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Antibiotic Resistance and Medicinal Drug Policy


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

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

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

Press Release WHO/41 12 June 2000
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
The start of antibiotic resistance Penicillin
Florey Chain 1940
Fleming 1928
History of resistance
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
  • Development of new antibiotics has slowed
    resistant microorganisms are increasing

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

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)

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
  • A small but growing number of patients are
    already showing primary resistance to AZT and
    other new therapies for HIV-infected persons.

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,
  • Therapy priced out of the reach of some
    third-world countries

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.

Social factors fuelling resistance
  • Poverty encourages the development of resistance
    through under use of drugs
  • Patients unable to afford the full course of the
  • 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.

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)

Antibiotic stewardship Australia
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,
  • Used for medical education, problem look-up and
    drug audit

Drug audit, and change strategies
Compare drug use with Guidelines recommendations
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

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.

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

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

Audit results
Audits results
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

Australian therapeutic guidelines Today
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