3/1/2016. Antibiotics --When Less is More. Most Urgent Threats. Serious Threats

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1 Antibiotics --When Less is More Ralph Gonzales, MD, MSPH Associate Dean, Clinical Innovation School of Medicine VP, Clinical Innovation, UCSF Health Most Urgent Threats Serious Threats Multidrug-Resistant Acinetobacter Drug-Resistant Campylobacter Fluconazole-Resistant Candida Extended Spectrum Enterobacteriaceae (ESBL) Vancomycin-Resistant Enterococcus (VRE) Multidrug Resistant Pseudomonas Drug-Resistant Salmonella (nontyphoidal and tyhphi) Drug-Resistant Shigella Methicillin-Resistant Staphylococcus Aureus (MRSA) Drug-Resistant Streptococcus Pneumoniae Drug-Resistant Tuberculosis In 11: 500,000 cases per year; 29,000 deaths -Lessa et al. NEJM 15;372:

2 From: National Burden of Invasive Methicillin-Resistant Staphylococcus aureus Infections, United States, 11 JAMA Intern Med. 13;173(21): doi: /jamainternmed Antibiotic Use Development of New Resistant Clones Transmission of Existing Resistant Clones In 11: 80,000 cases per year; 11,000 deaths -Dantes et al. JAMA Internal Medicine 13;173: Antimicrobial Resistance Date of download: 2/28/16 Copyright 16 American Medical Association. All rights reserved. GOALS 1. Slow the Emergence of Resistant Bacteria and Prevent the Spread of Resistant Infections 2. Strengthen National One-Health Surveillance Efforts to Combat Resistance Objectives 3. Advance Development and Use of Rapid and Innovative Diagnostic Tests for Identification of Resistant Bacteria 4. Accelerate Research to Develop New Antibiotics, Other Therapeutics, Vaccines and Diagnostics 5. Improve International Collaboration and Capacities... Common Adverse Effects of Antibiotics Allergic Reactions Nausea/Cramps/Diarrhea Yeast Infections 6/27 (Abx+) vs. 0/27 (control) About -25% risk J Am Board Fam Med. 08 Jul-Aug;21(4): /235 (23%) women developed post-antibiotic vulvovaginitis. BMJ. 04 Sep 4;329(7465):548. Unnecessary costs 7 2

3 Less Common Adverse Effects of Antibiotics Azithromycin and CVD Mortality --Patients with high cardiovascular risk Fluoroquinolones Tendon Rupture: 3x Risk The 90-day risk of Achilles tendon ruptures among FQ users was 17.7/100,000 (95%CI: ) vs. 5.7/100,000 baseline. Eur J Clin Pharmacol. 07 May;63(5): Retinal Detachment Increase risk = 4 per 10,000 person-years NNH = 2500 any FQ users Ray et al. N Engl J Med. 12;366: What s the Right Amount of Antibiotic Use? 11 3

4 Where to Focus Efforts?... URIs Condition Visits Rx Rate Bact. Prev Abx Excess Otitis Media 13 x % 65% 1.1 million Sinusitis 11 x % 40% 3.5 million Pharyngitis 14 x % 25% 5.2 million Bronchitis 13 x % 10% 6.5 million URI/cold 25 x % 5% 6.2 million TOTAL 76 x % 25% 22.5 million Data source: NAMCS, 1998; Clin Infect Dis, Why Do Physicians Prescribe Antibiotics for URIs? Treatment Expectations for URIs in an Urgent Care Clinic Patient Factors Green = Bacterial Cover All Bases Worked the Last Time Stress Decision to Prescribe Abx Physician Factors Green = Bacterial Dx Uncertainty Liability Cover All Bases Patient/Parent Expectations System Factors Co-Payments Visit Duration Advice Access 4

5 Relationship between patient desire for antibiotics and antibiotic prescription rate Evidence-Based Management of URIs Antibiotic prescription rate P=0.01 Low, Not Sure Moderate Strong Patient Desire for Antibiotics 18 What patients and health care providers can do reduce risk of infection with or spread of resistant bacteria 1995 Limit antibiotic use to conditions that definitely need them Practice good hygiene Minimize hand-mouth-eye contact Wash hands regularly Reduce stress Sleep, eat right, exercise 5

6 Penicillin-Resistant S. pneumoniae United States From: Antibiotic Prescription Rates for Acute Respiratory Tract Infections in US Ambulatory Settings JAMA. 09;302(7): doi: /jama High level resistance Intermediate Resistance 30 % Nonsusceptible : CDC Active Bacterial Core Surveillance (ABCS) System Emerging Infections Program : CDC Sentinel Surveillance Network Program to Improve Quality & Safety of Healthcare in Egypt NAMRU-3 Date of download: 2/29/16 Copyright 16 American Medical Association. All rights reserved. Penicillin-Resistant S. pneumoniae United States High level resistance Intermediate Resistance 30 % Nonsusceptible : CDC Active Bacterial Core Surveillance (ABCS) System Emerging Infections Program : CDC Sentinel Surveillance Network Program to Improve Quality & Safety of Healthcare in Egypt NAMRU-3 Presentation 24 Title and/or Sub Brand Name Here 6

7 Abx Resistance Reversal is Possible! European Surveillance of Antimicrobial Utilization -Goosens et al. Lancet 05;365: Table: Time Trend in S. pneumoniae resistance following single mass Azithromycin treatment in Ethiopia for trachoma prevention Haug S et al. Clin Infect Dis. 10;51: by the Infectious Diseases Society of America Correlation Between Antibiotic Utilization and Antibiotic Resistance in Community Bacteria 7