CARBAPENEM RESISTANCE IN CLINICAL CARE

DR.T.V.RAO MD

Dr.T.V.Rao MD 1

IMPORTANCE OF CARBAPENEMS IN CLINICAL CARE

• CARBAPENEMS ARE A POWERFUL GROUP OF BROAD SPECTRUM BETA-

LACTAM (PENICILLIN-RELATED) ANTIBIOTICS WHICH, IN MANY CASES, ARE

OUR LAST EFFECTIVE DEFENCE AGAINST MULTI-RESISTANT

BACTERIAL INFECTIONS. WHAT IS OF CONCERN, HOWEVER, IS THAT

RESISTANCE IS BEGINNING TO EMERGE TO CARBAPENEMS. NEW

ANTIBIOTICS NEED TO BE DEVELOPED TO COUNTER BACTERIA WITH THIS

TYPE OF RESISTANCE; WHAT IS MORE, HOSPITALS NEED GOOD INFECTION

CONTROL AND ANTIBIOTIC POLICY TO PREVENT THEIR SPREAD.Dr.T.V.Rao MD 2

TODAYS CONCERN IN DRUG RESISTANCE IS GRAM NEGATIVE BACTRIA MAINLY ENTEROBACTERIACEAE

• SCIENTISTS FROM THE PUBLIC HEALTH ENGLAND RECENTLY CO-AUTHORED A PAPER PUBLISHED

IN THE LANCET INFECTIOUS DISEASES ON THE EMERGENCE OF A NEW ANTIBIOTIC

RESISTANCE MECHANISM - NEW DELHI METALLO BETA LACTAMASE (NDM-1).

THIS IS AN ENZYME THAT INACTIVATES CARBAPENEM ANTIBIOTICS. IT IS CODED BY LOOPS OF

DNA -PLASMIDS- THAT CAN MOVE BETWEEN BACTERIA. BACTERIA WITH NDM ARE MOST

WIDESPREAD IN THE INDIAN SUBCONTINENT BUT HAVE SPREAD TO VARIOUS COUNTRIES

AROUND THE WORLD, INCLUDING THE UK, OFTEN VIA PATIENTS PREVIOUSLY HOSPITALISED IN

DEVELOPING COUNTRIES INDIA OR PAKISTAN.( REF – PUBLIC HEALTH ENGLAND)

Dr.T.V.Rao MD 3

WHAT ARE ENTEROBACTERIACEAE?

• ENTEROBACTERIACEAE ARE A FAMILY OF BACTERIA THAT INCLUDE KLEBSIELLA SPECIES AND

ESCHERICHIA COLI (E. COLI), WHICH ARE FOUND IN NORMAL HUMAN INTESTINES (GUT).

SOMETIMES THESE BACTERIA CAN SPREAD OUTSIDE THE GUT AND CAUSE SERIOUS

INFECTIONS, SUCH AS PNEUMONIA, BLOODSTREAM INFECTIONS,

URINARY TRACT INFECTIONS, WOUND INFECTIONS, AND

MENINGITIS. ENTEROBACTERIACEAE ARE ONE OF THE MOST COMMON CAUSES OF

BACTERIAL INFECTIONS IN BOTH HEALTHCARE AND COMMUNITY SETTINGS. CARBAPENEM

ARE A TYPE OF ANTIBIOTIC FREQUENTLY USED TO TREAT SEVERE

INFECTIONS.Dr.T.V.Rao MD 4

WHAT ARE CARBAPENEMS

• CARBAPENEMS ARE A CLASS OF Β-

LACTAM ANTIBIOTICS WITH A BROAD

SPECTRUM OF ANTIBACTERIAL ACTIVITY.

THEY HAVE A STRUCTURE THAT RENDERS

THEM HIGHLY RESISTANT TO MOST Β-

LACTAMASES.[1] CARBAPENEM

ANTIBIOTICS WERE ORIGINALLY

DEVELOPED FROM THE CARBAPENEM

THIENAMYCIN, A NATURALLY DERIVED

PRODUCT OF STREPTOMYCES CATTLEYA.Dr.T.V.Rao MD 5

CARBAPENEMS ARE VERY SIMILAR TO THE PENICILLIN'S

• IN TERMS OF STRUCTURE, THE

CARBAPENEMS ARE VERY SIMILAR TO

THE PENICILLIN'S (PENAMS), BUT THE

SULFUR ATOM IN POSITION 1 OF

THE STRUCTURE HAS BEEN REPLACED

WITH A CARBON ATOM, AND AN

UNSATURATION HAS BEEN

INTRODUCED—HENCE THE NAME OF

THE GROUP, THE CARBAPENEMS.Dr.T.V.Rao MD 6

CARBAPENEM

• CARBAPENEMS ARE ONE OF THE ANTIBIOTICS OF LAST RESORT FOR MANY

BACTERIAL INFECTIONS, SUCH AS ESCHERICHIA COLI (E. COLI) AND KLEBSIELLA

PNEUMONIAE.[3] RECENTLY, ALARM HAS BEEN RAISED OVER THE SPREAD OF

DRUG RESISTANCE TO CARBAPENEM ANTIBIOTICS AMONG THESE COLIFORMS,

DUE TO PRODUCTION OF THE NEW DELHI METALLO-Β-LACTAMASE, NDM-1.

THERE ARE CURRENTLY NO NEW ANTIBIOTICS IN DEVELOPMENT TO COMBAT

BACTERIA RESISTANT TO CARBAPENEMS, AND WORLDWIDE SPREAD OF THE

RESISTANCE GENE IS CONSIDERED A POTENTIAL NIGHTMARE SCENARIO

Dr.T.V.Rao MD 7

SPECTRUM OF ACTIVITYDrug

Strep spp. &

MSSAEntero-bacteriaeae

Non-

fermentorsAnaerobes

Imipenem + + + +

Meropenem + + + +

Ertapenem + + Limited activity +

Doripenem + + + +

CARBAPENEMASESClassification Enzyme Most Common Bacteria

Class A KPC, SME, IMI,

NMC, GES

Enterobacteriaceae(rare reports in P. aeruginosa)

Class B

(metallo-b-lactamse)

IMP, VIM, GIM,

SPM

P. aeruginosa

Enterobacteriacea

Acinetobacter spp.

Class D OXA Acinetobacter spp.

APPROVED FOR CLINICAL USE

• HE FOLLOWING DRUGS BELONG TO THE CARBAPENEM CLASS AND ARE APPROVED FOR USE BY

HEALTH AUTHORITIES:[CITATION NEEDED]

IMIPENEM, IN GENERAL GIVEN AS PART OF IMIPENEM/CILASTATIN (FDA APPROVAL 1985[6])

IMIPENEM CAN BE HYDROLYSED IN THE MAMMALIAN KIDNEY BY A DEHYDROPEPTIDASE ENZYME

TO A NEPHROTOXIC METABOLITE, AND SO IS GIVEN WITH A DEHYDROPEPTIDASE INHIBITOR,

CILASTATIN

MEROPENEM (FDA APPROVAL 1996)

ERTAPENEM (FDA APPROVAL 2001, SINCE APPROVED FOR MULTIPLE INDICATIONS)

DORIPENEM (FDA APPROVAL 2007)

PANIPENEM/BETAMIPRON (JAPANESE APPROVAL 1993)

BIAPENEM (JAPANESE APPROVAL 2001)

Dr.T.V.Rao MD 10

SPECTRUM OF USE

• THESE AGENTS HAVE THE BROADEST ANTIBACTERIAL SPECTRUM COMPARED TO

OTHER Β-LACTAM CLASSES SUCH AS PENICILLINS AND CEPHALOSPORINS. IN

ADDITION, THEY ARE GENERALLY RESISTANT TO THE TYPICAL BACTERIAL ENZYME,

Β-LACTAMASE, WHICH IS ONE OF THE PRINCIPAL Β-LACTAM RESISTANCE

MECHANISMS OF BACTERIA. CARBAPENEMS CIRCUMVENT Β-LACTAMASE BY

BINDING IT WITH HIGH AFFINITY AND ACYLATING THE ENZYME, RENDERING IT

INACTIVE.[8] CARBAPENEMS ARE ACTIVE AGAINST BOTH GRAM-POSITIVE AND

GRAM-NEGATIVE BACTERIA, AND ANAEROBES, WITH THE EXCEPTION OF

INTRACELLULAR BACTERIA (ATYPICALS), SUCH AS THE CHLAMYDIAE.

CARBAPENEMS ALSO ARE THUS FAR THE ONLY Β-LACTAMS CAPABLE OF

INHIBITING L,D-TRANSPEPTIDASES

Dr.T.V.Rao MD 11

BASIS OF MECHANISMS OF DRUG RESISTANCE

• CHANGE IN DRUG TARGET

• PRODUCTION OF AN ENZYME THAT MODIFIES OR INACTIVATES THE AGENT

• REDUCED ACCUMULATION OF THE AGENT

• LIMITED UPTAKE

• ACTIVE EFFLUX

• LOSS OF A PATHWAY INVOLVED IN DRUG ACTIVATION

Dr.T.V.Rao MD 12

Resistant StrainsRare

Resistant Strains Dominant

Antimicrobial Exposure

SELECTION FOR ANTIMICROBIAL-RESISTANT STRAINS

Dr.T.V.Rao MD 13

CARBAPENEMASES• BETA-LACTAMASES WITH VERSATILE HYDROLYTIC CAPACITIES.

• ABILITY TO HYDROLYZE PENICILLINS, CEPHALOSPORINS, MONOBACTAMS, AND CARBAPENEMS.

• 2 MAJOR GROUPS

• METALLO-B-LACTAMASES (MBLS)

• MAJOR R IN PSEUDOMONAS, ACINETOBACTER, AND ENTEROBACTER

• CONFER HIGH LEVEL OF R

• SERINE B-LACTAMASES

• OXACILLINASES OR D B-LACTAMASES (OXAA)

• NOT AS DIVERSE

• FOUND MOSTLY IN ACINETOBACTER

• CONFER ONLY LOW LEVEL OF HYDROLYTIC ACTIVITY THERFORE ANOTHER R IS NECESSARY TO RAISE MIC

• CLASS A CARBAPENEMASES

• FOUND IN PSEUDOMONAS AND ENTEROBACTER, BUT PREDOMINANT TYPE IS FOUND ON A PLASMID IN KLEBSIELLA

Dr.T.V.Rao MD 14

WHAT ARE CARBAPENEM-RESISTANT ENTEROBACTERIACEAE

• CRE, WHICH STANDS FOR CARBAPENEM-

RESISTANT ENTEROBACTERIACEAE, ARE A

FAMILY OF BACTERIA THAT ARE DIFFICULT

TO TREAT BECAUSE THEY HAVE HIGH

LEVELS OF RESISTANCE TO ANTIBIOTICS.

KLEBSIELLA SPECIES AND ESCHERICHIA

COLI (E. COLI) ARE EXAMPLES OF

ENTEROBACTERIACEAE, A NORMAL PART

OF THE HUMAN GUT BACTERIA, THAT CAN

BECOME CARBAPENEM-RESISTANT.

Dr.T.V.Rao MD 15

KLEBSIELLA PNEUMONIAE CARBAPENEMASE

• KPC IS A CLASS A B-LACTAMASE

• CONFERS RESISTANCE TO ALL B-LACTAMS INCLUDING EXTENDED-SPECTRUM

CEPHALOSPORINS AND CARBAPENEMS

• OCCURS IN ENTEROBACTERIACEAE

• MOST COMMONLY IN KLEBSIELLA PNEUMONIAE

• ALSO REPORTED IN: K. OXYTOCA, CITROBACTER FREUNDII, ENTEROBACTER SPP.,

ESCHERICHIA COLI, SALMONELLA SPP., SERRATIA SPP.,

• ALSO REPORTED IN PSEUDOMONAS AERUGINOSA (COLUMBIA)

Dr.T.V.Rao MD 16

Carbapenems: Resistance Issues

Outer

membrane

Periplasm

Cytoplasmicmembrane

D2 Porin (OprD)

Carbapenem nucleus

Ertapenem Imipenem

PBP

1

PBP

2

PBP

3

PBP

4

PBP

5

Penicillin-bindingproteins (PBPs)

Mutated or missingD2 porin

Courtesy of John Quinn, MD.

Dr.T.V.Rao MD 17

MECHANISMS OF CARBAPENEM RESISTANCE: IMPERMEABILITY

• OPRD FORMS NARROW TRANSMEMBRANE CHANNELS

THAT ARE NORMALLY ACCESSIBLE ONLY TO

CARBAPENEMS, NOT TO OTHER ß-LACTAMS

• LOSS OF OPRD PORIN IS ASSOCIATED WITH DECREASED

PERMEABILITY OF CARBAPENEMS AND INCREASED

CARBAPENEM MICS, WHEREAS OTHER ß-LACTAMS

REMAIN ACTIVEDr.T.V.Rao MD 18

KPC ENZYMES

• LOCATED ON PLASMIDS; CONJUGATIVE AND NONCONJUGATIVE

• BLAKPC IS USUALLY FLANKED BY TRANSPOSON SEQUENCES

• BLAKPC REPORTED ON PLASMIDS WITH:

• NORMAL SPECTRUM B-LACTAMASES

• EXTENDED SPECTRUM B-LACTAMASES

• AMINOGLYCOSIDE RESISTANCEDr.T.V.Rao MD 19

MECHANISMS OF CARBAPENEM RESISTANCE: EFFLUX SYSTEMS IN P.AERUGINOSA

• UPREGULATION OF MEXAB-OPRM EFFLUX SYSTEM

• ASSOCIATED WITH INCREASED MICS OF MEROPENEM, NOT IMIPENEM

• COREGULATION OF MEXE-MEXF-OPRN EFFLUX SYSTEM WITH OPRD

PORIN IN P AERUGINOSA

• UPREGULATION OF EFFLUX ASSOCIATED WITH OPRD

• ASSOCIATED WITH INCREASED MICS OF FLUOROQUINOLONES AS WELL AS CARBAPENEMS

• MECHANISM SOMETIMES SELECTED BY FLUOROQUINOLONES, RARELY BY CARBAPENEMS

Dr.T.V.Rao MD 20

EMERGENCE OF BACTERIAL RESISTANCE• IN THE UNITED STATES AND UNITED

KINGDOM, STRAINS OF CARBAPENEM-

RESISTANT ENTERIC BACTERIA HAVE BEEN

ISOLATED FROM PATIENTS HAVING

RECEIVED RECENT MEDICAL CARE IN

PAKISTAN, BANGLADESH, AND INDIA. THESE

STRAINS CARRY A GENE CALLED NEW DELHI

METALLO-Β-LACTAMASE (SHORTENED NDM-

1) THAT IS RESPONSIBLE FOR THE

PRODUCTION OF A METALLO-Β-LACTAMASE

ENZYME THAT HYDROLYSES CARBAPENEM.

Dr.T.V.Rao MD 21

KPC’S IN ENTEROBACTERIACEAE

Species Comments

Klebsiella spp. K. pneumoniae-cause of outbreaks

K. oxytoca-sporadic occurrence

Enterobacter spp.

Sporadic occurrence

Escherichia coli

Salmonella spp.

Citrobacter freundii

Serratia spp.

Pseudomonas aeruginosa – Columbia & Puerto Rico

MECHANISMS OF RESISTANCE

• A CLINICAL ISOLATE OF E. COLI FROM THE SPUTUM SAMPLE OF A PATIENT ADMITTED

TO A BEIJING HOSPITAL WAS FOUND TO SHOW UNUSUAL RESISTANCE TO

CARBAPENEM THAT DOES NOT RELY ON THE PRESENCE OF CARBAPENEMASE. THE

ISOLATE WAS DETERMINED TO HAVE FOUR SEPARATE MUTATIONS TO ACQUIRE THE

RESISTANCE TO CARBAPENEMS. TWO MUTATIONS REMOVED THE OUTER MEMBRANE

PROTEINS OMPF AND OMPC TO PREVENT THE ANTIBIOTICS FROM REACHING THE

PBPS (PENICILLIN BINDING PROTEINS) IN THE INNER MEMBRANE.[8] A REGULATOR

GENE MARR WAS MUTATED AND A NORMALLY NON-TRANSLATED MEMBRANE

PROTEIN YEDS WAS EXPRESSED; BOTH WERE DEMONSTRATED TO HAVE EFFECTS ON

THE ABILITY OF THIS STRAIN OF E.COLI TO RESIST CARBAPENEMS. THE BACTERIA ALSO

INCREASED THE EXPRESSION OF A MULTIDRUG EFFLUX PUMP.Dr.T.V.Rao MD 23

MECHANISMS OF RESISTANCE

• FOUND TO SHOW UNUSUAL RESISTANCE TO CARBAPENEM THAT DOES NOT RELY ON THE

PRESENCE OF CARBAPENEMASE. THE ISOLATE WAS DETERMINED TO HAVE FOUR SEPARATE

MUTATIONS TO ACQUIRE THE RESISTANCE TO CARBAPENEMS. TWO MUTATIONS REMOVED THE

OUTER MEMBRANE PROTEINS OMPF AND OMPC TO PREVENT THE ANTIBIOTICS FROM

REACHING THE PBPS (PENICILLIN BINDING PROTEINS) IN THE INNER MEMBRANE.[8] A

REGULATOR GENE MARR WAS MUTATED AND A NORMALLY NON-TRANSLATED MEMBRANE

PROTEIN YEDS WAS EXPRESSED; BOTH WERE DEMONSTRATED TO HAVE EFFECTS ON THE

ABILITY OF THIS STRAIN OF E.COLI TO RESIST CARBAPENEMS. THE BACTERIA ALSO INCREASED

THE EXPRESSION OF A MULTIDRUG EFFLUX PUMP.

Dr.T.V.Rao MD 24

MAJOR TYPES OF CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CRE)

• TYPES OF CRE ARE SOMETIMES

KNOWN AS KPC (KLEBSIELLA

PNEUMONIAE CARBAPENEMASE)

AND NDM (NEW DELHI METALLO-

BETA-LACTAMASE). KPC AND NDM

ARE ENZYMES THAT BREAK DOWN

CARBAPENEMS AND MAKE THEM

INEFFECTIVE.Dr.T.V.Rao MD 25

WHO ARE LIABLE TO GET CARBAPENEM-RESISTANT ENTEROBACTERIACEAE

(CRE)

• PATIENTS WHOSE CARE REQUIRES

DEVICES LIKE VENTILATORS (BREATHING

MACHINES), URINARY (BLADDER)

CATHETERS, OR INTRAVENOUS (VEIN)

CATHETERS, AND PATIENTS WHO ARE

TAKING LONG COURSES OF CERTAIN

ANTIBIOTICS ARE MOST AT RISK FOR CRE

INFECTIONS.

• HEALTHY PEOPLE USUALLY DO NOT GET

CRE INFECTIONS. Dr.T.V.Rao MD 26

WHEN TO SUSPECT A KPC-PRODUCER

• ENTEROBACTERIACEAE – ESPECIALLY KLEBSIELLA PNEUMONIAE

THAT ARE RESISTANT TO EXTENDED-SPECTRUM CEPHALOSPORINS:

• MIC RANGE FOR 151 KPC-PRODUCING ISOLATES

• CEFTAZIDIME 32 TO >64 MG/ML

• CEFTRIAXONE ≥ 64 MG/ML

• CEFOTAXIME ≥ 64 MG/ML

• VARIABLE SUSCEPTIBILITY TO CEFOXITIN AND CEFEPIMEDr.T.V.Rao MD 27

PATIENTS CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CRE) INFECTION

• CRE INFECTIONS ARE MOST COMMONLY

SEEN IN PEOPLE WITH EXPOSURE TO

HEALTHCARE SETTINGS LIKE HOSPITALS AND

LONG-TERM CARE FACILITIES, SUCH AS

SKILLED NURSING FACILITIES, AND LONG-

TERM ACUTE CARE HOSPITALS. IN

HEALTHCARE SETTINGS, CRE INFECTIONS

OCCUR AMONG SICK PATIENTS WHO ARE

RECEIVING TREATMENT FOR OTHER

CONDITIONS.Dr.T.V.Rao MD 28

PATIENTS AT RISK WITH CARBAPENEM-RESISTANT ENTEROBACTERIACEAE (CRE) INFECTION

• PATIENTS WHOSE CARE REQUIRES

DEVICES LIKE VENTILATORS

(BREATHING MACHINES), URINARY

(BLADDER) CATHETERS, OR

INTRAVENOUS (VEIN) CATHETERS,

AND PATIENTS WHO ARE TAKING

LONG COURSES OF CERTAIN

ANTIBIOTICS ARE AMONG THOSE

AT RISK FOR CRE INFECTIONS.Dr.T.V.Rao MD 29

SPREAD OF CRE INFECTION

• TO GET A CRE INFECTION, A PERSON

MUST BE EXPOSED TO CRE BACTERIA.

CRE BACTERIA ARE MOST OFTEN

SPREAD PERSON-TO-PERSON IN

HEALTHCARE SETTINGS THROUGH

CONTACT WITH INFECTED OR

COLONIZED PEOPLE, PARTICULARLY

CONTACT WITH WOUNDS OR

STOOLDr.T.V.Rao MD 30

CRE CAN BE A IATROGENIC INFECTION

• CRE CAN CAUSE INFECTIONS

WHEN THEY ENTER THE BODY,

OFTEN THROUGH MEDICAL

DEVICES LIKE INTRAVENOUS

CATHETERS, URINARY

CATHETERS, OR THROUGH

WOUNDS CAUSED BY INJURY

OR SURGERY.Dr.T.V.Rao MD 31

MECHANISM OF RESISTANCE IN CRE

• RESISTANCE TO CARBAPENEM CAN BE DUE

TO A FEW DIFFERENT MECHANISMS. ONE OF

THE MORE COMMON WAYS THAT

ENTEROBACTERIACEAE BECOME RESISTANT

TO CARBAPENEM IS THROUGH THE

PRODUCTION OF KLEBSIELLA PNEUMONIAE

CARBAPENEMASE (KPC). KPC IS AN ENZYME

THAT IS PRODUCED BY SOME CRE THAT WAS

FIRST IDENTIFIED IN THE UNITED STATES

AROUND 2001.Dr.T.V.Rao MD 32

KPC BREAKS DOWN CARBAPENEM

• KPC BREAKS DOWN

CARBAPENEM MAKING THEM

INEFFECTIVE. IN ADDITION TO

KPC, OTHER ENZYMES, SUCH AS

NDM-1, VIM, AND IMP, CAN

BREAKDOWN CARBAPENEMS

AND LEAD TO THE

DEVELOPMENT OFDr.T.V.Rao MD 33

CDC INFORMS • SOME CRE BACTERIA HAVE

BECOME RESISTANT TO

ALMOST ALL AVAILABLE

ANTIBIOTICS AND CAN BE

DEADLY—ONE REPORT CITES

THEY CAN CONTRIBUTE TO

DEATH IN UP TO 50% OF

PATIENTS WHO BECOME

INFECTED.

Dr.T.V.Rao MD 34

KPC – QUESTIONS

• IF I HAVE DETECT KPC-PRODUCTION,

SHOULD I CHANGE SUSCEPTIBLE

CARBAPENEM RESULTS TO

RESISTANT?

• NOT ENOUGH DATA TO MAKE A CLEAR

RECOMMENDATION

• CLINICAL OUTCOMES DATA WILL BE

NECESSARYDr.T.V.Rao MD 35

TESTING OTHER DRUGS

•TIGECYCLINE:

• TEST BY ETEST IF POSSIBLE – DISK

DIFFUSION TENDS TO OVERCALL

RESISTANCE

• NO CLSI BREAKPOINT, BUT THERE ARE

FDA BREAKPOINT

• SUSCEPTIBLE ≤ 2 MG/ML

• INTERMEDIATE = 4 MG/ML

• RESISTANT ≥ 8 MG/MLDr.T.V.Rao MD 36

TESTING OTHER DRUGS

• POLYMIXIN B OR COLISTIN

• COULD TEST EITHER, BUT COLISTIN USED

CLINICALLY

• DISK DIFFUSION TEST DOES NOT WORK – DON’T

USE!

• ETEST – WORKS WELL, BUT NOT FDA CLEARED

• BROTH MICRODILUTION – REFERENCE LABS

• BREAKPOINTS - NONE

• MIC ≤ 2 MG/ML, NORMAL MIC RANGE

• MIC ≥ 4 MG/ML INDICATES INCREASED

RESISTANCEDr.T.V.Rao MD 37

PROTECT YOUR PATIENTS FROM CRE.

• FOLLOW CONTACT PRECAUTIONS AND

HAND HYGIENE RECOMMENDATIONS WHEN

TREATING PATIENTS WITH CRE.

• DEDICATE ROOMS, STAFF, AND EQUIPMENT

TO PATIENTS WITH CRE.

• PRESCRIBE ANTIBIOTICS WISELY.

• REMOVE TEMPORARY MEDICAL DEVICES

SUCH AS CATHETERS AND VENTILATORS

FROM PATIENTS AS SOON AS POSSIBLE.Dr.T.V.Rao MD 38

PATIENT ARE TOLD TO FOLLOW

CLEAN YOUR OWN HANDS OFTEN,

ESPECIALLY:

BEFORE PREPARING OR EATING FOOD

BEFORE TOUCHING YOUR EYES, NOSE, OR

MOUTH BEFORE AND AFTER CHANGING

WOUND DRESSINGS OR BANDAGES OR

HANDLING MEDICAL DEVICES AFTER USING

THE BATHROOM AFTER BLOWING YOUR

NOSE, COUGHING, OR SNEEZING

Dr.T.V.Rao MD 39

DOCTORS AND NURSES SHOULD CARE TO PREVENT CRE INFECTIONS

• EXPECT ALL DOCTORS, NURSES

AND OTHER HEALTHCARE

PROVIDERS WASH THEIR

HANDS WITH SOAP AND

WATER OR AN ALCOHOL-

BASED HAND RUB BEFORE AND

AFTER TOUCHING YOUR BODY

OR TUBES GOING INTO YOUR

BODY.

Dr.T.V.Rao MD 40

HEALTH CARE PROVIDERS CAN

• KNOW IF PATIENTS IN YOUR

FACILITY HAVE CRE.

REQUEST IMMEDIATE ALERTS

WHEN THE LAB IDENTIFIES CRE.

ALERT THE RECEIVING FACILITY

WHEN A PATIENT WITH CRE

TRANSFERS, AND FIND OUT WHEN A

PATIENT WITH CRE TRANSFERS INTO

YOUR FACILITY.

Dr.T.V.Rao MD 41

IF WE DO NOT STOP MISUSE OF ANTIBIOTICS AND PRACTICE ANTIBIOTIC POLICY – WE ARE WALKING INTO DARKNESS

Dr.T.V.Rao MD 42

VISIT ME FOR MORE ARTICLES OF INTEREST ON INFECTIOUS DISEASES ON …..

Dr.T.V.Rao MD 43

• PROGRAMME CREATED AND DESIGNED BY DR.T.V.RAO MD

FOR MEDICAL AND PARAMEDICAL PROFESSIONAL FOR

GLOBAL EDUCATION ON ANTIBIOTIC RESISTANCE

• EMAIL

• DOCTORTVRAO@GMAIL.COM

Dr.T.V.Rao MD 44