‘Antibiotic Ireland’ Antimicrobial Resistance A Major Cause for ConcernImproper Prescribing or Patient’s Misconceptions, Expectation and Pressure on Dr’s to prescribe ?

1. Theresa Lowry-Lehnen
RGN, PGCC, Dip Counselling & Psychotherapy, BSc (Hon’s), MSc, PGCE (QTS) Science,
H. Dip. Ed, MEd, PhD Health Psychology

2. Penicillin
Thanks to the work of Alexander Fleming (1881-1955), Howard
Florey ( 1898-1968) and Ernst Chain (1906-1979), penicillin was first
discovered, developed and eventually produced on a large scale for
human use in 1943. Antibiotic therapy has played a major role in the
treatment of bacterial infectious diseases and the entire world has
benefited from one of the greatest medical advancements in history.
E. Chain H. FloreyA. Fleming

3.  A chemical substance
produced by a
microorganism, which
has the capacity to
inhibit the growth of or
to kill other
microorganisms;
antibiotics sufficiently
nontoxic to the host are
used in the treatment of
infectious diseases.
3

4.  Although a large number of antibiotics exist, they fall into
only a few classes with an even more limited number of
targets.
 –β-lactams (penicillins) –cell wall biosynthesis
 –Glycopeptide (vancomycin) –cell wall biosynthesis
 –Aminoglycosides (gentamycin) –protein synthesis
 –Macrolides (erythromycin) –protein synthesis
 –Quinolones (ciprofloxacin) –nucleic acid synthesis
 –Sulfonamides (sulfamethoxazole) –folic acid metabolism
4

5.  Antibiotic resistance: a global problem
 Resistance is inevitable with improper
use.
 No new class of antibiotic has been
introduced over the last two decades
 Appropriate use is the only way of
prolonging the useful life of an
antibiotic.

6.  Antibiotic 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

7.  Several International
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.
7

8. New Resistant Bacteria
Susceptible Bacteria
Resistant Bacteria
Resistance Gene Transfer
8

9.  The resistant strains arise
either by mutation and
selection or by genetic
exchange in which sensitive
organisms receive the genetic
material ( part of DNA) from the
resistant organisms and the part
of DNA carries with it the
information of mode of
inducing resistance against
one or multiple antimicrobial
agents. 9

10.  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 (if required).
 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.

11.  75% of outpatient antibiotics are used
inappropriately (WHO 2012).
 Patient’s misconceptions, expectations and
pressure on Doctors to prescribe antibiotics
inappropriately is a real problem in Ireland
and globally.
 Patients then frequently ask - Why am I no
better after taking the antibiotics?
 Side effects include gastric disturbances,
diarrhoea, rash and allergy.
11

12. Virus
 Common cold
 Influenza (flu)
 Acute Bronchitis
 Viral sore throats
 Measles
 Chicken Pox
 Diarrhoea (99%)
Bacteria
 Urine infections
 StrepThroat
 Boils/abscesses
 Gangrene
 Some pneumonia’s
 Some Ear infections (half)
 Some Sinus infections (< half)
 Tuberculosis
 Bacterial Meningitis
12

13.  For the treatment of bacterial infections.
 However;
 Not all fevers are due to bacterial infections
 Not all infections are due to bacteria
 Most viral infections self resolve in 1-3
weeks; colds, flu, gastric virus’s
 There is no evidence that antibiotics will
prevent secondary bacterial infection in
patients with a viral infection 13

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

15. Patient concerns
 Expect to be cured
 Need to return to work/school
 Similar symptoms treated with
antibiotics in the past.
Prescriber concerns
• Patient satisfaction
• Time pressures
• Diagnostic uncertainty
ANTIBIOTIC PRESCRIPTION

16. RHINITIS:
 1. Antibiotics should not be
given for viral rhino-sinusitis.
 2. Muco-purulent rhinitis
(thick, opaque, or discolored
nasal discharge) frequently
accompanies viral rhino-
sinusitis. It is not an indication
for antibiotic treatment unless
it persists without
improvement for more than
10-14 days.
SINUSITIS:
 Diagnosed 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

18.  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).

19.  Think…….
 Post nasal drip syndrome
 Asthma
 Gastroesophageal reflux

20. 1.Coughs and bronchitis in children rarely warrant antibiotic treatment.
2. Antibiotic treatment for prolonged cough (>10 days) may
occasionally be warranted:
- Pertussis should be treated according to established
recommendations.
- Mycoplasma pneumonia infection may cause pneumonia and prolonged
cough (usually in children > 5 years); 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 benefit from antibiotic therapy for acute
exacerbations.

21.  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.

22.  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 usually
present with running nose or chest signs). Fever
is generally moderate at the onset and peaks by
day 3-4.

23. A Balancing Act
Appropriate Initial
Antibiotic Treatment
Avoid Unnecessary
Antibiotics

24.  Inappropriate specimen selection and collection
 Inappropriate clinical tests
 Failure to use stains/smears
 Failure to use cultures and susceptibility tests
 Use of antibiotics with no clinical indication (example viral
infections)
 Broad spectrum antibiotics when not indicated
 Inappropriate choice of empiric antibiotics
 Empiric therapy is a medical term referring to the initiation
of treatment against an anticipated and likely cause of
infection prior to determination of a firm diagnosis. Most
often used when antibiotics are given to a person before the
specific microorganism causing an infection is known.
Practices Contributing to
Misuse of Antibiotics and Resistance
24

25. 25
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:

26.  Misuse of antibiotics threatens to undermine the
progress that has been made in medicine over
recent decades.The overuse of antibiotics makes
patients less likely to respond to treatment.
 Launching the action on antibiotics campaign to mark
European Antibiotic Awareness Day (November 2013),
Dr Fidelma Fitzpatrick, Consultant Microbiologist and
HSE/RCPI Clinical Lead said that a casual attitude to
antibiotics is damaging their effectiveness and that
we are we are seeing an alarming global rise in
‘superbugs’, such as drug-resistant bacteria that
cause pneumonia and meningitis, MRSA and E.coli.

27.  “Taking antibiotics when they aren’t needed means
that they might not work when you really need
them for a serious infection. That is why the action
on antibiotics campaign - supported by the
Department of Health, Health Service Executive, Irish
College of General Practitioners, Irish Pharmacy
Union, Royal College of Physicians and Royal College
of Surgeons in Ireland – is aiming to raise public
awareness on the correct use of antibiotics and to
preserve this precious resource for the use of future
generations”.
 (Dr Fidelma Fitzpatrick, Consultant Microbiologist and HSE/RCPI Clinical Lead)

28.  “Leading clinicians from the Health Service Executive,
general practice, hospital care, surgery, dentistry and
pharmacy all agree that everyone has an important
role to play in ensuring correct use of antibiotics,
and tackling the global health threat of antibiotic
resistance. The evidence is very clear – overuse and
misuse of antibiotics has allowed bacteria to develop
resistance and they are becoming immune to the
drugs we use to defend ourselves against them”.
 (Dr Fidelma Fitzpatrick, Consultant Microbiologist and HSE/RCPI Clinical Lead)

29.  “Antibiotics have utterly transformed modern
medicine. Before antibiotics were available, common
injuries such as cuts and scratches that became
infected could result in death or serious illness because
there was no treatment available. Thankfully, this
does not happen anymore as we have antibiotics
available to treat these infections. However
antibiotics must be used appropriately and by
misusing them we face the risk of returning to the
pre-antibiotic era.”
(Dr Fidelma Fitzpatrick, Consultant Microbiologist and HSE/RCPI Clinical Lead)

30. USA (2011) 30

31. Fischbach MA and Walsh CT Science 2009
31

32. 12 Steps to Prevent Antimicrobial
Resistance
12 Break the chain
11 Isolate the pathogen
10 Stop treatment when cured
9 Know when to say “no”
8 Treat infection, not colonization
7 Treat infection, not contamination
6 Use local data
5 Practice antimicrobial control
4 Access the experts
3 Target the pathogen
2 Get the catheters out
1 Vaccinate
PreventTransmission
Use AntimicrobialsWisely
Diagnose &Treat Effectively
Prevent Infections
32

33. Think before
prescribing. Are
antibiotics necessary
or correct for this
illness?
Are you using the
Right drug for the
Right bug ? 33

34.  Provide educational materials and
explain how the risks of antibiotics
outweigh the benefits when used
inappropriately.
 Build cooperation and trust.
 Responsibility to the community is
to use antibiotics correctly, for
appropriate indications.

35.  Be fully informed about the
appropriate use and misuse
of antibiotics.
 Are you demanding or
pressurizing your Dr into
prescribing antibiotics
unnecessarily for your
child?
 Are misconceptions/
demands for inappropriate
antibiotics doing your child
more harm than good?
The answer is YES. 35

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 AmericanAcademy of Pediatrics andAmerican Academy of Family Physicians, Pediatrics
2004;113:1451-1.
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accessed on slideshare, February 4th 2014.
 Harrison JW, SvecTA (April 1998). "The beginning of the end of the antibiotic era? Part II.
Proposed solutions to antibiotic abuse". Quintessence International 29 (4): 223–9
 Health, United States, 2009: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Health Statistics, 2009.
 Health, United States, 2010: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Health Statistics, April 2010.
 HSE Guidelines (2013) Keeping antibiotics effective is everyone’s responsibility. HSE, Ireland
 HuestonWJ (March 1997). "Antibiotics: neither cost effective nor 'cough' effective". TheJournal
of Family Practice 44 (3): 261–5. PMID 9071245
 Neuhauser et al (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
 T.Rao MD, Antibiotics- Use, Misuse and Consequences (Power-point)- accessed on slideshare,
February 4th 2014)
 Weiss AJ, ElixhauserA. Origin of Adverse Drug Events in U.S. Hospitals, 2011. HCUP Statistical
Brief #158. Agency for Healthcare Research and Quality, Rockville, MD. July 2013.PMID 9643260
 WHO (2012) Heath Information Statistics.