1. Use of antibiotics

2. Antibiotic use Antimicrobials are the 2 nd most common drugs prescribed by office based physicians In USA1992: 110 million oral antimicrobial rx written by office based physicians annual antimicrobial drug use rate = 439 /1,000 populaation

3.  A 21 year old university student presents with fever, body aches, and sore throat.  A 54 year old lady complains of dysuria, frequency, loin pain and fever.  A 36 year old man presents with cough, sputum, shotness of breath and fever

4. Indications for use :  Definite or probable bacterial infection  Serious infections  NOT FEVER

5. Where is the focus of infection ? Clinical assessment Gram stain & cultures

6. What is the likely organism : focus of infection gram stain patients age epidemiological setting prior culture data

7. What is the commonest cause of : urinary tract infection cellulitis billiary infection meningitis septic arthritis nosocomial pneumonia

8. After 48 hours – check culture results > Narrow antibiotic coverage >Infection vs colonization

9. Other factors for antibiotic selection : culture results tissue penetration bactericidal vs static renal disease liver disease pregnancy & lactation

10. Antibiotics excreted mainly by kidney Antibiotics excreted mainly by liver Antibiotics safe in pregnancy

11. Dosing of antibiotics depends on : MIC half life of drug patient factors Duration of therapy :

12. Antibiotic combinations Indications : Sepsis of unclear etiology Febrile neutropenia Prevent emergence of resistance Polymicrobial infection Synergy Disadvantages: Elimination of normal flora Colonisation by resistant organisms Drug toxicity Cost

13. Failure of therapy Patient factors Drug factors Organism factors

14. History of resistance

15. INCREASING ANTIBIOTIC RESISTANCE

16. Antibiotic Resistance Current problems with antibiotic resistant bacteria include: –MRSA 37% of all bloodstream isolates of S. aureus are now MRSA –resistance in respiratory pathogens 2.2% of S. pneumoniae are penicillin-resistant ~15-20% of H. influenzae are amoxicillin-resistant

17. Antibiotic Resistance –multi-resistant Gram-negative bacilli extended-spectrum β-lactamase producers –glycopeptide-resistant enterococci 21.6% of bloodstream isolates of E. faecium 3.3% of E. faecalis –MDR-TB 6.2% of M. tuberculosis isoniazid-resistant 1% are true MDR strains

18. Stop Antimicrobial Treatment When infection is treated When infection is not diagnosed When infection is unlikely

19. Hospital Control: Monitor 2-Monitor and evaluate empiric, therapeutic & prophylactic use – prescriptions include type of rx: E/T/P – Time limits  Empiric: 3 days  Prophylactic: 2 days  Therapeutic:7 days –extension requires justification written by the prescribing physician –requiring MD to justify prescriptions  proper usage.