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Antibiotics: Kab? Kyon? Kaha?

Nov 29 | 3:30 PM

Antibiotics are one of medicine's greatest achievements. Unfortunately, overprescribing antibiotics has resulted in bacteria that are resistant to them. Overuse of antibiotics contributes to the rise of antimicrobial resistance (AMR). Despite national, and international efforts to address the issue, reducing misuse is challenging. Antibiotic prescribing in hospitals continues to rise year after year. Join us as Dr. Mahadev Desai outlines how, when, and where antibiotics should be prescribed.

[Music] good evening everyone and welcome to netflix i'm dr niveda and on behalf of team netflix i welcome you all uh for this session today uh you all know him already we have dr madev desai he's a senior consultant physician from amsterdam and before we start the presentation we have a quick round of quiz to get the ball rolling a very easy question just to set the whole atmosphere about the topic so here goes the first question [Music] so you all can click on the options and then submit to what and then we'll uh have the result [Music] okay so the question was how many cells do we have in our body and uh 44 went to 100 trillion um we'll go to the second uh poll before we give out the answers uh so this is the second one so the question is how many microbes do we have in our body five trillion ten trillion a hundred trillion or a thousand trillion [Music] [Music] [Music] okay so we have uh 33 percent close to 10 trillion uh microbes in the body uh so do you want to give out the right answer no we'll be talking in the biscuit itself there's a flight for the same answer yeah okay fine so uh before without taking any more time from the talk i'll start the presentation and it's all your stuff good morning and welcome everyone i am happy to see such a large number of audience today and the topic which is very close to my heart and very important one that is use of antibiotics when how and where or cure i let me disclose that i have no in conflict of interest except that i want everyone to describe antibiotics judiciously and if we take after the session if you decide at least not to prescribe one or two antibiotics which is not required for one year i am sure it is going to be about 15 20 000 prescriptions will not be writing so that's my conflict of interest uh recently only the who has celebrated or the week that was called world antimicrobial awareness week that was between 18 and 24 novembers and the theme of this year was spread awareness stop resistance spread awareness stop resistance for and all antimicrobials which includes antibiotics antivirals antifungals and antiparasitic for the constraint of time we'll be discussing only about antibiotics but we have to spread awareness for the resistance to all antimicrobials and as rightly wh has given another banner that if we can use the medicine correctly then we'll preserve its effectiveness for a long time so with this background we move on to the topic but i'll take you to a journey before 95 years one gentleman who is seen in this picture looking at his patriotis he had been to he was a scottish microbiologist or bacteriologist at the time called and in 1928 he had been to a vacation with his family and when he came back what he saw in his laboratory surprise he saw that amongst the many petri disease which has staphylococcal organisms for which he was working right he saw that one of the patriots there was a mould white mole and surrounding the mole the staphylococcus were destroyed so he thought that there is something sub-substance in this mold which has killed this bacteria he kept on working on it he kept on working on it he also required many assistance and it took 10 years to identify what that organism or the drug was and he gave the name penicillin so penicillin was discovered by sir alexander fleming he was awarded with the sir and he was the hero of the second world war because it saved many lives in the second world war second world war there are so many casualties there are so many accidents and sepsis but because of the penicillin so many lives were saved and we thought that we have conquered the world of bacteria or one of the enemies at the time and we thought that we are going to live happily ever but that was not the case to be plus just in four years of the commercial production of the penicillin large scale the resistance to penicillin was reported in 1947. so that's exactly what the story of antibiotics use abuse overuse and the question that i posed was how many cells do we have in our body and how many microbes do we have in our body we are living with 10 trillion cells while the microbes are 100 trillions so it's really very very important to know and to decide whether we live in the microbes or microbes live in our body because it's the microbes and not microbes rule the world and we don't have to choose to chase or choose every microbe or kill every microbe because microbes are very very important and in fact now we use the human microbiota for many other diseases and conditions including the obesity cancers immunology the biggest threat to our existence is anti-microbial drug resistance and that is why whs is focusing on this time and again why do we have antimicrobial drug resistance the reason is we have been using it over using it abusing it misusing it's not that we are the only one who are using antibiotics antibiotics are used widespread in so many other fields other than the human or patients right they are used in agriculture to get better ill they are using poultry to get better quality of eggs they are also using cosmetics and even detergents and that is led to the emergence of antimicrobial resistance you can see in the picture if you just expand it that the fish marks is available and as a result the our antibiotic pipeline is dry we do not have many antibiotics to take care of and whatever antibiotics we have we have kept on seeing the resistance time in a day if you go by the drug approval class for the antibiotics for the two main organisms class of organisms the methicillin resistant staff aureus and gram-negative infections will be surprised to know that in last 25 years only five antibiotics have been approved for mrsa first was in quinopristine alpha pristine in 1999 then came linazolid in 2002. quinopristine is still not available here daptomycin tgacycline and television of which daptomycin integer cycling are available in india so these are the only five class of drugs which are available to us for last 25 years then gram negative infections only two of us two or two of these compounds we know once before 35 years and kaabapanims for 20 years even imipenemeropenem also is there for last 20 years we do not have any another drug whatever drug we use like polymixins or cholesterol for the resist organisms are pretty old they are not the newly approved drugs you'll be surprised to know the drug class which was approved in 2011 was called feduxomycin and this antibiotic was approved for antibiotic associated diarrhea so it's not for any other organisms but the organisms which have caused diarrhea to kill that organisms so it's an antibiotic so the area for which the fedoxomycin is approved yes there was one drug again which before fires which came which was discovered and that was called taxobactin which was discovered in january 2016. it's a very novel way of producing the antibiotic in soil and its foreground positive organisms as they had come to india but a very promising drug and the method of finding out the drug so with this information's background i'll just going to quickly about some of the myths of antibiotics how do we classify antibiotics and what do we do before prescribing antibiotic do we take a stock or have some checklist then what is the pharmacokinetics and pharmacodynamics antibiotics do we really need antibiotic combinations and all the antibiotics that are available are good enough to be used rationally and what happens if we misuse or abuse antibiotics so first is there is a myth not only amongst the patients and general public but also amongst medical fraternity there is there is a drug for every bug or there is a pill for every ill or broad spectrum antibiotic can take or of any infections we don't need to diagnose an infection if there is an infection given in broad spectrum antibiotic will take care of infection which is not true and more than that the another myth that antibiotics are safe we know so many side effects of antibiotics we'll be dealing with some of them antibiotics are not safe what is the fact about antibiotics is that antibiotics are not antibiotics right they are not cure all drugs antibiotics will work only if abscess is drained we know that whenever there is a foreign body or abscess and if you don't take care of that your antibiotics are not going to work so we need to keep these basic principles that we are taught in the first clinical term of medicine or surgery that you have to drain the absence you have to remove the foreign body then and then the antibiotics are going to work and i love this uh slogan that fever is not a sign of safe drugs and deficiency and if you are and give urgency cephalosporins and is going to take care of it that's not going to happen we all know it but do we practice it now coming to the practical questions of should patient be prescribed antibiotics does for these conditions say gastroenteritis common cold influenza like illness asymptomatic urinate infections a catheterized patient or before any diagnostic procedures if these are the five conditions that which with the patient come to us should we be prescribing antibiotics for this the answer could be yes or no let's see acute gastrin that is no because most of the acute gastroenteritis are viral or food borne infections for food poisoning where antibiotics are required not common cold again is not required asymptomatic uretech infection yes if a patient happens to be a pregnant woman or if there is diabetes we can still prescribe a justified prescribing antibiotics a catheterized patient generally because he has catheter doesn't require an antibiotic and before and diagnostic procedures yeah there are indications for surgical profile access before a procedure or an operation that will be same what i like the most is this statement by dr neil fishman a very categorically and correctly said that patients demand antibiotics roll everywhere patients demand antibiotics our patients come to us with this as information language amoxicillin lilia so it requires a minute to write a prescription but it takes 15 to 20 minutes not to write a prescription so most of the people would be reluctant to give otherwise but for want of time or just because they can't convince the patient they will be prescribing reflexively that shouldn't happen now coming to classification of antibiotics we don't intend to go in detail of it but we need to know something so that we know when we prescribe a particular antibiotic what is the rationale behind it so most of the antibiotics are classified because of the their site of action or mechanism of actions or their molecular structures or their spectrum activity whether they work mainly against the gram positive or gram-negative organisms or they work on aerobics or anaerobics based on this usually we have antibiotics which are based on the mechanism of actions we know that all bacteria have a cell wall a cell membrane and nucleus and many proteins within the cytoplasm to take care of the bacterial activity synthetic activity of the bacteria because bacteria have to survive and do out there work so the antibiotics which work on the inhibition of the cell wall synthesis these are because they destroy the beta electron ring they are called beta electron antibiotics we have penicillins cephalosporins carbonyms and monobacterms are the working on the cell wall synthesis then drugs also work on the cell membrane like the polymixin it is one of the most powerful weapon we have now because it destroys the cell membrane and bring out all the lipids from this bacteria and kill bacteria till that luckily there is hardly any resistance of the polymixins or cholesterol then bacteria many antibiotics work on the metabolism of the drugs that is either folic acid synthesis or nucleic acid synthesis our drugs like quinolones a reformpicine or sulphur trimethoprim work here and many antibiotics work on the protein subunits within the bacterial cytoplasm the drugs like macrolides clindamycin they all work on the protein synthesis within the bacteria once protein synthesis is abolished they bacteria no longer survive so there is no point in combining drugs with the same mechanism of action that is another point we have to keep in mind so based on this we have got this many class of antibiotics the antibiotics which have got a molecular structure of beta lactamark or bl or beta electrons then because the bacteria have to survive they have developed the inhibitor to the beta lactamase beta electron antibiotics that we used to give so that is called beta lactamase inhibitors the antibiotics which have got the property of beta electromagnetic inhibitor right i have made the beta electron work again then there are macro lights amino glycosides winolones oxazolidiums the tetracycline sulfonamides and there are some antibiotics which cannot be classified depending on their molecular structure or mechanics action they are put in a michelin screw so based on this we have got these number of antibiotics whether it is penicillin cephalosporins and clevelandic acid as a victim requires special mention because they are one of our important weapon for the beta electrum antibiotics combinations right because most of the organism have got the beta-lactam ring so macrolides then aminoglycoside we know and the miscellaneous groups are clindamycin polymixin nitrazoles or chlorophenic so we have got all these antibiotics in our armamentarium now let's see how do we use it before prescribing antibiotics we have to have some kind of our own checklist we have to think of three aspects of prescribed antibiotic the drug that we are going to is how to select a drug the bug that we are going to attend or attack we have to know and the host our patient where are which are the factors in the patient that will take us to select a particular drug so let's take one by one these factors before prescribing antibiotic we should prescribe antibiotic very judiciously and very consciously it should never be a reflex prescriptions right so when it comes to the drug we know that antibiotics can be bacterostatic or bacterocidal the bacterocidal antibiotics are not required in each and every patient who are immunocompetent and who are otherwise fine or the infection is mild when it comes to therapeutic or prophylactic use it's a very very important difference between the two remember when we use for a prophylactic purpose then we have to know that what kind of infection we want to prevent and what antibiotics will be giving for that purpose and how long will be given say for example as we have put one of the questions should an antibiotic be prescribed before any procedure yes usually the antibiotics are prescribed for the prophylaxis before any surgery the very rational is that the skin or the whatever part we are going to increase right is usually colonized with many of the pathogens it could be staph aureus it could be coagulas negative like staphylococcus hemolytics or it will be enterococci so these are the most common organisms which lead to the infections because of the entry of these organisms into the wood so what we need why we need antibiotic is to have the maximum antibiotic concentration at the time of putting the incision that is the very residual of giving a surgical prophylaxis and this has been recommended by most of the organizers since like the infection society of america and many other organizations that please give the antibiotics like cephazolin which has been the most important but there will be many instances where the group one that is the cephazolins have been resistant so we do require cepheroxin so either cephazoline or cephuloxime can be used or if you find that the organisms may be in a particular situation then you can use clindamycin ampersand sulfectum or vancomycin what is important is that this antibiotics should be given 30 to 60 minutes before the incisions so it may so happen and what we see that the sisters are given the instructions that give antibiotics so antibiotics are given before one or two hours and then the patient is sent to operation theater that's not the way the antibiotics should have been given when we give it as surgical profile axis antibiotics should be given if we give iv 30 to 60 minutes before the incisions when we use ancomycin we have to give an infusion form over one hour so maybe that is the only instance where we give it before start before two hours the infusion started for two hours but all other drug should be given 30 to 60 minutes before the incisions and when we use the word prophylactic antibiotic it should be not more than 24 hours the only exception is the bypass surgery generally the only one rose is given but if the surgery is going beyond 6-8 hours you may give the second rose but never ever the profile axis is beyond 24 hours this is many times the prescription of patients are prescribed antibiotics they should take well before the surgery that's not prophylactic antibiotic that's a therapeutic antibiotics therapeutic antibiotics are required only and only when there is an infections to prevent an infection you can't start antibiotics like that before the surgery or you should not continue to prevent infection after the 24 hours the next parameter that we need to look for at the organisms the organism which is the likely organism for the infection that we face in our patient could it be gram positive could be gram negative could be arab could be an europe are we dealing with one organisms or poly microbial infections you know there are certain infections are polymerable whether it is intra-abdominal infections septicemia whether it is diabetic foot infections whether it is aspiration pneumonia they are likely to be only microbial so our choice of antibiotics at that stage has to be covering the broad spectrum then antibiotics the infection can be local or systemic and mind you when we i'd isolate or identify certain bacteria it could be a chance colonizations or infections so that also we have to keep in mind that are we dealing with colonizations or infections so starting with one whether it's a gram positive infections gram negative infections or anaerobic infections suppose the gram positive infections are like upper aspect infections or skin soft disinfections or gram negative infections like retract infections or typhoid fever or anaerobic infections like the aspiration pneumonia or in injured close injury right so depending on what organisms are likely we have to select an antibody for gram-positive infections the best antibiotics are the penicillins the cephalosporins the first and second generations the macrolides tetracyclines newer pineal ones line solid and vancomycin though line isolated and vancomycin have excellent gram positive coverage they should be reserved for the specific infections like mrsa or mainly mrs that is methyl resistance therefore yes line isolate and vancomycin are no better or greater than the other class of the antibiotics in the same group for the sensitive organisms right so please do not waste this important drugs which we have very few drugs for the mrsa as we have said rightly uh before few minutes that for mrsa we have got very few drugs amongst them the oral one is only one that is the line isolate it should be reserved and also the lyle is not a safe drug that we'll see later from gram negative infections we have got amino glycosides which are obviously injectable ones quinolones injectable as well as oral extended spectrum penicillin like the ticarcelines or carbonyl cylinders then third second third fourth generations like cephalosporins then carbopendines again very good argumentation for the gram negative infections like imipenems and neuropenems and chloramphenicol a good drug but still is required for some of the situations right so for this for anaerobic infections we have got metanasan clindamycin carbophenylmine chloramphenicol i also have gram-negative or anaerobic covalent so when it comes to the attending the anaerobic infections if the patient is already receiving carbon m you need not add any of the other drugs or anaerobic coverage that's very important to remember and avoid unnecessary antibiotics so remember lindamycin karbapenums also have got anaerobic coverage materials we know right so the general rule that just make sure whether the infection is above or below the diaphragm generally it's not a sacral center it's not 100 but most of the infections above the diaphragm are the gram positive infections and below the diaphragm that is mainly the intra-abdominal and genitory or gram-negative infection so that your choice of antibiotics can dictate on that it doesn't mean that the pneumonia cannot occur with the gram-negative infections because there can be nosocomial infections hospital acquired infections but as a general rule if you just keep this in mind it may help you when it comes to antibiotic right we may think globally about all infections but we have to act locally what we mean by act locally is that what is the antibiotic sensitivity as well as the antibiotic resistance in our area our city our hospital our intensity carving for that we need to have a continuous dialogue with our colleagues with the microbiologist friends and we should know that wherever we are working with your the outpatient departments or the hospitals what is the trend for that particular time of that particular year it's a good idea to have that kind of dialogue so that we know which antibiotics are not working at a particular point of time again as i said there is no reason to treat a colonizer even though we know that colonizer can proceed to infections many times for that whenever we find any organisms from the samples if it is suppose a sample like urine or sputum or a wound swab it is expected to have some colonizations because they are not sterile site as against that if you find and organisms from the blood bronchiology or a biopsy material or mainstream urine you have got to keep that that respect that because it proline infections as against that the sputum showing this staphylococcal did not be the pathologic ones right we have got to see the other features like the clinical features whether the patient has signs and symptoms of inflammations like the fever or expectations or is wvc count is high or c reactive protein or esr is high and what is the overall status of the patients whether it's stable right so this is very very important and we have to make sure that we are not treating only colonizations except probably the colonizations like if there is a catheter invasive catheter maybe we have to attend at times those catheterize positive samples then another important the most important part of the patient antibiotic prescription is the host to whom we are going to give antibiotics we have got to spare few minutes to know the overall status of the patient whether the patient is immunocompromised or immunocompetent when we say mean a compromise that does not mean only hiv patients many of our patients who are having diabetes who are having steroids or who are receiving a cytotoxic drugs right because of their transplantations they are all immunocompromised there we have to choose a drug like electricity drugs and maybe we have to do it for a longer period then special situations when we prescribe it a drug to a pregnant woman or to a child or an elderly and we also have to keep in mind whether the patient has the renal insufficiency or liver impairment and we have got to have the habit of calculating the dosages according to the estimated gfr or creating clearance otherwise you may end up with an overall underground whether there is a history of recent antimicrobial exposure is very very important because we know that patients who have been the hospitals for one of the other reasons or received antibiotics they are one of the common reasons for the drug resistance if the patient has received cephalosporins while in the hospitals it is very likely that he end up with the mrs infections next time so knowing that whether the patient has received and there is no point in keep prescribing cephalosporins or amoxicillins in a patient who had recently been hospitalized and received some antibiotic for the same reasons and very very importantly we have to know the pharmacokinetics and pharmacodynamic properties of the antibiotics it's very very important not in detail but just one or two slides about this that we should know what is pharmacokinetics pharmacokinetics is when we solid pill or a drug what body does to the drug how the body handles the drug is called pharmacokinetics that means the absorption distribution metabolism and eliminations they are all part of pharmacokinetics while the pharmacodynamics are what the drug does to the body how the drug behaves how the drugs bind to the receptors how the drugs has posed receptor effects and what are the chemical interactions between two drugs these are called pde so pkpd parameters are very very important and when we choose a drug we should have at the back of our mind why we chose a particular drug right so choose an antibiotic with an according to the pkpd parameters now just a simple whenever you take any drug not necessarily antibiotic but here we stick to antibiotics when we take an antibiotic then there is going to be a maximum concentration of that antibiotic then the concentration gradually reduces depending on the disposal of the antibiotic right so there is something called minimum inhibitory concentration of a drug as far as an antibiotic is concerned so there are drugs which work in a different way as an antibody or as an antibacterial there are some drugs which work when they have maximum concentration of the antibiotics antibiotics the bacteria are killed so these are called concentration dependent antibiotics antibiotic which works best when they are in the maximum concentration are called concentration dependent antibiotics there are other antibiotics they work best when they are exposed for a longer period of time above their mic they are called time dependent antibiotics so when we prescribe antibiotics we should know whether we are prescribing a concentration dependent antibiotic or time dependent antibiotics and there are certain antibiotics which have got post antibiotic effects drugs like azithromycin even if you give for five days the effect lasts for another fight so that's also we have to keep in mind so depending on this we learn certain basics that if we prescribe a concentration dependent antibiotic obviously we give the one full dose in a day rather than giving the bad dosages when you give drugs like azithromycin levofloxacin and aminoglycoside we should be giving in a single full dose rather than giving the divided dosages because they are concentration dependent antibiotics right please please don't give azithromycin allele fluxes in vd or tds close that's not going to solve purpose in fact it's going to make the antibiotic useless in the time to come so concentration dependent antibiotic should be given an one large dose while time dependent antibiotics should be given spacing with spacing like bi tid or qds so that the antibiotic levels remain above mic for a longer period and that is how they will affect the killing of the bacteria so give amoxicillin cephalosporins or carbopenions in bid tid or qrd dosages and when we give intravenously instead of giving iv push between we give in 100 ml normal saline over a period of one or two hours to get the maximum effect of these drugs right so next time when we prescribe cephalosporins or carbopenions injectable ones make sure that we write in the order carbapenem or meropenem finite milligram in hundred cc over two hours eight hourly or bid depending on the requirement right very very important point to keep in mind another important on outdoor basis when we prescribe an antibiotics our patients consider antibiotics and for that matter all our allopathic drugs as villaith they feel that our medicines are going to give them lots of side effects they have to be taken with milk or food or other anti-seeds or something but this all these antibiotics that are mentioned here penicillin clock sacilin ampicillin this macrolides tetracycline quinolones they are best absorbed when they are taken on empty stomach remember they are best absorbed on empty stomach and of course this amphisil amoxicillin and quinolones can be also given with food because they do not affect much but by and large these antibiotics will be go on an empty stomach and make sure that you don't give it with antioxidants or iron because they definitely delay the absorptions so most antibiotic should be prescribed on empty stomach but there are certain antibiotics which should better be given with the food like methadone doxycycline nitropharyntoin and ittrachonus these are the four antibiotics which is better given with food materials in nitropharante mainly for its preventing the gi side effects while hydroconazole works better has a better absorption when it is taken with food so make sure that when you prescribe an antibiotic don't forget to mention whether it should be with food without food with antacids or with food then combinations of antibiotics we see market is flooded with so many combinations right do we really need combinations of antibiotics we do need it we don't say that antibiotic combinations are not here to stay or not required they are required but for seriously ill patients or there are poly micro infections as a diabetic food or buns or sepsis or perforated appendix or antique that's where we need antibiotic combinations and we need it for synergism conditions like tuberculosis we do combine four antibiotics together right and for immunocompromised patients or neutropenic patients definitely we need the antibiotic combinations and in fact when we need antibiotics in such a situation we should be giving as early as possible we said earlier you give better is the outcome with its pneumonia you have to give the first dose of antibiotic in the emergency room itself right for bacterial meningitis we just give it right immediately after the several sun fluid aspirations we should give the antibiotic right but do we need antibiotic combinations which are so many of them we have got of flux our center nozzle cephaloxime cleveland azathromycin ambroxol doxycycline serotonin peptidase then a2x all so many antibiotic combinations are available they are available only in india right we do we really need them we must not believe what we are forced to believe are our patients so unfortunately they have got the basilar decentry and amethyst entry on the same day do we really have to believe what they say that this is the best drug right we should see also at the pharmacokinetics and pharmacodynamic parameter of the combination of the drugs there are so many drugs which have a rational combinations but majority of irrational combinations right say for example the antibiotics like sulfur dioxide pyrimethamine trimethoprim definitely is good because they work sequentially on the metabolism of a bacteria so it's good ampicillin cloxacillin are good combinations because they have synergistic effect on the organisms amoxicillin travel in it and ambassadors albectum or fibril synthesizer vector as i said that the beta electrum and beta electromagnemeter's antibiotics definitely they are good combinations rational combinations and should be used when indicated absolutely no doubt about it but look at the antibiotic that we are bombarded with by the companies right the quinolone material result in nasal suffixem cleveland suffixin of fluxas in 200 milligrams of examine and 400 milligram of fluxaction a combinations or step or exam and and they will give their name like tower bow or maha and something and we are forced to believe that they are the better antibiotics not the case surely not the case line is only 600 milligrams safe exam 200 milligram we really wonder how these drugs get the approval from the regulators but they are there suffixing azithromycins all these irrational combinations if we stop prescribing even if they manufacture if you stop prescribing where are they going to they have to be drunk so make sure that next time when we prescribe a combinations we give a little thought do we real in these combinations do we really need these combinations and what to talk about adding the lactobacilli on serotonin peptides or hemorrhoxial and all better we don't talk about it many of these are added just to get out of the dpco that is the drug price controlling authority or others right when antibiotics are prescribed they have a certain ceiling for their organism and their class so to escape from that they add one drug and then they can charge whatever they want we should not be a prey to this kind of helix why the implications of mission abuse of antibiotics are far more than they just casually prescribe antibiotics we know so many antibiotics have so many drug drug interactions the drugs we feel they are safe like linus oriented or quinolones they are not safe they are combined with drugs like the theophyllines or the antistomatic life effects of innerdim or the older genus antihistaminics they are severe serious side effects like prolonged acute interval which can lead to sudden death so not that all antibiotics macrolides line usolids menolones are not safe right if they need a right patient it's okay but at least we see what other drugs are prescribed to their patients the advert reactions right from anaphylaxis to the liver and kidney damage so many of them we know in our pharmacology no point in but they also lead to the extended hospital state obviously more antibiotics more side effects or more cost but what is more important is the collateral damage as i said when you are talking of the history of antimicrobial exposure right in the patient in a recent past right if the patient has received central antibiotics it encourages certain kind of colonizations leading to infections and whenever cephalus current human large quantity it has led to the emergence of vancomycin resistance and probability or extend this extended spectrometer organisms right so these are the side effects or aftermath of the collateral damage and because of the shear overuse of quinolones we have mrs infections in planting and also we know that when we give antibiotics it leads to the super infections by the organisms like clostridium deficiency which we used to call the pseudomembranous colitis which used to be more common with certain antibiotics like clindamycin but we now know that it has organisms and it has a definite treatment for it we said that freedom reduxomycin is the latest antibiotics for antibiotic associate diarrhea what we do is vancomycin and metabolism for the crosstalk difficile infections and resistance most of the antibiotics are now facing the resistance of one or the other levels see it's common example of typhoid fever long back we used to give chloramphenicol and if the patient does not resolve the fever within 48 hours we would say that we have to revise the diagnosis the same thing came for quinoa and ciprofloxacin in 80s when they just came and now we see multi drug resistant typhoid fever where the klingons are not working right so resistance has become increasingly important but what is more important to me is that antibiotics are not like nsaids when you prescribe suppose an enzymes like dichlorophytic ibuprofen that patient has the damage maybe their families have damage but when you prescribe an antibiotic without reasons right it affects the society as a whole few patients recycling the antibiotics in the whole society has to face the multi-drug resistance in vaccine so it's a societal drug antibiotics are societal drugs and this should not be prescribed indiscriminately and we have to keep in mind that they are not the drugs for one and all see the example was in december 2009 there was one swedish resident who was from india and we went abroad he had gotten infections which was drug resistance and what they found out was horrifying what they found was a specific enzyme called ndm1 and the to our disrepute the name key one was new then leave metallo beta-lactamase because it was from a person who was residing in delhi at that point time so that was the enzyme they found out that it gives resistance to carbapenem class of antibiotics which were not having any resistance till that so carbapenemies was detected from those persons and this particular enzyme is carried away by the gene called vlad bla ndmg and this particular gene can transmit horizontal that means amongst other bacteria also so after the klebsiella that was first they found out that the commonly used or a bacteria which were otherwise common cells in our setups in icu's acinetobacter that also become resistance to this kind of drugs because of the widely prevalent ndm1 enzyme so this came and this has changed the whole scene so much so that now even one gastroenteritis can cost us one lakh rupees because no antibiotics are going to work on that patient even if it's a bacterial infections so how best we can use the antibiotics we have to minimize the use we have to differentiate between colonizer and infections we must talk to the microbiologist somehow the microbiologist and the microbial is not getting the due respect we must talk to the microsis what we are suspecting from where we have taken the samples and what is the patient's background so before and after sending the sample we should be discussing the microbiologist we should take their help not that we know correctly how to interpret there are some culture reports which have to be interpreted on the mic values there are some depending on the other parts and other ways so it's better that we discuss with the microbiologist about the correct interpretation and the isolation organisms and we should know when to escalate and de-escalate antibiotics in a sepsis or in a emergency situation if you are given the drugs combination of the drugs or in a neutropenic patients the moment we get the reports right that which drugs are working or which drugs are not working we should be de-escalating the drug so that's very very important that is called the time out of antibiotics we should be timing out the antibiotics and that's what we should be mentioning on our indoor case papers this is very very important and government of india has come out with the we also have got the cdc that is called ncdc that the national center for disease control and that is they come out frequently regularly with the guidelines of course these guidelines are guidelines they are not policies or they are not the law but the guidelines are to be used because they are based on the collective wisdom of the experts these experts have given the specific instructions and the antibiotics preferences as a drug of choice all the alternative drugs or different kinds of situations we can go through this by the www ncdc.gov dot in and i have given you some of the examples the last part which antibiotics to be given where so let's see one see national guideline for use of antimicrobials when we prescribe antibiotics for sinusitis see or first instance most of the sinusitis are viral 90 percent of the sinusitis or what we call a trinocinal site is are the viral infections where antibiotics are not but maybe in 10 percent of the patients suffering from the running nose fever we should prescribe antibiotics only if there is no improvement in 10 days time or high grade fever is persistent beyond three days along with really there is a prevalent discharge or cervical or the lymphadenopathy in the neck and the preferred antibiotics in acute rhinoceros sinusitis is amoxicillin with cleveland combinations right or the second choice is moxifloxacin this is what the national guidelines suggest either give amoxicillin cleveland or moxie fluxes the newer mineral ones for asymptomatic urine drug infections if you remember i just put these questions that should be describing every unit of infections antibiotics no right it is not required if the patient is asymmetromatic unless the patient happens to be a pregnant woman or patient based diabetes in that situations in pregnancy the safer drugs are nitroform is safe phosphomycin is safe amoxicillin and cephalosporins are safe we can prescribe it when we prescribe nitropharyntoid we have to make sure that patient has normal renal functions because nitropharyntene is concentrated in the urine if there is renal insufficiency nitroferentine is not going to be concentrated so it's going to be useless otherwise a very good urine specific antibiotic but again patients should not be having g6pd deficiency this things we keep in mind the symptomatic empirical antibiotic till we wait for the calcium sensitivity as per the government guidelines are either you give nitropharyntoid 100 milligram bid for fresh or till the culture reports comes or give cotrimexal or ciprofloxacin or cepheroxin so these are the national guidelines for uritek infections then what are the guidelines for the gi infections for gastroenteritis we do not the guidelines do not prescribe any antibiotic all that is required is rehydration oral rehydrations or depending if the patient is persistent vomiting there may be iv fluids for cholera give 300 milligram of doxycycline state that's all or maybe azithromycin if the patient happens to be child or a pregnant woman then azithromycin and as an alternative to doxycycline is as if azithromycin or ciprofloxacin again cholera needs very vigorous rehydrations but the antibiotic of choice is doxycycline or acetomycin or circular flux typhoid fuel very important we have mentioned just before also the multi drug resistant typhoid fever we do across so many of them and if you see this quinolones do not appear in the national guidelines but every man may not agree and if you have good response in our area fine can use it but what is important is when we use suffix zoom on an opt base for typhoid fuel the correct dose is 20 milligram per kilogram per day so for 60 kg weight we have to give 1200 milligram of suffix am that is very very important then only we are giving the right to so q suffix him 1200 milligram for 60 kg for typhoid fever if you give cotrimexial as an alternative we have to give 960 milligram video for 14 days all these antibiotics are for minimum seven days and for cotrimexial two weeks right as if suffixin is a 1200 milligram whenever we prescribe for a 60 kg persons keep that in mind if you prescribe acetomycin as for the national guidelines it's a bid dose for seven this finite milligram right for these particular indications otherwise as i said for other indications we always given a single dosages for inpatient when we prescribe the cephalosporins it is a third generation space apology that is after axon we should be giving 2 gram iv as i said again infusions 100 ml over 2 hours bid for two weeks or plus minus azithromycin for seven days so typhoid fever we can use c we have found not that we cannot use but as per the guidelines we should be prescribing suffix enzyme if in our area the typhoid is sensitive or our blood culture is shown that the say quinolones are sensitive we can definitely use it we have been using it but the mic well is the much higher so when we use ciprofloxacin we should be using 750 milligram bid or when we use off roxas and we will be using 800 milligram rather than the 200 or 400 milligram though correct dose is also very very important then for the cellulite is not a common skin soft tissue infections the guidelines suggest the amoxicillin level in it and the alternatives clindamycins for five to seven days for community acquired pneumonia or community acquired pneumonia most time the organisms are either strapped to staphylococcus one of the atypical ones like the microplasma or chlamydia or the so better we use amoxicillin or emulsion cleavage the linosolid is to be reserved again as repeat to be reserved for mrs infections the severe infections or the community acquired pneumonia with the underlying conditions like copd or ccf or diabetes with the even the these patients need to be hospitalized then better we prescribe the combination of emotional turbulent or safety exam some authorities do believe that we prescribe amoxil cleveland plus azithromycin which is a very good coverage for the atypical microorganisms and it is perfectly justified for patients where there is a chance of the committing by infections by the gram-negative infections it's better we prescribe piperacillin to azobectum or the immune venom or cephaloporosis vector so these are the antibiotics suggested for this kind of organisms what is more important that we must make every effort to prevent infections and at least in the outdoor or hospital setup we must make sure that we not only disinfect our hands but we also disinfect our stethoscope and all the instruments that we use for examining the patients or at the time of surgery it's really very important because the organisms like costume deficient they are resistant to alcohol as a disinfectant we should be using detergent or soap and water to clear clostridium efficiency that's very very important piece of information we should be knowing and it's unfortunate that the medical culture is much harder than the microbiological culture to change so we make sure that we do not become the reason for the infection in our next patients so coming to the summarizing we must resolve universally that we will use antibiotics only when indicated we'll choose a narrow spectrum and avoid a broad spectrum antibiotic we choose the right drug the right dose right durations the right route and as i said single dose as far as the concentration dependent antibiotic killers are concerned and the iv or anabolis not in bolus but in an infusion form or in a bid or tid or uds dose when we prescribe drugs which are time dependent killings will say no to any irrational combinations and we will reserve drugs like phenolones for typhoid tuberculosis or whenever there is the culture report suggests you have only that group of drugs working for that particular patients and by all means we'll say no to viral infections and gastroenteritis even if we take this message almond spreading i think we'll cut down the antibiotic precision by more than one third to 50 percent so that's what we that we end our talk but remember the antibiotic information is at the tip of our finger we can use all these apps which are freely available and they give all kinds of informations regarding the dose that those in the renal impairments on the liver impairment and what is their status in the pregnancy and lactating mothers so we should be using this more often we don't need to remember the dose of the antibiotics because except give the first dose and loading those we can always give even if the patient is the real environment the even if the drug which is nephrotoxic we can give the first dose is the second dose and the third that is very important that we should be keeping in mind right so just like the uk people have come out with the gate well soon without antibiotics is our message to all our friends thank you and there are any questions they are more than welcome thank you so much for the amazing session as usual there are loads of chats will be happy to have some of the senior members wanting to come on the stage to share their experience comments criticisms there are a lot of thank you messages um there is uh dr hiramat who is asked if you can talk about uh tuberculosis well i first and foremost information that you must know that tuberculosis for last three years four years has been a notifiable disease so one should not prescribe an antibiotic anti-tuberculosis drugs without inferring the authorities and without a tissue diagnosis are the clear-cut diagnosis of tuberculosis because the tuberculosis treatment has to be according to the government guidelines and tuberculosis whenever is there we have to have the diagnosis by the nucleic acid amplification test that is called cb net cartridge based nucleic acid test cb net test right or gene expertise if you are in private we have to confirm the diagnosis and we have to make sure that the tuberculosis basili that infection is there in a patient has reformed sensitive or reformation resistance because that cb net gives you not only the diagnosis but it also gives whether the infection is reform is sensitive or resistance if it is sensitive the all four drugs that are currently working work very well very important thing in tuberculosis is the antibiotic dose according to the weight of the patient it's very important we should not be giving just the combination that is available just to the the two drugs or three ducks like that and it's better that we take into account the tuberculosis specialist at least at the time of the diagnosis and now that the government is giving incentive for the patient as well as the one who diagnoses and manage the patients right only thing is we have got to register that there is a site for it and there is a direct benefit to this patient and patients get not only the drugs free but also gets the benefit of 500 rupees every month so it's better that we take help of the government initiative government wants to cut down the mdr tb cases and there are few drugs like buddha villain or melanomide which is available only to the government centers for all resistant cases otherwise most of the tuberculosis drugs the first plane drugs are working in the sensitive patients and drugs in the sensitive organism infections if there is a resistance there is again a criteria for which drugs would be used we should not be combined one drug a new drug we should become a minimum two drugs we should give minimum six drugs and minimum period of drugs would be at least 12 months when we prescribe dealing with the multi-drug resistance if the patient happens to have hiv and tuberculosis and again the infection has to be a treatment has to do for extended period but it's better that we consult with the regional national tuberculosis control that is rntcp agents nearby areas and take their help for the diagnosis as well as the continuation of the management thank you so much i hope that answered your question we have a follow-up uh not a follow-up question but on the lines of cuba classes we have dr sumit singh was asked what would be the best test for tb if there's no productive sputum well this is definitely an area where we have got to take into account the patient symptoms patients x-ray findings or the other parameters of inflammation like esr or c-reactive protein then maybe you have to go for the test called igra that is the keeping goals test right and but again the government insists that we should at least get they try to get the useful term it is a patient has curve that we should try to enhance induced book terms if it is available if it is not available obviously we have to conjunct with these parameters and then start the treatment but again that treatment has to be sanctioned by the government authorities otherwise it's a ipc uh section will be on you and you can be even analyzed for that including the imprisonment so tuberculosis treatment is not that simple nowadays it's better that we inform the authorities and go above when in doubt take the tuberculosis to help thank you so i hope that answers your question um we have okay uh we have dr harshita jen who's asked uh which are the say uh which are safe to use antibiotics during all three trimesters of pregnancy yeah i think that's a very good questions and the generally the penicillins and cephalosporins are very safe right and the doxycycline should not be used in any trimester quinolone should not be use any trimesters these two drugs are out and the penicillin cephalosporins are good nitropharyntone is safe right and the sulfur trimethyl combinations should not be given in the last part for the chronic teres in the newborn aminoglycosides are generally avoided in the pregnancy so given choice penicillins group of drugs like mpc and amoxicillin or cephalosporins are the safest drugs thank you sir for that um okay we have a lot of questions pouring in uh so uh we have a raised hand uh so we'll take that request renal failure the drugs uh that we generally use penicillins as i said cephalosporins are definitely safe the unsafe drugs are the drugs which we have to keep in mind are the aminoglycosides mainly sulfur trimethyl also can aggravate hyperkalemia so that bacterium type of drug should be avoided and all other antibiotics depending on the creatine clearance we should be giving the dosages so the main group of drugs to be avoided are the amino glycosides thank you so much for coming in somebody has suggested that the nitroframe turn is not as advisable in the first trimester i'll check with that but still then i will i think we stand corrected if it is not advisable in the first trimester i was under the impress that we can give it in all trimesters because this mentioned safe but we can correct it and we can verify it right not an issue [Music] um then we have dr sakshi singh was asked how many days should one wait to change the antibiotic if a cul if the culture is awaited or is not immune okay see whenever we prescribe antibiotics obviously it's archived for an infection for with the patient to have some symptoms so generally or we wait for 72 hours right for the antibiotics effect to see if the patient's symptoms there's a fever or cough or whatever is is resolved or his toxin is reduced right generally he's feeling well that means the antibiotics are working even if the culture sensitive or sometimes may so the contrary but if the patient is improving we may disregard the culture report if the patient is improving so parameters like the patient symptoms patient appetite patients well-being wbhc count esr all these also help us in deciding but generally we wait for 72 hours beyond that if the patient is not responding the culture reports are not available or not done we may change the end part thank you so much and likewise antibiotics are not continued indefinitely nowadays the trend is to reduce the antibiotics to not more than two to three days after the patient's symptoms are resolved if the patient is a hebrile for 48 hours into it hours you can safely discontinue the antibiotics in most situations there are very few situations like the legionella infections or meningitis where we have to give antibiotics for fewer we have to give for a longer period most patients antibiotics can be discounted in five to seven days [Music] okay ah thank you sir for that uh then we have dr gurvan kaur who's asked uh can we take citrizone for sneezing or other allergies without prescription and what are the side effects that can occur by it see all these drugs need to be have a prescription ideally right but obviously it's a very safe drug in most patients and the patient is taking concurrently other drugs like if the patient is taking the anti-ssri drugs or taking certain antibiotics then we should not be taking this kind of entry stamina cytosine as sadism they claim that it is not saturating but we see so many patients with sedations because of the saturation and some people in fact use it as sedatives which should definitely be discouraged it can be taken for a few days for but if you want to give it for a longer period it is better we substantiate that there is an allergy or by the other parameters and then we try to find out the allergen until then we might give it for few days it's better we give other specific anti-allergens like montreal cast also if required giving only entry stamina may not serve the purpose okay uh thank you sir for that um okay [Music] so we have okay just coming uh there just too many yeah um i think we okay there are no uh we have a raise hand request and we have dr predna bhari i'm accepting your request uh please turn on your audio video when prompted on a very regular basis like for thicker folliculitis or a viral diagnosis or basic tonsillitis like not even which has like come up with the full-on symptoms so how can we avoid this thing in a general common dispensary yes that is exactly what i said to begin with that we have to the first thing we have to get convince ourselves and that we convince the patients that these are the viral infections antibiotics do not work on the viruses so whether you wait say if we just give the symptomatic treatment correctly and advise about the gargling and the paracetamol around the clock right in good hydration and if required anti toxic drugs most of the patients result right it's a question of keeping the patients uh busy with all these things right rather than giving the antibiotics and because antibiotics are not going to work but there are certain upper aesthetic infections which are viral to begin with and then get secondary infections so that is why when they get the fever after elapse of a few days of april period and they have got the painful adrenophagia or throat sore throat or lymphadenopathy then it's the time to give the antibiotics but in the first instance definitely we should be convinced ourselves right we should have that conviction that no we don't i am not going to discriminate but if you want it yourself you can take it or you can choose other way around but will not prescribe antibiotics so it's our conv conviction that is very very important so can we avoid this also in a case of like folliculitis or any skin disorder with muscules or anything definitely locally also there is no reason to give antibiotics for each and every most of the patients are immunocompetent right in our immune system will take care of right if there is a breach of the skin the local antibiotic applications may be there for the breach in the skin but otherwise nothing is required sure thank you when we talk about the antibiotics we talk of the over prescription but there is a drug which is under pressure that is doxycyclines doctors is a wonderful drug and i think we are under prescribing it and it takes care of them so many atypical bacterial infections these days if it's in leptospirosis or if you say the scrub typhus fever or even the atypical communicable pneumonia everywhere doxycycline works right cholera we have seen that since so doxycycline is probably under prescribed because it is supposed to be a below status when we prescribe a toxicity which is not the case we should not go by the cost of the drug we should go by this effect and luckily the doxycycline is a very good drug no question about is under utilized [Music] absolutely in um and there are few companies which have got 400 million if the patient has a definite symptoms of tuberculosis then we can go for the igra of course it is not the 160 days and then i would better take the tv for his health rather than starting on my own because we need the confirmation is doing good and they are giving drugs including the experimental drugs also to all the facility of costs um so since we are in covid there's a question about it we have dr cyril sarji who's asked in this covert scenario can we give doxycycline and as a throw for five to seven days for what if you say as an anti-corvid no night see when they where in 2020 january february we did not have any drugs available we did not have any specific antiviral drugs or we did not have antibodies and that time these drugs were used as a repurposed drugs they will not give us an antibiotics they were given as their antiviral property only so but now it is proved that they are no longer good drugs or better we don't use it right if we give it for a secondary infection that's a totally different indications but for kovid as anti-viral efficacy they have proven useless so his hcq is hydroxychloroquine stop using it yes sir so we had another question here uh [Music] uh what are which are the safe antibiotics in pediatric practice well i think i'm not the right person to answer because i practice adult medicine but commonly we avoid tetracyclines we avoid chloramphenic or by all means and we also avoid minerals but some pediatricians do use quinolines but they have got the effect on the cartilage so these antibiotics are generally avoided [Music] but i am neither an id specialist nor air pediatrician so better athletic direction we'll probably have a pediatrician come up and talk about this we have a request to come up on stage we have doctors becky surgeon uh i'm accepting your request peace [Music] don't know why such irrational combination of antibiotics are present sir can you please whenever we come across such community combination of antibiotics can you please tell us how to develop an insight regarding to know whether the combination is irrational or rational for example if i tell you uh ciprofloxacin and trinidazole is a common combination that is prescribed for gastroenteritis although they have different mechanisms different than how to say that it's irrational and how the point is the indication for which we use do we really need these two combination drug combinations that's what we ask ourselves that first as i said we define we try to find out which organisms we are facing or likely to face in a particular instant and second thing the drug that we select is it required is a combination required see by clear cut that ciprofloxacin antennas did not have any pharmacological pharmacodynamic synergism they are totally different drugs right they are just combined so that you don't have to bother whether it's a basically decentralized entry or whether it is arabic or anaerobic or gram-positive gram negative but that is not the way we will be prescribing the antibiotics in any patient and as you say directly in gastrin diaries no antibiotics require all that you need is hydration and maybe anti-motility if you are sure that it's purely viral and the secretory diarrhea then only we need the antimony drugs like lopramide and otherwise all that is required is the hydration that's it the point is that there is so much of pressure uh from the industries right about the all these combinations that we also get carried away but i i for one believe that if the combination is not rational there are very few rational combinations we already mentioned sulphur triangular prime or bl bli combinations like amoxicillin glybulinate or diaper synthesis their clear-cut combinations were prescribed because they have take the advantage of their pharmacological properties in scientism they increase the efficacy when we combine the two drugs combining just for to avoid the diagnostic and all this that's not correct thank you so much for that and uh in the comments i do see dr apple would like to come up on the stage yes share your opinion about the topic we would really love to hear you on that you can click on the raise hand option on the right hand side of your screen and we can take you up on stage [Music] is a very senior internal medicine specialist had been a professor and teacher for so many of them very close friend and very senior persons and i think he has to give his comments only and not ask me any questions [Music] he's left a comment for you that it was a very informative session well his words mean a lot to me she always thank you so much um so if you also want to go through the questions i just saw it see some of the questions they are better taken with as a special fight whether related to pregnancy on tuberculosis i think we'll need to have some specialist persons for talking about the tuberculosis because we honestly do not say much in the practice that you were killing us for last couple of days we have stopped saying that you were close for the same reason of being unnecessarily dragged into the medical legality because we some of our colleagues have run into troubles some questions about the liver and luckily the in liver many antibiotics precisely the antibiotics which are metabolized by the liver like all doing the chlor compound and the tetracyclines then even emphysema amoxicillins and they are metabolism they were we should be very careful and we have to but usually in the mild liver impairment that's not an issue it comes only when the liver parameter liver is severely bad and in that case it's better that we refer a particular antibiotic indications in that and see in which particular childhood classification the patient falls for its severity and prescribed accordingly so it should be very very special specific uh indication and selection of the drugs but avoid the tetracyclines and the amoxicillin because they have many the foam piece and all this antiquities also have to be very careful even if any use that is antibiotic so in the comments we did see that you'll like this and if you all have any uh feedback if you all have any suggestions topic suggestions please do write to us and we'll be sure to take it up for the next time uh thank you so much for coming in today uh thank you so much for coming in thank you yes i also enjoyed the interactions and the large number remaining till the very end and it encourages us to come out with more and more topics of common interest to our viewers thank you advanced again my favorite lines not to forget that the omicron is here in nearby countries and it can come any time it's better that we maintain the appropriate behavior and there is no better vaccine than the mask right so maintain the mask the social distancing and vaccinations now there is some reports today itself in the south africa that the at least the infection has not defied the immunity so it's better that we continue most of the cases so far reported have are mild probably because of the vaccinations so we should make sure that all our patients have are fully vaccinated with that note we say goodbye thank you stay safe stay home good night you

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