1. Dr.T.V.Rao MD
Dr.T.V.Rao MD 1

2. 
Discovery Of Penicillin changes
the History of Medicine
Dr.T.V.Rao MD 2

3. 
Why we Need Antibiotics
Nearly One half of the Hospitalized
patients receive antimicrobial agents.
 Antibiotics are valuable Discoveries of the Modern
Medicine.
 All current achievements in Medicine are attributed
to use of Antibiotics
 Life saving in Serious infections.
Dr.T.V.Rao MD 3

4. 
What went wrong with
Antibiotic Usage
 Treating trivial infections / viral Infections with
Antibiotics has become routine affair.
 Many use Antibiotics without knowing the Basic
principles of Antibiotic therapy.
 Many Medical practioners are under pressure for
short term solutions.
 Commercial interests of Pharmaceutical industry
pushing the Antibiotics, more so Broad spectrum
and Newer Generation antibiotics. as every Industry
has become profit oriented.
Poverty encourages drug resistance due to
under utilization of appropriate Antibiotics.Dr.T.V.Rao MD 4

5. 
Introduction
 ‚The end of infectious diseases‛ was a
popular idea in the 1970s
Infectious diseases are still important in the
21st century due to:
 Boundless nature
 Emergence of new infections
 Re-emergence of old infections
 Increase in drug - resistant infections
Dr.T.V.Rao MD 5

6.  The last decade has seen the inexorable proliferation
of a host of antibiotic resistant bacteria, or bad
bugs, not just MRSA, but other insidious players as
well. ...For these bacteria, the pipeline of new
antibiotics is verging on empty. 'What do you do
when you're faced with an infection, with a very sick
patient, and you get a lab report back and every
single drug is listed as resistant?' asked Dr. Fred
Tenover of the Centers for Disease Control and Prevention
(CDC). 'This is a major blooming public
health crisis.'"
Science magazine; July
18, 2008
Dr.T.V.Rao MD 6

7. 
Four main groups of Bacteria a
Concern for Antibiotic Resistance
Gram positive
Gram negative
Anaerobes
Atypical
Dr.T.V.Rao MD 7

8. 
Gram +ve
Skin, Bone &
Respiratory
Gram -ve
GI-tract, GU &
RespiratoryAnaerobes
Mouth, teeth, th
roat, sinuses &
lower bowel
Generally. Infecting Microbes..
Atypicals
Chest and
genito-urinary
Peritonitis
Biliary infection
Pancreatitis
UTI
PID
CAP/HAP/VAP
Sinusitis
Cellulitis
Wound infection
Line infection
Osteomyelitis
Pneumonia
Sinusitis
Dental infection
Peritonitis
Appendicitis
Abscesses
Pneumonia
Urethritis
PID
Dr.T.V.Rao MD 8

9. Why inappropriate
use of antibiotics
contributes to
antibiotic resistance
– the “why”
Dr.T.V.Rao MD 9

10. 
Misuse of antibiotics in hospitals is one
of the main factors that drive
development of antibiotic resistance.
Patients in hospitals have a high
probability of receiving an antibiotic
and 50% [adapt to national figure
where available] of all antibiotic use in
hospitals can be inappropriate.
In-patients are at high risk of
antibiotic-resistant infections
Dr.T.V.Rao MD 10

11. 
 Studies prove that misuse of antibiotics may cause
patients to become colonized or infected with
antibiotic-resistant bacteria, such as methicillin-
resistant Staphylococcus aureus (MRSA), vancomycin-
resistant enterococci (VRE) and highly-resistant Gram-
negative bacilli.13-14
 Misuse of antibiotics is also associated with an
increased incidence of Clostridium difficile
infections.15-17
Misuse of Antibiotics Drives
Antibiotic Resistance
Dr.T.V.Rao MD 11

12. 
Basis of Antibiotic
Resistance
The antibiotic resistance is guided by Genomic
changes
Spread of R plasmids among the Bacteria
Do remember Antibiotics are used in Animal
husbandry apart from Medical use
The discovery of antibiotic resistance was
discovered with spread of R plasmids from
animal sources
The Human gut forms the interconnecting area
in R plasmids transmission leading ultimately to
antibiotic resistance
Dr.T.V.Rao MD 12

13. Plasmids played a Major Role in
spread of Antibiotic resistance.
Dr.T.V.Rao MD 13

14. 
Multiple Mechanism of
Drug Resistance
Dr.T.V.Rao MD 14

15. 
Spread of Antibiotic Resistance
 Indiscrimate use of
Antibiotics in Animals and
Medical practice
 R plasmids spread among
co-inhabiting Bacterial
flora in Animals ( in gut )
 R plasmids may be mainly
evolved in Animals spread
to Human commensal, -
Escherichia coli followed
by spread to more
important human
pathogens Eg Shigella spp.
Dr.T.V.Rao MD 15

16. 
Why Everyone worried about
Antibiotic ( misuse ) Use.
Drug resistance can reverse Medical progress
The following diseases are already in the list of
attaining the drug resistance, and Medical
profession will find difficult to cure in future.
1. Tuberculosis
2. Malaria
3. Sore throat and Ear Infections.
Dr.T.V.Rao MD 16

17. Misuse of antibiotics can include any of the following
When antibiotics are prescribed unnecessarily;
When antibiotic administration is delayed in critically ill
patients;
When broad-spectrum antibiotics are used too generously, or
when narrow-spectrum antibiotics are used incorrectly;
When the dose of antibiotics is lower or higher than
appropriate for the specific patient;
When the duration of antibiotic treatment is too short or too
long;
When antibiotic treatment is not streamlined according to
microbiological culture data results.
What is Misuse of
Antibiotics?
Dr.T.V.Rao MD 17

18. Dr.T.V.Rao MD 18

19. 
Aim of Antibiotic
Policy
Reduce the Antimicrobial resistance
Initiate best efforts in the hospital area as many
resistance Bacteria are generated in Hospital
areas and in particular critical care areas.
Initiate good hygienic practices so these bacteria
do not spread to others
Practice best efforts, these resistance strains do
not spill into critically ill patients in the Hospital
To prevent spill into Society, as they present as
community associated infections..
Dr.T.V.Rao MD 19

20. 
Objectives of Antibiotic Policy.
Antibiotics should not be used casually
Policy emphasizes, avoiding the use of
powerful Antibiotics in the Initial treatments.
We should create awareness that we are
sparing the powerful Broad spectrum Drugs
for later treatment
Patient saves Money
Doctors save Lives.
Dr.T.V.Rao MD 20

21. 
Aims of the Antibiotic
Policy
Create awareness on Antibiotics as misuse is
counterproductive.
More effective treatments in serious Infections.
Reduce Health care associated infections spilling
to society and increase of Community associated
Infections.
( A growing concern in Developing world )
Dr.T.V.Rao MD 21

22. 
Policy Deals on Broad
Basis
 Clinicians /
Microbiologists /
Pharmacists and
Nurses do take part.
 Policies are framed on
demands of the Clinical
areas, depending on
recent Infection
surveillance data
contributed from
Microbiology
Departments.
Dr.T.V.Rao MD 22

23. 
Antibiotic working Group
Monitors
Formulate Optimal guidelines in
Treatment of Infections with minimal
risk of Health care associated
Infections.
Create a plan for monitoring the Use
of Antibiotics across the Hospital
Dr.T.V.Rao MD 23

24. 
Education On Antibiotic policy
Acton plan for Education to all concerned
clinical staff on Antibiotic prescriptions.
 Evaluate the feed back of success and
failures of the policy.
Create Infection surveillance Data
Developing facilities in Microbiology
departments for auditing data and
guidance
Restrictions in prescribing and Antibiotic
availability.
A continuous education to Junior Doctors
Dr.T.V.Rao MD 24

25. 
Ideal Sample Collection is
Essential Requirement
Proper specimen collection is combined
responsibility of Clinical and Microbiological
Departments.
Continuous training of junior staff on sample
collection, and is most neglected necessity
A good clinical history is greatly helpful in
differentiating community acquired
infections from hospital acquired infections.
Dr.T.V.Rao MD 25

26. Pitfalls in Specimen
collection
A proper specimen
collection is most
neglected area of
Microbiology.
Scientific approaches
in Sample collection
is concern for
successful
Microbiological
evaluations,
Dr.T.V.Rao MD 26

27. Microbiology Services
Constant up
graduation of
Microbiology
departments is good
investment.
Quality control
methods in testing of
antibiotic resistance
pattern is a top
priority.
Dr.T.V.Rao MD 27

28. 
Role of Microbiology
Department
 Microbiology
departments asses trends
in development of
antimicrobial resistance.
 The results of
sensitivity/resistance
patterns should be
correlated with
Antimicrobial agents
currently used in the
Hospital.
 Identify and forecast that
nature of relation
between antibiotic use
and resistance.
Dr.T.V.Rao MD 28

29. Better services from
Microbiology Departments.
 Basic infrastructure
should be updated for
detection of MRSA and
ESBL producers.
 Documentation of all
Opportunistic infections.
and Hospital infection
outbreaks
Dr.T.V.Rao MD 29

30.  Measures that guide antibiotic prescribing are likely to
decrease antibiotic resistance in hospitals.32-34 Such
measures include:
 Obtaining cultures
 Take appropriate and early cultures before initiating empiric
antibiotic therapy,
 and streamline antibiotic treatment based on the culture
results35
 Monitoring local antibiotic resistance patterns
 Being aware of local antibiotic resistance patterns
(Antibiograms) enables
 appropriate selection of initial empiric antibiotic therapy
Measures that can decrease
antibiotic resistance
Dr.T.V.Rao MD 30

31. 
 The ESKAPE Pathogens: The so-called ESKAPE
Pathogens (Enterococcus faecium, Staphylococcus
aureus, Klebsiella pneumoniae, Acinetobacter
baumannii, Pseudomonas aeruginosa, and ESBL
positive bacteria, such as E. coli and Enterobacter
species) represent a grouping of antibiotic-resistant
gram-positive and gram-negative bacteria that cause
the majority of U.S. HAIs. The group is so-named
because these bacteria effectively ‚escape‛ the effects
of most approved antibacterial drugs.
PRIORITY ANTIBIOTIC-RESISTANT
BACTERIA PATHOGENS
Dr.T.V.Rao MD 31

32. 
Advantages of
Antibiotic Policy
Saves the Lives
Reduces the
morbidity
Saves Health related
costs
Reduces the
Antibiotic related
toxicity.
Patients are satisfied.
Dr.T.V.Rao MD 32

33. 
Staff Education on Antibiotic
Policy
Staff education is most Important principle in
success
Draw your own plans according to nature of
patients, your past experiences
Induction training for new staff
Continuing Medical Education to both Junior
and Senior Doctors
Include nursing staff, pharmacists for the
success of the Programme
Dr.T.V.Rao MD 33

34. 
Training in rational prescribing has
expanded in universities throughout
the world
 Problem-based
pharmacotherapy
 In 18 languages
 For medical students,
clinical officers
 Measurable improvement in
prescribing
 Now also: Teacher’s Guide to
Good Prescribing
Achievements
Dr.T.V.Rao MD 34

35. 
Patient Education on Antibiotic
Policy
Education of the patients and society is
important in Developing world.
Educate the patients many infections are
trival,viral, Do not need Antibiotics
If they understand Unnecessary consumption
of Antibiotics kills the Normal flora, and
reduces the Immunity and makes them
potential victims in future.
A difficult task in Developing countries.
Dr.T.V.Rao MD 35

36. 
Proved success of Antibiotic
Policies
Studies Prove
1 Rapid reversal of major clinical problems of
resistance to Chloramphenicol ,Erythromycin, and
Tetracycline in Staphylococcus aureus on
withdrawal of antibiotics.
2 Out breaks of Erythromycin resistant Group A
Streptococci and Penicillin resistant
Pneumococci, can be controlled by major
reduction in prescription of Erythromycin and
Penicillin.
3 Control of multiple resistant Gram – ve bacteria
and role played by reducing the prescription of 3rd
generation of Cephalosporins.
( I.M.Gould Review of the role of antibiotic policies in the control of antibiotic
resistance, Journal of Antimicrobial Chemotherapy 1999 43, 459 – 465. )
Dr.T.V.Rao MD 36

37. 
Make your conclusions and
contribute to Antibiotic Policy
It is true to say that there is no absolute proof
of causative association between antibiotic
use and resistance, But many authorities
believe the association to be virtually certain.
It is pragmatic and essential approach to
control of antibiotic resistance with control
of antibiotic use.
Make every one a partner in prevention of
Antibiotic resistance, and success will follow.
Dr.T.V.Rao MD 37

38. 
Antibiotic resistance –
a problem in the present and the
future
Antibiotic resistance
is an increasingly
serious public
health problem:
resistant bacteria
have become an
everyday concern in
hospitals across
World
Dr.T.V.Rao MD 38

39. 
CDC reports
CDC reports that
nearly 2 million
health care-associated
infections (HAIs) and
90,000 HAI-related
deaths occur annually
in the U.S. Many of
these infections and
deaths are caused by
antibiotic-resistant
infections.
Dr.T.V.Rao MD 39

40. 
New Innovations in
Diagnostic Microbiology
 New rapid diagnostic tests
would greatly facilitate
clinical trials of critically
needed new antibiotics. The
tests would enable
investigators to identify
potential study subjects
more easily, which would
permit smaller and less
expensive studies of
antibiotics as they move
through development
Dr.T.V.Rao MD 40

41. 
Infection Control Team
Leadership and
dedicated staff;
training and
education;
mechanisms that
serve to improve
antibiotic
resistance
Dr.T.V.Rao MD 41

42. 
Best way to keep the matters
in Order
Every Hospital should have a policy which is
practicable to their circumstances.
Rigid guidelines without coordination will
lead to greater failures
The only way to keep Antimicrobial agents
useful is to use them appropriately and
Judiciously
(Burke A.Cunha, MD,MACP Antimicrobial Therapy. Medical
Clinics of North America NOV 2006)
Dr.T.V.Rao MD 42

43. 
Prudent prescribing to reduce
antimicrobial resistance
• Only use an antimicrobial when clearly indicated.
• Select an appropriate agent using local antimicrobial
prescribing policy.
• Prescribe correct dose, frequency and duration.
• Limit use of broad spectrum agents and de-escalate
or stop treatment if appropriate (Hospital).
Dr.T.V.Rao MD 43

44. 
 Antibiotic prescribing practices and decreasing
antibiotic resistance can be addressed through
multifaceted strategies including:29-31
 Use of ongoing education
 Use of evidence-based hospital antibiotic
guidelines and policies
 Restrictive measures and consultations from
infectious disease physicians, microbiologists and
pharmacists
Multifaceted strategies can address
and decrease antibiotic resistance in
hospitals
Dr.T.V.Rao MD 44

45. 
 Training and educating health care professionals on
the appropriate use of antibiotics must include
appropriate selection, dosing, route, and duration of
antibiotic therapy. To ensure that training and
education is working, there should be extensive
collaboration between the antibiotic stewardship and
hospital infection prevention and control teams.
Without benchmarks, it is difficult to track successes
and weaknesses
Continuous Medical
Education a Must ..
Dr.T.V.Rao MD 45

46. 
Dr.T.V.Rao MD 46
Computerized Decisions
a Emerging Need …..
 Computerized decision
support can preserve
physician autonomy and
has been shown to
improve antibiotic use by
a number of different
measures: fewer
susceptibility
mismatches, allergic
reactions and other
adverse events, excess
dosages, and overall
amount and cost of
antibiotic therapy

47. 
Dr.T.V.Rao MD 47
Implementation of WHONET CAN
HELP TO MONITOR RESISTANCE
 Legacy computer
systems, quality
improvement teams, and
strategies for optimizing
antibiotic use have the
potential to stabilize
resistance and reduce
costs by encouraging
heterogeneous
prescribing patterns and
use of local susceptibility
patterns to inform
empiric treatment.

48. 
Hand Washing Reduces the
Spread of Antibiotic Resistant
Strains
Dr.T.V.Rao MD 48

49. 
The Programme created by
Dr.T.V.Rao MD for ‘e’ Learning
resources for Medical Professionals
in Developing World.
 Email
doctortvrao@gmail.com
Dr.T.V.Rao MD 49