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Role of pharmacists in combating drug resistatnce by neel ratnam.

THIS PRESENTATION IS ABOUT THE MISUSE OF DRUGS WHICH CAUSE RESISTANCE AND ITS IMPACT ON HEALTH AND ENVIRONMENT AND HOW PHARMACISTS COMBAT IT

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Role of pharmacists in combating drug resistatnce by neel ratnam.

  1. 1.  ROLE OF PHARMACISTS IN COMBATING DRUG RESISTANCE.  BY Neel Ratnam
  2. 2.  What is antimicrobial resistance  Why antibacterial resistance is a concern To Pharmacists  How antibacterials work  Mechanisms of resistance to antibacterials  Strategies to contain resistance
  3. 3. Microbiologist Physician Bacterial sensitivity test and find out the possible causes of development Treat Infection
  4. 4. Microbiologist Physician Pharmacologist Advise the proper and adequate antibiotics with balancing the economy of hospital
  5. 5.  Throughout history there has been a continual battle between human beings and multitude of micro-organisms that cause infection and disease.  The pharmacist's role in combating and preventing infectious diseases is essential as antibiotic and vaccine regimens become more complex due to the continuously evolving epidemiology of infections.
  6. 6.  The decrease in drug development makes the preservation of currently available antibiotics paramount.  Pharmacists as Custodian and experts in Medicines Must Play a Pivotal Role In combating Drug Resistance and Must understand How drug resistance happens at molecular level.
  7. 7. In his 1945 Nobel Prize lecture, Fleming himself warned of the danger of resistance – “It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them” History Nobel Lecture, December 11, 1945 Sir Alexander Fleming The Nobel Prize in Physiology or Medicine 1945
  8. 8. Environmental Factors Drug Related Factors Patient Related Factors Prescriber Related Factors Antibiotic Resistance
  9. 9.  Huge populations and overcrowding  Poor sanitation  Ineffective infection control programs  Widespread use of antibiotics in animal husbandry and agriculture and as medicated cleansing products
  10. 10.  Over the counter availability of antimicrobials  Counterfeit and substandard drug causing sub- optimal blood concentration  Irrational fixed dose combination of antimicrobials  Soaring use of antibiotics Policy Decision at Higher level
  11. 11.  Poor adherence of dosage Regimens  Poverty  Lack of sanitation concept  Lack of education  Self-medication  Misconception Patient Counseling, Awareness Program
  12. 12.  Inappropriate use of available drugs  Increased empiric poly-antimicrobial use  Poor clinical practice  Inadequate dosing  Lack of current knowledge and training
  13. 13.  Resistant organisms lead to treatment failure  Increased mortality  Resistant bacteria may spread in Community  Add burden on healthcare costs  Threat to return to pre-antibiotic era  Selection pressure
  14. 14. • The concentration of drug at the site of infection must inhibit the organism and also remain below the level that is toxic to human cells. •Principles Of Chemotherapy must be applied when selecting which antibiotic to use Antibiotic Resistance
  15. 15.  Selection of the most appropriate antimicrobial agent requires knowing 1) The organism’s identity : gram +/- 2) The organism’s susceptibility to a particular agent 3) The site of the infection- blood-brain barrier effects, protein binding, lipid solubility and MW of the drug 4) Patient’s factor- Renal/Hepatic nature,age, gender, pregnancy, lactation and immune system 5) The cost of therapy
  16. 16. 1. Inhibition of cell wall synthesis 2. Inhibition of function of cell membrane 3. Inhibition of protein synthesis 4. Inhibition of nucleic acid synthesis 5. Inhibition of folic acid synthesis
  17. 17. Defined as micro-organisms that are not inhibited by usually achievable systemic concentration of an antimicrobial agent with normal dosage schedule and / or fall in the minimum inhibitory concentration (MIC) range.
  18. 18. Understanding Mechanism of Antibiotic Resistance at Molecular Level Intrinsic (Natural) Acquired Genetic Methods Chromosomal Methods Mutations Extra chromosomal Methods Plasmids
  19. 19.  It occurs naturally 1. Lack target : • No cell wall; innately resistant to penicillin 2. Innate efflux pumps: • Drug blocked from entering cell or ↑ export of drug (does not achieve adequate internal concentration). Eg. E. coli, P. aeruginosa 3. Drug inactivation: Cephalosporinase in Klebsiella
  20. 20. Acquired Resistance Mutations • It refers to the change in DNA structure of the gene. • Occurs at a frequency of one per ten million cells. • Eg. Mycobacterium tuberculosis, Mycobacterium lepra. • Often mutants have reduced susceptibility
  21. 21. Plasmids • Extra chromosomal genetic elements can replicate independently and freely in cytoplasm. • Plasmids which carry genes resistant ( r-genes) are called R-plasmids. • These r-genes can be readily transferred from one R-plasmid to another plasmid or to chromosome. • Much of the drug resistance encountered in clinical practice is plasmid mediated
  22. 22. Mechanism of Resistance by Gene Transfer • Transfer of r-genes from one bacterium to another  Conjugation  Transduction  Transformation • Transfer of r-genes between plasmids within the bacterium  By transposons  By Integrons
  23. 23. Transfer of r-genes from one Bacterium to Another  Conjugation : Main mechanism for spread of resistance The conjugative plasmids make a connecting tube between the 2 bacteria through which plasmid itself can pass.
  24. 24. Transfer of r-genes from one Bacterium to Another  Transduction : Less common method The plasmid DNA enclosed in a bacteriophage is transferred to another bacterium of same species. Seen in Staphylococci , Streptococci  Transformation : least clinical problem. Free DNA is picked up from the environment (i.e.. From a cell belonging to closely related or same strain.
  25. 25.  Transposons are sequences of DNA that can move around different positions within the genome of single cell.  The donor plasmid containing the Transposons, co-integrate with acceptor plasmid. They can replicate during co- integration  Both plasmids then separate and each contains the r-gene carrying the transposon.
  26. 26.  Integron is a large mobile DNA that can spread Multidrug resistance  Each Integron is packed with multiple gene casettes, each consisting of a resistance gene attached to a small recognition site.  These genes encode several bacterial functions including resistance and virulence.
  27. 27. • Prevention of drug accumulation in the bacterium • Modification/protection of the target site • Use of alternative pathways for metabolic / growth requirements • By producing an enzyme that inactivates the antibiotic
  28. 28. Decreased permeability: Porin Loss Interior of organism Cell wall Porin channel into organism Antibiotic Antibiotics normally enter bacterial cells via porin channels in the cell wall
  29. 29. Interior of organism Cell wall Modified target site Antibiotic Changed site: blocked binding Antibiotics are no longer able to bind to modified binding proteins on the bacterial cell surface
  30. 30. • Bacteria are capable of flushing out antibiotics before they reach their target site.
  31. 31. Environment Cytoplasm Porin Efflux System Pump Efflux System Exit Portal Linker Lipoprotein
  32. 32. Modification/Protection of the Target site Resistance resulting from altered target sites: Target sites Resistant Antibiotics Ribosomal point mutation Tetracyclines,Macrolid es, Clindamycin Altered DNA gyrase Fluoroquinolones Modified penicillin binding proteins (Strepto.pneumonia) Penicillins Mutation in DNA dependant RNA polymerase (M.tuberculosis) Rifampicin
  33. 33. Drug Mechanism of resistance Pencillins & Cephalosporiins B Lactamase cleavage of the Blactam ring Aminoglycosides Modification by phosphorylating, adenylating and acetylating enzymes Chloramphenicol Modification by acetylytion Erythromycin Change in receptor by methylation of r RNA Tetracycline Reduced uptake / increased export Sulfonamides Active export out of the cell & reduced affinity of enzymes
  34. 34.  Developing new antibiotics  Judicious use of the existing antibiotics  Community Pharmacists as Gateway Practitioners-Prevent Antibiotic Misuse.  Vaccination-by preventing primary infection and indirectly by preventing bacterial super infection
  35. 35.  Education:- -Patient and clinician education  infection-control practices such as general hygiene, hand hygiene, cough etiquette, immunizations, and staying home when sick
  36. 36.  Prudent antimicrobial prescribing  UK hospitals have appointed microbiologists or infectious diseases physicians with antibiotic management , Pharmacists as Drug Experts Must undertake such roles as Lead Antibiotics Pharmacists  Establishment of Hospital Antibiotic Policy
  37. 37.  A dedicated pharmacist has the time and skills to monitor antibiotic prescribing and manage it appropriately  Key roles for pharmacists include:- • Education of medical, • Pharmaceutical and • Nursing staff, • Audit of local practices, • Monitoring of antibiotic consumption, • Participation in infection control, • Formulary development and • Appraisal of new antimicrobials
  38. 38.  Many physicians, medical microbiologists and infectious diseases physicians might feel threatened by such proposals but Pharmacists are inseparable to drugs
  39. 39.  Linezolid: targets 50S ribosome  Tigecycline: targets 30S ribosome  Daptomycin: depolarization of bacterial cell membrane  Dalbavacin: inhibits cell wall synthesis  Telavacin: inhibition of cell wall synthesis and disruption of membrane barrier function  Ceftobiprole: 5th generation cephalosporins  Ceftaroline: Advanced generation cephalosporin  Iclaprim: Inhibits Dihydrofolate reductase
  40. 40.  Target definitive therapy to known pathogen  Treat infection, not contamination  Treat infection, not colonization  Isolate Pathogen, utilise microbiology lab  Break the chain of contagion – Keep our hands clean.
  41. 41. Thank You !!!!!!!!!!!! Hope is not exhausted….yet

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    Feb. 25, 2021

THIS PRESENTATION IS ABOUT THE MISUSE OF DRUGS WHICH CAUSE RESISTANCE AND ITS IMPACT ON HEALTH AND ENVIRONMENT AND HOW PHARMACISTS COMBAT IT

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