Why is it an issue Ian Battersby BVSC DSAM DipECVIM FRCVS Antibiotic History wwwvetspecialistscouk wwwvetspecialistscouk No new class of antibiotics since 1980s How have we been using a commonly prescribed drug ID: 928453
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Slide1
Antibiotic prescribing: Why is it an issue?
Ian Battersby
BVSC DSAM
DipECVIM
FRCVS
Slide2Antibiotic History www.vetspecialists.co.uk
Slide3www.vetspecialists.co.uk
No new class of antibiotics since 1980s
How have we been using a commonly prescribed drug?
Unlike other drugs the more we use them their efficacy wanes….
Slide4Complex Issuewww.vetspecialists.co.uk
|
4
Human
Veterinary – Different species Mass prophylaxis Welfare
Environment
Different countries : legislation e.g. Scandinavia
Different opinions !
Common thought – we recognise action is needed
Slide5MDR BacteriaWho are the main players?Variety of Gram negative and Gram positive
‘
ESKAPE’ pathogens
Enterococcus
faeciumStaphylococcus aureus Klebsiella pneumonia
Acinetobacter baumannii
Pseudomonas aeruginosa
Enterobacter species
Slide6How do Antibiotics influence Resistance Development…..
Slide7Slide8X
Slide9Slide10Slide11Slide12Bacterial Hyper-Mutational State
Antimicrobial level not
high enough to inhibit/kill bacteria
Mechanisms
to repair DNA
replication
errors in bacteria
are inhibited
The
simpsons
Slide13Slide14Slide15Slide16Slide17Too often
Too Long
Poor Dosing
Sub Therapeutic
Levels
Slide18Practice Infection Control Policy
Hygiene/barrier
nursing protocols
Monitoring
Antibiotics Prescribing Policy
(or stewardship)
How effective can these policies be…
Hygiene/barrier
nursing protocols
Monitoring
Slide19Therapeutic antibiotic use patterns in dogs: observations from a veterinary teaching hospital.
J Small Ani
Pract
. June 2011;52(6):310-8.
OBJECTIVES: To describe therapeutic antibiotic use patterns in dogs at a small animal teaching hospital.
METHODS: A retrospective case analysis of randomly sampled antibiotic prescriptions in dogs from May
20
th
2008
to May
20
th
2009
RESULTS:
17% of therapeutic antibiotic prescriptions there was confirmed infection,
45
% suspected infection
38
% there was no documented evidence of infection.
Slide20Slide21Slide22Changing our prescribing habits
Slide23The challenge
Changing Habits is Hard
Forming habits from N = 1
“ prescribe antibiotics just in case”
vs.
“ prescribe as they are indicated”
Slide24Were Abi prescribed ?
Slide25Were Abi prescribed ?
Puppy
Not vaccinated
Vomiting and Haemorrhagic diarrhoea
PyrexicHypovolaemic, tachycardic
Slide26Were Abi prescribed ?
Relatively Bright , Hydration Good
2 episodes of diarrhoea in 12 hours
Likes to scavenge!
Eating and drinkingExamination NAD
Slide27Were Abi prescribed ?
24 hours
Anorexic
Lethargic
Diarrhoea 3x hrBorborygmi
VomitingIs drinking
Slide28Were Abi prescribed ?
24 hours
Anorexic
Lethargic
Diarrhoea 3x hrBorborygmi
VomitingIs drinking
Slide29Human Acute Diarrhoea Guidelines
29
Slide30Antimicrobials
No Antimicrobials
Fever
Bacterial
Infection
viral,
protozoal,
Fungal
Sterile inflammatory disease
Immune mediated disease
Para-neoplastic
Metaphyseal osteopathy
Stress
Consider the specificity of your findings for bacterial infection…
Other example neutrophilia or protein in the urine
Slide31Is there a bacteria infection involved??
Cytology
Culture
Procalcitonin
in humans
- pneumonia and sepsis
Slide32Surgical prophylaxis.“Antibiotics are not a substitute
for poor asepsis”
Slide33Slide34In vitro resistance vs. Clinical ( in vivo) resistance
Slide35Clinical Resistance/Failure
In vitro
sensitivity*
Pharmaco
dynamics
of the drug
Host factors
Individual drug
properties
Blood supply,
necrosis, drainage
Bacteria factors
Virulence
factors
* MIC limitations
Rex and Pfaller (2002) – The 90:60 rule
WBC, cytokine,
Ab, Comp
Slide36Clinical Resistance/Failure
In vitro
sensitivity*
Pharmaco
dynamics
of the drug
Host factors
Individual drug
properties
Blood supply,
necrosis, drainage
Bacteria factors
Virulence
factors
* MIC limitations
Rex and Pfaller (2002) – The 90:60 rule
WBC, cytokine,
Ab, Comp
Slide37Siberian Husky – Anal abscess
Slide38ANTIBIOTIC PSEUDOMONAS E.COLI ENTEROCOCCUS
Amoxycillin
RESISTANT
RESISTANT
RESISTANT
Amoxycillin-Clav
RESISTANT
RESISTANT
RESISTANT
Cephalexin RESISTANT
RESISTANT
RESISTANT
TMS RESISTANT Sensitive RESISTANT
Gentamicin Sensitive * Sensitive * Sensitive *
Marbofloxacin
Sensitive
Sensitive
RESISTANT
Erythromycin RESISTANT
RESISTANT
RESISTANT
Fusidic
acid RESISTANT
RESISTANT
RESISTANT
Clindamycin RESISTANT
RESISTANT
RESISTANT
Slide39Clinical Resistance/Failure
In vitro
sensitivity*
Pharmaco
dynamics
of the drug
Host factors
Individual drug
properties
Blood supply,
necrosis, drainage
Bacteria factors
Virulence
factors
* MIC limitations
WBC, cytokine,
Ab, Comp
Slide40We want to Treat Effectively but not too long
How long…………………..?
Slide41Humans – Cochrane
Reveiw
Uncomplicated UTI –
young women 3 days vs 5-10 day
older women 3-6 d vs. 7-14
Pyelonephritis (non hospitalised)
7-14d vs 14-42 d
Duration of Course
Slide42Hard to do…. MTZ , aminoglycosides
Avoid combinations therapy
Avoid using certain antibiotics as first line agents
Spectrum of Activity – Practice policy
There are very strong arguments that
antibacterials
with restricted use in human medicine (e.g. imipenem, linezolid,
teicoplanin
, vancomycin) should not
beused
in animals
Slide43Thank you for listening