Role of physician in identification, interpretation and

management of antimicrobial resistance

World Health
Day 2011

DR V DHARMA RAO
ASSOCIATE PROFESSOR
DEPARTMENT OF GENERAL MEDICINE
MAMATA MEDICAL COLLEGE
 1942–Face of Antibiotics

Millions of lives saved ..

Face of Antibiotics: today

“sometimes snatches away

health,sometimes gives it.”
Something has gone wrong
 What Factors Promote Antimicrobial
Resistance?

• Exposure to sub-optimal levels of

antimicrobial
• Exposure to microbes carrying
resistance genes
Inappropriate Antimicrobial Use

• Prescription not taken correctly

• Antibiotics for viral infections
• Antibiotics sold without medical
supervision
• Spread of resistant microbes in
hospitals due to lack of hygiene
Inappropriate Antimicrobial Use

• Lack of quality control in manufacture or

outdated antimicrobial
• Inadequate surveillance or defective
susceptibility assays
• Poverty or war
• Use of antibiotics in foods
•Why do all doctors prescribe antibiotics so often?

•Is this behaviour amenable to change?

•What does it have to do with hospital physicians?

If changes in prescribing in the community are to be achieved,
there probably needs to be a better appreciation of the issues
which drive it.

This understanding is important, not only for those working in

primary care, but also for those in hospital practice.

Physicians and microbiologists teach and influence GPs, medical

students, and junior doctors. Their advice and example is
important but is less influential, especially in primary care, if it
does not also reflect and address the difficulties experienced by
doctors who have to treat patients whose attitudes and
expectations may differ significantly from their own.
What are the issues behind dependence on
antibiotic prescribing?
Let us take an example.

The commonest presentation of acute respiratory

illness: a previously well adult consulting with a
new episode of cough and other lower respiratory
tract symptoms.

This is often called “acute bronchitis”, an imperfect

diagnostic label.

For most of these patients the doctor is uncertain

whether antibiotics are indicated, but still
prescribes them.
 The layers of the iceberg of lower respiratory tract illness (LRTi), infection (LRTI), and
pneumonia seen in hospital and the community.

Holmes W F et al. Thorax 2000;55:153-158

©2000 by BMJ Publishing Group Ltd and British Thoracic Society

Why do patients consult with acute lower
respiratory tract symptoms?
Patients consult because their symptoms distress
them and those around them
There is a strongly held and widespread belief among patients
that infection is the problem and antibiotics are the answer. 

This view, together with the doctor's willingness to prescribe

them, provides fertile ground for a spiral of demand and
supply.
Natural history of a disease
Symptoms which prompt consultation: the “trigger line”
 Graphical representation of the natural history and duration of symptoms of lower
respiratory tract illness.

Holmes W F et al. Thorax 2000;55:153-158

©2000 by BMJ Publishing Group Ltd and British Thoracic Society

What effect do antibiotics have on trigger lines?
•PATIENTS WHO HAVE AN INFECTION LIKELY TO RESPOND TO
ANTIBIOTICS

•PATIENTS IN WHOM THE NATURAL HISTORY OF THE

SYMPTOMS ARE NOT MODIFIED BY ANTIBIOTIC THERAPY BUT
THE GP FEELS PRESCRIBING IS THE ONLY PRACTICAL OPTION
The way forward
 UNHELPFUL STRATEGIES

• searching for new or more effective antibiotics

•by providing GPs with expert advice from secondary care or government that
“you should not prescribe antibiotics
 A MORE HELPFUL STRATEGY: ADJUSTING THE TRIGGER LINE

• to seek to alter patient behaviour and expectations—in our analogy, to raise the
trigger line
 PATIENT AND COMMUNITY STRATEGIES

Education and information reduces dependence on and belief in the value of

antibiotics in the community for minor illness.

Information given to patients should address four issues:

•the long natural history of lower respiratory tract symptoms;

•the clear evidence for the lack of effectiveness of antibiotics;
•the increasing problem with antibiotic resistance of common respiratory
pathogens;
•side effects due to indiscriminate antibiotic use.
 DOCTOR STRATEGIES

•Educating doctors
•Reassurance and education of the patient at the initial consultation
•Information Leaflets 
•Passing the prescribing decision back to the patient
•Post-dated prescriptions
 RESEARCH STRATEGIES

•When there is uncertainty in the doctors' decision to prescribe antibiotics, is

sharing that uncertainty and involving the patient in the prescribing decision a
useful strategy?

•Do psychological markers of health seeking behaviour offer an insight into why
some patients consult for diseases like lower respiratory tract illness?

•Do episodes of illnesses like LRTI have predictive value as a marker of the
subsequent development of more severe form of the disease?
(1)Use a consistent nomenclature.
(2)Discourage the use of labels such as “chest infection” and “bronchitis” which
imply disease, the presence of infection, and the need for antibiotics.
(3)Use open labels such as “chesty cough” which describe the symptom complex but
do not drive the prescribing decision for antibiotics.
(4)Recognise the long natural history.
(5)Develop educational materials which explain this natural history and the lack of
benefit for antibiotics to both individual patients and the community in most
situations.
(6)Encourage a better understanding of the issues by secondary care specialists.
(7)Direct prescribing to answering questions such as:
(a) which patients benefit from antibiotics, and how to identify them in
routine consultations?
(b) what is the spectrum of pathogens in lower respiratory tract illness?
(c) which education strategies reduce antibiotic prescribing?
Antibiotic Use: Is There Room for
Improvement?
“The desire to ingest medicines is one of
the principal features which
distinguish man from the animals”

Osler W. Aecquanimitas,1920
Implications: Addressing FQ Overuse / Misuse

• On whom/Where are they being used?

– Inpatient
– Outpatient
– Emergency Departments
• Why/How are they being used?
– Indications
– Dose/duration
 How are FQs Used: Appropriateness in Inpatients

None
1%
First line
35%

Alternative
59%
Experimental
5%

Ena, Diagn Microbiol Infect Dis 1998

 Appropriateness of FQ Use: EDs

• FQ Drug Use Evaluation (DUE)

• Sites: 2 Academic Medical Center Emergency
Departments (EDs)
• Subjects: 100 patients seen in EDs, then
discharged
• Appropriateness (of indication) of therapy
judged by existing institutional guidelines
– www.med.upenn.edu/bugdrug
– 3 independent ID reviewers

Lautenbach, Arch Intern Med 2003;163:601

 Appropriateness of ED FQ Use

81% of courses inappropriate

No Infection
(n=27)
33%

Other Agent
First Line Insufficient
(n=43) Information
53% (n=11)
14%

Lautenbach, Arch Intern Med 2003;163:601

 Appropriateness by Site of Infection
50
Appropriate
Inappropriate
40
p=0.76
30

20

10

Lautenbach, Arch Intern Med 2003;163:601

 Appropriateness of FQ Use: EDs
• 19/100 (19%) patients received appropriate FQ
therapy (judged by indication)
– 14 received both an incorrect dose & duration
– 4 received either an incorrect dose or duration
– 1 received the correct dose and duration
• Variation of FQ use by ED
– ED#1 (training program): 74% inappropriate
– ED#2 (no training program): 86% inappropriate
• OR (95%CI) = 0.39 (0.14, 1.09)

Lautenbach, Arch Intern Med 2003;163:601

Awareness and Use of CAP Guidelines
• Survey study of 621 physicians
– ATS CAP guidelines / local CAP guidelines
• 7 Pittsburgh area hospitals
– 1 University
– 3 community teaching
– 3 community non-teaching
• 345/621 (56%) responded
– Generalists (79%)
– ID (6%)
– Pulmonologist (5%)

Switzer GE, J Gen Intern Med 2003;18:816

Antimicrobial resistance control is not
an option, it is a must.
 Campaign to Prevent
Antimicrobial Resistance

Clinicians hold the solution!

 12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

12 Steps to Prevent Antimicrobial

Resistance: Hospitalized Adults
Clinicians hold the solution…
Take steps NOW to prevent antimicrobial resistance!
12 Contain your contagion
11 Isolate the pathogen Prevent Transmission
10 Stop treatment when cured
9 Know when to say “no” to vanco
8 Treat infection, not colonization Use Antimicrobials Wisely
7 Treat infection, not contamination
6 Use local data
5 Practice antimicrobial control
4 Access the experts
3 Target the pathogen Diagnose and Treat Effectively
2 Get the catheters out
1 Vaccinate Prevent Infection
 Campaign to Prevent Antimicrobial Resistance in Healthcare Settings

Prevention
IS PRIMARY!
Protect patients…protect healthcare personnel…
promote quality healthcare!