EDITORIAL ON SPECIAL ARTICLE
Year : 2019 | Volume
: 21 | Issue : 1 | Page : 2--3
Antimicrobial stewardship programme
Department of Clinical Microbiology and Immunology, GRIPMER, Sir Ganga Ram Hospital, New Delhi, India
Prof. (Dr) Chand Wattal
Department of Clinical Microbiology and Immunology, GRIPMER, Sir Ganga Ram Hospital, New Delhi - 110 060
|How to cite this article:|
Wattal C. Antimicrobial stewardship programme.J Acad Clin Microbiol 2019;21:2-3
|How to cite this URL:|
Wattal C. Antimicrobial stewardship programme. J Acad Clin Microbiol [serial online] 2019 [cited 2020 Feb 27 ];21:2-3
Available from: http://www.jacmjournal.org/text.asp?2019/21/1/2/264246
Before we embark on the various aspects of antimicrobial stewardship programme (AMSP), there are some rules of the game for antibiotic usage that one needs to understand. For example, no microbe causes disease in 100% of its hosts; therefore, infection is not synonymous with disease. A distinction between colonisation and disease needs to be made. For example, isolation of Neisseria meningitidis from the blood or cerebrospinal fluid of an individual could appropriately be a case of meningococcal meningitis. On the other hand, the recovery of similar organism from a non-sterile site, for example, the nasal passage in a symptom-free person, is considered colonisation rather than infection, despite the fact that the organism was isolated in the host. In each situation, the patient has infection since the person harbours N. meningitidis, but in the former, the outcome of the infection is disease, whereas in the latter, it is colonisation. Hence, isolation alone does not reflect the clinical condition of the patient nor does it suggest a need for any type of intervention and/or therapy. At present, we lack adequate quantitative and qualitative measures of damage to establish objectively whether the states of commensalism and colonisation are harmless to the host, or will eventually produce damage resulting in disease. However, the clinical manifestations that characterise the diseases caused by most microbes are relatively well-defined and agreed upon. The recognition of these clinical entities has an important bearing in the therapy of infections and thereby need for AMSP.
AMSP as a programme is very essential since we have reached the dead end and I would sum up by saying 'If we are not discrete and do not act now, after another 7–8 years, it may not matter if we have antibiotics'.
Persistent indiscriminate use and rising antibiotic resistance world over may result in 'post-antibiotic era'. This is an emergency situation for public healthcare 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. However, there is a scarcity of quality literature on classified antibiograms 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? It is encouraging to find that when the country seems to be seized with this menace of antibiotic resistance, and Indian Council of Medical Research has created a network of 20 high-quality laboratories in institutions of repute across the country to collate bacteriology data on a day-to-day basis. The quality control of all these laboratories is being monitored by a dedicated external quality assurance programme. A standard operating procedure (SOP) has been established for these laboratories to follow. The SOP is at par with the internationally accepted guidelines and methodologies. As a result, a quality database is getting generated from our country to make our own antibiograms. A beginning has been made. The National Centre for Disease Control of our country has also started collecting data and strengthening laboratories in the peripheral district hospitals. You all will agree that without a minimum clinical microbiology laboratory setup, any genuine antibiotic sensitivity data cannot be generated in the country. And at present, it is pathetic in the district and primary health centre levels. Even in bigger hospitals in towns, only pathologists are mostly hired who have no training for clinical microbiology. The public awareness of the later speciality is very poor.
In addition, for AMSP to be meaningful, the user needs to understand the concept of time and concentration-dependent class of antibiotics with understanding of their pharmacokinetics and pharmacodynamics.
Overuse of antimicrobial agents has been described world over in both community and hospital settings. In addition to its effect on patients, antibiotic misuse can provoke the emergence of bacterial resistance and increase healthcare cost. It is evident that optimising antibiotic use is a challenge that deserves our urgent attention. The concept of drug bug combination for both therapy and antimicrobial susceptibility testing are pivotal for successful outcomes. The right drug, at right time, right dose and right duration need to be followed completely to prevent the development of resistance, and this is the essence of AMSP.
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 on culture and sensitivity results if available will help reduce cost, decrease the incidence of superinfection and minimise 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. To develop a culture of cultures before starting antibiotics needs to be integrated in the concept of AMSP.
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.,
When we say having reached a dead end, it signifies we are at the end of a road from where we have nowhere to go. This further means that while treating a case of overwhelming infection, it is rare to salvage the patient. With the current anti-infective therapies, multidrug-resistant organisms have come to stay unless we change our practices. The matter is rendered more complicated due to the presence of more complex mechanisms of resistance that the bacteria have acquired beyond extended-spectrum β-lactamases such as blaNDM1, blaOxa48, blaVIM, blaIMP and porin loss, as a result of the unbridled use of antibiotics. Although this is the scenario world over, in our country, we are more vulnerable due to the overwhelmingly indiscrete use and across-the-counter availability of antibiotics.
Implementation of AMSP in a healthcare setting is a complex process. It amounts to essentially a behaviour change. Prescribers need to understand the dynamics of development of resistance, which also is a multifactorial process. It is well-known that a team of specialists having an infectious disease physician or clinical microbiologists on board for guiding antibiotic therapy have better outcomes by way of morbidity and mortality. For making an antibiotic policy, the five most common isolates causing disease and the list of antibiotics with their per cent sensitivity in decreasing order need to be known. Once this data is available, patient risk stratification can be made and choice for empirical antibiotic therapy, disease location wise, can be laid down, which is specific for that healthcare setting. In a bigger setup, the antibiograms within the specialities also can vary and need to be generated accordingly for spelling out directed or empirical antibiotic therapy. De-escalation is an important activity of AMSP, which cannot be ignored. It is essential that the patients are reviewed regularly and at the earliest opportunity deescalated from high-end broad-spectrum to narrow-spectrum antibiotics. This can minimise the development of resistance.
In this issue of the Journal of the Academy of Clinical Microbiologists, the special article provides very useful AMSP-related information from 25 centres within India. Such information from the field level would be useful to review our policies and assess the impact of interventions.
|1||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.|
|2||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.|
|3||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.|
|4||Wattal C. Medical microbiology and the infectious diseases burden: Is India prepared? J Int Med Sci Acad 2004;17:155-8.|
|5||Bhattacharya S, Joy VM, Goel G, Nath SR, Santosh S, George K, et al. Antimicrobial stewardship programme – from policies to practices: A survey of antimicrobial stewardship programme practices from 25 centres in India. J Acad Clin Microbiol 2019;21:4-9.|