Abuse of Antibiotics In clinical practise

BY

Dr. Hussein FatehyPhD-FCCP -MCTS

CONSULTANT PULMONOLOGISTAbbassia Chest Hospital

Cairo-Egypt

AntibioticsDefinition

Antibiotics are substances that kill or inhibit the growth of micro-organisms.Bacteriostatic (Tetracycline, Chloramphenicol)Bactericidal (Beta lactams, Aminoglycosides)

.

HistoryThanks to work by Alexander Fleming (1881-1955), Howard Florey ( 1898-1968) and Ernst Chain (1906-1979), penicillin was first produced on a large scale for human use in 1943. At this time, the development of a pill that could reliably kill bacteria was a remarkable development and many lives were saved during World War II because this medication was available.

E. Chain H. FloreyA. Fleming BC Yang

Penicillin: an extensively studied example

For lecture only BC Yang

Social and economic impact

Antibiotics can cause severe reactions, increasing hospitalization: in the United States, this accounts for billions of dollars of expense within the healthcare system. Adverse effects from antibiotics account for nearly 25% of all adverse drug reactions amongst hospitalized patients

Beringer PM, Wong-Beringer A, Rho JP (January 1998). "Economic aspects of

antibacterial adverse effects". PharmacoEconomics 13 (1 Pt 1): 35–49.doi:10.2165/00019053-199813010-00004

ARE ALL ANTIBIOTICS ALIKE?

Many types of antibiotics are available. Each works a little differently and acts on different bacteria. This is why you must have a prescription to buy antibiotics. Your doctor will decide which antibiotic will work best for your infection

ARE ANTIBIOTICS SAFE?

Antibiotics are usually safe when taken as directed by your doctor. However, people may develop allergies to specific antibiotics, and may have a reaction to them. Your doctor will ask if you have ever had allergic reactions to any medicines. This is to make sure you receive the right antibiotic.

Antibiotic Prescription

A Balancing ActA Balancing Act

Appropriate Initial Antibiotic Treatment

Appropriate Initial Antibiotic Treatment

AvoidUnnecessaryAntibiotics

AvoidUnnecessaryAntibiotics

PRINCIPLES OF ANTIMICROBIAL THERAPYDRUG: most

effective and specific drug

HOST: state of

competence

MICROBES: demonstrate and

isolate, know susceptibility

Empirical Therapy

Empiric therapy is a medical term referring to the initiation of treatment (against an anticipated and likely cause of infectious disease) prior to determination of a firm diagnosis.

It is most often used when antibiotics are given to a person before the specific microorganism causing an infection is known.

Factors considered when selecting empiric antimicrobial therapy

• Pharmacologic factors– Potential drug toxicity (i.e. aminoglycosides)– Bioavailability.– Distribution to the site of infection.

Microbiological factors:• Identification of the most likely pathogens and their unit-specific

susceptibility patterns.

Patient-specific factors• Presumed source of infection.• Presence of co-morbid conditions (i.e., recent surgery or trauma,

chronic illness)• Previous antibiotic administration history.

14

–Ineffective and unsafe treatment, –Exacerbation or prolongation of

illness, –Distress and harm to the patient–Higher cost–Increased mortality and morbidity

Bad prescribing habits lead to:

Inappropriate use

Antibiotics have no effect on viral infections such as the common cold. They are also ineffective against sore throats, which are usually viral and self-resolving.[1] Most cases of bronchitis (90–95%) are viral as well, passing after a few weeks—the use of antibiotics such as ofloxacin against bronchitis is superfluous and can put the patient at risk of suffering adverse reactions .[2]

1. Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL (August 1997)."Reattendance and complications in a

randomised trial of prescribing strategies for sore throat: the medicalising effect of prescribing antibiotics". BMJ 315 (7104): 350–2. doi:10.1136/bmj.315.7104.350. PMC 2127265. PMID 9270458.

2. Hueston WJ (March 1997). "Antibiotics: neither cost effective nor 'cough' effective". The Journal of Family Practice 44 (3): 261–5. PMID 9071245

Patient concerns

Expect to be cured Need to return to work/school Similar symptoms treated with

antibiotics in the past.

Physician concerns

• Patient satisfaction • Time pressures• Diagnostic uncertainty

ANTIBIOTIC PRESCRIPTION

Reasons for unnecessary and inappropriate prescribing

When parents demand antibiotics

• Provide educational materials and share your treatment rules to explain when the risks of antibiotics outweigh the benefits.

• Build cooperation and trust.

Antibiotic misuseAntibiotic misuse, sometimes called antibiotic abuse or antibiotic overuse, refers to the misuse or overuse of antibiotics, with potentially serious effects on health. It is a contributing factor to the creation of multidrug-resistant bacteria, informally called "super bugs": relatively harmless bacteria can develop resistance to multiple antibiotics and cause life-threatening infections

Harrison JW, Svec TA (April 1998). "The beginning of the end of the antibiotic era? Part II. Proposed solutions to antibiotic abuse". Quintessence International 29 (4): 223–9.

Antibiotic resistance

Though antibiotics are required to treat severe bacterial infections, misuse has contributed to a rise in bacterial resistance. The overuse of fluoroquinolone and other antibiotics fuels antibiotic resistance in bacteria .

Neuhauser etal (February 2003). "Antibiotic resistance among gram-negative bacilli in US intensive care units: implications for

fluoroquinolone use". JAMA 289 (7): 885–8.doi:10.1001/jama.289.7.885. PMID 12588273

Bacterial Resistance Bacteria can develop resistance to antibiotics in many ways:• Some doctors give patients antibiotics when they might not be helpful. For

example, a patient with a cold may pressure a doctor into prescribing an antibiotic because the patient hopes to get a quick fix to his/her illness. Antibiotics won't cure a cold because colds are caused by viruses, not bacteria.

• Antibiotics have no effect on viral infections. The treatment for a cold is generally rest, plenty of fluids and medicines for fever and headache.

• Antibiotics are misused because many patients do not take them according to their doctor's instructions. They may stop taking their antibiotics too soon, before their illness is completely cured. This allows bacteria to become resistant by not killing them completely.

• Some patients save unused medicine and take it later for another illness, or pass it to other ill family members or friends.

These practices may result in the wrong antibiotics being used. They can also lead to the development of resistant bacteria.

Reasons and causes of Antibiotic Resistance in the Community

Use of antimicrobials in Vet.

Over the counter availability.

Lack of diagnostic clinical microbiology labs.

Misuse of Antibiotics ie.failure to complete therapy, skipping doses or reuse of leftovers.

Less potent activity of Antibiotics ie. generics,transportation,expired, and decreased potency.

CAUTION in antimicrobial use for URTI

• Even a properly prescribed antibiotic can foster the growth of one or more strains of antibiotic-resistant bacteria for at least two to six months inside the person taking the pills.

• "Carrying" a microbe also means that, during that time, you're likely to "share" the resistant bug with family, co-workers and others in your path.

• That particular strain may not make you sick. But if you find yourself one day immune-suppressed, those resistant strains of bacteria living inside you increase the odds that any infection will be hard - or even impossible - to beat.

Hay, J of Antimicrobial Chemotherapy , Jul 2005

Rhinitis and sinusitisRHINITIS:1. Antibiotics should not be given for viral rhinosinusitis.2. Mucopurulent rhinitis (thick, opaque, or discolored nasal discharge) frequently accompanies viral rhinosinusitis. It is not an indication for antibiotic treatment unless it persists without improvement for more than 10-14 days.

SINUSITIS:1. Diagnose as sinusitis only in the presence of:- prolonged nonspecific upper respiratory signs and symptoms (e.g. rhinorrhea and cough without improvement for > 10-14 days), or- more severe upper respiratory tract signs and symptoms (e.g. fever >39C, facial swelling, facial pain).2. Initial antibiotic treatment of acute sinusitis should be with the most narrow-spectrum agent which is active against the likely pathogens

American Academy of Pediatrics and American Academy of Family Physicians, Pediatrics 2004;113:1451-1.

Antibiotics In Cold

• November, 18th

Sore throat – the evidence base• Most sore throats are viral and self-

limiting• Strep is isolated in 30% of sore throats

BUT• Asymptomatic carriage can be as high as

40%• Typical features only present in 15% of

patients with strep throat• Recent studies do not support antibiotics

as preventative of non-suppurative complications which are rare anyway

Prolonged cough

CoughCough needs to be diagnosed by doctor. Besides chronic bronchospasm, chronic cough can be caused by GERD, post-nasal drip or a combination of factors. All of these have different treatments, besides bronchodilators

Chronic coughThink…….* Post nasal drip syndrome* Asthma* Gastroesophageal reflux

Cough illness & Bronchitis1. Cough illness/bronchitis in children rarely warrants antibiotic treatment.2. Antibiotic treatment for prolonged cough (>10 days) may occasionally be warranted:- Pertussis should be treated according to established recommendations.- Mycoplasma pneumoniae infection may cause pneumonia and prolonged cough (usually in children > 5years); a macrolide agent (or tetracycline in children ≥ 8 years) may be used for treatment.- Children with underlying chronic pulmonary disease (not including asthma) may occasionally benefitfrom antibiotic therapy for acute exacerbations.

Bronchial Asthma

Bronchial Asthma

Guidelines do not recommend antibiotics for asthma attacks. The worse the symptoms, the more often this practice seems to occur.

Unless there is a coexisting bacterial infectious such as pneumonia or sinusitis, antibiotics should not be used.

Over use can cause drug resistant bacterial infections.

In adults, bacterial infections are almost never the cause of asthma exacerbations, and antibiotics are rarely needed. The most common triggers of an asthma attack in adults are viral infections, allergens, and irritants, non of which responds to an antibiotics.

Guidelines do not recommend antibiotics for asthma attacks. The worse the symptoms, the more often this practice seems to occur.

Unless there is a coexisting bacterial infectious such as pneumonia or sinusitis, antibiotics should not be used.

Over use can cause drug resistant bacterial infections.

In adults, bacterial infections are almost never the cause of asthma exacerbations, and antibiotics are rarely needed. The most common triggers of an asthma attack in adults are viral infections, allergens, and irritants, non of which responds to an antibiotics.

Pneumonia

Empirical antibiotic treatment of CAP

• Outpatients– Previously healthy and no antibiotic treatment in past 3

months• A macrolide or doxycyclin or amoxicillin/clavulanate

– Comorbidities or antibiotics in past 3 months• A respiratory fluoroquinolone p.o. or β-lactam + macrolide

• Inpatients – Respiratory fluroquinolone p.o. or iv., or β-lactam + macrolide

• Special concerns– Pseudomonas is a consideration (antistreptococcal,

antipseudomonas β-lactam (piperacillin/tazobactam, imipenem plus ciprofloxacin or levofloxa

– MRSA is a consideration: add linezolid or vancomycin iv.

Switch IV to Oral TherapySwitch IV to Oral Therapy

1. Cough and shortness of air are improving 1. Cough and shortness of air are improving

2. Patient is afebrile for at least 8 hours 2. Patient is afebrile for at least 8 hours

3. White blood cell count is normalizing 3. White blood cell count is normalizing

4. PO intake and GI absorption are adequate4. PO intake and GI absorption are adequate

ATS Guidelines 2004

Think

Switching from IV to Oral• Step-down therapy: Conversion of an IV antibiotic to another oral • Transitional therapy: Conversion from same IV antibiotic to oral but

not of same dosage or strength • Sequential therapy: Conversion from same IV antibiotic to oral of

same dosage and strength

Take home messages

•Viruses cause most common respiratory illnesses•Viral illness needs time to heal, antibiotic can not help

Taking antibiotics for viral illnesses will not: *cure the infection. *keep others from getting the illness. *make the patient feels better.But it will make it more likely to bacterial resistance.

Clinical differentiation is possible between bacterial and viral infection most of the times.

* Viral infection is disseminated throughout the system (URT/LRT). Fever is usually high at onset, settles by day 3-4. * Bacterial infection is localized to one part of the system ( acute tonsillitis does not present with running nose or chest signs ). Fever is generally moderate at the onset and peaks by day 3-4.

So there is no need to hurry

through antibiotic prescription.

Restrict antibiotic availability without prescription

Free sample

Mr: Don’t forget to take oneof our antibiotics freesample before you leave thehospital

RECOMMENDATIONSDon'ts about antibiotics DO NOT...pressure your doctor to prescribe an antibiotic . DO NOT...take antibiotics that have been sitting around the

house unless prescribed by your doctor for a current illness . DO NOT...give your antibiotics to other people. Their illness

is probably different than yours, and so your antibiotics will not help them to get well. Also, they might even be harmed by your medicine.

DO NOT...take antibiotics simply because you were exposed to someone with a disease. You are only increasing your chances of picking up a resistant infection. If you are exposed to an infectious disease, seek medical advice.

RECOMMENDATIONSDo's about antibiotics • DO...ask your doctor whether your infection or your family

member's infection will respond to antibiotics. • DO...ask your doctor about antibiotic-resistant bacteria and

what you can do to help prevent its occurrence. . • DO...follow the instructions for taking your antibiotic.

Always take the exact amount specified on the label at a specified time. Take the medicine for the entire time that your doctor has prescribed. Even if you feel better, take all of the medicine!