WHY THE EMPIRICAL ANTIBIOTIC THERAPY OVER RULES DIAGNOSTIC MICROBIOLOGY?
In spite many advances in Pharmacokinetics and clinical Microbiology there is no ideal Antibiotic of choice in any given clinical situation even the most common problems in antibiotic treatment do not have simple solutions. Today Antimicrobial agents are some of the most widely, and often injudiciously, used therapeutic drugs worldwide. Important considerations when prescribing antimicrobial therapy include obtaining an accurate diagnosis of infection; understanding the difference between empiric and definitive therapy; identifying opportunities to switch to narrow-spectrum, cost-effective oral agents for the shortest duration necessary; understanding drug characteristics that are peculiar to antimicrobial agent, accounting for host characteristics Choosing one antibiotic drug from among several candidates entails balancing the benefits and the detriments associated with each. Never forget very few patients in the society are evaluated with Diagnostic Microbiology to identity the true pathogen, just it means how many attend the teaching hospitals and good institutes with quality control in Antibiotic sensitivity test methods. We believe that empirical antibiotic treatment matching the in vitro susceptibility of the pathogen will afford the patient the best chance of survival and an uneventful recovery.3–5 However, we have been told repeatedly by senior consultants of the department that the budget is limited and third generation cephalosporins and Imipenam are disproportionately expensive. At end the of treatment generate multi drug resistant and superbugs in the hospital .We need a framework that enables us to balance the benefits and detriments of antibiotic drugs in any given situation. Cost effectiveness analysis can provide such a framework, but it must take into account the consequences of future resistance. However, even in the absence of a complete framework and complete data, approximations can be usefully made it means that we treat majority of the patients and empirical basis,
However the clinicians have to take faster decisions the timing of initial therapy should be guided by the urgency of the situation. In critically ill patients, such as those in septic shock, febrile neutropenic patients, and patients with bacterial meningitis, empiric therapy should be initiated immediately after or concurrently with collection of diagnostic specimens. In more stable clinical circumstances, antimicrobial therapy should be deliberately withheld until appropriate specimens have been collected and submitted to the microbiology laboratory. Important examples of this principle are subacute bacterial endocarditis and vertebral osteomyelitis/ other septic condition including the surgical site infections because microbiological results do not become available for 24 to 72 hours, initial therapy for infection is often empiric and guided by the clinical presentation. It has been shown that inadequate therapy for infections in critically ill, hospitalised patients is associated with poor outcomes, including greater morbidity and mortality as well as increased length of stay. Therefore, a common approach is to use broad-spectrum antimicrobial agents as initial empiric therapy with the intent to cover multiple possible pathogens commonly associated with the specific clinical syndrome. This is true for both community- and hospital-acquired infections when a pathogenic microorganism is identified in clinical cultures, the next step performed in most microbiology laboratories is antimicrobial susceptibility testing (AST). Antimicrobial susceptibility testing measures the ability of a specific organism to grow in the presence of a particular drug in vitro and is performed using guidelines established by the Clinical and Laboratory Standards Institute, (CLSI) a non-profit global Organization that develops laboratory process standards through extensive testing and clinical correlation. The goal of AST is to predict the clinical success or failure of the antibiotic being tested against a particular organism.
To convince the Clinicians continues to be greater challenge, they are many times guided by present status of the serious patients and any means take the optimal advantage of all available antibiotics and Pharmaceutical promotions leading to conflicts out of scientific promotions, there is growing trend of gram negative bacterial isolates in the clinical setting with emerging drug resistance, We should educate the clinicians on rationalism in antibiotics prescribed what consequences to the rest of the patients in the wards, and critical areas, Today world of Medicine face grave threat from Durg resistant Microbes as we call SUPERBUGS , Antibiotic resistance is a quickly growing, extremely dangerous problem. World health leaders have described antibiotic-resistant bacteria as "nightmare bacteria" that "pose a catastrophic threat" to people in every country in the world. Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a direct result of these infections. Many more people die from other conditions that were complicated by an antibiotic-resistant infection. Many wonder whether it is possible bring in Antibiotic policy in India, I wonder it is humanly difficult task as the reasons
1 There are few credited laboratories, which do Antibiotic Sensitivity with scientific approaches
2 Lack of coordination in the Diagnostic Microbiology laboratories many Seniors and Professors are out of reach to the practical work in the laboratory
3 Least money spent on Improvement in developing infrastructure of Diagnostic Microbiology laboratories
4 Many Private Microbiology laboratories work with least infrastructure with maximal gains and kick backs as routine practice
5 Above all great danger awaits the Private laboratories cater to whims and fancies of physician’s with commercial interests report any antibiotic against any isolate whether it is a pathogenic or commensals
HOWEVER IF THE MATTERS GOING ASTRAY IT IS CERTAIN THAT IN MANY DEVELOPING COUNTRIES INCLUDING INDIA WE HAVE TO TREAT THE FUTURE PATIENTS ON RANDOM AND EMPIRICAL BASIS BRINING IN GRAVE CHALLENGES IN FUTURE MEDICAL CARE JUST MEANS THE LIVES AT RISK JUST AT OUR LUCK INSPITE OF MANY QUALIFIED MICROBIOLOGISTS ?
DR.T.V.RAO MD PROFESSOR OF MICROBIOLOGY FREELANCE WRITER
In spite many advances in Pharmacokinetics and clinical Microbiology there is no ideal Antibiotic of choice in any given clinical situation even the most common problems in antibiotic treatment do not have simple solutions. Today Antimicrobial agents are some of the most widely, and often injudiciously, used therapeutic drugs worldwide. Important considerations when prescribing antimicrobial therapy include obtaining an accurate diagnosis of infection; understanding the difference between empiric and definitive therapy; identifying opportunities to switch to narrow-spectrum, cost-effective oral agents for the shortest duration necessary; understanding drug characteristics that are peculiar to antimicrobial agent, accounting for host characteristics Choosing one antibiotic drug from among several candidates entails balancing the benefits and the detriments associated with each. Never forget very few patients in the society are evaluated with Diagnostic Microbiology to identity the true pathogen, just it means how many attend the teaching hospitals and good institutes with quality control in Antibiotic sensitivity test methods. We believe that empirical antibiotic treatment matching the in vitro susceptibility of the pathogen will afford the patient the best chance of survival and an uneventful recovery.3–5 However, we have been told repeatedly by senior consultants of the department that the budget is limited and third generation cephalosporins and Imipenam are disproportionately expensive. At end the of treatment generate multi drug resistant and superbugs in the hospital .We need a framework that enables us to balance the benefits and detriments of antibiotic drugs in any given situation. Cost effectiveness analysis can provide such a framework, but it must take into account the consequences of future resistance. However, even in the absence of a complete framework and complete data, approximations can be usefully made it means that we treat majority of the patients and empirical basis,
However the clinicians have to take faster decisions the timing of initial therapy should be guided by the urgency of the situation. In critically ill patients, such as those in septic shock, febrile neutropenic patients, and patients with bacterial meningitis, empiric therapy should be initiated immediately after or concurrently with collection of diagnostic specimens. In more stable clinical circumstances, antimicrobial therapy should be deliberately withheld until appropriate specimens have been collected and submitted to the microbiology laboratory. Important examples of this principle are subacute bacterial endocarditis and vertebral osteomyelitis/ other septic condition including the surgical site infections because microbiological results do not become available for 24 to 72 hours, initial therapy for infection is often empiric and guided by the clinical presentation. It has been shown that inadequate therapy for infections in critically ill, hospitalised patients is associated with poor outcomes, including greater morbidity and mortality as well as increased length of stay. Therefore, a common approach is to use broad-spectrum antimicrobial agents as initial empiric therapy with the intent to cover multiple possible pathogens commonly associated with the specific clinical syndrome. This is true for both community- and hospital-acquired infections when a pathogenic microorganism is identified in clinical cultures, the next step performed in most microbiology laboratories is antimicrobial susceptibility testing (AST). Antimicrobial susceptibility testing measures the ability of a specific organism to grow in the presence of a particular drug in vitro and is performed using guidelines established by the Clinical and Laboratory Standards Institute, (CLSI) a non-profit global Organization that develops laboratory process standards through extensive testing and clinical correlation. The goal of AST is to predict the clinical success or failure of the antibiotic being tested against a particular organism.
To convince the Clinicians continues to be greater challenge, they are many times guided by present status of the serious patients and any means take the optimal advantage of all available antibiotics and Pharmaceutical promotions leading to conflicts out of scientific promotions, there is growing trend of gram negative bacterial isolates in the clinical setting with emerging drug resistance, We should educate the clinicians on rationalism in antibiotics prescribed what consequences to the rest of the patients in the wards, and critical areas, Today world of Medicine face grave threat from Durg resistant Microbes as we call SUPERBUGS , Antibiotic resistance is a quickly growing, extremely dangerous problem. World health leaders have described antibiotic-resistant bacteria as "nightmare bacteria" that "pose a catastrophic threat" to people in every country in the world. Each year in the United States, at least 2 million people become infected with bacteria that are resistant to antibiotics, and at least 23,000 people die each year as a direct result of these infections. Many more people die from other conditions that were complicated by an antibiotic-resistant infection. Many wonder whether it is possible bring in Antibiotic policy in India, I wonder it is humanly difficult task as the reasons
1 There are few credited laboratories, which do Antibiotic Sensitivity with scientific approaches
2 Lack of coordination in the Diagnostic Microbiology laboratories many Seniors and Professors are out of reach to the practical work in the laboratory
3 Least money spent on Improvement in developing infrastructure of Diagnostic Microbiology laboratories
4 Many Private Microbiology laboratories work with least infrastructure with maximal gains and kick backs as routine practice
5 Above all great danger awaits the Private laboratories cater to whims and fancies of physician’s with commercial interests report any antibiotic against any isolate whether it is a pathogenic or commensals
HOWEVER IF THE MATTERS GOING ASTRAY IT IS CERTAIN THAT IN MANY DEVELOPING COUNTRIES INCLUDING INDIA WE HAVE TO TREAT THE FUTURE PATIENTS ON RANDOM AND EMPIRICAL BASIS BRINING IN GRAVE CHALLENGES IN FUTURE MEDICAL CARE JUST MEANS THE LIVES AT RISK JUST AT OUR LUCK INSPITE OF MANY QUALIFIED MICROBIOLOGISTS ?
DR.T.V.RAO MD PROFESSOR OF MICROBIOLOGY FREELANCE WRITER
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