Rationalism of antibiotic therapy

1. Dr.T.V.Rao MD 1

2. Fleming and Penicillin
Dr.T.V.Rao MD 2

3. Self Medication
• The greatest possibility of evil in self-
medication is the use of too small doses so
that instead of clearing up infection, the
microbes are educated to resist penicillin and
a host of penicillin-fast organisms is bread
out which can be passed to other individuals
and from them to other until they reach
someone who gets a septicemia or a
pneumonia which penicillin cannot save.
Sir AlexanderFlemming
Dr.T.V.Rao MD 3

4. Antibiotic brands
• 50 penicillin's • 9 macrolides
• 71 cephalosporins • 2 streptogramins
• 12 tetracycline's • 3 dihydrofolate
• 8 aminoglycosides reductase
• 1 monobactam inhibitors
• 5 Carbapenems • 1 oxazolidinone
• 5.5 quinolones
Dr.T.V.Rao MD 4

5. Evolution of Enzymes
Plasmid-Mediated TEM and SHV
b-Lactamase
Third-Generation
Ampicillin Cephalosporins
1965 1970s 1980s 1987 2000
1983
1963
TEM-1
TEM-1 ESBL >120 ESBLs
Reported in ESBL in
E coli in Worldwide
28 Gram- Europe
S paratyphi United
Negative
States
Species
Dr.T.V.Rao MD 5

6. Development of anti-microbials
ertapenem
tigecyclin
The development daptomicin
linezolid
of anti-infectives … telithromicin
quinup./dalfop.
cefepime
ciprofloxacin
aztreonam
norfloxacin
imipenem
cefotaxime
clavulanic ac.
cefuroxime
gentamicin
cefalotina
nalidíxico ac.
ampicillin
methicilin
vancomicin
rifampin
chlortetracyclin
streptomycin
pencillin G
prontosil
1920 1930 1940 1950 1960
Dr.T.V.Rao MD 1970 1980 1990 2000 6

7. 1962 and 2000, no major classes of
antibiotics were introduced
Fischbach MA and Walsh CT Science 2009
Dr.T.V.Rao MD 7

8. A Changing Landscape for
Numbers of Approved Antibacterial Agents
18
16
Number of agents approved
14
12
Resistance
10
8
6
4
2
0
0
1983-87 1988-92 1993-97 1998-02 2003-05 2008
Bars represent number of new antimicrobial agents approved by the FDA during the period listed.
Infectious Diseases Society of America. Bad Bugs, No Drugs. July 2004; Spellberg B et al. Clin Infect Dis. 2004;38:1279-1286;
New antimicrobial agents. Antimicrob Agents Chemother. 2006;50:1912

9. Dr.T.V.Rao MD 9

10. Antibiotics
• Biology and Society
About 50% of the antibiotics produced
today are used in the livestock industry.
What impact does this have on the
treatment of human diseases?
Dr.T.V.Rao MD 10

11. ANTIMICROBIAL RESISTANCE:
The role of animal feed antibiotic additives
• 48% of all antibiotics by weight is added to
animal feeds to promote growth. Results
in low, sub therapeutic levels which are
thought to promote resistance.
• Farm families who own chickens feed
tetracycline have an increased incidence of
tetracycline resistant fecal flora
Dr.T.V.Rao MD 11

12. Prescribing an antibiotic
 Is an antibiotic necessary ?
 What is the most appropriate
antibiotic ?
 What dose, frequency, route and
duration ?
 Is the treatment effective ?
Dr.T.V.Rao MD 12

13. How are antibiotics overused or
Misused?
• Seven out of ten Americans receive
antibiotics when they seek
treatment for a common cold!
Only one-third of patients use
antibiotics the way doctors tell them.
• This allows bacteria to become
resistant by not killing them
completely. Dr.T.V.Rao MD 13

14. Antibiotic Prescribing
Children are real Concern
• Antibiotics were
prescribed in 68% of
acute respiratory tract
visits – and of those,
80% were unnecessary
according to CDC
guidelines
• Children are of
particular concern
because they have the
highest rates of
Dr.T.V.Rao MD 14
antibiotic use.

15. We too Contribute for Creating
Drug Resistance
• Every time a person
takes antibiotics,
sensitive bacteria are
killed, but resistant
microbes may be left to
grow and multiply.
Repeated and improper
uses of antibiotics are
primary causes of the
increase in drug-
resistant bacteria.
Dr.T.V.Rao MD 15

16. The consequences of antibiotic
resistance
• Increased morbidity & mortality
– “best-guess” therapy may fail with the patient’s
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
16 Dr.T.V.Rao MD

17. Costs Associated with
Increased Bacterial
Resistance
• ↑Treatment failures
• ↑Morbidity and mortality
• ↑Risk of hospitalization
• ↑Length of hospital stays
• ↑Need for expensive and broad
spectrum antibiotics
Dr.T.V.Rao MD 17

18. 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
• Globalization, increased travel and
trade ensure that resistant strains
quickly travel elsewhere. So does excessive
18
promotion. Dr.T.V.Rao MD

19. Developed countries Overuse
• 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.
Dr.T.V.Rao MD 19

20. Classification of Pencillins
• Natural
Benzyl penicillin
Phenoxymethyl penicillin Penicillin v
Semi synthetic and pencillase resistant
1 Methicillin
2 Nafcillin
3 Cloxacillin
4 Oxacillin
5 Floxacillin
Dr.T.V.Rao MD 20

21. Macrolides,Azalides,Ketolides
• Contain macro cyclic
lactone ring
Erythromycin. Is
popularly used drug
• Other drugs
Roxithromycin,Azithromy
cin
• Inhibits the protein
synthesis.
• Used as alternative to
pencillin allergy patients.
Dr.T.V.Rao MD 21

22. Dr.T.V.Rao MD 22

23. Cephalosporins
• Like penicillin acts
similar
• Products of the molds
of genus
Cephalosporium
except cefoxilin
• Divided into 4
generation of
Cephalosporins
depending on the
spectrum of activity.
Dr.T.V.Rao MD 23

24. Major generations of
Cephalosporins
• Cephalosporins are divided into 3 generations:
• 1st generation: Cephalexin, cefadroxil,
cephradine
• 2nd generation: Cefuroxime, cofactor
• 3rd generation: cefotaxime, Ceftazidime,
cefepime - these give the best CNS penetration
• 4th generation Cephalosporins are already
available
Dr.T.V.Rao MD 24

25. Different Generations of
Cephalosporins
• Cephalosporins are
grouped into
"generations" based on
their spectrum of
antimicrobial activity. The
first Cephalosporins were
designated first
generation while later,
more extended spectrum
Cephalosporins were
classified as second
generation
Cephalosporins.
Dr.T.V.Rao MD 25

26. 5th Generation Cephalosporins
• Ceftaroline is a new intravenous (IV)
cephalosporin that was FDA-approved
October 2010. It is labelled for the
treatment of adults with infections
caused by susceptible bacteria,
specifically skin and skin structure
infections (SSSIs) caused by methicillin-
sensitive
Dr.T.V.Rao MD 26

27. 5th Generation Cephalosporins
• Staphylococcus aureus (MSSA), methicillin-
resistant S aureus (MRSA), Streptococcus
pyogenes, Streptococcus agalactiae,
Escherichia coli, Klebsiella pneumoniae, or
Klebsiella oxytoca; and community acquired
pneumonia (CAP) caused by Streptococcus
pneumoniae (with or without concurrent
bacteraemia), MSSA, E coli, Haemophilus
influenza, K.pneumoniae, or K oxytoca
Dr.T.V.Rao MD 27

28. Ceftaroline is effective …
• Ceftaroline is a fifth generation
cephalosporin with excellent
activity against GPCs including
MRSA & DRSP Affinity for all PBPs
including PBP 2’ and PBP 2X Not
ESBL stable, Not active against
Non fermenters
Dr.T.V.Rao MD 28

29. Irrational Use of Third Generation
Cephalosporins
• Several studies have
demonstrated that patterns
of antibiotic usage greatly
affect the number of
resistant organisms which
develop. Overuse of broad-
spectrum antibiotics, such
as second- and third-
generation Cephalosporins,
generate resistant strains.
Dr.T.V.Rao MD 29

30. Advantages with Newer generations
• Each newer generation of cephalosporins
has significantly greater gram-negative
antimicrobial properties than the
preceding generation, in most cases with
decreased activity against gram-positive
organisms. Fourth generation
cephalosporins, however, have true
broad spectrum activity
Dr.T.V.Rao MD 30

31. Other Beta-lactams include
• Other beta-lactams include:
• Aztreonam: a monocytic beta-
lactam, with an antibacterial
spectrum which is active only against
Gram negative aerobes, including
Pseudomonas aeruginosa, Neisseria
meningitides and N. gonorrhoea.
Dr.T.V.Rao MD 31

32. How are Carbapenems Used?
Uses by Clinical Syndrome Use by Clinical Isolate
• Bacterial meningitis  Acinetobacter spp.
 Pseudomonas aeruginosa
• Hospital-associated
 Alcaligenes spp.
sinusitis
 Enterobacteriaceae
• Sepsis of unknown origin  Mogenella spp.
• Hospital-associated  Serratia spp.
pneumonia
 Enterobacter spp.
 Citrobacter spp.
 ESBL or AmpC + E. coli
and Klebsiella spp.
Reference: Sanford Guide MD
Dr.T.V.Rao 32

33. Spectrum of Activity
Strep spp. & Entero- Non-
Drug Anaerobes
MSSA bacteriaeae fermentors
Imipenem + + + +
Meropenem + + + +
Limited
Ertapenem + + activity
+
Doripenem + + + +

34. Emerging Carbapenem Resistance in
Gram-Negative Bacilli
• Significantly limits treatment options for
life-threatening infections
• No new drugs for gram-negative bacilli
• Emerging resistance mechanisms,
carbapenemases are mobile,
• Detection of carbapenemases and
implementation of infection control practices
are necessary to limit spread
Dr.T.V.Rao MD 34

35. Daptomycin (Cubicin®)
• New drug class (lipopeptide)
• Rapidly bactericidal
• New mechanism of action: acts by
binding to cell membrane and disrupting
the cell membrane potential
• No cross resistance
• Dose: 4-6 mg/kg once daily

36. Other drugs
• Imipenem: a
carbapenem with a
broader spectrum of
activity against Gram
positive and negative
aerobes and
anaerobes. Needs to
be given with
cilastatin to prevent
inactivation by the
kidney.
Dr.T.V.Rao MD 36

37. Quinolones
• Quinolones are the first
wholly synthetic
antimicrobials. The
commonly used
Quinolones.
• Act on the DNA gyrase
which prevents DNA
polymerase from
proceeding at the
replication fork and
consequently stopping
synthesis.
Dr.T.V.Rao MD 37

38. Aminoglycosides
• Aminoglycosides are group of
antibiotics in which amino
sugars liked by glycoside bonds
• Eg Streptomycin,
• Act at the level of Ribosome's
and inhibits protein synthesis
• Other Aminoglycosides –
Gentamycin,
neomycins,paromomycins,tobr
amycins Kanamycins and
spectinomycins
Dr.T.V.Rao MD 38

39. Dr.T.V.Rao MD 39

40. Tetracycline's
• Broad spectrum antibiotic
produced by Streptomyces
species
• 1. Oxytetracycle,
chlortetracycle and
tetracycline
• Tetracyclnes are bacteriostatic
drugs inhibits rapidly
multiplying organisms
• Resistance develops slowly
and attributed to alterations
in cell membrane permeability
to enzymatic inactivation of
the drug
Dr.T.V.Rao MD 40

41. Other Antimicrobial agents
• Lincomycins
Clindamycin
resembles Macrolides
in biting site and
antimicrobial activity.
Streptogramins
Quinpristin /
dalfopristin
useful in gram
positive bacteria
Dr.T.V.Rao MD 41

42. Antibiotics in Anaerobes
• Major anaerobes –
Anaerobic cocci,
clostridia and
Bactericides are
susceptible to Benzyl
pencillin
• Bact.fragilis as well as
many other anaerobes
are treatable with
Erythromycin,Lincomycin,
tetracycline and
Chloramphenicol
• Clindamycin is effective
against many strains of
Bacteroides
Dr.T.V.Rao MD 42

43. Metronidazole in Anaerobic
Infections
• Since the discovery of
Metronidazole in 1973
since then it was
identified as leading
agent anaerobes.
• But also useful in treating
parasitic infections
Trichomonas,
Amoebiasis and other
protozoan infections.
Dr.T.V.Rao MD 43

44. Treatment of N. gonorrhoea
• Only current CDC-recommended options for treating
N. gonorrhoea infections are from a single class of
antibiotics, the cephalosporins.
– Ceftriaxone, available only as an injection, is the
recommended treatment for all types of gonorrhea
infections (i.e., urogenital, rectal, and pharyngeal).
– Cefixime is the only oral agent recommended for
treatment of uncomplicated urogenital or rectal gonorrhea
Reduced susceptibility to cefixime being described in
Japan and other countries

45. Drug Resistance
• In spite discovery of several
antibiotics several
microorganisms attained
resistance.
• The major factor contributing
to persistence of infectious
disease has been the
tremendous capacity of
microorganisms for
circumventing the action of
inhibitory drugs.
• The drug resistance continues
to be a threat for usefulness of
the chemotherapeutic agents.
Dr.T.V.Rao MD 45

46. Inappropriate Antibiotic Use
 Use of antibiotics
with no clinical
indication (eg, for
viral infections)
 Use of broad
spectrum antibiotics
when not indicated
 Inappropriate choice
of empiric antibiotics
Dr.T.V.Rao MD 46

47. Multi Drug resistant pathogens
• If a bacterium carries
several resistance
genes, it is called
multiresistant or,
informally, a
superbug. The term
antimicrobial
resistance is
sometimes use to
explicitly encompass
organisms other than
bacteria MD
Dr.T.V.Rao 47

48. Extended-Spectrum β-Lactamases
• β-lactamases capable of conferring bacterial resistance to
– the penicillins
– first-, second-, and third-generation
cephalosporins
– aztreonam
– (but not the cephamycins or carbapenems)
• These enzymes are derived from group 2b β-lactamases (TEM-1, TEM-2,
and SHV-1)
– differ from their progenitors by as few as
one AA Dr.T.V.Rao MD 48

49. Antibiotic Resistance
Threat to Humans and Animals
• Antibiotic resistance has
become a serious
problem in both
developed and
underdeveloped nations.
By 1984 half of those
with active tuberculosis
in the United States had a
strain that resisted at
least one antibiotic. In
certain settings, such as
hospitals and some
childcare location
Dr.T.V.Rao MD 49

50. Carbapenemases
• Ability to hydrolyze penicillins, cephalosporins,
monobactams, and carbapenems
• Resilient against inhibition by all commercially viable ß-
lactamase inhibitors
– Subgroup 2df: OXA (23 and 48) carbapenemases
– Subgroup 2f : serine carbapenemases from molecular class
A: GES and KPC
– Subgroup 3b contains a smaller group of MBLs that
preferentially hydrolyze carbapenems
• IMP and VIM enzymes that have appeared globally, most
frequently in non-fermentative bacteria but also in
Enterobacteriaceae
Dr.T.V.Rao MD 50

51. K. pneumonia carbapenemases)
• KPCs are the most
prevalent of this
group of enzymes,
found mostly on
transferable plasmids
in K. pneumonia
• Substrate hydrolysis
spectrum includes
cephalosporins and
carbapenems
Dr.T.V.Rao MD 51

52. Consequences of Antibiotic drug
Resistance
• People infected with drug-resistant organisms
are more likely to have longer and more
expensive hospital stays, and may be more
likely to die as a result of the infection. They
require treatment with second- or third-
choice drugs that may be less effective, more
toxic, and more expensive. This means that
patients with an antimicrobial-resistant
infection may suffer more and pay more for
treatment. (Issues with Insurance)
Dr.T.V.Rao MD 52

53. Emerging Trends in Antibiotic
Resistance
• Reports of methicillin-resistant
Staphylococcus aureus (MRSA)—a
potentially dangerous type of staph bacteria
that is resistant to certain antibiotics and
may cause skin and other infections—in
persons with no links to healthcare systems
have been observed with increasing
frequency in the United States and
elsewhere around the globe.
Dr.T.V.Rao MD 53

54. Gram negative bacteria a great threat
• Multi-drug resistant
Klebsiella species
and Escherichia coli
have been isolated
in hospitals
throughout the
United States.
• It is a Universal
phenomenon
Dr.T.V.Rao MD 54

55. WHAT NEXT
• Indian hospitals have reported very high
Gram-negative resistance rates, with very high
prevalence of ESBL (Extended Spectrum Beta
Lactamases) producers and also high
carbapenem resistance rates. Increasing
carbapenem resistance will invariably result in
increased usage of colistin, currently the last
line of defence, with a potential for colistin-
resistant and Pan Drug Resistant bacterial
infections. Dr.T.V.Rao MD 55

56. Fungi too becoming resistant
• Antimicrobial
resistance is
emerging among
some fungi,
particularly those
fungi that cause
infections in
transplant patients
with weakened
immune systems. Dr.T.V.Rao MD 56

57. Resistance in Virus
• Antimicrobial
resistance has also
been noted with
some of the drugs
used to treat human
immunodeficiency
virus (HIV) infections
and influenza.
Dr.T.V.Rao MD 57

58. Parasites too are Problematic
• The development of
antimicrobial resistance to
the drugs used to treat
malaria infections has been
a continuing problem in
many parts of the world for
decades. Antimicrobial
resistance has developed to
a variety of other parasites
that cause infection.
•
Dr.T.V.Rao MD 58

59. Identification of The Etiological
Agent
 Laboratory diagnosis
 Interpretation of the report
 What is isolated is not necessarily the
pathogen
 Was the specimen properly collected ?
 Is it a contaminant or colonizer ?
 Sensitivity reports are at best a guide
Dr.T.V.Rao MD 59

60. Limitations of combination of antibiotics
• The role of combination
antimicrobial therapy for
the prevention of resistance
is limited to those situations
in which there is
 A high organism load
 A high frequency of
mutational resistance
during therapy.
• Classic examples are
tuberculosis or HIV
infection.
Dr.T.V.Rao MD 60

61. Problems With Improper Use of
Antibiotics
• They don’t help the patient at all
• Expense: 75% of outpatient antibiotics are used for
respiratory infections
• Patient expectations: why no better?
• Side effects: diarrhea, rash, allergy
• Development of resistance: the antibiotic
won’t work when you really DO need it for a
bacterial infection
Dr.T.V.Rao MD 61

62. WHO global strategy on reducing the
antibiotic resistance
• The WHO Global Strategy for
Containment of Antimicrobial
Resistance identifies the
establishment and support of
microbiology laboratories as a
fundamental priority in guiding
and assessing intervention
efforts. Dr.T.V.Rao MD 62

63. Importance of local antibiotic
Resistance data
 Resistance patterns vary
 From country to country
 From hospital to hospital in the same
country
 From unit to unit in the same hospital
 Regional/Country data useful only
for looking at trends NOT guide
empirical therapy
Dr.T.V.Rao MD 63

64. Streamlining or De-Escalation
of Therapy
–On the basis of culture and sensitivity
reports we can more effectively target
the causative pathogens, by elimination
of redundant combination therapy
–Resulting in decreased Ab exposure and
substantial cost savings
Dr.T.V.Rao MD 64

65. Continuous Medical Education
• Training and educating
a Must ..
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.
Dr.T.V.Rao MD 65

66. Antibiotic Pressure and Resistance in Bacteria
What factors promote their development and spread ?
 Alteration of normal flora
 Practices contributing to misuse of antibiotics
 Settings that foster drug resistance
 Failure to follow infection control principles
Dr.T.V.Rao MD 66

67. Practices Contributing to
Misuse of Antibiotics
 Inappropriate specimen selection and
collection
 Inappropriate clinical tests
 Failure to use stains/smears
 Failure to use cultures and susceptibility tests
Dr.T.V.Rao MD 67

68. Settings that Foster Drug Resistance
Hospital
 Intensive care units
 Oncology units
 Dialysis units
 Rehab units
 Transplant units
 Burn units
Dr.T.V.Rao MD 68

69. What Is Antimicrobial Stewardship?
• A combination of infection control and antimicrobial
management
• Mandatory infection control compliance
• Selection of antimicrobials from each class of drugs that does
the least collateral damage
• Collateral damage issues include
– MRSA
– ESBLs
– C difficile
– Stable derepression
– MBLs and other carbapenemases
– VRE
• Appropriate de-escalation when culture results are available
Dellit TH, et al. Clin Infect Dis. 2007;44:159-177.
Dr.T.V.Rao MD 69

70. IDSA Guidelines – Definition of
Antimicrobial Stewardship
• Antimicrobial stewardship is an activity that
promotes
– The appropriate selection of antimicrobials
– The appropriate dosing of antimicrobials
– The appropriate route and duration of
antimicrobial therapy
Dr.T.V.Rao MD 70

71. The Primary Goal of
Antimicrobial Stewardship
• The primary goal of antimicrobial stewardship is to
– Optimize clinical outcomes while minimizing unintended
consequences of antimicrobial use
• Unintended consequences include the following
– Toxicity
– The selection of pathogenic organisms, such as C difficile
– The emergence of resistant pathogens
Dr.T.V.Rao MD 71

72. Practices Contributing to
Misuse of Antibiotics
 Inappropriate specimen selection and collection
 Inappropriate clinical tests
 Failure to use stains/smears
 Failure to use cultures and susceptibility tests
Dr.T.V.Rao MD 72

73. Identification of The Etiological
Agent
 Laboratory diagnosis
 Interpretation of the report
 What is isolated is not necessarily the
pathogen
 Was the specimen properly collected ?
 Is it a contaminant or colonizer ?
 Sensitivity reports are at best a guide

74. 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.
Dr.T.V.Rao MD 74

75. Growing importance of
WHONET
• World over antimicrobial
resistance is a major
public health problem.
The WHONET software
program puts each
laboratory data into a
common code and file
format, which can be
merged for national or
global collaboration of
antimicrobial resistance
surveillance
Dr.T.V.Rao MD 75

76. Whonet helps us in ……
• The understanding of the
local epidemiology of
microbial populations;
the selection of
antimicrobial agents; the
identification of hospital
and community
outbreaks; and the
recognition of quality
assurance problems in
laboratory testing.
Dr.T.V.Rao MD 76

77. Drugs Under Development
PRSP, MRSA,VISA,VRE
• Lipopetides (Daptomycin: narrow
therapeutic index)
• Glycyclines
• Glycopeptides (Vancomycin analogues)
• Fluoroquinolones
• Macrolides/Ketolides
• Evernimicin (trials on hold)
Dr.T.V.Rao MD 77

78. Physicians Can Impact
Other clinicians
Patients
Optimize patient evaluation Optimize consultations with
Adopt judicious antibiotic other clinicians
prescribing practices Use infection control measures
Immunize patients Educate others about judicious
use of antibiotics
Dr.T.V.Rao MD 78

79. A good clinical practice saves antibiotics
• Treatment should be
limited to bacterial
infections, using
antibiotics directed
against the causative
agent, given in optimal
dosage, interval and
length of treatment, with
steps taken to ensure
maximum patient
compliance with the
treatment regimen and
only when the benefit of
treatment outweighs the Dr.T.V.Rao MD 79

80. Continuous Medical Education a Must
..
• 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
Dr.T.V.Rao MD 80

81. Chennai Declaration
• The Chennai Declaration wants India to take
urgent initiatives to formulate an effective
national policy to control the rising trend of
antimicrobial resistance and to ban on over-the-
counter sale of antibiotics.
• Chennai: ‘The Chennai Declaration: A roadmap to
tackle the challenge of antimicrobial resistance’
published in the latest edition of Indian Journal of
Cancer has recommended to make it mandatory
to set up an Infection Control Team (ICT) in all
hospitals.
Dr.T.V.Rao MD 81

82. Educating the Educated
• The recommendations include offering Post-
MD/DNB (internal medicine) sub-specialisation in
Infectious Diseases at all post-graduate centres
that offer sub-speciality training, compulsory
training in infection control and infectious
diseases training in under-graduate and post
graduate curriculum in all specialities. The
Medical Council of India should introduce one-
week antibiotic stewardship and infection control
training in the third, fourth and final year of
MBBS and two-week training at the PG level.
Dr.T.V.Rao MD 82

83. Creating a Task force
• Recommending the setting up of a National
Task Force to guide and supervise the regional
and State infection control committees, the
paper suggests that the National Accreditation
Board for Hospitals & Healthcare Providers
(NABH) insist on strict implementation of
hospital antibiotic and infection control policy,
during hospital accreditation and re-
accreditation processes.
Dr.T.V.Rao MD 83

84. Are we overusing Antibiotics
Dr.T.V.Rao MD 84

85. Good hand washing practices still reduces
antibiotic resistance and spread
Dr.T.V.Rao MD 85

86. Conclusions
 Antibiotic resistance is a major
problem world-wide
 Resistance is inevitable with use
 No new class of antibiotic introduced
over the last two decades
 Appropriate use is the only way of
prolonging the useful life of an
antibiotic
Dr.T.V.Rao MD 86

87. Antibiotics save Lives
Save Antibiotics from Misuse
Dr.T.V.Rao MD 87

88. Dr.T.V.Rao MD 88