antibiotics use and misuse at outpatient clinics

BYDR. Mahmoud Abdulkareem

MS, Cairo , FRCS ,GlasgowConsultant General Surgeon

King Fahad Specialist Hospital

Antibiotics Prescription at Outpatient ClinicsUse and Misuse

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Introduction

In the last century, nothing has made a bigger impact on human health than antimicrobial chemotherapy. After 20 years of clinical use, antibiotics have increased the average human life expectancy by ten years while in comparison, curing cancer would only extend life expectancy by two years.

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What went wrong with Antibiotic Usage

1. Treating trivial infections / viral Infections with antibiotics has become routine affair.

2. Many use antibiotics without knowing the basic principles of antibiotic therapy.

3. Many medical practitioners are under pressure for short term solutions.

4. Commercial interests of Pharmaceutical industry.

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Antibiotics are misused in hospitals

“It has been recognized for several decades that up to 50% of antimicrobial use is inappropriate”

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Antibiotic are misused in a variety of ways

1. Given when they are not needed2. Continued when they are no longer

necessary3. Given at the wrong dose4. Broad spectrum agents are used to

treat very susceptible bacteria5. The wrong antibiotic is given to

treat an infection03/08/2014 6

03/08/2014 7King Fahad Specialist Hospital Buraidah al-Qassim

Antibiotic Resistance

Nowadays, about 70 percent of the bacteria that cause infections in hospitals are resistant to at least one of the drugs most commonly used for treatment.

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Wound infections, gonorrhea, tuberculosis, pneumonia, septicemia and childhood ear infections are just a few of the diseases that have become hard to treat with antibiotics


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One part of the problem is that bacteria and other microbes that cause infections are remarkably resilient and have developed several ways to resist antibiotics and other antimicrobial drugs. Another part of the problem is due to increasing use, and misuse, of existing antibiotics in human and veterinary medicine and in agriculture.


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Selective pressure

Any use of antibiotics can increase selective pressure in a population of bacteria to allow the resistant bacteria to thrive and the susceptible bacteria to die off.

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As resistance towards antibiotics becomes more common, a greater need for alternative treatments arises. However, despite a push for new antibiotic therapies there has been a continued decline in the number of newly approved drugs. Antibiotic resistance therefore poses a significant problem.


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While the rate of development of antimicrobial resistance has been accelerating, the pace of development of new antimicrobial agents has slowed considerably during the past several decades. Only two classes of new antibacterials have come to market over the last 30 years. The period from 1983 to 2007 saw a 75 percent decrease in systemic antibacterials approved by the FDA, reflecting a decline in the antibiotic pipeline.


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New antibacterial agents approved by the FDA and EMA

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“post-antibiotic era” scenario.

Most alarming of all are the diseases caused by multidrug-resistant microbes, which are virtually non-treatable and thereby create a

“post-antibiotic era” scenario.

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03/08/2014 17 Kasr Al-Ainy Medical School in Cairo

It is important to have a clear understanding of the terms used for wound infection. Since 1985 the most commonly used terms have included wound contamination, wound colonisation, wound infection and, more recently, critical colonisation. These terms can be defined as:

Terminology

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Classic signs Additional signs

• Pyrexia • Inflammation • Oedema • Pain • Increase in exudate or pus

• Delayed healing • Bridging of skin across a wound • Dark/discoloured granulation tissue • Increased friability (tissue which bleeds easily) • Painful/altered sensation to the wound site/surrounding skin • Altered odour • Wound breakdown • Pocketing at the base of the wound • Increased watery/serous exudate rather than pus

Signs and symptoms of wound infection

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wound swabs

All wounds contain a variety of microorganisms, however it is only when wound infection is suspected from clinical signs that further investigation is required.

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HOW TO TAKE A WOUND SWAB

A representative area of the wound should be sampled. If the wound is large, it may not be feasible to cover the entire surface, but at least 1cm² should be sampled and material from both the wound bed and wound margin should be collected. If pus is present, the clinician should ensure that a sample is sent to the laboratory. Immediately following collection, the swab should be returned to its container (placed into the transport medium) and accurately labelled.

Returning the swab to its container

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Interpreting microbiology results

Conversely, where a microbiology result of ‘no growth’ or ‘no significant growth’ is returned, the result should be interpreted with care and should not be automatically interpreted as meaning that no infection is present, particularly if the patient has clinical signs and symptoms that suggest otherwise. In this situation such a result should be regarded as a false negative (Kingsley, 2003).

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Interpreting microbiology results

Diagnosing wound infection is essentially a clinical skill and microbiological investigations should only be used to aid diagnosis, rather than the other way round (Sibbald, 2003).

Not all laboratories look for pus cells when examining wound swabs. Micro- organisms reported from wound cultures are not necessarily indicative of SSI and if pus cells are not indicated as present in the wound culture report there must also be at least two clinical symptoms of infection and a clinicians diagnosis.03/08/2014 24

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Why is an antibiotic policy necessary? An antibiotic policy will: 1. improve patient care by promoting the best practice in

antibiotic prophylaxis and therapy, 2. make better use of resources by using cheaper drugs

where possible 3. retard the emergence and spread of multiple antibiotic-

resistant bacteria. 4. improve education of junior doctors by providing

guidelines for appropriate therapy 5. eliminate the use of unnecessary or ineffective antibiotics

and restrict the use of expensive or unnecessarily powerful ones

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What is the Ideal Antibacterial?

1-Selective target – target unique2- Bactericidal – kills3- Narrow spectrum – does not kill normal flora4- High therapeutic index – ratio of toxic level to therapeutic leve5- Few adverse reactions – toxicity, allergy6- Various routes of administration – IV, IM, oral8- Good absorption9-Good distribution to site of infection10- Emergence of resistance is slow

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1. Efficacy in treating the infection2. Severity of the patient’s illness 3. Physician’s previous experience with and

knowledge about the drug 4. Side effects 5. Cost to patient 6. Ease of use 7. Risk of contributing to the problem of

antimicrobial resistance

Factors Influencing Physicians’ Choice of Drug

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Good Practices 1. Consider whether or not the patient actually requires an antibiotic.

2. Avoid treating colonised patients who are not actually infected.

3. In general do not change antibiotic therapy if the clinical condition is improving.

4. If there is no clinical response within 72 hours, the clinical diagnosis, the choice of antibiotic and/or the possibility of a secondary infection should be reconsidered.

5. Consider the use of pharmacy ‘stop' policy after 5 days.

6. For surgical prophylaxis start the antibiotic with the induction of anaesthesia and continue for a maximum of 24 hours only.

7. Give the antibiotic for the minimum length of time that is effective.

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1. Antibiotics should only be prescribed for proven or clinically suspected bacterial infection unless recommended for prophylaxis.

2. Choice of antibiotic should be guided by clinical signs and symptoms, history and recent laboratory results.

3. Many antibiotics require dosage adjustment in renal impairment. 4. When treating blind (empirical therapy), and as a general rule, use

the narrowest spectrum drug that will cover the most likely pathogens. Where microbiological data, e.g. MRSA status, culture results and sensitivities are available, or become available after treatment is started, these should be taken into account. Always check (using electronic results system) if results of previous microbiology (inpatient or outpatient/GP) should influence empirical therapy, e.g. previous infection with MRSA, ESBL producing organism, or C difficile.

5. If clinically safe it is recommended to take samples for cultures before initiating antimicrobial treatment.

General principles

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