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Dr.T.V.

Rao MD

Dr.T.V.Rao MD

Antimicrobial Resistance

of antimicrobial The emerging clinical impact


resistance, urgent implementation of the Global Strategy for the Containment of Antimicrobial Resistance is a Priority . However, at the same time, a clear research agenda highlighting the most important current knowledge gaps needs to be defined to guide the direction of future research efforts.
Dr.T.V.Rao MD

Antibiotics and Mechanisms of Resistance

-lactams B-lactamases, Macrolides Aminoglycosides Fluoroquinolones Tetracycline's Chloramphenicol Sulfonamides Trimethoprim Vancomycin Streptogramins

altered PBP, efflux MLS, efflux AME, permeability altered topoisomerases, efflux efflux, altered target CAT, efflux altered dihydropteroate synthase altered dihydrofolate reductase bypass pathway
MLS, efflux, enzyme modification altered target
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Rifampicin

Genetics of Antimicrobial Resistance

Genetic diversity
nucleotide substitution, DNA rearrangements and gene acquisition Gene acquisition transformation, transduction and conjugation

Mobile genetic elements


gene cassettes integrons insertion sequence elements and transposons plasmids
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Why Are Resistant Infections Happening?

Enormous biomass of microorganisms


Genetic plasticity Antibiotics are microbial products, organisms have seen them before!
*Excessive

antibiotic use

World wide travel

*Lax infection control practices


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How Much Antibiotics ? 22,000 t


11,000 t dispensed to humans (50%)

in 150 million prescriptions written annually by physicians

8 -10,000 t given to animals (40%)

to treat or prevent infections mixed into feed to promote growth of agricultural animals

20-30 t Plant (0.1%)


30-200 t AquacultureDr.T.V.Rao MD (1%)
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Drugs for Human Treatment are Excreted into Sewage

Some drugs excreted in metabolized amounts via the urine and feces Some yield bioactive metabolites. Some excreted as conjugates

Dr.T.V.Rao MD

Metabolism of Antibiotics

Dr.T.V.Rao MD

Veterinary Medicines in the Environment

Dr.T.V.Rao MD

Antimicrobial Prescribing Facts


1/3 of all hospitalised inpatients at any given time receive antibiotics ~ up to 1/3 to are inappropriate ~ up to 30% of all surgical prophylaxis in inappropriate Antimicrobials account for upwards of 30% of hospital pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets. Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences , increased morbidity, mortality,increased cost, Dr.T.V.Rao MD increased litigation and reduce quality of life

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Why So Many Mistakes


High number and complexity of drugs High number and complexity of syndromes and pathogens Poor training in antibiotic use Variability over time and place in - pathogen prevalence - antibiotic susceptibilities - antibiotic formularies

Dr.T.V.Rao MD

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Hospital acquired infections cause of many Deaths


Every year, many lives are lost because of the spread of infections in hospitals. Health care workers can take steps to prevent the spread of infectious disease

Dr.T.V.Rao MD

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The spectrum of health research


Biomedical research Health policy and systems research Research on policy formulation, relationship to evidence, prioritization, etc Social sciences and behavioral research Operational research

Basic research: physical and biological sciences including chemistry, pharmacology, toxicology, genetics, etc

R&D for drugs, vaccines, diagnostics, appliances, etc

Research on Research on social and behavioural factors factors influencing health affecting and their relation to functioning of equity, access, programs, Research on lifestyle and healtheffectiveness of health systems management, seeking behaviours, targeting, functions, efficiency, etc impact on effectiveness, system factors behavior, affecting access disease scale-up, monitoring and burdens and evaluation, etc public health, etc

Understanding the biological nature of diseases; creating products to prevent or treat disease states

Understanding how to test, scale-up and follow through the introduction of interventions and optimize their benefits

Innovation Dr.T.V.Rao Impact MD

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What is Antimicrobial Stewardship

Ongoing effort by a health care institution to optimize antimicrobial use among hospitalized patients to ...

- Improve patient outcomes - Ensure cost-effective therapy, and - Reduce adverse sequelae of antimicrobial use (including antimicrobial resistance).
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What Can We Do?


Strengthen our Microbiology Departments ?

Keep aware National/Provin cial Surveillance Programs Get to know your microbiology laboratory

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What Can We Do?

Expect rapid turn around times Appropriate susceptibility test reporting


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What Can We Do?

Infection Control in the office & hospital Decrease antibiotic prescriptions for viral URIs by half! Improve communication with patients

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Hand Washing a must for Safety of our Patients

Proper hand washing is the most effective way to prevent the spread of infections in hospitals. If you are a patient, don't be afraid to remind friends, family and health care providers to wash their hands before getting close to you.
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Preventive Measures .
Covering coughs and sneezes Staying up-todate with immunizations Using gloves, masks and protective clothing Making tissues and hand cleaners available Following hospital guidelines when dealing with blood or contaminated items

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Organize your Clinical Microbiology Laboratory Bench

Microbiologists

should bring in change with dedication to bench work, and Proficiency Testing to improve the quality to services in Health care
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What most Proficiency Testing does not tend to look at:


Are negative samples reported as negative? Are contaminated samples reported as contaminated? Are complex samples submitted for referral? Are pre-analytic factors addressed?
Improper containers and transport Outdated samples. Mislabeled samples. Rejection criteria

Are post-analytic factors addressed?


Interpretive commentary included
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CDC Report April 2008

PT providers should publish scientifically


credible reports in peer-reviewed journals.

Ensure all clinical laboratories

participate in PT, including waved tests.

Develop a methodology-based Samples should mimic

approach for PT (one material for many assays).


patient samples with a minimum of matrix effect.

Small adjunct studies with

fresh frozen samples in conjunction with routine PT.

Evaluate alternatives to Develop innovative


approaches to PT.

current CLIA requirements for frequency and scoring.


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Probably yes, but hard to


prove.
Accredited programs do better on PT Laboratories with consistently high PT performance do better with accreditation Clinical Error? Clinical error detection? OFIs and Continual Improvement?

Does Proficiency Testing improve quality?

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Medical laboratory proficiency testing


Medical laboratory proficiency testing has been around for 60 years Respected as a valued monitoring tool
Inter-laboratory comparisons Internal audit Inter-technologist education

Starting to show its age


Testing the wrong thing in the wrong way Falling behind laboratory reality
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What is Antimicrobial Stewardship?


A marriage of infection control and antimicrobial management Mandatory infection control compliance Selection of antimicrobials from each class of drugs that does the least collateral damage Collateral damage issues include - MRSA - ESBLs - C.difficile - stable DE repression - MBLs and other carbapenemases - VRE Appropriate de-escalation when culture results are available

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Dellit TH et al Clin Infect Dis 2007; 44: 159-177

Objectives for Starting Antibiotic Stewardship


A.

Be able to list the recommended components of an antibiotic stewardship program B. Be able to detect antibiotic use improvement opportunities from the analysis of utilization data C. Be able to explain the barriers for successful implementation of such a program
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Why Develop an Antimicrobial Stewardship Program


From an Infection Preventionist Perspective:
Track and Reduce antimicrobial resistance Encourage appropriate treatment patterns ~ The right antibiotic, for the right duration Develop a collaborative practice between MDs/LIPs, Pharmacy, Laboratories and Infection Preventionists with best patient outcome in mind.

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WORKSTREAMS
1. INFORMATION MANAGEMENT (HPS AND ISD) 2. EDUCATION (NES) 3.ORGANISATION AND ACCOUNTABILITY (NQIS)
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WORKSTREAMS
4.INFECTION MANAGEMENT (SPA,NQIS,NES,HPS-ISD, Professional Organisations)
All the work-streams work in parallel but with vertical integration Work stream work underpinned by an AMT Clinical Network
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HIGH BURDEN, HIGH IMPACT CONDITIONS

INFECTION MANAGMENT PHILOSOPHY

EVIDENCE OF BENEFIT FOR INTERVENTION ALSO TARGET SYSTEMS CHANGE TO BRING ABOUT DESIRED BENEFIT INTEGRATE, DEVELOP AND IMPLEMENT EXISITING AND NEW PROJECTS OVER 3 YEAR TIME FRAME: WORK CLOSELY WITH WORK PROGRAMMES OF KEY STAKEHOLDERS (e.g HPS, SPA) IMMEDIATE OPPORTUNITIES AROUND SNAP-CAP, C.difficle and Surgical Prophylaxis.
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Goals of Committee

Assist providers in appropriate use of antimicrobial therapy with improved patient outcomes Slow the development of antimicrobial resistance Develop evidence- based appropriate use guidelines Educate providers and staff regarding guidelines Track resistance patterns and report back to medical and hospital staff Report committee progress and outcomes to P&T, and Executive Committees
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Clean Hands Saves Many Lives

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Follow me for more topics of Interest on Infectious Diseases

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Programme Created by Dr.T.V.Rao MD for Awareness on Use and Misuse of Antibiotics by Medical Professionals

Email
doctortvrao@gmail.com

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