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1、ANTIBIOTIC ANTIBIOTIC RESISTANCERESISTANCEInfectiousDiseaseEpidemiologySectionOfficeofPublicHealthLouisianaDeptofHealth&Hospitals.YourTaxesatWork.phone:(504)568-5005fax:(504)568-5006Brief History of ResistanceAntibiotic Failures are NOT all due to ResistanceLackofeffectivenessinvivomaynotbeduetobact
2、erialresistance;theantibioticmaynotbeabletoreachthemicroorganisms:cannotgothroughbloodbrainbarrierbetootoxicatdosesrequiredtobeeffectiveagainsttargetedmicroorganisms.Antibiotics Use Promotes ResistanceSustained Antibiotic Use Contributes to Resistanceinitial3-month:useofAMIrestricted,TOB&GENunrestri
3、ctedthen12monthswhenAMIwasprimaryaminoglycosideMuscato JJ1991.An evaluation of the susceptibility patterns of gram-negative organisms isolated in cancer centres with aminoglycoside usage.Journal of Antimicrobial Chemotherapy.27 Suppl C:1-7.Resistance Seems to Develop Mostly in ICUProjectICARE(Intens
4、iveCareAntibioticResistanceEpidemiology)byCDCandEmoryUSPHtocollectdataon8UShospitals:For8/10pathogensconsidered,resistancewashigheramonginhospitalisolates Antibiotic Use in Agriculture Promotes ResistanceChickensfedtet-feedIn1weekintestinalfloraentirelytetRorganismsresistantintestinalbacteriainfarmm
5、embers,notinneighborswithin6months:farmdwellers:31%weeklyfecalsamples80%tetRneighbors:6.8%resistantbacteriacontainedtransferableplasmidsselectivepressurebytet-feedextendstohumanbeingsincontactwithchickensandthefeed Levy SB 1976.Changes in intestinal flora of farm personnel after introduction of a te
6、tracycline-supplemented feed on a farm.NEJM295(11):583-8 Bacteria of ConcernCDCABCprogram(ActiveBacterialCoreSurveillance):Streptococcuspyogenes(grpA)Streptococcusagalactiae(grpB)StreptococcuspneumoniaeHaemophilusinfluenzaeNeisseriameningitidisEnterococciListeriamonocytogenes8speciesofbacteria=75%of
7、allbacterialisolated:StaphylococcusaureusEnterococcussppHaemophilusinfluenzaeEscherichiacoliKlebsiellasppEnterobactersppProteussppPseudomonasaeruginosaAntibiotic Sensitivity SurveillanceNOcomprehensivesurveillancesysteminUSAorworldbestdata:NNISsensitivityofNI,4%ofbacteriasIDinUSAIDjournalsreportABre
8、sistance,largeliteratureonresistanceimpressionresistancegrowingformanyhospitals,antibioticsusceptibilitypatternsnotverydifferentnowthan10yearsagoSensitivity of Some BacteriaStreptococcus pneumoniaeNCCLSdefinedsusceptibleMIC0.06intermediate0.12MIC2.0penicillineffectiveonbacteriaclassifiedasresistantf
9、orCSF,penicillinnoteffective25-50%DRSP in LouisianaActivesurveillanceforDRSP1997-1999:21%2000:42%2001:48%Passivesystem:Region1hadthehighestratein200039.5/100,000Laboratory SurveillanceOPHlaboratory-basedabresistancesurveillanceSelectbacterialpathogensStaphylococcusspecieswithreducedsusceptibilityorw
10、ithintermediateresistancetovancomycin,HaemophilusInfluenzaeNeisseriameningitidisentericpathogens:Salmonella(10%totalsamplesize)Shigella(20%totalsamplesize),Campylobacter(25%totalsamplesize)ONLYisolatesfrominvasivediseaseorsterilesiteSendtoOPHLaboratoryOPHparticipatesintheNationalAntimicrobialResista
11、nceMonitoringSystem(NARMS)bysubmittingevery10thnon-typhoidalSalmonellaisolateandoneCampylobacterisolateperweektoCDCforsusceptibilitytesting.Louisiana AntibiogramAntibiotic UseAntibiotic Use:HospitalICARE phase 2 project antibiotic use:Defined Daily Dose(DDD)/1,000 patient dayswidevariationinantibiot
12、icuseaccordingtohospitalsAntibiotic Use:MD OfficeUSA:antimicrobials2ndmostcommondrugsrxbyofficebasedphysiciansafterCNSdrugs1992:110millionoralantimicrobialrxwrittenbyofficebasedphysiciansannualantimicrobialdruguserate=439/1,000population/yearhighestrateforchildren(15)=625/1,0001980-1992:nomajorchang
13、esinantibioticsutilizationrateAntibiotic Resistance Common among Upper respiratory tract PathogensDRSP25%MultiresistanceMoraxella75%lactamaseproducingH.influenzae25%lactamaseproducingPrevention1-VaccinateInfluenzavaccineS.pneumoniaevaccine7vaccineserotypesarealsomostresistantSovaccinereducesincidenc
14、eofinfectionsduetothe7serotypesandincidenceofresistantstrains3-Treat infection,not contaminationBloodculturesUseproperantisepsisforbloodculturesAvoidculturingvascularcathetertipsAvoidculturingthroughtemporaryvascularcatheters4-Treat infection,not colonizationTreat pneumonianot the tracheal aspiraten
15、ot endotracheal tubeTreat urinary tract infectionnot the indwelling catheternot simple bacteriuriaTreat bacteremianot the catheter tip or hubTreat bone infection not the skin floraGuidelinesPEDIATRICSJanuary1998January1998Volume101Volume101Number1Number1AmericanAcademyofPediatricsAmericanAcademyofPe
16、diatricsSupplementtoPediatricsSupplementtoPediatricsPrinciples of Judicious Use ofPrinciples of Judicious Use ofAntimicrobial Agents for Antimicrobial Agents for Pediatric Upper Respiratory Pediatric Upper Respiratory Tract InfectionsTract Infections20March200120March2001Volume134Volume134Number6Num
17、ber6AnnalsofInternalMedicineAnnalsofInternalMedicineGuidelinesforAppropriateGuidelinesforAppropriateAntibioticUseforAntibioticUseforTreatmentofAcuteTreatmentofAcuteRespiratoryTractRespiratoryTractInfectionsinAdultsInfectionsinAdultsContentsContentsBackground,SpecificAimsandBackground,SpecificAimsand
18、MethodsMethodsNonSpecificUpperRespiratoryNonSpecificUpperRespiratoryTractInfectionsinAdultsTractInfectionsinAdultsAcuteSinusitisinAdultsAcuteSinusitisinAdultsAcutePharyngitisinAdultsAcutePharyngitisinAdultsAcuteBronchitisinAdultsAcuteBronchitisinAdultsGuidelines for Prophylactic UseInsomehospitals,5
19、0%ofantibioticusedforprophylaxisforpreventionofSWI:2hrsnoteffective(manyablives2hrsdecreasetherateofpneumoniabutnotmortalityratebecausethosewhoreceivedantibioticsmorepronetoantibioticresistantinfectionsdifficulttotreatAntibioticreducenormalfloraandsometimesrenderspatient moresusceptibletoinfection(e
20、xmeningococci)Guidelines for Empiric TreatmentBaseempirictreatmentonthemostlikelymicroorganismsReports of case with rare antibiotic resistance patterns in literature Unusual&exotic cases given too much importanceMalpractice litigation of unusual cases have negative effects on efforts to convince phy
21、sicians to use narrow spectrum antibiotics Usethelesssophisticated(narrowspectrum,oldtimer,cheap)thatwilldothejob6-Use Local DataKnow your antibiogramKnow your formularyKnow your patient population7-Stop Antimicrobial TreatmentWhen infection is treatedWhen infection is not diagnosedWhen infection is
22、 unlikely8-Prevent Person to Person TransmissionHealth Care Facility:Use standard infection control precautionsFollow airborne,droplet and contact precautionsWhen in doubt,consult infection control expertsCommunity SettingStay home when you are sickKeep your hands cleanSet an example9-Prevent Transm
23、issionfrom EnvironmentGettheCathetersoutUsecathetersonlywhenessentialUsethecorrectcatheterUseproperinsertionandcatheter-careprotocolsRemovecatheterswhentheyarenolongeressentialFollowdisinfectionprotocolsFromstethoscopestoendoscopes10-Use Hospital ControlsEducational&PersuasiveApproachesminoreffectFa
24、cilitativeStrategiesclinical specialist or pharmacy clinician to advisecomputer help screens when orderingPowerStrategiesFormulary ControlMonitor usage with time limits on prophylactic,empiric,therapeutic usesRestriction of Drugs classified as:Uncontrolled:available for all physicians,Monitored:usag
25、e monitored thru systemRestricted:ID specialist onlyHospital Control:Power1-FormularyControlmostcommonmethodpharmacyandtherapeuticscommitteeselectsabinhospitalformularybasedontheabmedicalusefulness,cost,relevancetoepidemiologicsituationnoduplicationconstantrevisionHospital Control:Monitor2-Monitoran
26、devaluateempiric,therapeutic&prophylacticuse prescriptions include type of rx:E/T/P Time limits Empiric:3 daysProphylactic:2 daysTherapeutic:7 daysextension requires justification written by the prescribing physicianrequiring MD to justify prescriptions proper usage.Hospital Control:Restrict3-Restri
27、ctionofDrugsclassifiedas:Uncontrolled:available for rx by all physiciansMonitored:available but usage monitored through systemRestricted:available only after consultation with ID specialist or limited list of MDHospital Control4-Antimicrobialformforms consume time to be filledact as a deterrent for
28、casual prescriptionsinformation obtained on form used to monitor proper usage5-Laboratoryreportingfocus on formularynon formulary abS reported when multiple resistance occurs reporting of abS prompt to allow rapid switching to more appropriate and narrow spectrum ab6-Concurrentcontrolmost beneficial to patient care,not retrospectiveeasier implemented when rx thru computer system