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A ntimicrobial Therapy & Infection

ControlControl

Dr ZiadAMemish

Dr ZiadAMemishDr

Ziad A

MemishDr

Ziad A

Memish

Director GCC States Center for Infection Control & Executive Director, Infection Prevention and Control Program

SaudiNati nalGua dHealthAffai s

Riyadh

Saudi Nati o nal Gua r d

Health

Affai r s

Riyadh

Introduction

Introduction

Antibiotics were hailed as "miracle drug" after their initial introduction in the 1940sinitial introduction in the 1940s
In 1967 US surgeon General William H. Stewart reportedly declared that it was time to close the book reportedly declared that it was time to close the book on infectious diseases However, the emergence of new infectious diseases &However, the emergence of new infectious diseases development of AR underscored the continued importance of Rx of infectious diseases

Introduction

Introduction

Antimicrobial consumption costs more than $ 7 billion annually in the US ($ 4 billion for HAI due to ARannually

in the US 4 billion for HAI due to AR bacteria) Antimicrobials account for up to 30% of hospital drugAntimicrobials account for up to 30%
of hospital drug budget Up to 50% of antimicrobial usage in US hospitals isUp to 50%
of antimicrobial usage in US hospitals is inappropriate in spite of strict control measures

Antimicrobial ResistanceAntimicrobial

Resistance

AR is increasing worldwide despite efforts to minimize the problemthe problem

AR is a naturally occurring phenomenon, but the

process is amplified by misuse of antimicrobialsResistance commonly stems from inadequate Rx or overuse Ii ddifibiiI

ntervent i ons are centere d on re d uct i on o f ant ibi ot i c use

Increase in

antibiotic use Increase inIncrease inresistant strainsLimited treatment alternatives

Ineffective empiric

alternatives •more antibiotics increased

Ineffective empirictherapy

•increased morbidity increasedmortality •more antibiotics

Increased

Increased

hospitalisation tibi ti healthcare resource use •more an tibi o ti cs use

Antimicrobial ResistanceAntimicrobial

Resistance

50% of antibiotic consumption in developing countries is in humans & 50% is in animalsis

in humans 50%
is in animals

80% of human consumption occurs in the community

& 20% in hospitalsWithin the community, 80% of antibiotic use is for treatment of RTI (the majority being viral in etiology)Mfhji fhM

any o f t h e ma j or res i stance emanate f rom t h e hospital environment Im p act of increasin g

HAI due to

pg

AR bacteria

Prolonged hospitalisationIncreased risk of deathMore toxic/expensive therapy neededMore toxic/expensive therapy needed

Increased chance of inappropriate therapy

•independent risk factor for increased mortality

Increased costs

Antibiotic resistance:

implications for treatment Start with the appropriate empiric antibiotic first in nosocomial infectionsnosocomial infections Administer antibiotics at the right dose for the appropriate dtid ura ti on

If appropriate, change antibiotic dosage or therapy based on resistance and pathogen informationRecognise that prior antimicrobial administration is a risk factor for the presence of resistant pathogensKnow the unit's resistance

p rofile and choose antibiotics p accordingly

Penicillin Resistance in Pneumococci

Versus outpatient Beta-lactam Sales

Livermore DM Lancet Infect Dis 2005; 5: 450-59

Resistance Trend to Penicillin (Yellow) &

Macrolides (Blue) among

S pneumoniae

from

Macrolides

(Blue) among S pneumoniae from

Bacteremias in England and Wales

Livermore DM Lancet Infect Dis 2005; 5: 450-59

(A) Resistance trends to ciprofloxacin in E coli from bacteraemias in

England and Wales, 1990-2004.

(B) Resistance trends to fluoroquinolones in Ecoli from European (B)

Resistance

trends to fluoroquinolones in E coli from

European

countries, 2001-04

Livermore DM Lancet Infect Dis 2005; 5: 450-59

Recommendations from the European Union conference on 'the Microbial Threat', held in Co p enha g en in 1998 pg (the Copenhagen Recommendations 1998) Carbon C, et al Clin Microbil Infect Dis 2002;8 (S 2): 92-106 Wh y

The Unnecessar

y

Use of

yy

Antimicrobials

Inadequate knowledge and support for prevention, diagnosis and treatment of infectious diseasesdiagnosis

and treatment of infectious diseases

False expectation of the benefits of antimicrobials to healthhealthUnawareness of effects of antimicrobial use on emergence of resistant microbesemergence

of resistant microbes

Economic benefits to drug sellers and prescribers

Factors Contributin

g to Increased g

Antimicrobial Resistance

Sicker patient populationLi idltiL

arger i mmunocomprom i se d popu l a ti on

New procedures and instrumentationEmerging pathogensComplacency regarding antibioticsIneffective infection control and complianceIncreased antibiotic use

Recommendations for Prevention &

Reduction of Antimicrobial Resistance inReduction

of

Antimicrobial

Resistance

in

Hospitals

Implementation of a system for periodic monitoring of AR in community and nosocomial isolatesAR in community and nosocomial isolates

Implementation of a system for periodic monitoring of antibiotic use according to hospital location and/orantibiotic

use according to hospital location and/or prescribing service Monitoring of relationship between antibiotic use andMonitoring of relationship between antibiotic use and

AR; assignment o responsibility through practice

guidelines Application of contact isolation precautions in patients known or suspected to be colonized or infected with id i l i ll i i i ep id em i o l og i ca ll y i mportant m i croorgan i sms Shales DM, et al Clin Infect Dis 1997; 95: 584-599

Structure of a Hospital-Wide Quality-

Improvement Program to AddressImprovement

Program

to

Address

AR

Murthy R Chest2001; 119: 405S-411S

Use of Antimicrobial AgentsUse

of

Antimicrobial

Agents

The most important factors contributing to the misuse of antimicrobial agents :of antimicrobial agents -Inadequate availability of trained personnel

Excessive variety poor quality and public

Excessive

variety poor quality and public misconception about antimicrobial drugs

Lack of diagnostic and epidemiologic information

Lack of diagnostic and epidemiologic information and facilities Healthcare system disincentives for appropriate useHealthcare system disincentives for appropriate use Inade q uate Availabilit y of Trained qy

Personnel

No published data systematically address this important problemimportant problem In countries with limited resources, insufficient number of:of: Infectious Disease physiciansClinical pharmacistsClinical pharmacists

MicrobiologistsHospital epidemiologistHospital

epidemiologist

Problems With Antimicrobial

Drugs Excessive variety (competitive business promotion, confuse prescribers and patients alike)confuse prescribers and patients alike) Poor or inconsistent quality of drugsPublic misconception about antimicrobial agentsPublic misconception about antimicrobial agents

Lack of Diagnostic and

Epidemiologic Information &Epidemiologic

Information

Facilities

Physicians are forced to treat infections presumptively when they do not have sufficient infowhen they do not have sufficient info Funds to buy antimicrobial discs are unavailable Weakness in e p idemiolo gy ca p abilities lead to lack of pgyp

AR surveillance data

Health S

y stem Disincentives for y

Rational Use

"Over-the-counter" drugsFi i l i ti f h i i d i tit ti tFi nanc i a l i ncen ti ves f or p h ys i c i ans an d i ns tit u ti ons t o over prescribe Antimicrobial use in animal husbandryAntimicrobial use in animalquotesdbs_dbs5.pdfusesText_9