ANTIBIOTIC RESISTANCE;
WHAT’S TO BE DONE?
(TOP 5: WASTE OF ANTIBIOTICS)
Dr SG Jones.
EUROPEAN ANTIBIOTIC
AWARENESS DAY
18 NOVEMBER
What is antibiotic resistance?
• when bacteria adapt and develop a way to protect themselves
from being killed by antibiotics
• bacteria are more likely to develop resistance when antibiotics
are overused or not used as prescribed
Why is it a problem?
• infections caused by antibiotic resistant bacteria are more
difficult to treat leading to increased levels of disease and
death and longer hospital stays
• operations like bone, heart or bowel surgery, and treatments
like chemotherapy all require antibiotics to be successful; if our
antibiotics do not work these procedures will become
impossible without risk of infection
What can I do?
Developed by
• become an Antibiotic Guardian by choosing a pledge to
undertake a simple action that can help prevent the
development and spread of antibiotic resistance
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ANTIBIOTICGUARDIAN.COM
What is the problem.
• Multiple Antibiotic resistance.
• Particularly Gram Negatives:
ESBLs
CPEs- Carbapenemase producers; very few
antibiotic classes left to treat.
• Less so with gram positives – MRSA, GISA, VRE.
• Poor incentives for industry to develop new classes of
antibiotic, very few in pipeline.
Increase in E.coli septicaemias by 12%
Proportional
prescribing:
GPs 78%
Hospitals 15%
Other community
prescribers 6%
Overall increase by 6% - GP 4%, Hospitals  12%, Other community
prescribers 32%.
European Antibiotic
prescribing data.
Antibiotic Stewardship.
‘Right antibiotic, at right time, and for right duration’.
Documentation important – on drug chart and patient
notes (continuity of care).
Allergies, Antibiotic, Indication,
Duration, Review date.
Review of prescription at 48 -72 hrs.
Antibiotic Stewardship.
• Does it work in reducing resistance?
- Evidence base sparse.
• Interactions with bacteria, host, environment and wider
community are highly complex and incompletely
understood.
• All antibiotic use has potential to induce resistance, not
just inappropriate use ( 5-20%).
22020%$%
0
Inappropriate Rx.
80%
Necessary and justifiable Rx.
In no particular order of wastefulness.
1.The chronic ulcer.
• Swabbing chronic ulcers /pressure sores is a dangerous
game.
• Human agar plates – you practically always grow
bacteria, sometimes polymicrobial.
• What are you going to do with this lab report?
Cycle of Antibiotic misuse.
District nurse sees pressure ulcer
2 weeks later -no change
in ulcers appearance
No clinical
assessment of pt.
Prescribes
Antibiotic x
Swab is
taken
Lab reports:
bacterial growth
No examination
of patient
GP sees report
thinks- ‘must treat’.
2. The phantom pneumonia.
• Confusion with exacerbation of COPD/bronchitis,
old pulmonary fibrosis, heart failure.
• The poor quality Chest Xray, some pulmonary
oedema in a generally frail and unwell patient.
• Antibiotics started just in case.
• Diagnosis not reviewed and patient receives full
course of antibiotics for CAP ( usually TAZ
+Claritho)
3. Asymptomatic bacteruria in elderly.
• Common phenomenon, esp in elderly.
• Bacteria (planktonic) enter bladder periodically and
transiently – usually flushed away.
• Does not constitute a UTI.
• Patient does not have key symptoms of:
1. Dysuria.
2. Frequency/ urgency.
• These patients should not be tested – dipstick MSU.
 Urine culture will often grow bacteria and a report will
be sent from lab which induces clinician to treat.
• These patients should not receive antibiotics.
Without dysuria  no urine testing and no
antibiotic treatment
4. The colonised urinary catheter.
• CSU taken
lab results( WBC, bacteria cultured)
patient treated with antibiotics.
• In time, most urinary catheters become colonised with
bacteria.
• Long term catheters often develop biofilm.
• Lower UTI in catheterised patient does not make sense
as a pathophysiological concept
Urinary catheter biofilm formation.
5.Stasis dermatits – chronic cellulitis
• No such thing as chronic cellulitis.
• Chronic skin changes on top of chronically oedematous
legs; sometimes ulcerate.
• Often bilateral – cellulitis very rarely erupts in two places
simultaneously
• Multiple courses of antibiotics given, over several
months/years, with little response.
Stasis dermatitis / venous stasis ulceration.
Over-reliance on inflammatory markers
• Indicators of inflammation not specifically infection.
• Not as responsive as we think – especially on downward
trend.
• Should not be used as lone indicators – need to be tied in
with clinical signs of infection.
• Treat the patient and not just the numbers.
Some wider concerns.
• Antibiotics used for non infection indications:
as prokinetics, anti-encephalopathy, control of pruritus in
cholestasis.
• Long term prophylaxis: recurrent urinary tract infections
COPD/Bronchiectasis, SBP.
• Over extension of peri-operative prophylaxis from 1-2
doses extended to 2-4 days.
Extension of prescribing rights to non
medical HCWs.
• Everyone wants to be an independent prescriber.
• Proliferation of PGDs, driven by cost and medical
availability. Evidence of poor oversight and lack of audit.
• Specialist nurses in community e.g. COPD nurses, ulcer
specialists.
• Over the counter medicine creep.
Psychology of prescribing – who can say
no?
• 1940s to 1980s: Paternalistic view of medicine – ‘doctor
knows best’.
• 1990s to 2000s: Patients charter – government as
protector and promise of good care –
• 2000s to present day: ‘Patient experts’, ‘partnership
medicine’, ‘internet self diagnosis’• Patient satisfaction surveys – net promoters/detractors
etc.
Cycle of global factors influencing generation of antibiotic resistance.
Developed world.
Lack of effective
antibiotics.
Greater sophistication of
modern medicine –
increased age and fragility
of patients, more immunocompromised, ever more
invasive techniques.
Developing world.
Poor national healthcare
systems
Unlicensed / criminal
pharmaceutical
production – ‘fake’
antibiotic market.
Spread of multi-resistant
bacteria in hospitals /
community (UK, Europe,
USA etc) – increased use
of broader spectrum
antibiotics.
Inadequate national and
international surveillance
systems both in scope
and sophistication.
Global movement of
resistant organisms
and resistance genes
Low incentive for
pharmaceutical
companies to innovate
and develop new
antibiotic molecules.
Inadequate state
regulation of
prescribed drugs.
Inadequate local
enforcement.
Poor provision of
primary medical care.
Lack of microbiology
laboratory facilities at
local /national level.
Over the counter
purchase of antibiotics:
pharmacies, corner
shops, street markets.
High burden of infective
diseases, poor
sanitation, poor
standard of dwellings.
Increased
international travel /
migration.
Globalisation, human
trafficking.
Mass worldwide use of antibiotics as growth promoters in livestock.
Poverty, inadequate
access to basic
healthcare – need to pay
for access.
SGJ. Nov 2013.
Global issues.
• Unregulated antibiotic market – corner shop, open air
•
•
•
•
markets, large drug stores.
Extensive, and growing, illegal/ fake antibiotic industry.
Doctors contracted/ induced to prescribe certain
pharmaceuticals ( Japan).
Expansion of global air travel.
Inadequate microbial/ Ab resistance screening
infrastructure.
Fake pharmaceuticals.
Facilities range from crude to hi
tech. £18 billion industry (WHO
2011) accounting for 10% of all
pharmaceutical sales worldwide.
Bottom left- raid on warehouse
East midlands 2010.
Unregulated pharmaceutical market.
Movement of bacteria and
viruses around the globe.
So what’s being done.
Recognition – WHO, EU, Infectious disease soc of
America, UK Gov, World Economic Forum.
Longitude Prize £10M – universal infection detector.
US Gov. Barack Obama has directed NSC to develop a
national action plan.
Partnership.
• Public private partnership: Bill and Melinda Gates
Foundation –accelerated anti TB drug programme.
• EU Federation of Pharmaceutical Industries –antibiotic
discovery programme.
• Return of several smaller pharma companies into market
– money to be made.
Decoupling reward from sales.
• Need to understand that antibiotics are a world asset.
• Drug company may spend £xbillion and 15 years of
development to bring a new antibiotic to market.
• Then may be used for only 100 patients /year.
• Health care systems need to pay for innovation not units
sold.
Prioritisation and conservation.
• Global charter.
• Access through health care systems.
• Conservation through clinical prioritisation tailored to
diagnosis.
• Most antibiotic tonnage used as growth promoters in
animal feed – need worldwide treaty.
Thank you - Any Questions?