Antimicrobial Resistance Clinical Skills & Awareness IPSF Public Health - Medicine Awareness Workshop 61th IPSF World Congress, Hyderabad 2015
Introduction
content Key facts: Antimicrobial resistance Page 2
Antimicrobial resistance (AMR) has become a serious threat to global public health in recent years. It is becoming evident that resistance to common antibiotics that we often take for granted is occurring at an alarming rate. AMR is no longer an issue for the future; it is happening now - across the world! As future pharmacists we have a major role in the prevention of antimicrobial resistance and it is our duty to inform our patients and fellow colleagues about the importance of the responsible use of antimicrobials. Help us to preserve antibiotics as powerful weapons against a variety of infectious diseases! Become an Antibiotic Guardian!
What does the future hold ? Page 4
The Antimicrobial Stewardship Page 5
Clinical cases and answers Page 7
Spread awareness: useful links Page 10
Special thanks and references Page 12
Ms Lara-Turiya Seitz IPSF Medicine Awareness Coordinator 2014-15
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Mr Sam Doherty
What is antimicrobial resistance? 10 Facts you need to know about antimicrobial resistance (AMR): “Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it. Thus it threatens the effective prevention and treatment of an everincreasing range of infections caused by bacteria, parasites, viruses and fungi.� - World Health Organization How you take your medicine can have a global impact. If you take an antibiotic but do not take the full dose or treatment length, the drug may only kill bacteria that is sensitive to it and leave more resistant bacteria to grow, multiply, and spread to other people. Shortening the antimicrobial treatment duration, taking a lower dose, or not taking the correct number of doses are all ways of antimicrobial misuse. Misusing antimicrobials can lead to a decreased drug level in your body so that some bacteria may survive and become more resistant. Another contributor to antimicrobial resistance is the use of poor quality medications. When a medication is not regulated for quality control, it may have too low of a dose of the active component. In some countries, access to antimicrobials is difficult, and patients may need to take medications that are not properly regulated. Additionally, patients may be forced to stop taking the antimicrobial drugs before completing the recommended treatment length. Generally, colds and the flu cannot be treated by antibiotic medications, because the majority of colds and the flu are caused by viruses. Antibiotics do not treat viruses, and taking them will not reduce your symptoms. Antimicrobial resistance can make it more difficult to treat common infections that were once easy to treat with antimicrobial medications. After antimicrobial treatment failure, the patient may have more serious consequences from the infection, longer treatment durations, more doctors visits, longer hospital stays, and more expensive treatment regimens. “In 2012, there were about 000 450 new cases of multidrug-resistant tuberculosis (MDR-TB). Extensively drug-resistant tuberculosis (XDR-TB) has been identified in 92 countries. MDR-TB requires treatment courses that are much longer and 2
less effective than those for non-resistant TB.� - World Health Organization “Treatment failures due to resistance to treatments of last resort for gonorrhoea (third-generation cephalosporins) have now been reported from 10 countries. Gonorrhoea may soon become untreatable as no vaccines or new drugs are in development.� - World Health Organization Market failure and disincentives have made it difficult for drug companies to develop new antibiotics. Antibiotics are not as profitable for drug companies as other types of medications that patients may take for a longer amount of time. Often times, a new antibiotic is only used for severe circumstances due to fear of resistance and does not create much initial revenue for the drug companies. Both human and animal antimicrobial drug use contribute to antimicrobial resistance. When antimicrobial resistance develops in animals and in food, it can be transferred to humans, increasing treatment difficulty. Reference: (IPSF Antimicrobial Resistance Awareness Campaign Kit 2015)
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What does the future hold ? Deaths attributed to AMR every year by 2050
http://amr-review.org/
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AMR is present in ALL parts of the world. New resistance mechanisms emerge and spread globally. According to WHO at least 2 million people get infected each year which cannot be treated by our common antibiotics Antibiotic resistance costs yearly about 20$ billion. Resistant infections make people sicker, thus they stay in the hospital longer and need more expensive treatments. Without effective antibiotics, modern medical treatments such as operations, transplants and chemotherapy will become impossible. Resistance to one of the most widely used antibacterial drugs for the oral treatment of urinary tract infections caused by E. coli – fluoroquinolones – is very widespread.
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What can be done?
Antimicrobial Stewardship: Start Smart, then Focus
Start smart:
• As narrow spectrum antibiotic as possible (while still being effective) • As short antibiotic course as possible; • Switched from the intravenous to the oral route (as soon as clinically appropriate) • Take a thorough drug allergy history; • Prescribe single dose antibiotics for surgical prophylaxis where antibiotics have been shown to be effective.
Reasons:
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Minimize pressure of emergence of antimicrobial resistance; Reduce risk of healthcare-associated infections (C. difficile); Reduce side effects from antibacterial use; Cost-effective prescribing.
Then Focus: Reviewing the clinical diagnosis and the continuing need for IV antibiotics at 72-48 hours and documenting a clear plan of action - the ‘antimicrobial prescribing decision The five ‘antimicrobial prescribing decision’ options: Stop, Switch, Change, Continue and OPAT: 1. Stop antibiotics if there is no evidence of infection. 2. Switch antibiotics from IV to oral whenever appropriate. 3. Change antibiotics – ideally to a narrower spectrum – or broader if required. 4. Document next review date or stop date for IV and oral antibiotics. 5. Outpatient Parenteral Antibiotic Therapy (OPAT)
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Clinical Cases Case I: Intensive Care Unit (Hospital) Patient: John C. Lewis (m)
DOB: 1937/06/17
eGFR: 38 mL/min/1.73m² Diagnosis: pneumonia (Pneumocystis carinii) Treatment: Co-Trimoxazole – 960mg (i.v.) OD Do you have any concerns about this treatment?
Dosing intervals: OD: once daily BD: twice daily (every 12 hours) TDS: three times a day (every 8 hours) QDS: four times a day (every 6 hours)
Our thoughts: A 78 year old male patient diagnosed with a pneumonia is being treated with Co-Trimoxazole 960mg (i.v.) once daily. Here it is not the antibiotic prescribed which is the problem but rather the dose of antibiotic prescribed. British National Formulary (BNF) monograph tells you: normal treatment dosage is 120mg/Kg daily in 4-2 divided doses for 21-14 days. Prescribing errors such as this can lead to patients harm due treatment failure and leaving the patient at risk of developing resistance. As we know the patient›s eGFR is more than 30mL/min/1.73m² therefore a higher dose can be prescribed. After this intervention monitor of the patient›s renal function and a review of the i.v. antibiotic after 3-2 days will be required, with the possibility of switching to oral after this length of time if appropriate.
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Case II: Common cold (Community pharmacy) Ms Smith is presenting her eight-year-old son Philip to you in the pharmacy. She just took him to the Doctor for some antibiotics to clear his chest as he had a cold for a week and is still sniffling and coughing. The Doctor refused to prescribe any antibiotics and Ms Smith comes now to the pharmacy being furious. How would you respond to her? Our thoughts: In this scenario it is important to manage Ms Smith’s expectation of antibiotic therapy. Ms Smith’s son is suffering from a common cold which are primarily caused by viral infections. Antibiotics will not work on the common cold as they fight bacteria-related illnesses. Therefore prescribing antibiotics for her son would have no benefit but may expose her son to undesirable side effects such as diarrhoea, vomiting or rash. Prescribing antibiotics when they are not needed can lead to antibiotic resistance. This is when bacteria resist the effects of an antibiotic and it means that the infections they cause are more difficult to treat in the future. At this stage may be appropriate to offer cough syrup for symptomatic relief of her sons cold and/ or Paracetamol to reduce pain and discomfort. Lifestyle advice can also be given such as resting drinking plenty of fluids and eating healthy.
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Case III: Bronchitis (Community pharmacy) Patient: Amalia (f ); 20 years Diagnosis: bronchitis Treatment: Doxycycline 200mg OD as starting dose; 100mg OD for the following 7 days Medication history: Iron deficiency (Ferro Sanol Duodenal Capsules, once a day) What counselling advice would you offer Amalia when taking Doxycycline? Our thoughts: Amalia is taking Iron supplements for her Iron deficiency anemia. Iron can interfere with the absorption of Doxycycline. As a pharmacist it is important to make the patient aware of this interaction. Counsel the patient to take her Doxycycline 2 h before or 2 h after antacids containing aluminum, calcium, or magnesium; preparations containing iron or zinc; or dairy products (eg, milk, cheese, ice cream).Also inform patient about the photosensitivity side effects of Doxycycline and advise to avoid strong sunlight and to use a high factor sun cream.
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Case IV: Patient: Lea (f ), 26 years Diagnosis: uncomplicated urinary tract infection Treatment: Cefuroxime (p.o.) 250mg BD 3 days Allergy History: penicillin allergy; symptoms: anaphylactic shock Do you have any concerns about this treatment? Lea has a history of penicillin allergy with symptoms including anaphylactic shock. Research has shown there is a %20-%10 chance of patients who are allergic to beta-lactam antibiotics such as penicillin also being allergic to cephalosporin antibiotics such as cefuroxime. However due to the patient›s previous severe allergy to penicillin, cefuroxime would not to be the correct choice of antibiotic. As a pharmacist you should advise the doctor to change the antibiotic to more appropriate options such as Trimethoprim, Nitrofurantoin or Fosfomycin which are commonly used for urinary tract infections.
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Get active and raise awareness: IPSF Campaign Kit
- Introduction - Myths & Facts - Key Facts - Did you know that? - How to run a medicine awareness campaign
http://publichealth.ipsf.org/ antimicrobial-resistanceawareness/
ReAct Toolbox
http://www.reactgroup.org /toolbox/
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https://antibioticguardian.com/
Become an Antibiotic Guardian CPPE: Antibacterial resistance – a global threat to public health: the role of the pharmacy team http://bpsa.co.uk/downloads/cppe-antibacterial-learning.pdf
Free Online Course (Sept. 2015): Antimicrobial Stewardship: Managing Antibiotic Resistance https://www.futurelearn.com/courses/antimicrobial-stewardship/
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With special thanks to Mr Ryan Hamilton, MRPharmS, AMRSC, Specialist Pharmacist in Antimicrobials Ms Bronwen Holloway, Project Officer of ReAct Europe Mr Dušan Jasovský, Policy Associate of ReAct Europe
References • http://www.who.int/drugresistance/en/ • www.cdc.gov/drugresistance/ • http://ecdc.europa.eu/en/activities/diseaseprogrammes/ARHAI/Pages/ index.aspx • http://www.idsociety.org/Topic_Antimicrobial_Resistance/ • http://www.efsa.europa.eu/en/topics/topic/amr.htm • http://www.bpsa.co.uk/websites/123reg/LinuxPackage22/bp/sa/_c/bpsa. co.uk/public_html/downloads/cppe-antibacterial-learning.pdf
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