Rational use of antibiotics by Dr. Basil Tumaini

Rational use of antibiotics by Dr. Basil Tumaini, presented during CME at Kilema hospital in Moshi District Council

1. Rational Use Of Antibiotics Dr. Basil B. Tumaini, MD 13 th July 2013 Kilema hospital Moshi District Council

2. Outline Introduction Inappropriate use of antibiotics Rational use of antibiotics Antibiotic combination Some rational antibiotic use advices Take home messages References Dr. Basil, KH/13/02 13 July 2013 2

3. Antibiotics Antibiotics are chemical substances obtained from microorganisms (such as bacteria and fungi) that able to inhibit the growth of, or kill, the other microorganisms . Antibiotics are widely used and frequently abused Antibiotics are not antipyretics ! 13 July 2013 3 Dr. Basil, KH/13/02

4. Two groups of antibiotics Bactericidal Kill microorganisms Examples: Penicillins , Aminoglycosides , Rifampicin Bacteriostatic Inhibit the growth of microorganisms Examples: Chloramphenical , Tetracyclines , Clindamycin Dr. Basil, KH/13/02 13 July 2013 4

5. Ideal Antibiotics Criteria Proven efficacy Specific for target pathogens Minimal alteration of host natural flora Safe Cheap Adequate at the site of infection Antibacterial effect is not interfered by body fluid, exudates, plasma protein or enzymes and persist for a long duration in the blood Resistance develops slowly Given by any route 13 July 2013 5 Dr. Basil, KH/13/02

6. Inappropriate use of antibiotics Is a worldwide problem More than 50% of all medicines are prescribed, dispensed or sold inappropriately , and half of all patients fail to take medicines correctly The overuse, underuse or misuse of medicines harms people and wastes resources. 13 July 2013 6 Dr. Basil, KH/13/02

7. In developing countries, less than 40% of patients in the public sector and 30% in the private sector are treated according to clinical guidelines . More than 50% of all countries do not implement basic policies to promote rational use of medicines. Dr. Basil, KH/13/02 13 July 2013 7

8. Common problems Polypharmacy Overuse of antibiotics and injections Failure to prescribe in accordance with clinical guidelines Inappropriate self-medication Inappropriate antibiotic combinations 13 July 2013 8 Dr. Basil, KH/13/02

9. COMMON CAUSES OF FAILURE OF ANTIBIOTIC THERAPY DRUGS Inappropriate drug Inadequate dose Improper route of administration Accelerated inactivation Poor penetration 13 July 2013 9 Dr. Basil, KH/13/02

10. HOST Poor host defence Undrained pus Retained infected foreign bodies Crusta /necrotic tissues 13 July 2013 10 Dr. Basil, KH/13/02

11. 3. Pathogen Drug resistance Superinfection Dual infection initially 4. Laboratory erroneous report of susceptible pathogen Dr. Basil, KH/13/02 13 July 2013 11

12. Dynamics of irrationality Health care being equated to drug therapy . Drug prescription thus becomes a natural inevitable consequence Lack of confidence leads to drug overuse Dearth of seniors as “role models” Influence of drug industry – only source of knowledge to many / biased information / incentives for prescriptions 13 July 2013 12 Dr. Basil, KH/13/02

13. Why take antibiotics? "The desire to take medicine is perhaps the greatest feature which distinguishes man from animals." " One of the first duties of the physician is to educate the masses not to take medicine " H. Cushing, Life of Sir William Osler (1925) William Osler, MD (1849 - 1919) 13 July 2013 13 Dr. Basil, KH/13/02

14. Is an antibiotic necessary? Useful only for the treatment of bacterial infections Not all fevers are due to infection Not all infections are due to bacteria There is no evidence that antibiotics will prevent secondary bacterial infection in patients with viral infection 13 July 2013 14 Dr. Basil, KH/13/02

15. The treatment of certain infections might be better achieved with other means such as surgery E.g., debridement of local cellulitis in moderate CA-MRSA infections of the skin Dr. Basil, KH/13/02 13 July 2013 15

16. Effects of irrational therapy False sense of security Masking / confusing / delaying correct diagnosis Emergence of drug resistant organisms Increased cost Higher incidence of ADR Wastage of resources Loss of faith in medical profession 13 July 2013 16 Dr. Basil, KH/13/02

17. Solutions Adequate time for detailed communication Be transparent and confident Documentation of explained statements Follow science and standard protocols Continued medical education ( CME ) Record keeping and self audit 13 July 2013 17 Dr. Basil, KH/13/02

18. The rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and at the lowest cost to them and their community. WHO conference of experts Nairobi 1985 correct drug appropriate indication appropriate drug considering efficacy, safety, suitability for the patient, and cost appropriate dosage, administration, duration no contraindications correct dispensing, including appropriate information for patients patient adherence to treatment 13 July 2013 18 Dr. Basil, KH/13/02

19. Pillars of rational drug therapy Genuine indication Minimum number of drugs Inexpensive and appropriate formulation Preferably oral route – avoid injections Monitor adverse drug reaction (ADR) Patient education related to drugs and disease 13 July 2013 19 Dr. Basil, KH/13/02

20. Is an antibiotic indicated ? Have appropriate specimens been obtained? What organisms are likely to be responsible? Which agent is best ? Is an antibiotic combination appropriate ? Considerations in prescribing antibiotics 13 July 2013 20 Dr. Basil, KH/13/02

21. Any special host factors ? Best route of administration What is the appropriate dose ? Is modification needed later ? Optimal duration of therapy? Considerations in prescribing antibiotics (2) 13 July 2013 21 Dr. Basil, KH/13/02

22. Antibiotic Combination Useful when there is synergism Blockade of sequential steps in a metabolic sequence e.g., Trimethoprim – sulfamethoxazole (cotrimoxazole) Inhibition of enzymatic inactivation e.g., Amoxicillin – clavulanate (co-amoxiclav, e.g., Augmentin ® ) Enhancement - Aminoglycosides e.g., Penicillins - Aminoglycosides 13 July 2013 22 Dr. Basil, KH/13/02

23. Useless when there is antagonism Inhibition of cidal activity by static agent - Tetracyclines – Beta-lactam antibiotics (penicillins, cephalosporins) Induction of enzymatic inactivation - Ampicillin - Piperacillin 13 July 2013 23 Dr. Basil, KH/13/02

24. II Indifference Synergism Antagonism No drug No drug No drug Drug A Drug A Drug C Drug B Drug B Drug A A + B A + B A + C Hours after inoculation → I III Log of number of viable bacteria/ml 13 July 2013 24 Dr. Basil, KH/13/02

25. Clinical indication of antibiotic combination ► Mixed infection ► Synergism ► Risk of developing resistant organisms ► Increase antibiotic coverage ► Infection of unknown origin 13 July 2013 25 Dr. Basil, KH/13/02

26. Disadvantages of antibiotic combination ► Increase risk of ADR ► Increase development of MDR pathogens ► Increase cost ► Increase treatment failure ( antagonism ) 13 July 2013 26 Dr. Basil, KH/13/02

27. Irrational Antibiotic Combinations Irrational Fixed dose combinations (FDC) Nor floxacin and Tin idazole Ampi cillin and cloxa cillin Other irrational combinations IV Ampicillin + IV Cloxacillin IV Benzyl penicillin + IV Cloxacillin Also prescribing routinely IV Ceftriaxone + IV Cloxacillin is irrational 13 July 2013 Dr. Basil, KH/13/02 27

28. Some Rational antibiotic use advices (1) 1. Severe pneumonia Infants < 2 months: IV Benzyl penicillin + Gentamicin Children 2 months – 5 years: IV Benzyl penicillin or IV Chloramphenicol 13 July 2013 Dr. Basil, KH/13/02 28

29. Some Rational antibiotic use advices (2) 2. Pneumonia Infants < 1 month: avoid cotrimoxazole Children: cotrimoxazole BD or amoxicillin 13 July 2013 Dr. Basil, KH/13/02 29

30. Some Rational antibiotic use advices (3) 3. No pneumonia: cough or cold No antibiotics needed Safe cough remedy, e.g., tea with honey 4. Hospital acquired infections IV Ampicillin + IV Gentamicin for 7-10/7 13 July 2013 Dr. Basil, KH/13/02 30

31. TAKE HOME MESSAGES Adherence to standards during prescription. Ref. Standard Treatment Guidelines, etc. Use antibiotics only when indicated Avoid unnecessary polypharmacy Use antibiotic combinations wisely Monitor ADR Continuous medical education (CME) Adequate instructions /information to our patients 13 July 2013 Dr. Basil, KH/13/02 31

32. References (1) WHO. Model list of essential drugs . Geneva: World Health Organization, (1988). Ernest J. Resistance to antimicrobials in humans and animals . BMJ, 331: 1219–20, (2005) B Till, et al. A survey of inpatient antibiotic use in a teaching hospital . S Afr Med J, 80: 07-10, (1991) 13 July 2013 Dr. Basil, KH/13/02 32

33. References (2) Editorial. Antibiotic audit . Lancet, 1: 310, 311, (1981). Edward A, et al. Strategies for promoting judicious use of antibiotics by doctors and patients . BMJ, 317: 668–71, (1998). Schaffner W, et al. Improving antibiotic prescribing in office practice . JAMA, 250: 1728-32, (1983) 13 July 2013 Dr. Basil, KH/13/02 33

34. References (3) Ekedahl A, et al. Drug prescription attitudes and behaviour of general practitioners. Effects of problem oriented educational programme . Eur J Clin Pharmacol, 47: 381-7, (1995) The United Republic of Tanzania Ministry of Health and Social Welfare. Standard Treatment Guidelines (STG) and the National Essential Medicines List (NEMLIT) for Mainland Tanzania . 3rd Ed, (2007) 13 July 2013 Dr. Basil, KH/13/02 34