ANTIBIOTIC RESISTANCE IS A MAJOR PROBLEM FACED BY MEDICAL COMMUNITY AND CHALLENGE FOR NATION'S HEALTH POLICY.

1. Dr. RAGHU PRASADA M S
MBBS,MD
ASSISTANT PROFESSOR
DEPT. OF PHARMACOLOGY
SSIMS & RC.

2. Antibiotic resistance develops when bacteria adapt and
grow in the presence of antibiotics. The development of
resistance is linked to how often antibiotics are used
Declared a crisis by the
World Health Organization
Centers for Disease Control and Prevention (CDC)
Institute of Medicine
Infectious Diseases Society of America, and
virtually all other relevant organizations

3. Antibiotics are non-renewable resources
Once resistance evolves, it can spread very rapidly across
borders and around the world
Drug resistance threatens to erase gains made in disease
treatment and control in developing countries
Infections with resistant organisms are associated with
increased morbidity and mortality
Extended stays in hospitals
Reduced treatment options
Untreatable infections
Increased healthcare costs

4. S. pneumonia: Up to
55% resistance to
penicillin in some
regions
HIV: Report of
resistance to
all marketed
agents
S. dyentariae: 90% resistance to
cotrimoxazole S.Typhi: Outbreaks
of multi-resistant strains in 11
countries
M. tuberculosis:
Multi-drug resistant
tuberculosis
P. falciparum:
Chloroquine resistance
in 81/92 countries

6. Diseases Agent Resistances
Pneumonia S pneumoniae Penicillin
Dysentery S dysenteriae Multiple resistances
Typhoid S typhi Multiple resistances
Gonorrhea N gonorrhoeae Penicillin and
tetracycline
Tuberculosis M tuberculosis Rifampicine and INH
Nosocomial infections S aureus Methicillin, vancomycin
E species Vancomycin
Klebsiella,
Pseudomonas
Multiple resistances

7. Resistance to new drugs
arises rapidly as they are
introduced
Mostly hospital acquired
infections
Community-acquired
resistance is becoming
more common
Resistant bacteria
become dominant

8. Overall use of antibiotics is
increasing rapidly
Irrational drug combinations
Increasing drug pressure increases
the rate of evolution of resistance,
but removing drug pressure does
not always lead to a decrease in
resistance
Transmissible resistance (on
plasmids) is especially problematic

9. Prevent antibiotic from reaching its target
Impaired cell membrane permeability
Efflux phenomenon
Prevent the antibiotic from binding to its target
Supplementary targets
Decreased affinity by target modification
Inactivation before reaching the target

10. Enterobacteriaceae Enterococci
StaphylococciPseudomonas
Campylobacter
Vibrio cholerae
Pneumococci
Streptococci

11. The concentration range tested for a drug and the
interpretative criteria for various categories are based on
extensive studies that correlate with
Serum achievable levels for each antimicrobial agent
Particular resistance mechanisms
Successful therapeutic outcome
In practice situations the entire range may not be used for
decision making and therefore the concept of breakpoint
concentration

12. Increase prescription auditing
Doctors, Pharmacist and Patients
Setting up national prescription surveillance networks
to track the evolution and spread of resistant
pathogens
Hospitals with extensive insurances will definitely help
in auditing

13. Data on antibiotic use
and drug resistance data
by microbe Strong
testimony supporting
resistance
Identify areas of great
need for corrective
intervention.

14. Regions where antibiotics are unavailable
Regions with high levels of resistance coexist
in the same country
Little or no regulation of antibiotics, at pharmacies
Susceptibility testing and drug regulation are difficult
in rural settings
Costs money, lives and undermines effectiveness of
health delivery programs
Threat to global stability and national security

15. Do’s
Understanding emergence and spread of antimicrobial
resistance and the factors influencing it
Establish a nationwide well coordinated antimicrobial
program with well defined and interlinked responsibilities
and functions of different arms of the program
Rationalizing the usage of available antimicrobials

16. Do’s
Reducing antibiotic selection pressures by appropriate
control measures
Promotion of discovery of newer and effective
antimicrobials based on current knowledge of
resistance mechanisms
Rapid and accurate diagnosis of infections and
infectious diseases

17. Do’s
For monitoring use and misuse of antibiotics:
Schedule H of the drug and cosmetics act contains a
list of 536 drugs which are required to be dispensed
on the prescriptions of a registered medical
practitioner.
A separate schedule - Schedule H1 under the Drugs
and Cosmetics Rules to regulate sale of antibiotics
exclusively.
Tigecycline, Daptomycin - restricting their access to
only tertiary hospitals.

18. Do’s
For monitoring use and misuse of antibiotics:
Appropriate steps should be taken to curtail the
availability of fixed dose combination of antibiotics in
the market
Hospital based sentinel Surveillance System for
monitoring antibiotic resistance to be set up with the
identification of one of more Central institutions under
the ministry of health as coordinating centres at the
National Level.

19. For promoting rational use of drugs various strategies:
Educational strategy:
Training
Printing materials
Media-based Approach
Managerial strategy:
Monitoring & supervision
Generic substitution
Patient cost sharing

20. Enforcement, sanction, drug withdrawal, market control
Formulation & implementation of an antibiotic policy
With quality assured laboratory data in real time develop
antibiotic policies that are standard national / local
treatment guidelines.
Advocating evidence based immunotherapy or
combination therapy. This must include consideration of
spectrum of antibiotics , pharmacokinetics /
pharmacodynamics, adverse effects monitoring,
Cost and special needs of individual patient groups

21. Antimicrobial resistance (AMR) monitoring and Strengthening
diagnostic strategies are appropriate diagnostic tools rapid
identification of pathogens for AMR surveillance.
Robust quality assurance system  “Neutral” central institute.
Reduce Inappropriate Antibiotic Use in Outpatients
Switch antibiotics from intravenous (IV) to oral formulations to
hasten discharge and reduce risks associated with IV catheters.
This switch is easily done with many antibiotics (linezolid,
metronidazole, fluoroquinolones, some cephalosporins,
fluconazole, etc).

22. 1. Improve awareness and understanding of
antimicrobial resistance through effective
communication, education and training
2. Strengthen the knowledge and evidence base
through surveillance and research
3. Reduce the incidence of infection through effective
sanitation, hygiene and infection prevention measures
4. Optimize the use of antimicrobial medicines in
human and animal health
5. Develop the economic case for sustainable investment that
takes account of the needs of all countries, and increase
investment in new medicines, diagnostic tools, vaccines and
other interventions

23. Molecular methods
polymerase chain reaction test for the detection of
MRSA, vancomycin resistant Enterococcus, Neisseria
gonorrhoeae, Chlamydia trachomatis, group B
Streptococcus, tuberculosis, Candida albicans, and
many others.
Coming soon are tests that will detect practically every
bacterium as well as other pathogens, making an
etiologic diagnosis to facilitate antibiotic decision
making within 12 hours of collecting the culture.

24. We need a novel method to deal with antibiotic
development and its related costs. Possibilities include:
A public private partnership such as the
combined resources of the Bill & Melinda Gates
Foundation, Janssen Pharmaceuticals, and the TB
Alliance, which has now produced bedaquiline(2016),
the first new FDA approved drug for tuberculosis in the
past 40 years, DELAMANID- bactericidal drug
Synriam as a fixed-dose combination of arterolane
maleate and piperaquine phosphate by Sun Pharma.

25. WHONET is a free software developed by the WHO
Collaborating Centre for Surveillance of Antimicrobial
Resistance for laboratory-based surveillance of infectious
diseases and antimicrobial resistance.
The principal goals of the software are:
1 to enhance local use of laboratory data; and
2 to promote national and international collaboration
through the exchange of data.
The understanding of the local epidemiology of microbial
populations; the selection of antimicrobial agents; the
identification of hospital and community outbreaks; and the
recognition of quality assurance problems in laboratory
testing

26. Antibiotic resistance is a major problem world-wide. Evolution and
spread of antibiotic resistance is a consequence of how antibiotics are
used and miss-used in humans, animals and the environment.
Resistance is inevitable with use
No new class of antibiotic introduced over the last two decades
Appropriate use is the only way of prolonging the useful life of an
antibiotic
A world without effective antibiotics is a terrifying but real prospect.
Overuse of antibiotics has led to dangerous outbreaks of drug
resistant disease, and puts us in very real danger of a global pandemic