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Antimicrobial resistance & stewardship in resource-poor settings

Antibiotics saved millions of lives during the World Wars, and have continued to do so ever since. Today, the most complex medical interventions are possible because of them. Unfortunately, overuse and misuse of antibiotics has caused rising fear of a post-antibiotic era which is fast becoming a reality with no new antibiotics discovered in the recent past and rising drug resistance with superbugs. Studies report that 30-50% of antibiotics prescribed in healthcare settings are unnecessary or inappropriate (Centres for Disease Control and Prevention (CDC).

There is universal urgency for addressing optimal use of antibiotics which is possible only through an antimicrobial stewardship program. This is a simple solution for addressing the massive problem of antimicrobial resistance, a man-made disaster of the 21st century. There are multiple mechanisms of drug resistance in bacteria. The biggest challenge for any healthcare practitioner today is to treat multidrug-resistant organismassociated infections, especially in acute care settings and that too in resource-poor settings.

Some of the biggest medical problems in the history of medicine have been tackled with simple solutions like vaccination for smallpox. Similar tactics can also be applied for addressing antibiotic resistance by use of simple, basic practices like isolation precautions and barrier nursing in resource-limited settings for patients colonised by multidrug resistant organisms. Isolation precautions have been proven as an effective modality. Rather basic infection control practices have been time-tested during Ebola outbreaks recently, and also for unknown or undiagnosed diseases which are yet to be identified. The techniques are simple, yet highly effective. They are perfect to implement for resource-limited settings and are also justified since they do no harm to sick patients with multidrug resistant infections who seek medical care. Isolation precautions help to prevent the spread of infection from one patient to another patient, thus breaking the chain of transmission of pathogens.

One of the challenges is also to find out the burden of drug-resistant bugs in resource poor settings, since there is poor availability of microbiology culture facilities. Such facilities are confined to either public teaching hospitals or private hospitals. There is a lot of cross-discipline practice in laboratories wherein the facilities might be doing cultures, but the reporting is not done by a clinical microbiologist. It is done by pathologists who have little expertise or exposure, or perhaps by automated systems which is just oversimplification by depending upon the intelligence of a machine or software. There is always a possibility of over-reporting or underreporting in such circumstances. Needbased laboratory in community settings are vanishing with the advent of referral laboratory concept wherein most samples for testing are outsourced. There too, compromise in quality is there because the culture needs to be plated immediately after collection, otherwise contaminants can overgrow and give false positive results especially in samples like urine and sputum.

Another important aspect is quality of material supplied for testing antibiotic sensitivity. For example: Quality of disc, content of disc, method used for inoculum preparation, standard guidelines if any used; incubation period, lawn preparation, sterility maintenance, technical expertise and quality of media. There are other factors like preparation of media, pH, temperature of incubation, inoculums effects etc. which indirectly affect the results of testing. False susceptibility or resistance can be due to the same. There are also laboratories which are run by trained laboratory technical staff who are qualified for performing tests but not for interpretation of medical tests, yet they are signing the test reports because there is short supply of medical doctors and poor regulation by the government and other overseeing agencies.

The poor availability of culture facility is one of the reasons because of which the drug resistance in tuberculosis and pan-drug resistant bacteria belonging to Enterobacteriaceae family became so rampant in the 21st century. Another reason is too much availability of culture; too much dependency can make the problem worse, especially for doctors because of consumer and medico-legal aspects. In the background, the government is providing shelter for quacks to flourish under its ministry without scientific authentication of facts or findings. These factors too affect the prescribing practices for antibiotics. Most of the quacks have clinics and antibiotic prescriptions from these categories of doctors who are not lawfully allowed to practice antibiotic therapy.

Today is the era of Google search. Patients know their symptoms and what should be the guidelines for treatment. If doctors don’t give antibiotics, patients ask for the same. If the consultant who is an expert in a medical field does not prescribe some, they can easily go down the lane and to one of the quacks who will. Antibiotics are also available over the counter at pharmacies and chemist and druggist shops locally.

We have to understand that the problem of antibiotic resistance is perpetual and the extent to which it has become so rampant in community is a failure of human behavioral systems which are complex to understand. In case of antibiotic resistance, the stakeholders are multiple, starting from lawmakers to the last link in the chain that is the ultimate consumer who is a patient seeking medical care. Apart from medical use, the growth promotional use of antibiotics is practiced in animal husbandry and poultry. Antibiotics are used to promote growth and to prevent illnesses. Somewhere there is awareness which is building up at a large scale, but efforts and practices are still in infancy.

We may follow international and foreign guidelines and formulate policies, without realizing the ground reality of the indigenous nature of complex interactions leading to larger problems. There is an urgent need to recognize the extent of the problem by reorganizing and reorienting surveillance systems which will clearly reflect the picture of antibiotic resistance in the community. There is a need for better laboratory infrastructure to know the actual estimate of the problem especially at district and sub district level. There is also an unmet need for concept of community laboratory that caters to local populations and their needs for bacterial culture and antibiotic sensitivity testing. The medical curriculum needs include integrated problem solving solutions and enhances the skill set of antibiotic prescribing community. There is a need for a leadership system that will drive the antimicrobial stewardship programs at organizational level. Also, the entire focus should be decentralized to organizational level as every organization has different pattern of pathogens, their drug resistance and set practices which caters to these local level issues. Hospital environment and hygiene research should be promoted so also research on new drug resistance mechanisms and developing new molecules and infection control practices.

There is urgent need for reforms in government policies, law enforcement, training and education of doctors, nurses, pharmacists and clinical pharmacology experts, pharmaceutical industry and their representatives, veterinarian experts, animal husbandry specialists, dentists and ultimately society at large. Another important environmental aspect is improving sanitation and hygiene at local level; proving clean and potable water for consumption, reducing soil, water and air pollution, appropriate management of effluents, garbage and sewage and improving overall cleanliness can definitely help in eliminating pathogens or help in breaking the chain of transmission of pathogens.

“In such a case, the thoughtless person playing with penicillin treatment is morally responsible for the death of a man who finally succumbs to infection with a penicillin resistant organism. I hope the evil can be averted.” — Sir Alexander Fleming, Nobel Laureate for the discovery of penicillin, in a newspaper interview in 1945.

Dr. Dhruv K. Mamtora,
Consultant Microbiologist and Infection control officer,
S.L. Raheja Hospital, Mumbai

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