Are antibiotics over-prescribed in India?

Context: The National Centre for Disease Control (NCDC) recently found that over half of the nearly 10,000 hospital patients surveyed for a study were given antibiotics to prevent, rather than treat, infection. 

• The survey mapped patients treated on one to five days each at 20 tertiary care institutes across 15 States and two Union Territories between November 2021 and April 2022.
• It found that 55% of the patients surveyed were prescribed antibiotics as prophylaxis, or as a preventive; only 45% were prescribed antibiotics to actually treat infections; and of them, only 6% were prescribed the drugs after identifying the specific bacteria.

What is antimicrobial resistance (AMR) and how did India reach this stage?

Antimicrobial Resistance (AMR) is the resistance of microorganisms to antimicrobial agents to which they were originally sensitive.Multiple types of bacteria, such as E. coli, Klebsiella, Acinetobacter, Staphylococcus aureus, and enterococcus, have developed resistance to even the latest generation antibiotics.

Factors contributing to the rise of AMR include inappropriate use of antibiotics in non-bacterial infections, both through prescribing practices and over-the-counter use:

• Inadequate laboratory facilities hinder the rapid identification of appropriate antibiotics based on cultures, leaving clinicians with limited guidance.
• Lack of sufficient training in antibiotic selection, escalation, and de-escalation contributes to the problem.
• Inadequate monitoring of AMR and insufficient control over antibiotic prescription and dispensing practices persist despite warnings.
• Incentivization of prescribing practices by the pharmaceutical industry adds to the problem.
• Inappropriate use of antibiotics in human, animal, and agricultural sectors generates drug-resistant bugs.
• Poor sanitation and inadequate infection prevention in healthcare institutions contribute to the spread of drug-resistant superbugs.
• AMR is a complex socio-economic and political challenge, requiring a comprehensive approach beyond scientific solutions by doctors and researchers alone.

Should there be standardisation for ensuring uniformity in prescribing antibiotics?

• Training doctors in appropriate antibiotic use is crucial, but the primary challenge lies in accurately diagnosing bacterial infections.
• Differentiating bacterial from non-bacterial infections relies heavily on clinical judgment, as laboratory and radiological investigations provide supporting information.
• Initial diagnosis of bacterial infections remains primarily clinical until more accurate and rapidly available diagnostic methods are developed.
• More than half of antibiotic prescriptions globally, as indicated by NCDC survey results, are unnecessary.
• Overcrowded outpatient units in both government and private hospitals limit the time available for proper patient examination and history-taking.
• Lack of access to rapid diagnostics and a widespread network of laboratories contributes to overprescription.
• Antibiotics are chosen as a quicker and more affordable option compared to extensive investigations like blood cultures.
• Although guidelines exist, the implementation of proper antibiotic prescription practices remains a challenge.
• Limited access to rapid diagnostics, inadequate laboratory facilities, and financial constraints drive doctors to opt for antibiotics as a pragmatic and cost-effective solution.
• Correcting factors such as improving access to rapid diagnostics, building a robust laboratory network, and addressing overcrowded outpatient units is essential to reduce unnecessary antibiotic prescriptions and combat antimicrobial resistance (AMR).

How important is the judicial use of antibiotics in the world and what is the immediate danger that we face?

• Immediate threat of Antimicrobial Resistance (AMR) is evident, leading to increased mortality.
• Study shows 75% of patients with E. coli or Klebsiella infection in hospitals are resistant to third- or fourth-generation antibiotics.
• Concerns rise with high resistance to the next generation of antibiotics (carbapenem resistance).
• Trickle-down effects from poultry and agriculture, especially in industrialized agriculture, contribute to AMR.
• Infections in immuno-compromised patients, such as cancer patients, result in fatalities due to AMR.

What measures have been put in place by the Central government most recently to control AMR in India? And are they enough?

• In 2011, the first National Policy for Containment of Antimicrobial Resistance was introduced, accompanied by a ban on over-the-counter use of antibiotics (H1 rule), though not effectively implemented.
• In 2013, a modified H1 rule banning only second- and third-line antibiotics was introduced, but implementation remains a challenge.
• Acknowledgment of India's efforts in implementing measures to tackle AMR, with room for improvement and better enforcement of laws.
• The 2019 ban on colistin use in poultry farming is a significant step, considering colistin is a potent antibiotic for treating human infections.
• Emphasis on restricting access to reserve antibiotics to reduce the likelihood of resistance.
• Observation that countries with high privatized healthcare exhibit the highest per capita antibiotic usage, highlighting the importance of strengthening public health systems.
• States with well-established public health systems tend to have lower AMR rates, emphasizing the significance of planned expenditure, structured service delivery, and robust accountability in the public health sector.

Solutions:

• Tackling AMR requires a comprehensive approach beyond reducing antibiotic consumption.
• AMR is interconnected with governance, infrastructure, sanitation, poverty, and access to clean drinking water.
• Rationalizing antibiotics is crucial for AMR and patient safety, but addressing factors like hospital sanitation and infection control is equally vital.
• Small steps, similar to those emphasized during the COVID-19 pandemic, are essential in the fight against AMR.
• Despite health being a State subject, strong Centre-State coordination is crucial to effectively control Antimicrobial Resistance (AMR).
• Recognition that AMR cannot be tackled in isolation; interconnectivity with various stakeholders, including patients, is essential.