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EDITORIAL
Ahead of print publication  

Antimicrobial resistance an alarming global concern: Antimicrobial stewardship is the key


1 Department of Pediatrics, Army Hospital Research and Referral, New Delhi, India
2 Department of Internal Medicine, Army Hospital Research and Referral, New Delhi, India

Date of Submission07-Nov-2022
Date of Decision22-Nov-2022
Date of Acceptance23-Nov-2022
Date of Web Publication02-Dec-2022

Correspondence Address:
Anuj Singhal,
Army Hospital Research and Referral, New Delhi
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_167_22



How to cite this URL:
Shaw SC, Mahesh M, Singhal A. Antimicrobial resistance an alarming global concern: Antimicrobial stewardship is the key. J Mar Med Soc [Epub ahead of print] [cited 2023 Feb 6]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=362604




  Introduction Top


India is among the leading consumers of antimicrobials for both humans and animals. The factors such as inappropriate use of antibiotics [Table 1][1],[2], limited diagnostic facilities, inadequate patient education, unauthorized sale of antimicrobials, lack of well-functioning drug regulatory mechanisms, and nonhuman use of antimicrobials for use in the food industry/for animal husbandry are all factors responsible for unnecessary and excessive use (or misuse) of antimicrobials.[3] The ease with which antimicrobials are prescribed and used in India has led to a significant increase in antimicrobial resistance (AMR). It is by far one of the biggest challenges of health-care system, making the old antimicrobials ineffective and the new ones not available or not affordable.[4] The situation is really alarming as there is increasing resistance to even last-resort antibiotics such as carbapenems and colistins among Gram-negatives and to vancomycin and linezolid in Staphylococcus aureus.[5]
Table 1: Examples of inappropriate use of antibiotics

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  Scenario in Armed Forces Hospitals Top


The health care structure in the organization ranges from primary health-care centers like medical inspection rooms at field areas to tertiary care hospitals. Even though there is inappropriate use of antibiotics at individual level, some steps are being taken in Armed Forces Medical Services to remedy the same, such as studies on antibiotic policy,[6] infection control committee, better diagnostics in infectious diseases, and teamwork in approach to problem cases.


  Measures to Be Initiated Top


There is a dire need to initiate appropriate measures [Table 2][7],[8] to fight against this problem, develop a concerted multipronged strategy.
Table 2: Strategies to combat inappropriate use of antibiotics

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  What is Antimicrobial Stewardship Program? Top


Knowing that the problem of AMR is not going to be solved by the pharmaceutical companies as research in making new antimicrobials is a long process and often “low profit” one, the solution has to be to prevent the emergence of resistance or the person-to-person spread of resistant organisms.[3] A successful antimicrobial stewardship program (AMSP) is a systematic approach to use antimicrobials rationally and optimally to control AMR and to reduce inappropriate use of antimicrobials. AMSP refers to comprehensive strategies meant for rational use of antimicrobial agents by optimal usage of antimicrobial drugs, correct duration of therapy, correct dosing and route of administration with minimal toxicity, building of capacity for stewardship activities, developing policies and guidelines, educating health-care workers and introducing relevant interventions, specifically customized for Indian setting.[9] AMSP is used by health-care institutions to decrease inappropriate antimicrobial use, improve outcomes of patients, and reduce adverse effects of antimicrobial use including AMR, toxicity, and excessive costs.[10] Two of the most effective strategies are restrictive methods, requiring approval to prescribe a particular antimicrobial, and the proactive strategy of prospective review with direct intervention and proper feedback to the provider.[11]


  How Does This Antimicrobial Stewardship Program Function? Top


The infectious disease (ID) specialist (is a physician or someone trained in ID), a clinical microbiologist, a clinical pharmacist and infection control nurses are essential for a functional AMSP program in any hospital. As AMSP needs optimal resource allocation, the administrators should always be on board, for allocation of sufficient workforce, financial support, and information technology resources. Inputs from clinical microbiologist on local resistance patterns (hospital antibiograms) should be solicited and evidence-based antibiotic policy should be made with optimum dose and duration, with minimum side effects using the fewest formulary drugs. Hospital antibiograms should be periodically revised and guidelines about antibiotic policy should be prepared based on the site of infection (intra-abdominal infections, head-and-neck infections, urosepsis, pneumonia, skin or soft-tissue infection, and bone and joint infections). The guidelines should also mention first line and alternate regimens for treatment. Periodic training of all health-care staff on antimicrobial use should be ensured. There should be regular audits to review the clinical notes, prescriptions, laboratory results, etc., and even more importantly, the audit of use of carbapenems and polymyxin in the hospital. There should be a monitoring system preferably electronic to check antibiotic prescription and usage, and even expenditure on antibiotics should be monitored. The curriculum in medicine and nursing should include AMSP at both undergraduate and postgraduate levels. There should be ongoing awareness drives among patients, administrators, and governing authorities by various means including digital messaging.[9]

Among many interventions, important ones are optimizing the duration of therapy as infections are often treated for longer than the recommendations and each additional day of antibiotics increases the risk of harm to the patient and also increases resistance. There must be consistent efforts to improve diagnostic accuracy including point-of-care tests, send relevant samples for culture before initiating antibiotics, and to utilize optimally viral diagnostics and/or procalcitonin for stopping antibiotics. Using restricted antimicrobials for empirical treatment, optimization of dose, documentation of indication for initiating antibiotics every time, automatic change from intravenous to oral, computerized duplicative therapy alerts, shortening duration of treatment in case of prophylactic use, time-sensitive automatic stop orders, and changing of broad-spectrum antibiotics once culture results are available are the other noteworthy interventions.[12]

There should be quality initiative (QI) projects to improve the antimicrobial usage in a hospital, as QIs have been found to be very effective in optimizing antibiotic usage and a relatively simple, systematic, and practical way of dealing with this problem. The objective measurements should be done for ensuring improvement. The three kinds of measures in QI are process measures, outcome measures, and balancing measures. The process measures may include compliance with care bundles (e.g., central line insertion bundle, ventilator-associated pneumonia bundle), duration of antibiotic usage, and rates of evaluation for sepsis. Outcome measures may be the rate of unindicated use of antibiotics, infection-related mortality rate, length of hospital stay, yield of bacterial cultures, and AMR rates. The balancing measures may be readmission rates, rates of complications, treatment-related adverse effects, and expenditure on treatment.[9],[13],[14],[15]


  Conclusion Top


The goals of the implementation of AMSP would be to reduce the emergence of resistant organisms, minimize adverse consequences of antibiotics, and to reduce expenditure on antimicrobials. It is indeed the need of the hour and there is no single template or means to optimize use of antimicrobials in hospitals. Implementation of AMSP needs flexibility, and addressing the relevant factors of a particular hospital, as there is real complexity of medical decision-making in antibiotic use and quality of care is not uniform among different hospitals.[12]



 
  References Top

1.
Doron S, Davidson LE. Antimicrobial stewardship. Mayo Clin Proc 2011;86:1113-23.  Back to cited text no. 1
    
2.
Dryden M, Johnson AP, Ashiru-Oredope D, Sharland M. Using antibiotics responsibly: Right drug, right time, right dose, right duration. J Antimicrob Chemother 2011;66:2441-3.  Back to cited text no. 2
    
3.
Ayukekbong JA, Ntemgwa M, Atabe AN. The threat of antimicrobial resistance in developing countries: Causes and control strategies. Antimicrob Resist Infect Control 2017;6:47.  Back to cited text no. 3
    
4.
Sahni A, Bahl A, Martolia R, Jain SK, Singh SK. Implementation of antimicrobial stewardship activities in India. Indian J Med Spec 2020;11:5-9.  Back to cited text no. 4
  [Full text]  
5.
Gandra S, Mojica N, Klein EY, Ashok A, Nerurkar V, Kumari M, et al. Trends in antibiotic resistance among major bacterial pathogens isolated from blood cultures tested at a large private laboratory network in India, 2008-2014. Int J Infect Dis 2016;50:75-82.  Back to cited text no. 5
    
6.
Bhatt P, Patel A, Sahni AK, Praharaj AK, Grover N, Chaudhari CN, et al. Emergence of multidrug resistant enterococci at a tertiary care centre. Med J Armed Forces India 2015;71:139-44.  Back to cited text no. 6
    
7.
Katoch R, Rajagopalan S. Warfare Injuries: History, triage, transport and field hospital setup in the armed forces. Med J Armed Forces India 2010;66:304-8.  Back to cited text no. 7
    
8.
Danish Khan I, Mohan Gupta R, Sen S, Rajmohan K, Kumar Jindal A, et al. Emerging antimicrobial resistance and evolving healthcare: Dangerous crossroads for the community and the military. J Arch Mil Med 2017;5:e12097.  Back to cited text no. 8
    
9.
Walia K, Ohri VC, Madhumathi J, Ramasubramanian V. Policy document on antimicrobial stewardship practices in India. Indian J Med Res 2019;149:180-4.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
MacDougall C, Polk RE. Antimicrobial stewardship programs in health care systems. Clin Microbiol Rev 2005;18:638-56.  Back to cited text no. 10
    
11.
Duguid M, Cruickshank M, editors. Antimicrobial Stewardship in Australian Hospitals. Sydney: Australian Commission on Safety and Quality in Health Care; 2011.  Back to cited text no. 11
    
12.
Centers for Disease Control and Prevention. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2014.  Back to cited text no. 12
    
13.
Meyers JM, Tulloch J, Brown K, Caserta MT, D'Angio CT, GOLISANO CHILDREN'S HOSPITAL NICU ANTIBIOTIC STEWARDSHIP TEAM. A quality improvement initiative to optimize antibiotic use in a level 4 NICU. Pediatrics 2020;146:e20193956.  Back to cited text no. 13
    
14.
Konda KC, Singh H, Madireddy A, Poodari MMR. Quality improvement initiative approach to decrease the unindicated usage of antibiotics in a neonatal intensive care unit of a tertiary care teaching hospital in Hyderabad, India. BMJ Open Qual 2021;10:e001474.  Back to cited text no. 14
    
15.
Jain M, Bang A, Meshram P, Gawande P, Kawhale K, Kamble P, et al. Institution of an antibiotic stewardship programme for rationalising antibiotic usage: A quality improvement project in the NICU of a public teaching hospital in rural central India. BMJ Open Qual 2021;10:e001456.  Back to cited text no. 15
    



 
 
    Tables

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Introduction
Scenario in Arme...
Measures to Be I...
What is Antimicr...
How Does This An...
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