ANTIBIOTICS IN RELATION TO INFECTION PREVENTION AND CONTROL Dr. T. - - PowerPoint PPT Presentation

ANTIBIOTICS IN RELATION TO INFECTION PREVENTION AND CONTROL

• Dr. T. B. Menge
• B. Pharm; M.Sc (Pharmacology & Toxicology) .

DEPUTY CHIEF PHARMACIST, KENYATTA NATIONAL HOSPITAL .

WHY DO WE NEED TO BE CONCERNED ABOUT ANTIBIOTIC US E?

.

Current Status

 Antimicrobials are among the most commonly used medicines

 More than 30% of all hospitalized patients are treated with one or more courses of antibiotics  KNH Study:

 NBU: 48% medicines used; 75% patients on 1- 4 antibiotics  ICU: 70% patients on antibiotics  22% medicines prescribed

 Antimicrobials among most MISUSED medicines

 50% all viral infection treated with antibiotics

WHAT INFLUENCES A DOCTOR TO PRESCRIBE ANTIBIOTICS?

WHAT INFLUENCES A DOCTOR TO PRESCRIBE ANTIBIOTICS?

The reasons driving unnecessary prescribing are complex, but include

 pressures from patients and parents,  constraints on physician time,  a lack of appreciation of the possible impact

• n resistance

1. Felmingham et al. J Antimicrob Chemother 2000; 45:191–203 2. Macfarlane et al. BMJ 1997; 315:1211–1214 3. Ball et al. J Antimicrob Chemother 2002; 49:31–40

Pe e r g roups / pre sc ribing a nd pha rma c y a dvisors Hospita l e xpe rts, F

• rmula rie s a nd g uide line s

Pha rma c e utic a l re pre se nta tive s

Re g ula tory c ontrol me c ha nisms

Pa tie nts’ or Pa re nt’s de ma nds Doc tor’s a spira tions

Acute respiratory infection

 Case: 40-year-old male with non-productive cough x 4 days; non-smoker; no comorbidity  Exam: Afebrile; P-72; R-20; lungs – no localized findings Survey of PCPs: No Yes  Should antibiotics be used? 90% 10%  Would antibiotics be used? 12% 88%

Tom File: Personal Communication

Relationship between pneumococcal resistance and beta-lactam usage

Adapted from Bronzwaer et al. Emerg Infect Dis 2002; 8:278–282 BEL FIN GER ITA LUX NET POR SPA SWE UK IRE

5 10 15 20 25 5 10 15 20 25 30 35

% Resistance DDD/1000/day

Risk factors for the development

• f antibacterial resistance

 Low antibacterial dosages and long treatment duration are risks for carriage of penicillin- resistant S. pneumoniae

Guillemot et al. JAMA 1998; 2 7 9 : 365–370

 The risk of carrying penicillin-resistant S. pneumoniae increases by 4% for each additional day of antibacterial use in the previous 6 months

Nasrin et al. BMJ 2001; 3 2 3 : 1–4

 Short-course, high-dose amoxicillin therapy reduces pneumococcal carriage and minimizes the impact of therapy on drug-resistant pneumococci

Schrag et al. JAMA 2001; 2 8 6 : 49–59

I m prove antibiotic use

Monitor and provide feedback on

• ccurrence of AMR

Optim ize choice and duration of em piric antim icrobial therapy Optim ize antim icrobial prophylaxis I m plem ent form ulary restrictions for im portant types of antim icrobial use

I m prove antibiotic use

Monitor and provide feedback on

• ccurrence of AMR

| ( 1) x1 | ( 2) x1 | ( 3) x1 | ( 4) x1 | | ( 1) x1 | ( 2) x1 | ( 3) x1 | ( 4) x1 | ANTI BI O G RAM M ES | Aci net obact er | E. col i | S aur eus | ANTI BI O G RAM M ES | Aci net obact er | E. col i | S aur eus | | | | | | | | |

• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Peni ci l l i ne G | | | | RESI ST | Peni ci l l i ne G | | | | RESI ST | Fl ucl oxaci l l i ne | | | | RESI ST | Fl ucl oxaci l l i ne | | | | RESI ST | Am

• xi ci l l i ne | RESI ST | RESI ST | RESI ST | |

Am

• xi ci l l i ne | RESI ST | RESI ST | RESI ST | |

Co- am

• xi cl av | I NTERM

| RESI ST | RESI ST | | Co- am

• xi cl av | I NTERM

| RESI ST | RESI ST | | Pi per aci l l i ne | RESI ST | RESI ST | RESI ST | | Pi per aci l l i ne | RESI ST | RESI ST | RESI ST | | Pi per ac. +t azob | RESI ST | RESI ST | I NTERM | | Pi per ac. +t azob | RESI ST | RESI ST | I NTERM | |

• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Cef ur oxi m e | RESI ST | RESI ST | RESI ST | RESI ST | Cef ur oxi m e | RESI ST | RESI ST | RESI ST | RESI ST | Cef t azi di m e | I NTERM | RESI ST | RESI ST | RESI ST | Cef t azi di m e | I NTERM | RESI ST | RESI ST | RESI ST | Cef t r i axone | RESI ST | RESI ST | RESI ST | RESI ST | Cef t r i axone | RESI ST | RESI ST | RESI ST | RESI ST | Cef epi m e | I NTERM | RESI ST | RESI ST | RESI ST | Cef epi m e | I NTERM | RESI ST | RESI ST | RESI ST | I m i penem | S | I NTERM | S | RESI ST | I m i penem | S | I NTERM | S | RESI ST | Azt r eonam | | | | RESI ST | Azt r eonam | | | | RESI ST |

• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +
• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +

Am i kaci ne | RESI ST | S | RESI ST | I NTERM | Am i kaci ne | RESI ST | S | RESI ST | I NTERM | G ent am i ci ne | RESI ST | RESI ST | S | S | G ent am i ci ne | RESI ST | RESI ST | S | S | Tobr am yci ne | | RESI ST | | S | Tobr am yci ne | | RESI ST | | S |

• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +
• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +

Nor f l oxaci ne | RESI ST | RESI ST | S | RESI ST | Nor f l oxaci ne | RESI ST | RESI ST | S | RESI ST | Ci pr of l oxaci ne | | RESI ST | S | S | Ci pr of l oxaci ne | | RESI ST | S | S |

• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +
• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +

Cl i ndam yci ne | | | | S | Cl i ndam yci ne | | | | S | Er yt hr om yci ne | | | | RESI ST | Er yt hr om yci ne | | | | RESI ST |

• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +
• - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - +

Patient X, transferred from Kisum u

I s this patient in your I CU? Can you treat his infection? Can you prevent cross-infection?

Antibiotic tre a tme nt without mic robiolog ic c ulture s in China (Hospita l) a nd Ne pa l (ICU)

Suping Hu e t a l. J I nfe c t 2003; 46:161-63 Sha nkar e t a l. Am J I nfe c t Co ntro l 2003; 31: 410-14

1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 0 1 0 0 No culture Culture

% China n=466 Ne pa l n=149

I m prove antibiotic use

Monitor and provide feedback on

• ccurrence of AMR

Optim ize choice and duration of em piric antim icrobial therapy

Surviva l Among 401 Pa tie nts with Nosoc omia l Pne umonia Assig ne d to Short (8 d) or L

• ng (15 d)

Antimic robia l T re a tme nt

Proba bility of Surviva l

10 20 30 40 50 60

Da ys a fte r Bronc hosc opy

0.0 0.2 0.4 0.6 0.8 1.0

15- da y 8- da y

Courtesy: J. Chastre, Paris JAMA 2003; 290: 2588-98

42.1% 62.3% 20 40 60 80%

“8-da y” (n=197) “15-da y” (n=204)

E me rg e nc e of multire sista nt pa thog e ns for pa tie nts who ha d pulmona ry infe c tion re c urre nc e

P = 0.04

Courtesy: J. Chastre, Paris JAMA 2003; 290: 2588-98

I m prove antibiotic use

Monitor and provide feedback on

• ccurrence of AMR

Optim ize choice and duration of em piric antim icrobial therapy Optim ize antim icrobial prophylaxis

Common Misc onc e ptions in Surg ic a l Prophyla xis



Bro a d-spe c trum is b e tte r



L

• ng e r a ntib io tic

pro phyla xis is b e tte r



Pro phyla xis sho uld b e c o ntinue d until a ll “tub e s” a re o ut

Misuse of prophylactic antibiotics in a university hospital, China

Suping Hu et al. J Infect 2003; 46: 161-63 5 1 0 1 5 2 0 2 5 3 0 3 5 4 0 4 5 5 0 Duration of perioperative prophylaxis < 7 d 8 - 1 3 d > 1 3 d

% 80% of prophylactic antibiotics (191/ 239) were started after the end of the operation

I m prove antibiotic use

Monitor and provide feedback on

• ccurrence of AMR

Optim ize choice and duration of em piric antim icrobial therapy Optim ize antim icrobial prophylaxis I m plem ent form ulary restrictions for im portant types of antim icrobial use

Va ria ble Pre - inte rve ntion pe riod Inte rve ntion pe riod (1995/ 96) (1997/ 98)

Via ls (# ) 199,427 132,496 T

• ta l c o sts ($)

699,543 347,261

Sa e z-L lo re ns e t a l. Pe d I nfe c t Dis J 2000; 19: 200-6

Does restriction alw ays w ork ?

Formulary restriction at Mass Gen Hosp, Boston (USA) : “ Imipenem, tic/ clav, aztreonam, cefta, cipro, pip/ tazo require prior approval by infectious diseases “ The reality at the same hospital … . 35-y old woman with severe sepsis: “ Ampicillin-sulb, clindamycin, penicillin, gentamicin, vancomycin were infused intravenously “

Gilbert et al. Am J Med; 1998; 104: 17-27 Case report 28-2002 of the MGH, NEJM Sept 12, 2002, p.831-37

Are a dministra tive (impo se d) re stric tio ns b e ne fic ia l?

Re stric tive fo rmula ry po lic y impo se d o n 6

US HMOs



L imita tio ns o n drug s within a c la ss o r c la sse s



E xc lusio n o f c e rta in c la sse s c o mple te ly

Ove ra ll c a re c o sts inc re a se d 

T he mo st re stric tive po lic ie s = g re a te st c o st inc re a se

Po lic ie s drive n b y c o st (a c q uisitio n o f drug ) 

ig no re o ve ra ll b e ne fits,



ha ve une xpe c te d c o nse q ue nc e s

Horn et al. Amer J Managed Care 1996; 2:253-264

Austra lia : I nitia tive to re duc e c o -a mo xic la v usa g e in 1º c a re

• T

he polic y c re a te d:

– uninte nde d c ha ng e s in pre sc ribing be ha viour – hig he r c osts (sig nific a nt inc re a se d hospita liza tion/ inve stig a tion)

Beilby et al. Clin Infect Dis. 2002 34:55-64 Number of patients

100 200 300 400 500 600 H

• s

p i t a l i z a t i

• n

R e f e r r a l s R a d i

• l
• g

y P a t h

• l
• g

y O t h e r t e s t s

Before letter After letter

I m prove antibiotic use

Monitor and provide feedback on occurrence

• f AMR

Optim ize choice and duration of em piric antim icrobial therapy Optim ize antim icrobial prophylaxis I m plem ent form ulary restrictions for im portant types of antim icrobial use I m prove antim icrobial prescribing by education, Clinical guidelines, adm inistrative m eans

I m pact of an educational program on antibiotic use in a tertiary care hospital in Thailand

Thamlikitkul V et al. J Clin Epidemiol 1998; 51: 773-78

Pre- intervention Post- intervention OB-GYN 6 4 3 5 PEDS 5 9 5 0 OPHTHALM 5 7 2 8 MEDICINE 4 6 3 7 ENT 4 4 2 8 SURGERY 4 1 3 7 ORTHOPEDICS 3 6 2 6

Prevalence of antibiotic use (in-patients, % )

Why do we ne e d a c onse nsus?

 Premise:



resistance has increased to an all time high



prescribing is at an all time high (and increasing)



no new agents are appearing (yet!)

 Guidelines are available –

but are:



frequently ignored and are often ineffective



• ften inconsistent with basic principles

Antibiotic prescribing is excessive and sub-optimal

Ba ll e t a l. 2002. J Antimic rob Che mothe r; 49:31–40

Consensus prescribing principles

• TREAT

bacterial infection only

• OPTIMIZE

diagnosis / severity assessment

• MAXIMIZE

bacterial eradication

• RECOGNIZE (local) resistance prevalence
• UTILIZE

pharmacodynamics - for effective agents and dosage

• INTEGRATE local resistance, efficacy and cost-

effectiveness

Ba ll e t al. J Antimic rob Che mothe r 2002; 49:31–40