Antibiotics (including other antimicrobials) are undoubtedly one of the most successful therapeutic agents that have significantly reduced morbidity and mortality not only in human beings but also in all other animals. But the success of these antibiotics is marred by the emergence of hard to treat multiple antibiotic resistant infections. At present, fewer antibiotics are in pipeline and there is a danger of heading towards post antibiotic era. Dr. Margaret, Director General of World Health Organization, confirmed “post antibiotic era means, in effect an end to modern medicine as we know it. Things as common as strep throat or a child’s scratched knee could once again kill.” Though scientifically antibiotics and antimicrobials are two different terminologies, in general practice they are treated as synonyms. In this article they are used interchangeably and they include all substances with antibacterial, antifungal or antiparasital activities.
The antimicrobial resistance is threatening the remarkable progress that has been made against the communicable diseases like TB, HIV, and Malaria. The routine medical care, surgery, cancer treatment, organ transplantation etc. are impossible without the availability of effective antibiotics. Antimicrobial resistance is more common in hospital settings than in the community due to selection pressure on microbes caused by high intensity of antimicrobial use. Every time an antimicrobial is used, the susceptible bacteria are killed leaving behind the resistant ones. The use of antimicrobials selects for resistant bacteria is called selection pressure. In our country, we have many issues: no documentation or availability of national data on antimicrobial resistance, poor infection control practices in health settings, free availability of antibiotics without the prescriptions and above all poverty limiting the purchasing power. Poor infection control practices in the healthcare setting leads transfer of resistant organisms between the patients and between patients and staff. The increasing resistance in the hospital may also cause increasing resistance in the community.
Realising the danger of antimicrobial resistance four core interventions are advocated to fight against the antibiotic resistance. These are preventing infections and preventing the spread of resistance; promoting antimicrobial resistance surveillance; improving the use of antibiotics; and developing new antibiotics and diagnostic tests. Preventing infections can be achieved through good infection control practices in the hospital. Avoiding infections reduces the use of antibiotics which in turn reduces the chances of developing resistance. Immunizations, safe food preparations, hand washing and using antibiotics as required and when necessary are important ways to prevent the spread of infections. Data on antibiotic resistance, antibiotic resistant infections, causes of infections, and identifying the risk factors help in developing specific strategies to prevent these infections and prevent the spreading of resistant bacteria. Improving antibiotic prescribing and their use are very important as the use of antibiotics in humans and animals are rampant and are most of the time unnecessary. Stopping of these unnecessary and inappropriate uses of these antibiotics would go in slowing down the spreading of resistant bacteria. The development of new antibiotics would be helpful in treating the resistant bacteria. But the development of new antibiotic is not easy task. The pharmaceutical companies now do not give much attention to the development or discovery of antibiotics as there is likely of resistance after some period of use. The drug may not even be useful for the patent period that makes investment very risky. The development of new diagnostic tests helps tracking the development of resistance.
While the coordinated strategies using the four inventions are essential fighting the antimicrobial resistance, improving antibiotic prescribing and use are perhaps the single most important action required to greatly slow down the development and spread of antibiotic resistant infections. The commitment to always use antibiotics appropriately and safely in the health care system or the hospital is important. The World Health Organization has been advocating the hospital based antibiotic policy for promoting rational use of antibiotics in the hospital. A significant proportion of prescriptions of antibiotics are reported as unnecessary and/or inaccurate with respect to dosage, duration of treatment, or the antibiotics selected. Prescription audit with feed back to the prescribers are known to be effective in changing behaviour with respect to prescribing and use of antimicrobials. The World Health Organization says “Prescription auditing is an indispensible and effective tool to monitor antimicrobial prescription practices. If properly done, it can help treating physicians to improve the antimicrobial prescription skills and help the hospital to adhere to, monitor and improve compliance to antibiotic policy.” The antibiotic use audit is similar to drug use evaluation. The prescription auditing should be done by a team of physician, infectious disease specialists, clinical microbiologists, and pharmacologists. The WHO urges to use the structured policy and procedure for antibiotic use auditing. The audit should be done at regular intervals to make sure that the prescriptions adhere to the hospital’s antibiotic policy and guidelines. Antibiotics given during the discharge of inpatients and those prescribed to outpatients should be monitored in order to contain the spread of resistance to the community. The National Policy for Containment of Antimicrobial Resistance of India (2011) too advocates auditing of prescription of antibiotics to promote rational use of antibiotics in health facilities. But this needs to be mandatory and implemented.
Antimicrobial resistance is a global problem requiring a global effort and solution. The development of resistance is a natural process. It cannot be stopped but need to be slowed down. It is necessary to initiate coordinated action on the root cause of developing resistance – the misuse of antimicrobials. The policy or guidelines must be in place to improve the use of existing antimicrobials. The antibiotic use audit would at least help promoting (if not completely ensuring) the appropriate use of these therapeutic agents. The changing practices in the hospital is not easy.
(Authors are with Department of Pharmacy, Annamalai University, Annamalai Nagar, Tamil Nadu 608 002)