|Year : 2015 | Volume
| Issue : 2 | Page : 75-76
Rational antibiotic therapy
Department of Pediatrics, JN Medical College, Belagavi, Karnataka, India
|Date of Web Publication||17-Jan-2016|
N S Mahantshetti
Department of Pediatrics, JN Medical College, Belagavi, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Mahantshetti N S. Rational antibiotic therapy. Indian J Health Sci Biomed Res 2015;8:75-6
The discovery of penicillin by Alexandar Flemming has been the greatest boon to humankind and the greatest scientific invention of the 20 th century. It transformed the management of infectious diseases. Since then, the pharmaceutical companies has flooded the market with innumerable antibiotics. However, in the 21 st century, this boon is gradually evolving into a bane due to the emerging global problem of "antibiotic resistance." The "antibiotic resistance" is even more magnified in the developing countries where the infectious disease burden is high and the replacement of older, less expensive antibiotics with newer more expensive antibiotics would mean increased economic burden to the countries. To curtail this problem and to develop actionable policy recommendations relevant to low- and middle-income countries, "the global antibiotic resistance partnership" (GARP) was established in 2009 with India, Kenya, South Africa, and Vietnam as working groups. The groups surveyed the usage of antibiotic use and resistance and related factors and also provided recommendations.
India is contributing to the highest bacterial disease burden in the world, and consequently, one of the largest users of antibiotics. The use of antibiotics has increased by more than 40% from 2005 to 2009, especially with cephalosporins and quinolones. The reasons for this increase are mainly inappropriate use of antibiotics which in turn has led to increased antibiotic resistance. Though this issue is receiving attention in diseases such as tuberculosis, malaria, HIV/AIDS, and enteric fever, the same is not true for common infections such as pneumonia and diarrhea. There is a need to have research in these infections and to develop and implement policies to manage these problems. The emergence of "Delhi Bug" - New Delhi Metallo - β - lactamase-1 reported in 2009, which hit the headlines in 2010 is an eye opener to wake up and act.
There are various factors responsible for antibiotic resistance viz., (a) misuse and overuse of antibiotics e.g., using antibiotics for viral upper respiratory tract infections or viral diarrhea, (b) using higher antibiotics when not required e.g., use of quinolones for diarrhea led to the resistance of enteric fever to quinolones, (c) incorrect dose, incorrect frequency, and or duration, especially in pediatrics and liquid preparations, and (d) incorrect choice of antibiotics e.g., using cefixime for respiratory infections.
Why are doctors doing this? The probable reasons could be (a) lack of diagnostic microbiological facilities being easily available, (b) practice of prescribing antibiotics for all patients with fever, due to misconception that "fever is equal to bacterial infection," (c) patient's expectations compels the doctor to prescribe an antibiotic, (d) pressure from pharmacists, (e) lack of awareness of the public regarding the need of antibiotics, and (f) misuse of combination therapy, e.g., oflaxacillin with ornidazole for acute diarrhea. The market forces and drug control of India are also responsible to some extent for misuse and overuse of antibiotics.
- Availability of antibiotics for "over the counter" use
- Promoting irrational combinations, e.g., ceftriaxone with tazobactam, cefixime with clavulanic acid. These combinations have been launched without adequate research
- Lack of regulations and policies for the use of newer antibiotics, especially drugs such as carbapenems
- Lack of surveillance, especially for "hospital acquired infections (HAI)" and for monitoring antibiotic resistance." Antibiotic surveillance resistance has been limited to Indian Council of Medical Research and some private agencies
- Effective-vaccination policies for prevention of bacterial infections.
Another reason for antibiotic resistance is indiscriminate use of antibiotics in livestock and poultry for nontherapeutic reasons such as growth promotion. Lack of regulations in India for the use of antibiotics in animal and poultry foods is one of the main reasons for this misuse.
HAIs are another concern which needs attention mainly due to Staphylococcus aureus and Pseudomonas aeruginosa. A survey conducted in 12 Intensive Care Units, in seven hospitals of 7 cities in India showed that HAIs ranged from 4% to 83% being maximum in the burns ward. We need more studies on infection surveillance in hospitals.
| Recommendations|| |
GARPs eventual goal is to develop workable and effective interventions: The recommendations aim at:
- Reducing the need for antibiotics
- Lowering resistance - enhancing drug pressure through improved antibiotic targeting
- National surveillance of antibiotic resistance and antibiotic use
- Standard treatment guidelines as developed for diarrhea, tuberculosis, and HIV. Need to develop " pocket cards" for locally recommended treatments for common conditions and distribution of "antibiograms" regularly to update doctors
- Increasing the use of diagnostic tests, which necessitates behavioral changes and improvements in microbiology laboratory capacity
- Setting up and/or strengthening infection control committees in hospitals
- Checklist for surgical procedure such as the WHO's surgical safety checklist
- Educational approach: Continuing of education to doctors, nurses, dentists, and pharmacists
- Improving antibiotic supply chain and quality: Revision of "National List of Essential Medicines" restricting the list and availability of powerful antibiotics will curtail the use of these antibiotics and thus prevent antibiotic resistance
- Restricting the use of antibiotics for nontherapeutic uses in agriculture such as the use of antibiotics for growth promotion. These interventions should help to reduce the spread of antibiotics resistance, improve public health directly, benefit the populace, and reduce pressure on the healthcare system
- Increasing the types and coverage of childhood vaccines offered by the government would reduce the disease burden enormously and spare antibiotics.
India being a partner in the GARP has the advantage of the growing global network to share research protocols, analysis, decisions, interventions, and implementation plans. To achieve this enormous task, we as doctors need to act and contribute to make GARP's goal a reality. Antibiotic resistance is like a "time bomb" that is silently ticking which will soon explode causing global devastation. Hence, we need to act soon or else we will end up going backward to the "preantibiotic era" with no weapon to treat even common infections.