use in the hospital, but a multidisciplinary team

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Indian Journal of Medical Microbiology, (2012) 30(4): 381-3
1
Guest Editorial
Development of antibiotic resistance and its audit in our country: How to develop an
antibiotic policy
Chand Wattal
Persistent indiscriminate use and rising antibiotic
resistance world over may result in “Post antibiotic era”
in 7-10 years from now. This is an emergency situation
for public health care and calls for immediate redress.
Implementation of effective antibiotic policy can be one
significant step in this direction. The basis of antibiotic
policy rests in generating microbiological data and
prescription auditing at any one geographical place. But
there is a scarcity of quality literature on classified antibiogrammes from India, which is an impediment in
formulating local, regional or national-level antibiotic
policy. Why are we shy of measuring and sharing the data
resulting in its scarcity. Anti-biogramme, prescription
auditing and generation of drug resistance index (DRI)
could take us a long way in looking at the control of
resistance and rational use of antibiotics in our country.
The concept of time and concentration-dependent class of
antibiotics with understanding of their pharmacokinetics
and pharmocodynamics are important factors for successful
antibiotic therapy. I consider development of antibiotic
resistance no less than global warming. Various issues
involved in utilizing antibiotics intelligently and measuring
its impact as well are discussed here. Overuse of antimicrobial agents has been described world over in both
community[1,2] and hospital[3,4] settings. In addition to
its effect on patients,[5] antibiotic misuse can provoke
emergence of bacterial resistance[3] and increase healthcare cost.[6] It is evident that optimizing antibiotic use is a
challenge that deserves to be undertaken.
It has been observed that the infectious disease
physician plays a crucial role in controlling antibiotic
Corresponding author (email: <[email protected]>)
Department of Clinical Microbiology and Immunology, Sir Ganga
Ram Hospital, New Delhi, India
Received: 31-08-2012
Accepted: 18-10-2012
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DOI:
10.4103/0255-0857.103755
use in the hospital,[7] but a multidisciplinary team
approach is known to do better.[6,8] Bantar et al.[9]
published alarming rate of bacterial resistance in a
surveillance study involving 27 Argentinean health-care
centres and noted high rate of nosocomial infections,
surgical prophylaxis errors leading to unnecessary cost
increases in the hospital[10] and confirmation of misuse of
antibiotics in the same hospital. These findings provide
compelling evidence of the need for more rational use
of anti-microbial agents. To our knowledge, a systematic
strategy for control of antibiotic use in our country has
not been undertaken or published, as a result of which it
is difficult to compare consumption of antibiotics across
hospitals in India.
Inappropriate empiric antibiotic therapy is widespread
and is associated with increased mortality in critically
ill patients. Initial antibiotic selection must account for a
variety of host, microbiologic and pharmacological factors.
Institution-specific data, such as susceptibility patterns
and local antibiotic use need be known. Tailoring antimicrobial therapy based upon culture and sensitivity results
if available, will help reduce cost, decrease the incidence of
super-infection and minimize the emergence of resistance.
Therefore, it could be rewarding to invest in seeking
microbiological answers in a patient whom we clinically
believe has an infective aetiology (bacterial) before
instituting antibiotics.
The concept of antibiotic policy is not new and a lot of
effort goes into this exercise wherever it is undertaken. It is
its implementation in letter and spirit that requires serious
thinking.
Antibiotic Resistance Scenario and Prescription Auditing
With the current anti-infective therapies, multidrug resistant (MDR) organisms have come to stay
unless we change our practices. The matter is rendered
more complicated due to the presence of Extended
Spectrum β-lactamase (ESBL) and carbapenamaseproducing organisms as a result of the unbridled use of
Cephalosporins[3,11] and carbapenems.[4] Though this is
the scenario world over, particularly in intensive care
units, in our country, we are more vulnerable due to the
overwhelmingly indiscrete use and across-the-counter
availability of antibiotics.
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382
Indian Journal of Medical Microbiology
Illustrating this point is the high prevalence of
Methicillin Resistant Staphylococcus aureus (35%43% in ICU) and VRE (10%-44%) prevalent in Indian
hospitals.­[12,13] In a study at our institute, we demonstrated
a rise in consumption and resistance to broadspectrum anti-microbial agents and also established an
association between consumption and resistance to these
antibiotics.[4] There was a significant (P < 0.05) rise in
ESBL producers in E. coli from 40 to 61 per cent over
a period of 10 years.­[3] We also observed a predominant
burden, particularly in intensive care unit (ICU)’ s, of
MDR Acinetobacter spp. and CRE Klebsiella spp.[3,4]
Surprisingly , amongst the enterobacteriaceae, Klebsiella
spp. has become the most notorious bug having acquired
New Delhi Metallobeta lactamase -1 genes, as compared
to other enterobacteriaceae.[14] Resistance to even the
[13]
newly introduced drug, tigecycline, has risen to 37%.­
The creeping resistance to colistin in MDR bacteria[13]
is probably the “last straw” in this pandemonium. This
grim scenario warrants a directed effort towards continued
surveillance and antibiotic stewardship to minimize
selection pressure and spread.
The high resistance coupled with high anti-microbial
consumption of approx. 201.2-226.5 Defined Daily Dose
per 100 bed days in tertiary-care hospitals needs some
serious introspection by all stake holders.[3] Unfortunately,
data on anti-microbial consumption too, are scarce in India.
In our community, during the surveillance of antimicrobial prescription by physicians in Delhi, we found
high and irrational use of antibiotics in the community,
due to peer pressure to prescribe high-end antibiotics and/
or inability to diagnose infections, as the main reasons for
abuse of antibiotics.[15,16]
More importantly, communicating data of anti-microbial
prescription to policymakers for actionable plan remains a
challenge. Development of a new index[17] called DRI is an
effort in this direction. DRI is comparable to the composite
economic indices that measure consumer prices and a
stock market value. It is an aggregate resistance to various
drugs across specified period of time. Annual change in the
DRI helps in assessing the rate of depletion of antibiotic
effectiveness and also identify difficult to treat organisms
e.g., Klebsiella spp., and Acinetobacter spp. DRI can also
help measure outcomes of any policy being implemented,
e.g., antibiotic policy.
The advantages of DRI are:
• It is comparable across time and location
• Calculable with minimal data
• Simple enough for policymakers and non-infectious
disease medical practitioners to comprehend gaps in
drug effectiveness, affordability and accessibility.
Several
strategies
for
regulating
anti-microbial
vol. 30, No. 4
prescribing practices have been proposed, such as formulary
replacement or restriction,[18] introduction of order forms,[19]
health care provider education, feedback activities[20] and
required approval from an infectious diseases physician for
drug prescription.[7] Although most of these interventions
have been assessed separately, data from prospective studies
evaluating the impact of these different strategies in the
same hospital setting remain scarce. In addition, results of a
coordinated approach by a multidisciplinary team composed
of infectious disease physicians, clinical microbiologists and
pharmacists have rarely been reported.[8] We have shown
a significant reduction in antibiotic use when Hospital
Infection Control (HIC) committee performed feedback
activities. For feedback activities and effective antibiotic
policy it requires regular yearly data on anti-biogramme
and antibiotic consumption. It is needless to emphasise that
this data are expected to be quality-controlled. Lack of this
could either be due to inadequate resources for compilation
of such data or shying away from disclosing it in public
domains for fear of backlash.
The recent episode of NDM1 as one of the novel
mechanism of resistance acquired by bacteria did see us
in the eye of the storm. Thereafter, an urgent need has
been felt to create a reliable data base across the country
regarding the prevalence of antibiotic resistance in the
community and hospitals. The Ministry of Health and
Family Welfare Govt. of India is ceased with the burning
issue of drug resistance, prescription auditing and HIC in
the country, and has started an initiative in this direction.
Extensive guidelines have been made by the experts from
all the fields of medicine, veterinary and agriculture and
horticulture sciences involving Central Scientific and
Industrial Research Organization (CSIR) as well. A schedule
H1 has been created for top-end antibiotics, and drugs like
cephalosporins, amikacin, carbapenems, glycopeptides
and tigecycline to be made available only at tertiary-care
health facilities. While restrictions in the use of antibiotics
in resource-constrained settings is recommended, it cannot
be viewed without balancing treatment access to poor
patients in rural India, an issue put at the forefront by our
Union Health Minister. For the first time in the 15th fiveyear plan, the planning commission has allocated funds
adequately to lay down the firm foundation of a network
across the country to make the base-line data of antibiotic
resistance available. Three central govt.-controlled hospitals,
Lady Hardinge Medical College, Safdarjang Hospital
and Ram Manohar Lohia Hospital have taken the lead in
establishing a work module for the rest of the country to
emulate, in framing an antibiotic policy and HIC guidelines
based on their own anti-biogrammes. A model work sheet
has been developed by the expert group committee on
rational antibiotic use and framing of antibiotic policy
which has been web cast on the official web site of the
National Centre for Diseases Control (NCDC) earlier called
as National Institute of Communicable Diseases (NICD)
www.ijmm.org
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October-December 2012
Wattal: AMR and developing antibiotic policy
(http://www.scribd.com/doc/54122265/Indian-NationalPolicy-for-Containment-of-Antimicrobial-Resiatance-2011).
Networking of laboratories across the country as has
been realized is essential for a consensus guideline and to
understand the requirement of vaccines for our country. It is
also required to understand the researchable areas relevant
for our country. It is hard to understand as to why do we
fear sharing our data. As a result, the national data base does
not exist. Or if any sparse data are available, is it qualitycontrolled? Why are we shying away from this activity?
Should we all answer?
10.
11.
12.
13.
References
1. Ganguly NK, Arora NK, Chandy SJ, Fairoze MN, Gill JP,
Gupta U, et al. Rationalizing antibiotic use to limit antibiotic
resistance in India. Indian J Med Res 2011;134:281-94.
2. Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing
for adults with colds, upper respiratory tract infections,
and bronchitis by ambulatory care physicians. JAMA
1997;278:901-4.
3. Datta S, Wattal C, Goel N, Oberoi JK, Raveendran R,
Prasad KJ. A ten year analysis of multi-drug resistant blood
stream infections caused by Escherichia coli & Klebsiella
pneumoniae in a tertiary care hospital. Indian J Med Res
2012;135:907-12.
4. Goel N, Wattal C, Oberoi JK, Raveendran R, Datta S,
Prasad KJ. Trend analysis of antimicrobial consumption and
development of resistance in non-fermenters in a tertiary
care hospital in Delhi, India. J Antimicrob Chemother
2011;66:1625-30.
5. Beilby J, Marley J, Walker D, Chamberlain N, Burke
M; FIESTA Study Group. Effect of changes in antibiotic
prescribing on patient outcomes in a community settings: A
natural experiment in Australia. Clin Infect Dis 2002;34:55-64.
6. Barenfanger J, Short MA, Groesch AA. Improved
antimicrobial interventions have benefits. J Clin Microbiol
2001;39:2823-8.
7. John JF Jr, Fishman NO. Programmatic role of the infectious
diseases physician in controlling antimicrobial costs in the
hospital. Clin Infect Dis 1997;24:471-85.
8. Gums JG, Yancey RW Jr, Hamilton CA, Kubilis PS. A
randomized, prospective study measuring outcomes after
antibiotic therapy intervention by a multidisciplinary consult
team. Pharmacotherapy 1999;19:1369-77.
9. Bantar C, Famiglietti A, Goldberg M. Three-year surveillance
study of nosocomial bacterial resistance in Argentina. The
14.
15.
16.
17.
18.
19.
20.
383
Antimicrobial Committee; and the National Surveillance
Program (SIR) Participants Group. Int J Infect Dis 2000;4:85-90.
Bustos JL, Vesco E, Tosello C, Almará A, Boleas M, Magnin
E, et al. Alarming baseline rates of nosocomial infection and
surgical prophylaxis errors in a small teaching hospital in
Argentina. Infect Control Hosp Epidemiol 2001;22:264-5.
Cunha BA. Antibiotic resistance. Med Clin North Am
2000;84:1407-29.
Wattal C, Goel N, Oberoi JK, Raveendran R, Datta S, Prasad
KJ. Surveillance of multidrug resistant organisms in tertiary
care hospital in Delhi, India. J Assoc Physicians India
2010;58:32-6.
Sir Ganga Ram Hospital. Microbiology newsletter, 2012.
Available from: http://sgrh.com/newsletters/mb%20apr%20
2012.pdf. [Last accessed 2012 Aug 25].
Snitkin ES, Zelazny AM, Thomas PJ, Stock F, Henderson DK,
Palmore TN; NISC Comparative Sequencing Program Group
et al. Tracking a hospital outbreak of carbapenem-resistant
Klebsiella pneumoniae with whole-genome sequencing. Sci
Transl Med 2012;4:148ra116.
Wattal C, Raveendran R, Kotwani A, Sharma A, Bhandari
SK, Sorensen TL, et al. “Establishing a new methodology
for monitoring of antimicrobial resistance and use in the
community in a resource poor setting”. J Appl Ther Res
2009;7:16-24.
Kotwani A, Wattal C, Katewa S, Joshi PC, Holloway K.
Factors influencing primary care physicians to prescribe
antibiotics in Delhi India. Fam Pract 2010;27:684-90.
Laxminarayan R, Klugman KP. Communicating trends
in resistance using a drug resistance index. BMJ Open
2011;1:e000135.
Lee J, Carlson JA, Chamberlain MA. A team approach to
hospital formulary replacement. Diagn Microbiol Infect Dis
1995;22:239-42.
Gyssens IC, Blok WL, van den Broek PJ, Hekster YA, van der
Meer JW. Implementation of an educational program and an
antibiotic order form to optimize quality of antimicrobial drug
use in a department of internal medicine. Eur J Clin Microbiol
Infect Dis 1997;16:904-12.
De Santis G, Harvey KJ, Howard D, Mashford ML, Moulds
RF. Improving the quality of antibiotic prescription patterns in
general practice. The role of educational intervention. Med J
Aust 1994;160:502-5.
How to cite this article: Wattal C. Development of antibiotic resistance
and its audit in our country: How to develop an antibiotic policy. Indian
J Med Microbiol 2012;30:381-3.
Source of Support: Nil, Conflict of Interest: None declared.
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