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Antibiotic Resistance and Medicinal Drug Policy

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Why the concern about antibiotic resistance? ... gentamicin for peritonitis, thereby ignoring the anaerobic flora of the bowel. ... – PowerPoint PPT presentation

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Title: Antibiotic Resistance and Medicinal Drug Policy


1
Antibiotic Resistance and Medicinal Drug Policy
  • Dr. Ken Harvey School of Public Health, La Trobe
    University,
  • Melbourne, Australia

1
2
Lecture outline
  • Why the concern about antibiotic resistance?
  • The history, microbiological and social
    determinants of antibiotic resistance
  • Containing antibiotic resistance microbiological
    surveillance, antibiotic utilization studies and
    other interventions
  • One countrys response the quality use of
    medicines pillar of Australian drug policy
  • The current challenge using information
    technology to further improve antibiotic use

3
Press Release WHO/41 12 June 2000
DRUG RESISTANCE THREATENS TO REVERSE MEDICAL
PROGRESS Curable diseases from sore throats and
ear infections to TB and malaria -- are in danger
of becoming incurable A new report warns that
increasing drug resistance could rob the world of
its opportunity to cure illnesses and stop
epidemics.
3
4
The start of antibiotic resistance Penicillin
Florey Chain 1940
Fleming 1928
5
History of resistance
6
Bacterial evolution vs mankinds ingenuity
  • Adult humans contains 1014 cells, only 10 are
    human the rest are bacteria
  • Antibiotic use promotes Darwinian selection of
    resistant bacterial species
  • Bacteria have efficient mechanisms of genetic
    transfer this spreads resistance
  • Bacteria double every 20 minutes, humans every 30
    years
  • Development of new antibiotics has slowed
    resistant microorganisms are increasing

7
Surveillance of resistance Australia
  • Data are collected from 29 laboratories around
    Australia, including public hospital and private
    laboratories, in both metropolitan and country
    areas.
  • Australia, like China, is a contributor to the
    WHO A-R Infobank http//oms2.b3e.jussieu.fr/arinf
    obank/

8
Resistance Australia 2000
  • Hospitals
  • vancomycin-resistant enterococci (VREs)
  • multi-resistant Staph. aureus (MRSA) NB.
    vancomycin-resistant strains have been found in
    Japan and the USA but not yet in Australia
  • Community
  • Strep. Pneumoniae (Penicillins 15 I, 2 R
    macrolides tetracyclines 20 R)
  • Haemophilis influenzae (Penicillins 20 R
    macrolides tetracyclines 10 R)
  • E. coli (amoxycillin 45 R amoxy-clav 10 R
    trimeth 15R)

9
Resistance The World 2000
  • In much of South-East Asia, resistance to
    penicillin has been reported in up to 98 of
    gonorrhoea strains.
  • In Estonia, Latvia, and parts of Russia and
    China, over 10 of tuberculosis (TB) patients
    have strains resistant to the two most effective
    anti-TB drugs.
  • Thailand has completely lost the use three of the
    most common anti-malaria drugs because of
    resistance.
  • A small but growing number of patients are
    already showing primary resistance to AZT and
    other new therapies for HIV-infected persons.

10
The consequences of antibiotic resistance
  • Increased morbidity mortality
  • best-guess therapy may fail with the patients
    condition deteriorating before susceptibility
    results are available
  • no antibiotics left to treat certain infections
  • Greater health care costs
  • more investigations
  • more expensive, toxic antimicrobials required
  • expensive barrier nursing, isolation, procedures,
    etc.
  • Therapy priced out of the reach of some
    third-world countries

11
Therapy priced out of the reach of the poor
  • A decade ago in New Delhi, India, typhoid could
    be cured by three inexpensive drugs. Now, these
    drugs are largely ineffective in the battle
    against this life-threatening disease.
  • Likewise, ten years ago, a shigella dysentery
    epidemic could easily be controlled with
    cotrimoxazole a drug cheaply available in
    generic form. Today, nearly all shigella are
    non-responsive to the drug.
  • The cost of treating one person with
    multidrug-resistant TB is a hundred times greater
    than the cost of treating non-resistant cases.
    New York City needed to spend nearly US1 billion
    to control an outbreak of multi-drug resistant TB
    in the early 1990s a cost beyond the reach of
    most of the world's cities.

12
Social factors fuelling resistance
  • Poverty encourages the development of resistance
    through under use of drugs
  • Patients unable to afford the full course of the
    medicines
  • Sub-standard counterfeit drugs lack potency
  • In wealthy countries, resistance is emerging for
    the opposite reason the overuse of drugs.
  • Unnecessary demands for drugs by patients are
    often eagerly met by health services and
    stimulated by pharmaceutical promotion
  • Overuse of antimicrobials in food production is
    also contributing to increased drug resistance.
    Currently, 50 of all antibiotic production is
    used in animal husbandry and aquiculture
  • Globalization, increased travel and trade ensure
    that resistant strains quickly travel elsewhere.
    So does excessive promotion.

13
Postponing the end of the antibiotic era
  • Antibiotic stewardship (prudent use)
  • Contain the spread of resistant micro-organisms
    and relevant genes (infection control)
  • Develop new antibiotics that have novel modes of
    action or circumvent bacterial mechanisms of
    resistance (research)

14
Antibiotic stewardship Australia
15
What are Antibiotic Guidelines?
  • Best practice recommendations concerning the
    treatment of choice for common clinical problems
  • Written by national experts
  • Evidence based where possible, peer-consensus
    where not
  • Regularly updated every 2 years
  • Endorsed by the Australian Medical Association,
    etc.
  • Used for medical education, problem look-up and
    drug audit

16
Drug audit, and change strategies
Compare drug use with Guidelines recommendations
17
First Australian drug audits1978-82
  • The 700 bed Royal Melbourne Hospital was
    surveyed. The 240 bed sample comprised
  • 3 general medical units
  • gastroenterology unit
  • haematology-oncology unit
  • 4 general surgical units
  • orthopaedic unit

18
Inappropriate prescribing
  • Example of a drug not required
  • A patient with suspected infected burns received
    oral flucloxacillin and penicillin V. Therapy was
    continued for 23 days despite the failure of 3
    separate swabs to produce any growth on culture.
    Culture of the fourth swab grew
    methicillin-resistant Staphylococcus aureus.

19
Inappropriate prescribing
  • Example of incorrect administration
  • Surgical antibiotic prophylaxis accounted for
    100 prescriptions and, of these, 23 were given 2
    to 12 hours AFTER the operation, a delay that
    largely nullified their value.
  • Example of inadequate cover
  • A patient received gentamicin for peritonitis,
    thereby ignoring the anaerobic flora of the
    bowel. Metronidazole or clindamycin should have
    been added

20
Change strategies used
  • Feedback of audit results to prescribers followed
    by discussion at grand rounds and unit meetings
  • Use of Antibiotic Guidelines in undergraduate and
    postgraduate teaching
  • Rewriting the next edition of Antibiotic
    Guidelines, incorporating additional text to
    clarify misunderstandings and problems observed

21
Audit results
22
Audits results
23
Initial conclusions
  • Antibiotic prescribing improved
  • Surgeons (prophylaxis) were responsible for more
    inappropriate prescribing than physicians
  • Some persisting patterns of inappropriate
    antibiotic use appeared to reflect pharmaceutical
    company promotion
  • There was also a need for ongoing campaigns
    because hospital staff changed

24
Australian therapeutic guidelines Today
25
Dr. Harveys visit to China was sponsored by
  • The World Health Organization
  • and hosted by Professor Yong-Hong Yang
  • Beijing Childrens Hospital
  • Professor Li Dakui
  • Peking Union Medical College

25
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