"Worldwide more than 50 per cent of all medicines are prescribed, dispensed, or sold inappropriately, while 50 per cent of the patients fail to take them correctly", says World Health Organization Policy Perspective in Medicines (2002).

The antimicrobials have been helpful reducing the morbidity and mortality due infectious diseases. Worldwide the major infectious diseases kill over 11 million people per year. Many communicable diseases have been contained. The antimicrobials constitute about 20-40 per cent of hospitals' medicine budget. Even after several significant developments in medical sciences, the antimicrobials remain essential for the treatment of many killer infectious diseases. Unfortunately they are one of the most irrationally used groups of medicines.

The antimicrobials usually include antibacterial agents including antibiotics, antiviral and antiprotozoal that act against bacteria, virus and protozoa. The estimate showed that perhaps half of all antibiotic consumption may be unnecessary. The unnecessary and irrational uses of these medicines have clinical, environmental and economic consequences. The antimicrobial misuse leads to poor patient outcome, unnecessary adverse reactions and wasted resources. The overuse and misuse of antimicrobials are the key drivers of antimicrobial resistance (AMR). The AMR is not just related to bacteria and mycobacteria but also to virus and protozoa.

The common types of antimicrobial misuse include: the use of antibiotics in treatment of minor respiratory and gastrointestinal infections, viral infections and self limiting bacterial diseases that do not benefit from use of antimicrobials; incorrect choice of antimicrobial for common problems, to cite an example - use of broad spectrum antimicrobials when a narrow spectrum drug would be sufficient; insufficient dose or duration due to unaffordability; inappropriate choice of antimicrobials for surgical prophylaxis; wrong dose and duration of appropriate antimicrobial prophylaxis and treatment and the tendency to use newly introduced and expensive antimicrobials, when there is no evidence supporting better drug susceptibility of the newer drug over an older one.

The following various strategies have been advocated worldwide to promote appropriate use of antimicrobials:

Hospital based strategy

• Establishment of antimicrobial committee or subcommittee at health facility level to set norms and monitor antimicrobial use
  
• Development of standard treatment guidelines for infectious diseases based on antimicrobial resistance pattern
  
• Limiting the antimicrobial prescribing to various levels like non-restricted, restricted and very restricted
  
• Prescription auditing of antimicrobial use
  
• Improving diagnostic facility to clinicians to help prescribing appropriately
  
• Promoting surveillance of antimicrobial resistance
  
• Following good infection control practices

Community based strategy

• Orienting and sensitizing doctors and other health workers on the need of rational use of antimicrobials and danger of microbial resistance
  
• Creating awareness among the drug sellers on the ills of dispensing antimicrobials without prescription
  
• Educating the patients or consumers on the need of using antimicrobials when required only and to avoid self medications.

National level strategy
Developing guidelines/policy on antimicrobial use

• Developing guidelines on infection control
  
• Initiating national antimicrobial resistance surveillance programme
  
• Developing evidence based standard treatment guidelines for infectious diseases

Some of the common issues
India is a big country with health being the primary responsibility of state governments. The government health spending is too very low is just 1-2 per cent of GDP while the overall health spending is around 5 per cent of GDP. The availability of medicines is always a problem in many public hospitals and the consumers spend on their own for medicines. The medicines often are unaffordable that make the patients not to complete the full course of antimicrobials.

The antimicrobials are available in retail without prescriptions though they belong to prescription only medicines. The free availability leads to rampant misuse of these medicines. This is because of poor implementation of drug regulation. The Government now considers restricting the dispensing of antimicrobials through need of duplicate prescription. The Government is actively considering the idea of making it mandatory for the dispenser of medicines to keep a copy of dispensing while dispensing antimicrobials. But the questions remain how many doctors especially in community will write prescription in duplicate.

There are no national guidelines on infection control and antibiotic use. There is no antibiotic policy or antimicrobial surveillance. However, now the Government of India proposes to develop infection control and antibiotic policy. However, certain hospitals like Christian Medical College, Vellore, have policies in place to follow infection control practice and promote rational use of antimicrobials. The national guidelines would sensitize and help other hospitals to develop their own programmes.

The Government of India now proposes the prescription audit of antimicrobials in public hospitals. The prescription auditing is a proven method for improving the use of medicines but it is a continuing process. There should be sufficient trained manpower available in hospitals to carry out this responsibility. The functioning of Drugs and Therapeutics Committee and provision of clinical pharmacy are two main strategies followed worldwide to promote rational or appropriate use of medicines. Earlier even the National Human Rights Commission too recommended to the Government to make provision of clinical pharmacy service in hospitals. The Pharm D and M Pharm Pharmacy Practice qualified pharmacists are suitable professionals to carry out this type of responsibility besides the medically qualified clinical pharmacologists.

The inappropriate use of antimicrobials are not just restricted to the hospital setting or community, but to other fields like veterinary and agriculture. Unless the concerted efforts are initiated by all stakeholders, the inappropriate use would continue to have social, economic and medical impact on human health. The Government of India's recent initiatives to develop antibiotic policy, national infection control guideline, and implement prescription audits in public hospitals, controlling the availability of antimicrobials at community through duplicate prescription dispensing are welcome step in promoting the rational use of antimicrobials.

Let's save the antimicrobials for future generation through appropriate use!

(The authors are with Department of Pharmacy Practice, Annamalai University, Annamalai Nagar)