Bugs vs Drugs: Antibiotic Resistance in the Community Charles Welborn, MD, MS, MPH&TM, FAAP, FACEP Division of Emergency Medicine Sidra Medical and Research Center The 2nd Al Jahra International Pediatric Conference May 5, 2017

DISCLOSURE I do not have any relevant financial relationship with commercial interest to disclose.

Learning Objectives Describe the scope of antimicrobial resistance Illustrate the need for tailored and focused antimicrobial therapy

Antimicrobial stewardship is any system to optimize antimicrobial use

Background In the United States in 2013, approximately 2 million patients affected 23,000 deaths attributed to antimicrobial resistance 250,000 hospitalizations for Clostridium difficile infections $20 BILLION in increased healthcare costs

Background Between 2000 and 2010, antimicrobial use increased 36% Majority of this increase occurred in rapidly developing countries MDR, MRSA, and ESBL has moved to the community 142,000 ED visits in the US secondary to antibiotic adverse events.

Background Up to 50% of antibiotics prescribed in the emergency department are unnecessary

Antimicrobial Resistance in Kuwait carbapenem-resistant bacteria, which kills up to half of infected patients - has increased up to 90 percent over the past two decades Although non-prescription sales of antibiotics are illegal in the GCC states, 68 percent of pharmacies in Abu Dhabi, 78 percent in Riyadh and 87 out of 88 pharmacies included in a study in Saudi Arabia had sold antibiotics to patients unnecessarily and/or without a prescription 75 percent of patients who received antibiotic treatment in the intensive care unit of a Qatar hospital in 2004 did not have a microbiologically-proven infection

Antimicrobial Resistance in Kuwait Average resistance level for all surveyed bacteria was about 27% from 1999 to 2003 - higher than the 17% for the U.S. and about the same as the 28% China.

Aspects of Antimicrobial Stewardship #1 – Multidisciplinary Quality Improvement

Aspects of Antimicrobial Stewardship #2 – Review local antimicrobial resistance patterns

Aspects of Antimicrobial Stewardship #3 – Antimicrobial order sets

Aspects of Antimicrobial Stewardship #4 – Review all cultures and adjust antibiotic coverage as needed

Aspects of Antimicrobial Stewardship #5 – Antimicrobial Champion

Aspects of Antimicrobial Stewardship #6a – Consider cultures when instituting antimicrobial therapy

Aspects of Antimicrobial Stewardship #6b – Reserve broad spectrum antimicrobials (including antifungal and/or antiviral agents) for patients with septic shock

Aspects of Antimicrobial Stewardship #6c – Avoid antibiotics for uncomplicated skin abscesses

Aspects of Antimicrobial Stewardship #6d – Administer antibiotics for pharyngitis/tonsillitis only for positive rapid strep testing or culture positive strep

Aspects of Antimicrobial Stewardship #6e – No antibiotics for URIs “Bronchitis” “Sinusitis” “Possible ear infection” Use POCT

Aspects of Antimicrobial Stewardship #6f - Use the Electronic Medical Record to review past antibiotic therapy and culture results

Summary Antimicrobial stewardship is a crucial element in the management of increasing antimicrobial resistance Antimicrobial stewardship adoption is difficult in the face of multiple obstacles Multidisciplinary involvement in stewardship programs offers support from related professional disciplines