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Antibiotic Resistance and Medicinal Drug Policy. Dr. Ken Harvey School of Public Health , La Trobe University , Melbourne, Australia. 1. Lecture outline. Why the concern about antibiotic resistance? The history, microbiological and social determinants of antibiotic resistance

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antibiotic resistance and medicinal drug policy

Antibiotic Resistance and Medicinal Drug Policy

Dr. Ken HarveySchool of Public Health, La Trobe University,

Melbourne, Australia


lecture outline
Lecture outline
  • Why the concern about antibiotic resistance?
  • The history, microbiological and social determinants of antibiotic resistance
  • Containing antibiotic resistance: microbiological surveillance, antibiotic utilization studies and other interventions
  • One country’s response: the quality use of medicines pillar of Australian drug policy
  • The current challenge – using information technology to further improve antibiotic use

Press Release WHO/4112 June 2000


Curable diseases – from sore throats and ear infections to TB and malaria --are in danger of becoming incurable

A new report warns that increasing drug resistance could rob the world of its opportunity to cure illnesses and stop epidemics.


bacterial evolution vs mankind s ingenuity
Bacterial evolution vs mankind’s ingenuity
  • Adult humans contains 1014 cells, only 10% are human – the rest are bacteria
  • Antibiotic use promotes Darwinian selection of resistant bacterial species
  • Bacteria have efficient mechanisms of genetic transfer – this spreads resistance
  • Bacteria double every 20 minutes, humans every 30 years
  • Development of new antibiotics has slowed – resistant microorganisms are increasing
surveillance of resistance australia
Surveillance of resistance: Australia

Data are collected from 29 laboratories around Australia, including public hospital and private laboratories, in both metropolitan and country areas.

Australia, like China, is a contributor to the WHO A-R Infobank:

resistance australia 2000
Resistance: Australia 2000
  • Hospitals
    • vancomycin-resistant enterococci (VRE’s)
    • multi-resistant Staph. aureus (MRSA) NB. vancomycin-resistant strains have been found in Japan and the USA but not yet in Australia
  • Community
    • Strep. Pneumoniae (Penicillins 15% I, 2% R; macrolides & tetracyclines 20% R)
    • Haemophilis influenzae (Penicillins 20% R ; macrolides & tetracyclines 10% R)
    • E. coli (amoxycillin 45% R ; amoxy-clav 10% R ; trimeth 15%R)
resistance the world 2000
Resistance: The World 2000
  • In much of South-East Asia, resistance to penicillin has been reported in up to 98% of gonorrhoea strains.
  • In Estonia, Latvia, and parts of Russia and China, over 10% of tuberculosis (TB) patients have strains resistant to the two most effective anti-TB drugs.
  • Thailand has completely lost the use three of the most common anti-malaria drugs because of resistance.
  • A small but growing number of patients are already showing primary resistance to AZT and other new therapies for HIV-infected persons.
the consequences of antibiotic resistance
The consequences of antibiotic resistance
  • Increased morbidity & mortality
    • “best-guess” therapy may fail with the patient’s condition deteriorating before susceptibility results are available
    • no antibiotics left to treat certain infections
  • Greater health care costs
    • more investigations
    • more expensive, toxic antimicrobials required
    • expensive barrier nursing, isolation, procedures, etc.
  • Therapy priced out of the reach of some third-world countries
therapy priced out of the reach of the poor
Therapy priced out of the reach of the poor
  • A decade ago in New Delhi, India, typhoid could be cured by three inexpensive drugs. Now, these drugs are largely ineffective in the battle against this life-threatening disease.
  • Likewise, ten years ago, a shigella dysentery epidemic could easily be controlled with cotrimoxazole – a drug cheaply available in generic form. Today, nearly all shigella are non-responsive to the drug.
  • The cost of treating one person with multidrug-resistant TB is a hundred times greater than the cost of treating non-resistant cases. New York City needed to spend nearly US$1 billion to control an outbreak of multi-drug resistant TB in the early 1990s; a cost beyond the reach of most of the world's cities.
social factors fuelling resistance
Socialfactors fuelling resistance
  • Poverty encourages the development of resistance through under use of drugs
    • Patients unable to afford the full course of the medicines
    • Sub-standard & counterfeit drugs lack potency
  • In wealthy countries, resistance is emerging for the opposite reason – the overuse of drugs.
    • Unnecessary demands for drugs by patients are often eagerly met by health services and stimulated by pharmaceutical promotion
    • Overuse of antimicrobials in food production is also contributing to increased drug resistance. Currently, 50% of all antibiotic production is used in animal husbandry and aquiculture
  • Globalization, increased travel and trade ensure that resistant strains quickly travel elsewhere. So does excessive promotion.
postponing the end of the antibiotic era
Postponing the end of the antibiotic era
  • Antibiotic stewardship (prudent use)
  • Contain the spread of resistant micro-organisms and relevant genes (infection control)
  • Develop new antibiotics that have novel modes of action or circumvent bacterial mechanisms of resistance (research)
what are antibiotic guidelines
What are Antibiotic Guidelines?
  • Best practice recommendations concerning the treatment of choice for common clinical problems
  • Written by national experts
  • Evidence based where possible, peer-consensus where not
  • Regularly updated every 2 years
  • Endorsed by the Australian Medical Association, etc.
  • Used for medical education, problem look-up and drug audit
d rug audit and change strategies


Implementchange strategies

Developconsensus approach

Drug audit, and change strategies

Compare drug use with Guidelines recommendations

first australian drug audits 1978 82
First Australian drug audits:1978-82
  • The 700 bed Royal Melbourne Hospital was surveyed. The 240 bed sample comprised:
    • 3 general medical units
    • gastroenterology unit
    • haematology-oncology unit
    • 4 general surgical units
    • orthopaedic unit
inappropriate prescribing
Inappropriate prescribing
  • Example of a drug not required:
    • A patient with suspected infected burns received oral flucloxacillin and penicillin V. Therapy was continued for 23 days despite thefailure of 3 separate swabs to produce any growth on culture. Culture of the fourth swab grew methicillin-resistant Staphylococcus aureus.
inappropriate prescribing19
Inappropriate prescribing

Example of incorrect administration:

Surgical antibiotic prophylaxis accounted for 100 prescriptions and, of these, 23 were given 2 to 12 hours AFTER the operation, a delay that largely nullified their value.

Example of inadequate cover:

A patient received gentamicin for peritonitis, thereby ignoring the anaerobic flora of the bowel. Metronidazole or clindamycin should have been added

change strategies used
Change strategies used
  • Feedback of audit results to prescribers followed by discussion at grand rounds and unit meetings
  • Use of Antibiotic Guidelines in undergraduate and postgraduate teaching
  • Rewriting the next edition of Antibiotic Guidelines, incorporating additional text to clarify misunderstandings and problems observed
initial conclusions
Initial conclusions
  • Antibiotic prescribing improved
  • Surgeons (prophylaxis) were responsible for more inappropriate prescribing than physicians
  • Some persisting patterns of inappropriate antibiotic use appeared to reflect pharmaceutical company promotion
  • There was also a need for ongoing campaigns because hospital staff changed
dr harvey s visit to china was sponsored by
Dr. Harvey’s visit to China was sponsored by

The World Health Organization

and hosted by Professor Yong-Hong Yang

Beijing Children’s Hospital

& Professor Li Dakui

Peking Union Medical College