National Antibiotic Guideline for Common Infectious Diseases in Bangladesh

Dr. S.M. Masuduzzaman

Assistant Professor ( Respiratory Medicine)

Kushtia Medical College Hospital

Disclaimer

Fever is not an indication of ��Ceftriaxone deficiency

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National AMR surveillance in

Bangladesh

Introduction

Antibiotic Resistance is a growing global public health threat that is imposing serious effects on management of the infectious diseases. The World Health Organization (WHO) and other international bodies identified antibiotic resistance as the biggest emerging threat for the globe, another pandemic.

Introduction

The causative microbes of common infectious diseases of Bangladesh are resistant to antibiotics, which include acute respiratory infection (ARI), gastrointestinal infection, tuberculosis (TB), urinary tract infections (UTI), neonatal infections (sepsis), ear infections (otitis media), typhoid fever, and skin & soft tissue infections (SSTIs). Due to lack of standard culture facility, diagnosis and treatment of common infections are mostly empirical.

Goal

To prevent inappropriate use of antibiotic.

The objectives

1. To recommend treatment for common infections requiring antibiotic therapy.
2. To promote “AWaRe” classification and approach at all level before prescribing an antibiotic.
3. To promote rational use of antibiotics.
4. To serve as a tool of antimicrobial stewardship in the hospital.

Principles of Antibiotic Therapy and Rational Antibiotic Prescribing

The rational use of medicines has been defined by the WHO as requiring that patients receive medications appropriate to their clinical needs, in doses that meet their own requirements, for an adequate time, and at the lowest cost to them and their community.

Principles of Antibiotic Therapy and Rational Antibiotic Prescribing

A thorough clinical assessment of the patient is imperative to ascertain the underlying reason. Where appropriate and clinically indicated, the initial assessment should be supported by relevant laboratory investigations (blood, urine, sputum, wound swab) to establish a definitive microbiological diagnosis and to determine the susceptibility of the organism to various antibiotics.

Principles of Antibiotic Therapy and Rational Antibiotic Prescribing

The routine use of antibiotics to treat fever (less than 5 days) is inappropriate, as not all fever is caused by infections and antibiotics are only indicated for bacterial infections. Antibiotics should not be prescribed when bacterial infections are unlikely, such as for common cold, coughs and bronchiolitis and others.

Steps of rational antibiotic use

Step 1 : Clinical Diagnosis

A clinical diagnosis most often helps us to predict causative pathogens fitting into a clinical syndrome which would tailor the correct antibiotic rather than blindly relying on fever.

Our though process here should be-

1. Is it an infection?
2. What are the possible non-infectious mimics?
3. Have we taken the appropriate cultures to confirm the diagnosis?

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Steps of rational antibiotic use

Step 2 : Limiting empiric antibiotic therapy

Generally, empiric antibiotic therapy is recommended for a selected group of patients as described below after taking appropriate cultures.

• Febrile neutropenia
• Severe sepsis and septic shock
• Community acquired pneumonia
• Ventilator associated pneumonia
• Aspiration and suppurative pneumonia
• Enteric fever
• Bacterial meningitis

Steps of rational antibiotic use

Step 3 : Choose the appropriate antibiotic

Approach includes

• Based on possible resistant patterns and the spectrum of the antibiotic.

• Use the correct dose, route and duration.

• Ensure chosen antibiotic has adequate tissue penetration at the site of infection.

• Optimize pharmacokinetics/pharmacodynamics parameters according to co-morbidities.

Steps of rational antibiotic use

Step 4 : De-escalation/Modification

Modify empiric broad spectrum antibiotics depending on culture and antibiotic susceptibility result and patient status. Approach includes:

▪ the empiric antibiotic(s) that were started are stopped

▪ or reduced in number (e.g. combination therapy to a single agent)

▪ and/or narrowed in spectrum (broad spectrum to narrow spectrum)

▪ switching to new agent based on susceptibility result

Steps of rational antibiotic use

• Stop polymyxins and glycopeptides if no carbapenem resistant organisms (CRO) or methicillin resistant Staphylococcus aureus (MRSA) identified on cultures.

• Avoid double or redundant Gram-negative or Gram-positive or anaerobic coverage.

Steps of rational antibiotic use

• Discontinue antibiotics if a non-infectious mimic identified.

• Change IV to oral antibiotics.

• De-escalation is safe in all patients including febrile neutropenia and septic shock and reduces mortality and length of hospital stay.

Steps of rational antibiotic use

Step 5 : No antibiotics in the following clinical situations-

▪ Viral pharyngitis

▪ Viral rhinosinusitis

▪ Non-infectious cardio-pulmonary syndromes misdiagnosed as pneumonia

• Asymptomatic bacteriuria and pyuria including in catheterized patients.

• Microbial colonization and culture contamination (Check culture report for colony count and others).

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classification of Antibiotics

AWaRe

AWaRe

The 2019 WHO AWaRe Classification Database was developed on 1st October 2019 according to the recommendation of the WHO Expert Committee on Selection and Use of Essential Medicines. It includes details of 180 antibiotics classified as Access (A), Watch (Wa) or Reserve (Re), their pharmacological classes, Anatomical Therapeutic Chemical (ATC) codes and WHO Essential Medicines List status.

AWaRe

Access group antibiotics:

This group includes antibiotics that have activity against a wide range of commonly encountered susceptible pathogens while also showing lower resistance potential than antibiotics in the other groups. These antibiotics are first line for treating an infectious cause of disease in appropriate clinical setting.

AWaRe

AWaRe

AWaRe

AWaRe

Watch group antibiotics:

This group includes antibiotic classes that have higher resistance potential and includes most of the highest priority agents among the Critically Important Antimicrobials for Human Medicine and/or antibiotics that are at relatively high risk of selection of bacterial resistance. These medicines should be prioritized as key targets of stewardship programs and monitoring.

AWaRe

AWaRe

AWaRe

AWaRe

Reserve group of antibiotics:

This group includes antibiotics and antibiotic classes that should be reserved for treatment of confirmed or suspected infections due to multi-drug-resistant organisms. Reserve group antibiotics should be treated as “last resort” options. These medicines could be protected and prioritized as key targets of national and international stewardship programs involving monitoring and utilization reporting, to preserve their effectiveness.

AWaRe

Antibiotic Prescribing with Misconceptions

1. Newer drugs are always better.

There is a limited knowledge of new antibiotic at the time of marketing and therefore, caution should be exercised while prescribing a new antibiotic. The exact therapeutic status and adverse effect profile of a new drug are evident only after several years of its use in population.

Antibiotic Prescribing with Misconceptions

2. Expensive drugs are better than cheap drugs.

This is also not true. Uncomplicated UTI responds very well to Cotrimoxazole, Norfloxacin, Ciprofloxacin, Ofloxacin, Cephalexin and Nitrofurantoin while third generation Cephalosporins and newer aminoglycoside antibiotics should be reserved for complicated UTI. Expensive higher class of antibiotics offer no advantage over cheap Cefazolin in prophylaxis of surgical site infection.

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Antibiotic Prescribing with Misconceptions

3. Polypharmacy is always better

More the numbers of drugs in prescription, better will be the therapeutic effect is a wrong notion. Empirical polypharmacy is only indicated in polymicrobial infections (like intra-abdominal abscess, lung abscess) and in life threatening infections (like meningitis, septicemia etc.).

Antibiotic Prescribing with Misconceptions

4. Fixed dose drug combinations (FDCs) are always better

Though the market is flooded with too many FDCs, but only few drugs have scientific justification for combining the ingredients. Antibacterial FDCs are enlisted in National and WHO Essential Medicine List like Sulfamethoxazole-Trimethoprim, Amoxicillin – clavulanic acid, Piperacillin – Tazobactam and Ceftazidime – Avibactam.

Unjustified Polypharmacy (such as Cefuroxime and Clavulanic acid) and use of irrational FDCs lead to increased cost of therapy, increased risk of Adverse Drug Reactions.

Antimicrobial Stewardship

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Clinical scenarios

Acute fever

In case of children less than 5 years sign and symptoms should be checked cautiously and according to IMCI management should be done. Patients more than 5 years of age with acute fever should be treated with Paracetamol for Day 1-3. At the same time investigations (CBC with ESR, Urine RME, CXR P/A view, Blood C/S, tests for Dengue/ Malaria if needed) related with the clinical features should be done on Day 4-5.

Acute fever

Empirical antibiotics can be prescribed on Day 6-7 with further investigations and modify the antibiotics according to the culture sensitivity report when available.

Respiratory tract �infection: CAP

Respiratory �tract infection: HAP

Respiratory tract infection: �Aspiration pneumonia

Bacterial meningitis

Brain abcess, subdural empyema

Acute and subacute endocarditis

Infectious gastroenteritis

Typhoid fever

UTI

Acute otitis media

Chronic Otitis media

Pharyngitis/Tonsilitis

Acute bacterial �rhinosinusitis

Acute conjunctivitis

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Antibiotic prophylaxis in surgery

Boil and abcess of skin and soft tissue

Acute appendicitis

Breast abcess

Acute cholecystitis

Epidi-dymo orchitis

Soft tissue infection/cellulitis

Open trauma/fracture

Osteomyelitis

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Obstetric and Gynecological

Bacterial vaginosis

Genital Chlamydia

Cesarian section

Wound infection

Intrapartum pyrexia and

Septic abortion

Pelvic inflammatory

disease

Mastitis �(Post partum)

Puerperal pyrexia

and sepsis

Urinary tract infection

in pregnancy

Chorioamnionitis

Premature rupture

of membrane

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Infections in Pediatrics

Acute post streptococcal

glomerulonephritis

Bacterial meningitis

Infective endocarditis

Neonatal sepsis

Neonatal sepsis

Pneumonia

Enteric fever

Infectious gastroenteritis

Acute cystitis

Acute pyelonephritis

Skin infection/cellulitis

Rheumatic fever

Antibiotics in pregnancy and lactation

Antibiotics in pregnancy and lactation

Antibiotics in pregnancy and lactation