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      “Ten Commandments” for the Appropriate use of Antibiotics by the Practicing Physician in an Outpatient Setting

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          Abstract

          A multi-national working group on antibiotic stewardship, from the International Society of Chemotherapy, put together ten recommendations to physicians prescribing antibiotics to outpatients. These recommendations are: (1) use antibiotics only when needed; teach the patient how to manage symptoms of non-bacterial infections; (2) select the adequate ATB; precise targeting is better than shotgun therapy; (3) consider pharmacokinetics and pharmacodynamics when selecting an ATB; use the shortest ATB course that has proven clinical efficacy; (4) encourage patients’ compliance; (5) use antibiotic combinations only in specific situations; (6) avoid low quality and sub-standard drugs; prevent prescription changes at the drugstore; (7) discourage self-prescription; (8) follow only evidence-based guidelines; beware those sponsored by drug companies; (9) rely (rationally) upon the clinical microbiology lab; and (10) prescribe ATB empirically – but intelligently; know local susceptibility trends, and also surveillance limitations.

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          Most cited references63

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          General Principles of Antimicrobial Therapy

          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 agents (such as pharmacodynamics and efficacy at the site of infection); accounting for host characteristics that influence antimicrobial activity; and in turn, recognizing the adverse effects of antimicrobial agents on the host. It is also important to understand the importance of antimicrobial stewardship, to know when to consult infectious disease specialists for guidance, and to be able to identify situations when antimicrobial therapy is not needed. By following these general principles, all practicing physicians should be able to use antimicrobial agents in a responsible manner that benefits both the individual patient and the community.
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            Antibiotics as intermicrobial signaling agents instead of weapons.

            It has been widely assumed that the ecological function of antibiotics in nature is fighting against competitors. This made them a good example of the Darwinian struggle-for-life in the microbial world. Based on this idea, it also has been believed that antibiotics, even at subinhibitory concentrations, reduce virulence of bacterial pathogens. Herein, using a combination of genomic and functional assays, we demonstrate that specific antibiotics (namely tobramycin, tetracycline, and norfloxacin) at subinhibitory concentrations trigger expression of determinants influencing the virulence of the major opportunistic bacterial pathogen Pseudomonas aeruginosa. All three antibiotics induce biofilm formation; tobramycin increases bacterial motility, and tetracycline triggers expression of P. aeruginosa type III secretion system and consequently bacterial cytotoxicity. Besides their relevance in the infection process, those determinants are relevant for the ecological behavior of this bacterial species in natural, nonclinical environments, either by favoring colonization of surfaces (biofilm, motility) or for fighting against eukaryotic predators (cytotoxicity). Our results support the notion that antibiotics are not only bacterial weapons for fighting competitors but also signaling molecules that may regulate the homeostasis of microbial communities. At low concentrations, they can even be beneficial for the behavior of susceptible bacteria in natural environments. This is a complete change on our vision on the ecological function of antibiotics with clear implications both for the treatment of infectious diseases and for the understanding of the microbial relationships in the biosphere.
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              Excessive antibiotic use for acute respiratory infections in the United States.

              Estimating the amount and cost of excess antibiotic use in ambulatory practice and identifying the conditions that account for most excess use are necessary to guide intervention and policy decisions. Data from the 1998 National Ambulatory Medical Care Survey, a sample survey of United States ambulatory physician practices, was used to estimate primary care office visits and antibiotic prescription rates for acute respiratory infections. Weight-averaged antibiotic costs were calculated with use of 1996 prescription marketing data and adjusted for inflation. In 1998, an estimated 76 million primary care office visits for acute respiratory infections resulted in 41 million antibiotic prescriptions. Antibiotic prescriptions in excess of the number expected to treat bacterial infections amounted to 55% (22.6 million) of all antibiotics prescribed for acute respiratory infections, at a cost of approximately $726 million. Upper respiratory tract infections (not otherwise specified), pharyngitis, and bronchitis were the conditions associated with the greatest amount of excess use. This study documents that the amount and cost of excessive antibiotic use for acute respiratory infections by primary care physicians are substantial and establishes potential target rates for antibiotic treatment of selected conditions.
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                Author and article information

                Journal
                Front Microbiol
                Front. Microbio.
                Frontiers in Microbiology
                Frontiers Research Foundation
                1664-302X
                24 November 2011
                2011
                : 2
                : 230
                Affiliations
                [1] 1simpleDivision of Infectious Diseases, Hospital Carlos Durand, University of Buenos Aires Buenos Aires, Argentina
                [2] 2simpleFundación Lusara Mexico City, Mexico
                [3] 3simpleMedical Microbiology, Aberdeen Royal Infirmary, Foresterhill Aberdeen, UK
                [4] 4simpleDivision of Medical Microbiology, Island Medical Program, University of British Columbia Victoria, BC, Canada
                [5] 5simpleDivision of Infectious Diseases, Jackson Memorial Hospital, University of Miami Coral Gables, FL, USA
                [6] 6simpleDivision of Infectious Diseases, University of Alberta Edmonton, AB, Canada
                [7] 7simpleDepartment of Clinical Sciences, Institute of Tropical Medicine Antwerp, Belgium
                [8] 8simpleInfectious Diseases and Hospital Infection Control, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro Rio de Janeiro, Brazil
                [9] 9simpleUnit for Infection Prevention and Control, Tygerberg Hospital and Faculty of Health Sciences, Stellenbosch University Cape Town, South Africa
                [10] 10simpleDivision of Infectious Diseases and Infection Control Program, American University of Beirut Medical Center Beirut, Lebanon
                [11] 11simpleDivision of Infectious Diseases, Shizuoka Cancer Center Hospital Shizuoka, Japan
                [12] 12simpleService Prévention et Contrôle de l’Infection, Hôpitaux Universitaires de Genève Genève, Switzerland
                Author notes

                Edited by: Tzi Bun Ng, The Chinese University of Hong Kong, China

                Reviewed by: Mamie Hui, The Chinese University of Hong Kong, China

                *Correspondence: Carlos F. Amábile-Cuevas, Fundación Lusara, Apartado Postal 8-895, 08231, Mexico City, Mexico. e-mail: carlos.amabile@ 123456lusara.org

                The International Society of Chemotherapy Antimicrobial Stewardship Working Group: Alex Aiken (Nairobi, Kenya), Amani Alnimr (Al Khobar, Saudi Arabia), Luis Bavestrello (Valparaíso, Chile), Jean Carlet (Creteil, France), Anahi Dreser (Cuernavaca, México), Sabiha Essack (Durban, South Africa), Po-Ren Hsueh (Taipei, Taiwan), Nadia Ismail (Al Khobar, Saudi Arabia), Deogratias Kaddu-Mulindwa (Adelaide, Uganda), Hans Jø rn Kolmos (Odense, Danmark), Takahiro Mochizuki (Shizuoka, Japan), Linus Ndewga (Nairobi, Kenya), Carla Odio (San José, Costa Rica), Miguel Angel Peredo (México DF, México), Silvio Vega (Panamá, Panamá), Rajlakshmi Viswanathan (Kolkata, India), Heiman Wertheim (Hanoi, Viet Nam).

                This article was submitted to Frontiers in Antimicrobials, Resistance and Chemotherapy, a specialty of Frontiers in Microbiology.

                Article
                10.3389/fmicb.2011.00230
                3225075
                22164154
                b8c55ffe-7917-439a-85a5-86f5c10e9ad4
                Copyright © 2011 Levy-Hara, Amábile-Cuevas, Gould, Hutchinson, Abbo, Saxynger, Vlieghe, Cardoso, Methar, Kanj, Ohmagari, Harbarth and ISC-ASW Group.

                This is an open-access article subject to a non-exclusive license between the authors and Frontiers Media SA, which permits use, distribution and reproduction in other forums, provided the original authors and source are credited and other Frontiers conditions are complied with.

                History
                : 25 August 2011
                : 29 October 2011
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 75, Pages: 7, Words: 6575
                Categories
                Microbiology
                Perspective Article

                Microbiology & Virology
                generic antibiotics,self-prescription,antibiotic stewardship,guidelines,antibiotic resistance,treatment compliance

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