Continuous surveillance of bacterial infections. Hospital acquired infection Community acquired infection
- 30. Interventions • Prohibiting 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.
- 31. Community pharmacist • Pharmacist 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
- 32. 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 experts 3 Target the pathogen 2 Get the catheters out 1 Vaccinate Prevent Transmission Use Antimicrobials Wisely Diagnose and Treat Effectively Prevent Infection Clinicians hold the solution…
- 33. Antimicrobial Resistance: Key Prevention Strategies Optimize Use Prevent Transmission Prevent Infection Effective Diagnosis and Treatment Pathogen Antimicrobial-Resistant Pathogen Antimicrobial Resistance Antimicrobial Use Infection Susceptible Pathogen
- 34. Antibiotic prescribing Indication for use (definitive, empirical, prophylaxis) Route of administration, dosage regimen, duration of treatment, adverse effects If the drug was on a reserved list Drug combinations Whether it was approved by a microbiologist Was culture and sensitivity performed Development of treatment guidelines
- 35. ANTIMICROBIAL PRESCRIBING: GOOD PRACTICES • Send for appropriate investigations in all infections. • All antibiotic initiations would be done after sending appropriate cultures • Follow 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.
- 36. Empiric Therapy Where 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.
- 37. Empiric Therapy Side 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.
- 38. Hand Washing is Important Because… Hand hygiene compliance rates of 10%-40% have been observed in the developed countries.
- 39. • Policy should be reviewed by experts who are not the members of the policy development group, but are experts in the relevant field. Revise policy • Policy is not static. It is a living document. It should be reviewed at periodic intervals, updated according to current medical knowledge, clinical practice and local circumstances. Revise policy
- 40. THANK YOU