Judicious use of antibiotics

Antibiotics, Clinical

There is the need for Government and third-party audit to assess appropriate antibiotic use is non-existent in our country

Antibiotics have been lifesaving since early 1920s after the first invention of penicillin by Dr Alexander Fleming. The inventor at that time itself (1940s) warned humanity against misusing the ‘magic bullet’, the efficacy against microbes would vanish because of development of resistance. We proved him right, in less than a century. Not only did we render the original molecule null, but also its successive modifications. This has resulted in a global epidemic of antimicrobial resistance. The proverbial “operation was successful, but the patient died” is soon going to be true; even minor infections such as tonsillitis/ appendicitis could prove fatal, because we have exhausted all the effective options.
The reasons for the occurrence of antimicrobial resistance are many folds. Most important of them all is the ability of the microbial organisms to adopt to the changing environment. The bacteria modify their own cell walls, enzymatic systems and develop mutant versions to tackle the onslaught of antibiotics. These changes in the bacteria are assisted by several actions by the humans. They are, using wrong doses (usually under doses), wrong antibiotic, not completing the prescribed dosage schedule, and treating viral infections with antibiotics, which are not essential.
What are the adverse outcomes of drug resistance?
The bacteria, which get resistant will withstand treatment with even normal doses of appropriate antibiotics, thereby rendering the treatment ineffective. Even relatively minor infections get difficult to or impossible to treat. The cost and morbidity of treatment will increase. A cross infection may increase the community acquiring multi drug resistant microbial infection. An infection, which was hitherto treatable becomes extremely resistant and fatal. The case of resistance of tuberculosis to conventionally used antitubercular treatment is a case in point. This scenario is complicated by the fact that there are no new antibiotics in the pipeline. The reasons are two fold; firstly, the pharmaceutical industries are not keen on investing on research and development of newer antibiotics, because their use will again be curtailed by the infection control community. They are therefore called the “orphan molecules”. Secondly, the governments have not invested in developing these molecules.
Several reckless actions that caused antimicrobial resistance to antibiotics are:
a. Prescription of wrong choice, dose and duration by qualified doctors appears to be a major problem in India. Many pharmaceutical companies lure the physicians into abusing antibiotics for mutual gains. Recently, the government of India has come down heavily on the pharmaceutical industry from carrying out nefarious sponsorship of doctors. This is a welcome move, and this has to reach the logical end by tackling the ill informed doctors from dangerous prescriptions.
b. Self-administration of antibiotics facilitated by means of ‘over the counter’ (OTC) dispensation. It is common to find pharmacies dispensing antibiotics to gullible customers, who will encourage the harmless, normally existing bacteria in their body to get resistant. This can be stopped by making dispensation of medicines by OTC impossible. Such dispensations should be strictly audited, and wrong doers must be punished.
c. The poultry farmers, aquaculture industry, and agriculture industry misuse antibiotics for non -medical purposes. This terrible practice must stop immediately.
d. Government and third-party audit to assess appropriate antibiotic use is non-existent in our country. Many developed countries have data on each doctor’s prescription patterns, based on which, individual doctor could be audited. In India, we need to develop such tools.

Why should antibiotics be rationally used?
Judicious and rational use of antibiotics is perhaps the only tool available to us today. The humongous problem of antimicrobial resistance was caused by irrational reckless use of antibiotics. We have reached a point, where no newer antibiotics are available. By judicious and rational use of antibiotics, we may be able to undo some of the problems of worsening antimicrobial resistance. If we don’t carry out antimicrobial stewardship, we may be left with a few last antibiotics to treat infections.
Hospital spaces have a role to play. At Fortis hospitals, where the author works, a few initiatives have been brought in to curb the menace of antibiotic abuse. They are:
a. At institutional level, a list of irrational combinations of antibiotic has been prepared and these formulations are banned from being stocked in all the pharmacies of Fortis hospitals.
b. No doctor can start treatment (barring a few rare exceptions) with higher antibiotics.
c. If antibiotics are to be used for more than 2 doses, the doctor will have to justify the use by filling up a “antibiotic use justification form”
d. The hospital information technology team tracks the use of higher antibiotics in real time.
e. The hospital infection prevention and control committee (HIPACC) issues doctors indulging in inappropriate antibiotic use a “private information letter (PIL)” which informs them about the inappropriate use effected by them. This letter also supplies information about hazards of inappropriate use of antibiotics. In developed countries, the facility director issues a ‘show cause’ notice to such doctors. It may be one of the best practices for hospital spaces in India to emulate.
f. Group of doctors from similar sub-specialties are involved in meetings highlighting the best practices of their colleagues, who could be matched. The HIPAC committee also involves in spreading good practices among doctors to other hospitals as well via ‘continuing medical education’.
g. The efficacy of antibiotics in each hospital space is assessed by using a unique index called “Drug Resistance Index” (DRI). This index could benchmark each hospitals efficacy in curbing antibiotic abuse. At Fortis hospitals, DRIs of all the hospitals are tracked by the Central Infection prevention and control committee.
With these measures, there is a gradual decline of use of precious higher antibiotic at Fortis hospitals. By generating peer pressure among doctors, a sense of competitive spirit is generated, that promotes overall improvement in appropriate antibiotic use.
The issue of antimicrobial resistance to antibiotics is multifaceted and requires the will and tenacity of many stakeholders from the governments of countries to the general public. The physicians play a major pivotal role in aligning these members to achieve success. Many countries have already escalated the epidemic of antimicrobial resistance to a high priority requiring the attention of the highest government officials. Even India has in principle produced a ‘white paper’ – a well-researched document with good scientific evidence. However, its execution in letter and spirit is yet to occur. While these governmental procedures are underway, responsible doctors may ‘suo moto’ participate in self-regulated antimicrobial stewardship and contribute to the good cause.

Dr Murali Chakravarthy is Chairman, Central Infection Prevention and Control Committee, Fortis Healthcare.