1.Antimicrobial Stewardship 1. Antibiotic Policy2. Infection Control ManualDr. Ashok Rattan,Chairman : Laboratory Medicine

2. Discovery & Development ofAnti-bacterials is one of the mostimportant discovery of the20th Century 2 3. Power of antibioticsDiseasePre Antibiotic eraDeaths withChange in deaths duedeathsantibioticsto antibioticsCAP (1) 35%10% - 25%HAP (2) 60%30% - 30%Heart Infection (3)100%25% - 75%Brain Infections(4)> 80%< 20%- 60%Skin Infection(5) 11%< 0.5%-10%By comparison. Treatment of heart attacks with aspirin or clot busting drugs (6) - 3%Ref.: (1)IDSA Position Paper. Clin Infect Dis 2008; 47 (S3): S 249 65 (2) IDSA/ACCP/ATS/SCCM position paper. CID 2010; 51 (S1): 51 3 (3) Kerr AJ. SABE Lancet 1935; 226: 383 4 (4) Waring et al. Am J Med 1948; 5: 402 18 (5) Spellberg et al CID 2009; 49: 383 91 (6) Lancet 1998; 351 : 233 41. 3 4. Introductions of New Antibiotic Classes1940 1950 19601970 1980 1990 2000 2002 2004 2006 2007 2008 2010 Ceftaroline 2010 Doripenem 2007Tigecycline 2006Telithromycin 2004 Quinolones 1962Daptomycin 2003 Streptogramin 1962 Ertapenem 2001Oxazolidinone 2000Glycopeptides 1958Macrolides 1952 Aminoglycosides 1950 Tetracycline 1949Me too drugs Different Generations Penicillin 1940Sulfas 19364 5. Mankind has always hadthe benefit of good adviceBy the year 2000, nearly allexperts agree that bacterial andviral diseases will have beenvirtually wiped out The futurists: looking toward year 2000 (Time magazine, february 25, 1966) US surgeon general William Stewart: The time has come to close the book oninfectious diseases (1969) 5 6. Increasing Incidence of Resistance in the USMRSE, MRSA, VRE, PRSP, GISA 1980-2006 100PercentageMRSEof 80PathogensResistant toAntibiotics 60MRSAPRSP40 VRE20 VRSAVISA 0 197519801985 1990 1995200020061997 6 7. Bad bugs, no drugs: No ESKAPECID 2009; 48: 1 - 12E nterococcus faeciumS taphylococcus aureusK lebseilla pneumoniaeA cinetobacter baumaniiP seudomonas aeruginosaE nterobacter species Clostridium difficile & E. coli 7 8. We have a basic problem We must make the best use of what we have 8 9. Consequences of antibiotic use Inhibition of non pathogenic bacteria Selection of resistant mutantsToxicity / side effectsClinical cure9 10. Antimicrobial StewardshipInhibition of non pathogenic bacteria Selection of resistant mutants Toxicity / side effectsClinical cure 10 11. Antimicrobial StewardshipEffective antimicrobial stewardship Comprehensive infection controlAudit & feedbackManaging data and informationGuidelines & algorithms Policies & proceduresAntibiotic order form Regulatory requirementsCombination Employee healthDe escalation Prevent transmission, investigate outbreaksDose optimizationEducation & trainingParentral oralMobilize resources: human &Cyclingfinancial11 12. Empiric treatmentBroad spectrum antibioticNo sample collectedProlongedtreatment Selection of MDR Mutant bacteria12 13. Empiric treatmentBroad spectrum antibioticNo sample collectedProlongedtreatment RewardSelection of MDRMutant bacteria13 14. Knowledge of local ecologyOPDIPDICU 14 15. PK/PD terminology32 C max/ MIC16 AUC / MIC t > MIC 8SerumConc. 4 C max(ug/ml) 2 1 0.5 MIC0.250.12Time > MIC0.060 15 16. PK/PD correlation with efficacyT > MIC AUC or Cmax/MICTarget: >40 % of dosing 10010PenicillinAminoglycosidesCephalosporinsFluoroquinolonesCarbapenems MetronidazoleDaptomycinMonobactamKetolidesMacrolidesAzithromycinClindamycinStreptograminOxazolidinonesGlycopeptidesGlycylcyclinesAmphotericinFlucytosineFluconazole 16 17. De Escalation strategy 17 18. Short duration of therapyAutomatic stop orders18 19. Antibiotic Use BundleInitiation bundle:1.1. Clinical rationale for antibiotic initiation documented2.2. Appropriate samples for smear & culture collected & submitted to the laboratory3.3. Antibiotic selected according to local policy & risk group4.4. Antibiotic ordered as per plan 1. (name, dose, route, frequency & tentative duration)5.5. Removal of foreign body or ID, as appropriate, considered19 20. Lewisham Empirical Antimicrobial Prescribing (LEAP) Initiation Care Bundle[Complete this section for all Community or Hospital Acquired Infections]Care Bundle ElementEvidentComments Yes / No1Clinical signs of infection documented in medical notes2Appropriate clinical specimens sent to microbiology / blood samples requested3Antimicrobial prescription in accordance with local guidelines and appropriate for individual patient4Antibiotic plan documented ?5Foreign body removed or pus drained, as appropriateTotal no. care bundle elements evident % Compliance20 21. 21 22. Day 3 bundle:1.1. Was an antibiotic plan documented 1. (name, dose, route, frequency & planned duration ?)2.2. Review of diagnosis after lab reports ?3.3. If positive microbiology results, was there any adaptation: streamlining or discontinuation4.4. Was IV -> oral switch considered & implemented5.5. Were all four above mentioned steps followed ?22 23. Lewisham Empirical Antimicrobial Prescribing (LEAP) Initiation Care Bundle[Complete this section for all Community or Hospital Acquired Infections]Care Bundle ElementEvidentComments Yes / No1Was an antibiotic plan documented (name, dose, route, frequency & planned duration ?)2Review of diagnosis after lab reports ?3If positive microbiology results, was there any adaptation : streamlining or discontinuation4Was IV -> oral switch considered & implemented5Were all four above mentioned steps followed ?Total no. care bundle elements evident % Compliance23 24. Gram +ve problemNailed down Vancomycin & TeicoplaninTigecycline& ColistinLinezolidDaptomycinCeftaroline Gram ve infections may leave us exposed24 25. Hand washing is an important strategy tocontrol MRSA 25 26. Surveillance culture is an important strategy to control MDR GNB 26 27. Rapid diagnostic tests would helpTAT 20 min to 4 hoursProcalcitonin for initiation of antibacterialtherapyPOCT for infectious markersLateral flow Immunological testsReal time PCR; Multiplex PCR for SepsisMALDI TOF MSEmergent indications for antibiotic useSever sepsis or septic shockInfections known to have fulminant course27 28. Extinction of MDR Bacteria is not an achievable GoalBacteria have inhabited the Earth longer than humansand in far greater numberHumans have capability of causing extinction of otherspecies, mostly unintentional (Dodo, ? Tiger)However, Extinction of MDR bacteria is not an achievable goal by Man Kind28 29. Our innovations must stay ahead of bacterial adaptationNew strategies may includeDiscovery & Development of new antimicrobialsAntimicrobial stewardship and appropriate guidelines for use of older drugsRapid point of care diagnostic testsBiomarkers for diagnostic & prognostic accuracyStrict Infection control29 30. Current Crisis of MDR InfectionsAct of GOD (nature) Act of Man KindSpread of resistant geneSelection of resistantfrom antibiotic mutants by use & overproducing bacteria to use of antibioticspathogens Spread of MDR strainsAcquisition of resistance from one patient toto available drugs by another by nonmutationapplication ofInfection Controlpolicies30 31. but we CAN 31 32. Dennis Maki, IDSA Meeting 1998Developing new antibiotics without having mechanismsto insure their appropriate use is much like supplyingyour alcoholic patients with a finer brandy. 32 33. 33