The Rational Use of Antibiotics_IMS.pptx

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1. The Rational Use of Antibiotics Victor Lim International Medical University Kuala Lumpur, Malaysia

2. Describe the principles of rational use of antibiotics Discuss the consequences of inappropriate use of antibiotics List the 4 priority areas and objectives of the Malaysian Action Plan on Antimicrobial Resistance 2017-2021 Learning Outcomes

3. One of the most commonly used group of drugs by all specialties of medicine (except psychiatry) Also one of the most commonly abused group of drugs Antibiotics

4. Achieve desired clinical outcome Minimise adverse effects on the patient Contain cost of health care Avoid emergence of antibiotic resistance – most important Reasons for appropriate use

5. A major clinical challenge today Few new antibiotics discovered last 30 years Bad Bugs No Drugs World Health Organisation 3 rd Global Patient Safety Challenge : (1) Hand washing (2) Safe Surgery (3) Tackling Antibiotic Resistance Theme of World Health Day : Antibiotic Resistance :No action today ! No drugs tomorrow ! Antibiotic Resistance

6. The Discovery Void

7. The pipeline is still dry Report published in April 2021 There has been little progress made in efforts to develop new, desperately needed antibiotics to tackle drug-resistant infections. https://www.who.int/publications/i/item/9789240021303

8. The Review on Antibiotic Resistance Chaired by Jim O’Neill December 2014

9. 4.7 million will die from AMR infections in Asia

10. Use only when necessary Use the most appropriate antibiotic Use the right dose, frequency, route and duration Assess effectiveness of treatment – this is usually forgotten Rational Use

11. REMEMBER Antibiotics can only treat bacterial infections Not all fevers are due to infection Not all infections are due to bacteria One of the most common causes of inappropriate use is giving antibiotics with upper respiratory infections when the most likely causative agent is a virus No evidence that antibiotics can prevent secondary bacterial infection Use only when necessary

12. A 16 year old teenager fell off his bicycle and grazed his left knee. On examination there was an abrasion over the (L) knee and slight redness around the wound. There was no pus discharge. You would Clean the wound with antiseptic Clean the wound with antiseptic and give him a tetanus booster Clean the wound with antiseptic and prescribe a course of antibiotics Question Stop 1

13. Not all bacterial infections require antibiotics Consider other options : antiseptics surgery – collections of pus needs to be drained remove unnecessary catheters and lines

14. What is the likely etiological agent ? What is it likely to be sensitive to ? What patient factors that are needed to consider when choosing the antibiotic? What antibiotic factors ? Choosing an antibiotic

15. Clinical diagnosis Clinical acumen the most likely site/source of infection the most likely pathogens Knowledge of Likely sensitivity universal data more importantly local data The aetiological agent

16. A 50 year old man came to the OPD with a painful swelling at back of his neck. A diagnosis of an uncomplicated cutaneous abscess was made. You would drain the abscess and prescribe a course of Penicillin Ampicillin Cloxacillin Vancomycin Question Stop 2

17. Resistance patterns can vary From country to country From hospital to hospital in the same country From unit to unit in the same hospital Importance of knowing local antibiotic resistance data

18. You have the throat swab result of a 12 year old patient who complained of sore throat. Pseudomonas aeruginosa was isolated which was (R) to Ampicillin and Erythromycin but sensitive to Ceftazidime , Meropenem and Imipenem . You would prescribe Ceftazidime Meropenem Imipenem Nothing Question Stop 3

19. Interpret the report Pathogen or coloniser /contaminant was the specimen properly collected ? sensitivity reports are at best a guide Laboratory diagnosis

20. Age (choose something with least adverse effects – beta lactam and macrolides) Physiological functions – all antibiotics are metabolized in the liver and excreted in the kidneys (hepatotoxic and nephrotoxic antibiotics) Genetic factors – G6PD deficiency (ask patient before prescribing sulfonamides and co- trimoxazole that causes haemolytic anaemia ) Pregnancy – there are antibiotics that can cause problems in the fetus, use the safest antibiotics Site and severity of infection – blood brain barrier (antibiotic to reach CSF) Allergy Patient factors

21. Pharmacokinetic/ pharmacodynamic (PK/PD) profile absorption excretion tissue levels (a good concentration of antibiotic at the site/tissue of infection) Toxicity and other adverse effects Drug-drug interactions Cost Antibiotic factors

22. Oral vs parenteral (IV or IM) For serious infections start with parenteral route (i/v) Switch to an oral agent as soon as practicable (patient get better) Choice of regimen

23. No risks of complications associated with intravascular lines Catheter associated blood stream infection (becoming very common) Thrombophlebitis Much cheaper Shorter hospital stay No cost of administration ( labour cost) Advantages of oral treatment

24. In most instances the optimum duration is unknown Duration varies from a single dose to many months (example tuberculosis, chronic osteomyelitis) depending on the infection Better higher doses for shorter durations than lower doses for longer durations Duration of treatment THE SHORTER THE BETTER

25. Early review of response (2-3 days after you start) Routine early review Increasing or decreasing the level of treatment depending on response change route (IV to oral) change dose (high to low or low to high) change spectrum of antibacterial activity (start off with broad spectrum, after bacteriology report, change to narrow spectrum) stopping antibiotic (patient doing very well) Assess efficacy of treatment

26. The National Medical Care Survey 2014 conducted by the Ministry of Health covered 27,587 patients of 545 public and private clinics nationwide. 57% of patients received antibiotics for URTIs in private clinics as opposed to 16% in government clinics 22% of patients received antibiotics for gastroenteritis in private clinics as opposed to 9% in government clinics Star Infographic 31 May 2015

27. CHANGING BEHAVIOUR Patient education Provision of information alone may not be sufficient Communication skills of both physician and patient also important for behavioral change Financial Incentives where GPs prescribe and dispense

28. Antibiotic resistance is a major problem world-wide Resistance is inevitable with use Very few new antibiotic introduced for clinical use over the last 30 years Behaviour change necessary No action today, no drugs tomorrow Conclusions