Antimicrobial resistance journal club .pptx

Antimicrobial resistance

1. Defeating silent enemy : AMR looming as global pandemic Mentors : Dr Niranjan Pathak sir Dr Akshay Mohnani sir Presentor : Dr Gnanshree Dave

2. ABSTRACT Antibiotics are magic bullets that have saved millions worldwide. Enormous and irresponsible use of antibiotics has led to resistance to antibiotics, which is a matter of global health concern. The superbugs are responsible for life-threatening infections, treatment failure, and high mortality worldwide. The urgent healthcare threat caused by antimicrobial resistance (AMR) to nonfermenting gram-negative bacteria is being increasingly acknowledged worldwide. Antibiotic resistance found in organisms in hospital settings is now increasingly found in the community.

3. FACTORS Potential factors contributing to the molecular mechanism of antibiotic resistance :- Intrinsic resistance acquired resistance genetic alteration DNA transfer K ey factors contributing to emergence Of antibiotic resistance are :- E xcessive utilization of antibiotics and negligent prescription by healthcare practitioners The primary pathogens linked to fatalities caused by resistance were :- ESKAPE pathogens Escherichia coli (E. coli), Staphylococcus aureus (S. aureus), Klebsiella pneumoniae (K. pneumoniae ), Streptococcus pneumoniae (S. pneumoniae ), Acinetobacter baumannii (A. baumannii ), Pseudomonas aeruginosa (P. aeruginosa ) Enterococcus sp.

4. CONSEQUENCES Treatment failure Long illnesses & longer hospital stays More prescriptions of higher costlier antibiotic Higher morbidity & mortality

5. Facts & Figures 70% of pathogenic bacteria have developed resistance to at least one commercially available antibiotics 35% of common human infections are resistant to the currently available antibiotics 80-90 % resistance rates in LMIC d/t rampant misuse of antibiotics, agricultural use of antibiotic use, poor quality of drugs, inadequate surveillance, substandard healthcare, malnutrition , infections that are chronic and recurring, inability to afford more effective drugs

6. Classification acc to CDC report , Nov’19.

7. AMS STRATEGIES Antibiotic prescription in ambulatory care & antibiotic exposure in the community Shift in the public perception of the risks and benefits associated with antibiotics Implementation of rapid diagnostic tests to promptly identify MDR organisms Conduct a prospective audit of antibiotic use and consider preauthorization Timely transition from intravenous to oral antibiotic therapy, aiming to reduce healthcare costs and the length of hospital stays Antibiotic de-escalation -switching from broad-spectrum antimicrobials to narrower spectrum , in the ICU setting to minimize the emergence of MDR bacteria and healthcare expenses

8. Goals of Antimicrobial Stewardship Programs Cost-effective approach Minimize the potential risks of adverse events Optimize the chances of achieving favorable clinical results Extend the lifespan of existing antibiotics by reducing the selec tive pressure Multifaceted approach involving policymakers, the healthcare industry, healthcare professionals, the agricultural sector, and individual patients Seek out novel antimicrobial agents Devise effective strategies aimed at diminishing the emergence and prevalence of resistance One health approach : attain optimal health outcomes for all, encompassing humans, animals, plants, and the environment

9. Rational Antibiotic Use Make a clinical diagnosis & know the causative organism Restrict the administration of empirical antibiotics to only those patients who are critically ill. Consider the potential resistant patterns when selecting a suitable antibiotic. Deescalation or modification of empiric broad-spectrum antibiotics is determined by the culture & susceptibility reports & clinical condition Discontinue the use of antibiotics in clinical scenarios such as rhino sinusitis, viral pharyngitis, and bronchitis, noninfectious cardiopulmonary syndromes, asymptomatic bacteriuria and pyuria Limit the treatment duration & Enhance pharcokinetic-pharmacodynamic parameters : loading doses , monitor TDL

10. GUIDELINES FOR ANTIBIOTIC PRESCRIPTION IN ICU IN INDIA : CAP MRSA : Empiric addition of either vancomycin or teicoplanin is recommended; Linezolid is a suitable alternative : intolerant to vancomycin, ( VRSA), or renal failure. Anaerobic : clindamycin , moxifloxacin , or amoxicillin- clavulanate . • If there is an indication, carbapenems or piperacillin- tazobactam can be used as empirical therapy for anaerobes.

11. VAP Colistin if CRE > 20 % Empirical antibiotic regimen not to include coverage for atypical organisms routinely If no carbapenem / piptaz : add METRO / CLINDA : anaerobes Unconventional : FQ + Macrolide

12. DURATION OF THERAPY : CAP & VAP CAP requiring ICU admission: 7–10 days. CAP due to Pseudomonas/or aspiration pneumonia: 14 days. Necrotizing pneumonia due to GNB, MRSA, or anaerobes: 14–21 days. Duration of treatment should be tailored to the specific causative organism, the patient’s response to treatment, the severity of the disease, and any associated complications VAP with positive clinical response to therapy: Short course for 7–8 days. Consider a prolonged duration, that is, 14 days of antibiotic treatment in cases of VAP caused by NF-GNBs or linked to severe immunodeficiency , structural lung disease, empyema, lung abscess, necrotizing pneumonia

13. CRBSI GPB + GNB MRSA + MR-CONS : Vanco / Teico . ALTERNATE : Linid + Daptomycin GNB : 4 TH generation cephalosporin , carbapenem or combo of b-lactam/b-lactamase inhibitor with or without aminoglycoside Candida : echinocandin / fluconazole Uncomplicated S . aureus CRBSI , & IE : min 2 weeks Complicated cases of the same : min 4 - 6 weeks. Gram-negative CRBSI : min 1 week CONS bacteremia : 5–7 days. S uspected fungal CRBSI : min 2 weeks

14. Urogenital sepsis ESBL-producing gram-negative organisms: β-lactam in combination with a β-lactamase inhibitor, aminoglycosides, or carbapenems It is not recommended to use antibiotics targeting gram-positive organisms as the initial empirical regimen for UTI. Antifungals should be considered as part of the empirical treatment in suitable clinical scenarios.

15. Abdominal infections No routine use of prophylactic antibiotics to prevent pancreatic infection after acute pancreatitis, regardless of its severity. Select appropriate antibiotic regimen for infected pancreatic necrosis based on local microbiological data, susceptibility patterns, the pharmacokinetic properties of antibiotics , & patient’s previous antibiotic exposure. Empirical therapy for treatment-naïve patients presenting with infected pancreatic necrosis : piperacillin- tazobactam , carbapenems , or cefoperazone-sulbactam . In patients who are not showing a response or have already been exposed to above : include colistin in the empirical treatment regimen. Duration of antibiotic therapy should be determined based on the clinical, laboratory, and radiological parameters

16. CNS INFECTIONS CAI - MENINGITIS : 3 rd Gen Cephalosporin Ceftriaxone + Vancomycin >50 years old, add ampicillin or amoxicillin β-lactams are contraindicated : Chloramphenicol + Vancomycin >50 years old , add cotrimoxazole Alternate regimen : ciprofloxacin/ aztreonam + Vancomycin >50 years old , add cotrimoxazole S . pneumonia = 10–14 days S . agalactiae = 14–21 days. N . meningitides / H. influenza = 7-day aerobic GNB = 21 days Listeria monocytogenes = 21 days If no microorganism is identified = at least 10–14 days

17. CNS INFECTIONS NOSOCOMIAL MENINGITIS Empirical antibiotics of choice = vancomycin + cefepime , ceftazidime , or meropenem . Colistin may be administered if there is a high occurrence of CRE or drug-resistant acinetobacter in the particular unit/ department. If β-lactams are contraindicated, substitute it with either ciprofloxacin or aztreonam . If the infection shows inadequate response to suitable systemic antibiotics either clinically or microbiologically, intraventricular/intrathecal antibiotics should be considered.

18. SSTI MODERATE NON PURULENT : IV penicillin or clindamycin SEVERE NON PURULENT (5 days): piperacillin- tazobactam + coverage for MRSA, such as teicoplanin , vancomycin, daptomycin , or linezolid . SEVERE PURULENT (2-3 weeks) : IND f/b piptaz + mrsa Monomicrobial necrotizing infection caused by S. pyogenes or Clostridial species : penicillin + clindamycin

19. UKNOWN CAUSE OF SEPSIS C ombination of ceftriaxone and either doxycycline or a macrolide as empirical antimicrobial therapy C ombination of a β-lactam/β-lactamase inhibitor with either a fluoroquinolone or an aminoglycoside WITH empirical therapy Duration : 7-10 days or longer if needed

20. Factors contributing to AMR

21. Factors contributing to AMR

22. QUIZ TIME

23. 1 During your weekly ward rounds , you notice that 2 catheterized patients are being treated with antibiotics . Only one of them had symptoms of catheter associated UTI (fever with no other localization) Both patients are being treated with tab. Nitrofurantoin 100 mg BD based on culture sensitivity report Your Comments ?

24. 2 During your weekly ward rounds, you find that a case of probable IPA is on day 6 of voriconazole (tablet 200 mg BD). He is on o2 support by facemask at 6-8 L /min and has poor oral intake. On reviewing charts , you find that no loading dose is given What will you do next ?

25. 3 You are reviewing charts of pt in ICU who has developed VAP. Given the high chances of CRE , he was started on Polymyxin B with loading dose . Today is day 4 of treatment and culture reports have arrived s/o Klebsiella pneumonia sensitive to meropenem / imipenem / piptaz / cef-sulb What antibiotic will you continue ?

26. 4 You find another pt with VAP due to Pseudomonas aeruginosa . This pt was also started on empirical Polymyxin B . But after culture reports , treatment de-escalated to Piptaz . However pt has failed to show any significant clinical response despite 5 days of therapy. pseudomonas susceptibility profile – Piptaz / cef-sulb / meropenem What do you think is the reason for this failure to treat ?

27. 5 A 14 yr old boy presented with rt upper limb cellulitis secondary to trauma . He is also having high grade fever and is empirically started on Ceftriaxone and Vancomycin . Blood c/s – MSSA What should be done next ?

28. 6 70 yr old man with c/o cough , dyspnea, fever since 3 days. He was recently admitted for similar complaints 2 months ago and had required ICU with IV drugs . He is started on ceftriaxone and azithromycin Comments ?

29. 7 c/o Meningitis (post – evd ), drain fluid has grown pseudomonas sensitive to meropenem / imipenem . Treating team has started meropenem 1 gm TDS but with no significant improvement ?

30. 8 65 yr old T2DM with diabetic foot . Tissue culture sent . Started on levofloxacin 750mg OD as per c/s reports. Pt developed HAP, sepsis with renal dysfuction and had a cardiac arrest and died . What went wrong and what could have been done ?

31. OPD SCENARIOS ORNIDAZOLE – OFLOXACIN FOR DIARRHOEA AZITHROMYCIN- AMOXYCILLIN FOR URTI NITROFURANTOIN/CITAL FOR CYSTITIS

32. Conclusion While the ICU has traditionally been seen as the main source of MDR, there has been a noticeable shift towards nursing homes, general wards, and the community Improved infection control practices and appropriate antibiotic use without unnecessary overuse, is crucial to preserve effectiveness of commonly used antibiotics Combination therapies of current antibiotics and antibiotic adjuvants is one of the solutions to address the emerging AMR phenomenon C onsistently monitor the trends of antibiotic resistance in order to assess the efficacy of interventions and detect any emerging patterns of resistance.

33. THANK YOU