Learning to use antimicrobials responsibly
The article has been authored by Kamini Walia, Indian Council of Medical Research, New Delhi.
Antibiotic resistance that first appeared in hospitals in the 1950s is now a global public health challenge. Indiscriminate and inappropriate use of antibiotics has led to the emergence of multi-drug resistant bacteria jeopardising the cure for several infections. This exponentially increases treatment costs as well as morbidity and mortality associated with drug-resistant infections. In India, human antibiotic consumption is among the highest in the world. Published reports by Indian Council of Medical Research (ICMR) also document increasing trends of resistance in pathogens of public health importance.
As per the World Health Organization (WHO) classification, antibiotics are divided into three classes, i.e. Access, Watch and Reserve. The ‘Access’ antibiotics are first- or second-line treatments for common infections and should be widely accessible. Antibiotics in the ‘Watch’ category should be applied only to a limited group of well-defined syndromes. Their use should be closely monitored. ‘Reserve’ antibiotics should be applied as a last resort to treat multi- or extensively drug-resistant bacteria.
Studies published in India document that more than 50-75% of prescriptions happen from the Watch and Reserve category across all healthcare settings. These figures are a cause for concern as overuse of broad-spectrum antimicrobials threaten the emergence of resistance in many gram-positive and gram-negative pathogens, which are typically difficult to treat. As a result, this warrants the use of higher-generation antimicrobials, for example, from the Reserve group, which are invariably more expensive and increase the cost of treatment. A combination of factors has contributed to the growing use of broad-spectrum antimicrobials. This includes the absence of a definitive diagnosis of disease-causing pathogen and its antimicrobial susceptibility profile, increasing antimicrobial resistance to other antibiotic classes, lack of availability of first-line penicillin antibiotics belonging to the Access group and marketing and promotion practices of drug manufacturers. Overlooking this behaviour of excessive use of broad-spectrum antimicrobials from the Watch and Reserve group by physicians does not portend well for the times to come and may have severe consequences for the treatment of drug-resistant infections in Indian patients and associated morbidity and mortality.
The pipeline of new antimicrobials is running dry, and there are no new antimicrobials on the horizon. It is, therefore, vital to use judiciously and responsibly what we have. There is an acute need to implement the practice of antimicrobial stewardship (AMS) in all health care settings. AMS will entail education and sensitisation of physicians, institution of systems to capture antimicrobial consumption, and creation of mechanisms of audit and feedback on prescriptions across India’s diverse health care system. Every healthcare setting should create monitoring mechanisms, be it large multispecialty tertiary care hospitals, both public and private, medical colleges, State-funded health care systems, standalone private nursing homes, and general practitioners. These hospitals need to track their antibiotic consumption patterns and take necessary steps to reduce prescriptions from the Watch group. The National Medical Commission (NMC) has made it mandatory for all medical colleges to have a functional AMS committee. This practice must be supported by adequate diagnostic support by strengthening clinical microbiology laboratories and improving infection control practices in hospitals and the community to reduce the prophylactic use of antimicrobials.
There is now enough data available from the country to conclude that widespread inappropriate human use of antibiotics is the most important driver of antibiotic resistance in India. The government of India’s initiatives like the National Action Plan on AMR, creation of Integrated Public Health Laboratories, ICMR’s National Essential Diagnostics List, Free Diagnostics Initiative of National Health Mission and Kayakalp Programme augur very well with an overall aim of rationalising antimicrobial prescriptions by reducing infections and improving diagnostics. Investment and expeditious implementation of all these initiatives have the potential to translate into gains in terms of lives saved.
The article has been authored by Kamini Walia, Indian Council of Medical Research, New Delhi.