1. Antibiotic control Thursday 1/17/07

2. Antibiotic use Antibiotic resistance How can we change / reduce Ab use??? Will it reduce Ab resistance???

3. Suggested Ab use strategies for controlling resistance: Ab restriction / Infectious Disease consultants Combination therapies Cycling “Hit hard and early” – abbreviated Ab treatments PK/PD – mutant prevention concentration Judicious Ab educational interventions

4. Antibiotic restriction Macrolide restriction in Finland / Seppala et al. NEJM 1997 Total consumption of macrolides by outpatients in Finland Frequency of Ery-R GAS isolates from throat + pus in Finland

5. Macrolide restriction in Finland / Bergman et al. CID2004 Azithromycin and other macrolide consumption in Finland Ery-R in GAS isolates in Finland

6. Combination therapies What are the conditions under which this will work? It is effective in preventing antibiotic resistance for TB, HIV, but for any of the bacteria we discussed? Not shown effective for other bacteria.

7. Antibiotic cycling Two or more antibiotic classes are alternated on a time scale of months – years. Squeezing the balloon…

8. Kollef M. CID 2006

9. Abbreviated antibiotic treatments For many infections still as effective as ‘standard treatments’ (UTI/ OM/pneumoniae?/ rt. Endocarditis) But less Ab pressure.

10. Using PK/PD to reduce resistance emergence Time dependent killing (T>MIC) Concentration dependent killing (AUC/MIC or Cmax/MIC) MPC (mutant prevention concentration) - flouroquinolones

11. Educational interventions to implement judicious Ab use To decrease misuse and abuse of antibiotics (estimated as >50% prescriptions to outpatients).

12. But can Ab control reduce Ab resistance?