There’s a pressing need to implement antibiotic protocol in all hospitals

Patients admitted to hospitals for surgery or treatment are susceptible to healthcare-associated infections (HAI) such as central line-associated bloodstream infections, catheter-associated urinary tract infections and ventilator-associated pneumonia. These are exceedingly critical medical conditions to manage, as the bacteria responsible are resistant to even the strongest antibiotics available, a phenomenon referred to as antimicrobial resistance (AMR). 

In the face of the onslaught of these superbugs, the hospital staff administer a high dose of antibiotics or one antibiotic after another in the hope that at least one of them might work.

Patients in hospitals have low immunity and are often too weak to fight off germs, thereby making the entire treatment procedure complicated. Due to the high levels of exposure to antibiotics in hospital settings, particularly in intensive care units (ICU), these bacteria develop resistance as a natural survival strategy. Termed superbugs, these resistant bacteria cause more dangerous infections that require advanced antibiotics.

A surveillance study conducted by the International Nosocomial Infection Control Consortium in 45 low- and middle-income countries from 2012 to 2017 found that pooled rates of catheter-associated urinary tract infections and central line-associated bloodstream infections were three to six times higher than in intensive care units in the United States.

A 2022 global report by World Health Organization on infection prevention and control observed that the risk of acquiring HAIs is up to 20 times higher in relatively poor countries.

The situation in India is particularly alarming. According to a report published in medical journal The Lancet in September 2023, a network of 26 tertiary-level hospitals in India established to implement HAI surveillance and prevention activities reported 2,622 healthcare-associated bloodstream infections and 737 healthcare-associated urinary tract infections (UTIs) from 89 ICUs between May 2017 and October 2018. 

High levels of resistance to at least one drug of the last-resort carbapenem class of antibiotics were found in HAIs caused by Klebsiella spp. (bloodstream infections 72.4 per cent, UTIs 76.3 per cent), Escherichia coli (bloodstream infections 58 per cent, UTIs 62 per cent), Acinetobacter spp. (bloodstream infections 77.2 per cent, UTIs 75.7 per cent) and Pseudomonas spp. (bloodstream infections 63.7 per cent, UTIs 71.9 per cent). Alarmingly, all of them are dreaded gram-negative pathogens.

While advancements in modern medicine have provided us with more sophisticated tools to combat this issue, antibiograms, which are used in most large tertiary care centres to collect data on drug resistance patterns, have been instrumental in this fight. With the advent of automated systems and technological advancements, the process of generating antibiograms has become more efficient and accurate. 

These antibiograms aid in the appropriate identification of patients at risk and the administration of suitable empiric antibiotic therapy. They are an essential resource for institutions to track changes in AMR and guide empirical antimicrobial therapy. 

Another report, Situation analysis: Antibiotic use and resistance in India, based on a study conducted by nonprofit Global Antibiotic Research and Development Partnership and public health research organisation One Health Trust, has pointed out that in Indian ICUs, the prevalence of vancomycin-resistant enterococcus, a deadly nosocomial infection, was five times higher than in the rest of the world.

The government is aware of the gravity of the situation and has initiated steps towards an antibiotic stewardship programme. The apex biomedical research institution, Indian Council of Medical Research (ICMR), initiated an antibiotic stewardship programme on a pilot project basis in 20 tertiary care hospitals across India to control the misuse and overuse of antibiotics in hospital wards and ICUs.

The government has undertaken several initiatives to address this major public health challenge. One of the key initiatives was the launch of National Programme on AMR Containment, coordinated by the National Centre for Disease Control (NCDC) in Delhi. The objective is to enhance the capacity of medical colleges and other large hospitals to generate quality AMR surveillance data and monitor its patterns in the country. 

Under this programme, a network of laboratories has been established under the National AMR Surveillance Laboratory Network (NARS-Net). NARS-Net began with eight medical college laboratories through a sentinel surveillance approach. The sentinel surveillance network sites have been progressively expanded to include 40 laboratories in 31 states and Union territories as of March 2023, along with the National Reference Laboratory for Bacterial Pathogens at NCDC.

India had also launched its National Action Plan on AMR (NAP-AMR) in April 2017 with six strategic priorities. These are, improving awareness and understanding of AMR through effective communication, education and training; strengthening knowledge and evidence through surveillance and reducing the incidence of infection through effective infection prevention and control. 

Optimising the use of antimicrobial agents in health, animals and food; promoting investments for AMR activities, research and innovations and strengthen India’s commitment and collaborations on AMR at international, national and sub-national levels are the rest of the priorities . 

The Union Health Ministry is now planning to prepare a National Action Plan on AMR 2.0. 

However, while large tertiary care centres have their own infection control teams, smaller centres often lack the manpower, training and management commitment to dedicate resources for infection control. These centres could be a game changer with enhanced government support, something that could also benefit non-governmental organisations working towards data collection and creating awareness about AMR.

There is a need for continuing medical education updates for practising doctors to update their knowledge on the latest breakpoints and susceptibility patterns. The ramifications of AMR should also be included in the medical curriculum and infection-control protocols should be uniformly implemented in healthcare settings.

Doctors and hospitals should join hands to take on this threat through an antibiotic protocol, which should be enforced across all hospitals in the country. With an appropriate protocol in place, the right antibiotic can be administered at the right time, thus cutting down on the presumptive treatment period.

A more robust system that ensures the uniform implementation of AMR-related programmes and protocols across all healthcare settings in the country and active participation of all stakeholders is required to tackle the threat of AMR.

Saransh Chaudhary is President, Global Critical Care, Venus Remedies Ltd and CEO, Venus Medicine Research Centre

Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth