Antibiotics use and misuse at outpatient clinics

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Why antibiotics misuse is a problem

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  • BY DR. Mahmoud Abdulkareem MS, Cairo , FRCS ,Glasgow Consultant General Surgeon King Fahad Specialist Hospital Antibiotics Prescription at Outpatient Clinics Use and Misuse 03/08/2014 1
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  • Introduction In the last century, nothing has made a bigger impact on human health than antimicrobial chemotherapy. After 20 years of clinical use, antibiotics have increased the average human life expectancy by ten years while in comparison, curing cancer would only extend life expectancy by two years. 03/08/2014 3
  • What went wrong with Antibiotic Usage 1. Treating trivial infections / viral Infections with antibiotics has become routine affair. 2. Many use antibiotics without knowing the basic principles of antibiotic therapy. 3. Many medical practitioners are under pressure for short term solutions. 4. Commercial interests of Pharmaceutical industry. 03/08/2014 4
  • Antibiotics are misused in hospitals It has been recognized for several decades that up to 50% of antimicrobial use is inappropriate 03/08/2014 5
  • Antibiotic are misused in a variety of ways 1. Given when they are not needed 2. Continued when they are no longer necessary 3. Given at the wrong dose 4. Broad spectrum agents are used to treat very susceptible bacteria 5. The wrong antibiotic is given to treat an infection 03/08/2014 6
  • 03/08/2014 7King Fahad Specialist Hospital Buraidah al-Qassim
  • Antibiotic Resistance Nowadays, about 70 percent of the bacteria that cause infections in hospitals are resistant to at least one of the drugs most commonly used for treatment. 03/08/2014 8
  • Wound infections, gonorrhea, tuberculosis, pneumonia, septicemia and childhood ear infections are just a few of the diseases that have become hard to treat with antibiotics Antibiotic Resistance 03/08/2014 9
  • One part of the problem is that bacteria and other microbes that cause infections are remarkably resilient and have developed several ways to resist antibiotics and other antimicrobial drugs. Another part of the problem is due to increasing use, and misuse, of existing antibiotics in human and veterinary medicine and in agriculture. Antibiotic Resistance 03/08/2014 10
  • Selective pressure Any use of antibiotics can increase selective pressure in a population of bacteria to allow the resistant bacteria to thrive and the susceptible bacteria to die off. 03/08/2014 11
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  • As resistance towards antibiotics becomes more common, a greater need for alternative treatments arises. However, despite a push for new antibiotic therapies there has been a continued decline in the number of newly approved drugs. Antibiotic resistance therefore poses a significant problem. Antibiotic Resistance 03/08/2014 13
  • While the rate of development of antimicrobial resistance has been accelerating, the pace of development of new antimicrobial agents has slowed considerably during the past several decades. Only two classes of new antibacterials have come to market over the last 30 years. The period from 1983 to 2007 saw a 75 percent decrease in systemic antibacterials approved by the FDA, reflecting a decline in the antibiotic pipeline. Antibiotic Resistance 03/08/2014 14
  • New antibacterial agents approved by the FDA and EMA 03/08/2014 15
  • post-antibiotic era scenario. Most alarming of all are the diseases caused by multidrug-resistant microbes, which are virtually non-treatable and thereby create a post-antibiotic era scenario. 03/08/2014 16
  • 03/08/2014 17KasrAl-AinyMedicalSchoolinCairo
  • It is important to have a clear understanding of the terms used for wound infection. Since 1985 the most commonly used terms have included wound contamination, wound colonisation, wound infection and, more recently, critical colonisation. These terms can be defined as: Terminology 03/08/2014 18
  • Classic signs Additional signs Pyrexia Inflammation Oedema Pain Increase in exudate or pus Delayed healing Bridging of skin across a wound Dark/discoloured granulation tissue Increased friability (tissue which bleeds easily) Painful/altered sensation to the wound site/surrounding skin Altered odour Wound breakdown Pocketing at the base of the wound Increased watery/serous exudate rather than pus Signs and symptoms of wound infection 03/08/2014 19
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  • wound swabs All wounds contain a variety of microorganisms, however it is only when wound infection is suspected from clinical signs that further investigation is required. 03/08/2014 21
  • HOW TO TAKE A WOUND SWAB A representative area of the wound should be sampled. If the wound is large, it may not be feasible to cover the entire surface, but at least 1cm should be sampled and material from both the wound bed and wound margin should be collected. If pus is present, the clinician should ensure that a sample is sent to the laboratory. Immediately following collection, the swab should be returned to its container (placed into the transport medium) and accurately labelled. Returning the swab to its container 03/08/2014 22
  • Interpreting microbiology results Conversely, where a microbiology result of no growth or no significant growth is returned, the result should be interpreted with care and should not be automatically interpreted as meaning that no infection is present, particularly if the patient has clinical signs and symptoms that suggest otherwise. In this situation such a result should be regarded as a false negative (Kingsley, 2003). 03/08/2014 23
  • Interpreting microbiology results Diagnosing wound infection is essentially a clinical skill and microbiological investigations should only be used to aid diagnosis, rather than the other way round (Sibbald, 2003). Not all laboratories look for pus cells when examining wound swabs. Micro- organisms reported from wound cultures are not necessarily indicative of SSI and if pus cells are not indicated as present in the wound culture report there must also be at least two clinical symptoms of infection and a clinicians diagnosis. 03/08/2014 24
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  • Why is an antibiotic policy necessary? An antibiotic policy will: 1. improve patient care by promoting the best practice in antibiotic prophylaxis and therapy, 2. make better use of resources by using cheaper drugs where possible 3. retard the emergence and spread of multiple antibiotic- resistant bacteria. 4. improve education of junior doctors by providing guidelines for appropriate therapy 5. eliminate the use of unnecessary or ineffective antibiotics and restrict the use of expensive or unnecessarily powerful ones 03/08/2014 26
  • What is the Ideal Antibacterial? 1-Selective target target unique 2- Bactericidal kills 3- Narrow spectrum does not kill normal flora 4- High therapeutic index ratio of toxic level to therapeutic leve 5- Few adverse reactions toxicity, allergy 6- Various routes of administration IV, IM, oral 8- Good absorption 9-Good distribution to site of infection 10- Emergence of resistance is slow 03/08/2014 27
  • 1. Efficacy in treating the infection 2. Severity of the patients illness 3. Physicians previous experience with and knowledge about the drug 4. Side effects 5. Cost to patient 6. Ease of use 7. Risk of contributing to the problem of antimicrobial resistance Factors Influencing Physicians Choice of Drug 03/08/2014 28
  • Good Practices 1. Consider whether or not the patient actually requires an antibiotic. 2. Avoid treating colonised patients who are not actually infected. 3. In general do not change antibiotic therapy if the clinical condition is improving. 4. If there is no clinical response within 72 hours, the clinical diagnosis, the choice of antibiotic and/or the possibility of a secondary infection should be reconsidered. 5. Consider the use of pharmacy stop' policy after 5 days. 6. For surgical prophylaxis start the antibiotic with the induction of anaesthesia and continue for a maximum of 24 hours only. 7. Give the antibiotic for the minimum length of time that is effective. 03/08/2014 29
  • 1. Antibiotics should only be prescribed for prove