An ‘International Conference on Antibiotic Stewardship and Infectious Diseases,’ was held at Amrita Institute of Medical Sciences, Kochi, from October 27-28, 2018. Experts in Antimicrobial Resistance (AMR) from around the world gathered at the conference and highlighted the importance of ‘Antibiotic Stewardship,’ which means a combination of practices to rationalize antibiotic use through the right dose, right drug, right duration, right frequency, right patient and right indication. Rationalizing the use of antibiotics is essential to reduce the burden of infectious diseases, the experts said at the event, which saw the participation of ten prominent international speakers from the UK, the US and South Africa.

Dr. Sanjeev K. Singh, Medical Superintendent, AIMS, observed that over-consumption of antibiotics is rampant in India. "A recent study in Kerala has found that 89% of all doctors prescribe antibiotics on daily basis. Hence, when a patient suffers from, say, symptoms of upper-respiratory infection, diarrhea or vomiting – which usually indicate a disease that is viral in nature and therefore should not be treated with antibiotics – the patient gets prescribed a course of antibiotics. It therefore comes as no surprise that India consumes the highest volume of antibiotics in the world.” 

Dr. Singh also noted that even though the spread of antibiotic resistance is high around the world, the access to antibiotic drugs is controlled and a third party monitors their use and consumption, leading to rational practices. An Antimicrobial Stewardship Program along with good Antibiotic Prescription Practices (GAP) is an effective strategy for optimization and rationalization of the use of antimicrobials. All healthcare professionals in India need to be educated on rational antibiotic prescription practices, he opined. This, along with effective patient education to not take antibiotics unnecessarily, can help optimize the use of antimicrobials in Indian hospitals. Such optimization is urgently needed considering that as many as 90% of the estimated antibiotic resistant deaths in the world come from low and middle income countries. However, this is going to be an uphill task as data regarding infection control practices in Indian hospitals is currently unavailable and their hygiene and sanitation standards are not up to the mark. Dr. Singh completed his speech with an observation that the absence of standardization of these aspects in hospitals across the country is a matter of serious concern. 

Dr. Arjun Srinivasan, Associate Director, Healthcare Associated Infection Prevention Programs, Centers for Disease Control and Prevention, US Dept. of Health, also agreed with Dr. Singh’s observations and stated that the loss of effective antibiotic therapy threatens to make once-treatable infections deadly again and jeopardize the delivery of modern medicine. Dr. Arjun stated that one of the best ways we can preserve the power of life-saving antibiotics is to improve the way we use them through a concept known as ‘antibiotic stewardship.’ The goal is to ensure that everyone gets the right antibiotic when they need one. He concluded by saying that improving access to effective antibiotics as well as the way we use them will require partnerships between the public and private sectors, as well as engagement from patients. 

Dr. Alison Holmes, Director of the NIHR Health Protection Research Unit at Imperial College, London, and Public Health England said, “Individually and collectively, we all have responsibility in preserving the effectiveness of antibiotics, which means we must use them wisely and that we must also reduce the need for antibiotics by maximizing action to prevent infections from occurring.” 

Talking about the challenges of early and accurate diagnostics of infectious diseases, Dr. Sanjeev Singh said, “The results of traditional bacterial cultures and antimicrobial susceptibility testing, which may take up to several days to obtain, remain one of the major barriers in providing optimal therapy. As the currently available lab parameters like the white cell count and C Reactive Protein are non-specific, these surrogate markers may not lead to definitive diagnosis and treatment, but rather to an empirical treatment.”  

Dr. Singh further elaborated that advancements such as rapid diagnostics, the syndromic approach which uses multiplex Polymerase Chain Reaction (PCR) to rule out infections, better diagnostics for virology, and the use of better markers like procalcitonin can help in the early detection of infections. Even though the scenario of microbes gaining antibiotic resistance remained a serious matter of concern, Dr. Singh was optimistic that such a situation would never give rise to an apocalypse-like situation. He further clarified his argument by stating that if at all a post-antibiotic era was reached, it can be contained with measures like good hygiene practices, safe disposal of waste, vaccination for vaccine preventable diseases and good infection control practices.

Today, India faces a serious threat from infectious diseases as more and more microbes are found to gain antibiotic resistance due to the irrational use of antibiotics, along with the lack of restrictions on their use. Along with these, non-standardization of microbiology laboratories, lack of sanitation and use of antibiotics in animal husbandry and fisheries played a major role in creating this hazardous situation. If this situation persists, there is a danger of the country slipping back into the pre-antibiotic era. Already the crude infectious disease-related mortality rate in India is 416.75 per 100,000 persons, which is about twice the prevalent rate in United States (World Bank data). There is also a 15-times greater burden of infectious diseases per person in India than in the UK and the scenario of microbes becoming more and more resistant towards antibiotics may make things worse. 

The Amrita Institute of Medical Sciences instituted an Antibiotic Stewardship Program four years ago, which has led to significant reduction in the use of high-end antibiotics. Colistin prescription was reduced by 74%, Linezolid by 86%, and Dorpenum and Ertapenum by 34% and 38%, respectively. Mortality has been reduced by 24% and cost-benefit because of implementation of the Antibiotic Stewardship Program is Rs 2.3 crore in a year. In addition, Healthcare Associated Infections have dropped significantly for Ventilator Associated Pneumonia (64%), Blood Stream Infections (34%), Urinary Tract Infections (23%) and Surgical Site Infections (32%),” concluded Dr. Sanjeev Singh. 

Amrita Institute of Medical Sciences is also playing a key role in the implementation of Kerala Antimicrobial Resistance Containment Plan along with the Indian Medical Association. It currently has trained 122 trainers and is in the process of capacity building in all 14 districts of Kerala, over the next six months.

Key takeaways from the conference were:

  • The loss of effective antibiotic therapy threatens to make once-treatable infections deadly again and jeopardize the delivery of modern medicine. 
  • Rationalizing the use of antibiotics is essential to reduce the burden of infectious diseases. 
  • Four years ago, the Amrita Institute of Medical Sciences (AIMS) instituted an Antibiotic Stewardship Program which has led to significant reduction in the use of high-end antibiotics.
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