By- SUGANDH KHANDELWAL
The rise of antimicrobial resistance (AMR) has become a pressing public health concern globally, with India being one of the most affected countries. The misuse and overuse of antibiotics in healthcare settings have driven the need for robust antimicrobial stewardship programs (ASPs). This aims to address this critical challenge by proposing actionable strategies customized for the unique needs of the Indian healthcare landscape.
In India, the Ministry of Health & Family Welfare (MoHFW) launched the NAP-AMR in 2017 to combat antimicrobial resistance (AMR). The plan was developed in alignment with the Global Action Plan (GAP) on AMR. The NAP-AMR was implemented for five years. In 2022, the MoHFW held expert consultations to develop the NAP-AMR 2.0. The consultations included representatives from the private sector, technical institutions, professional groups, industry, cooperatives, NGOs, and international partners.
Antimicrobials – including antibiotics, antivirals, antifungals, and antiparasitics – are medicines used to prevent and treat infectious diseases in humans, animals and plants. Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites no longer respond to antimicrobial medicines. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become difficult or impossible to treat, increasing the risk of disease spread, severe illness, disability and death.
Global Concern:
Antimicrobial medicines are the cornerstone of modern medicine.The emergence and spread of drug-resistant pathogens threatens our ability to treat common infections and to perform life-saving procedures including cancer chemotherapy and caesarean section, hip replacements, organ transplantation and other surgeries.
In addition, drug-resistant infections impact the health of animals and plants, reduce productivity in farms, and threaten food security.
AMR has significant costs for both health systems and national economies overall. For example, it creates need for more expensive and intensive care, affects productivity of patients or their caregivers through prolonged hospital stays, and harms agricultural productivity.
Current Scenario:
The global rise in antibiotic resistance poses a significant threat, diminishing the efficacy of common antibiotics against widespread bacterial infections. The 2022 Global Antimicrobial Resistance and Use Surveillance System (GLASS) report highlights alarming resistance rates among prevalent bacterial pathogens. Median reported rates in 76 countries of 42% for third-generation cephalosporin-resistant E. coli and 35% for methicillin-resistant Staphylococcus aureus are a major concern. Projections by the Organization for Economic Cooperation and Development (OECD) indicate an anticipated twofold surge in resistance to last-resort antibiotics by 2035, compared to 2005 levels, underscoring the urgent need for robust antimicrobial stewardship practices and enhanced surveillance coverage worldwide.
Global Agenda on Antimicrobial Resistance:
To address AMR globally, countries adopted the Global Action Plan (GAP) on AMR during the 2015 World Health Assembly and committed to the development and implementation of multisectoral national action plans with a One Health approach to tackle AMR. The GAP was subsequently endorsed by the Governing Bodies of the Food and Agriculture Organization of the United Nations (FAO) and the World Organisation for Animal Health (WOAH, formerly known as OIE) and the United Nations Environment Program.
Key Elements:
- Standardized Protocols for Prescribing: Hospitals will adopt evidence-based guidelines to ensure the appropriate use of antibiotics, minimizing unnecessary prescriptions.
- Strengthened Laboratory Capabilities: Enhancing diagnostic capacities to identify pathogens accurately and rapidly can help tailor treatment plans, reducing reliance on broad-spectrum antibiotics.
- Continuous Medical Education: Training for healthcare professionals on the latest AMR trends and best practices will be integral to these programs.
- Patient Awareness Campaigns: Educating the public about the dangers of self-medication and overuse of antibiotics is essential to curb demand-side misuse.
- Regulatory Oversight: Strengthened surveillance and reporting mechanisms at the hospital level to monitor antibiotic usage and resistance patterns.
These tailored strategies aim to empower healthcare providers to combat AMR effectively while ensuring better patient outcomes. As India grapples with its high disease burden and varied healthcare infrastructure, such initiatives could significantly impact improving antimicrobial stewardship nationwide.
The program is set to be piloted in select hospitals, with results expected to guide broader implementation in the future.
Antimicrobial Stewardship Programs (ASPs):
Antimicrobial Stewardship Programs (ASPs) are critical for ensuring the responsible use of antibiotics in healthcare settings. Below is a list of some key ASPs and their core components commonly implemented globally, including strategies that are adaptable to hospitals in different income settings:
- CDC Core Elements for Hospital ASPs:
- Leadership commitment
- Accountability with a designated leader
- Drug expertise via a pharmacist
- Action to improve prescribing practices
- Monitoring antibiotic prescribing and resistance patterns
- Reporting prescribing trends and resistance data
- Education for clinicians and staff on optimal prescribing
2. Global Core Standards by One Health Trust:
- Senior leadership engagement
- Infection management professional involvement
- Structured education and practical training
- Continuous surveillance and monitoring of ASP activities
- Data sharing on resistance and antibiotic use
3. WHO Toolkit for Low- and Middle-Income Countries:
- Establishing facility-level AMS frameworks
- Implementing basic AMS interventions such as formulary restrictions and audit-feedback systems
- Strengthening microbiology laboratory support for resistance tracking
These programs aim to reduce inappropriate antibiotic use, improve patient outcomes, and combat antimicrobial resistance. Hospitals can adapt these frameworks based on resources, staff availability, and regional priorities.
NABH Framework for Antimicrobial Stewardship Programs:
In India, the NABH (National Accreditation Board for Hospitals & Healthcare Providers) provides detailed guidelines and protocols for implementing Antimicrobial Stewardship Programs (ASPs) in hospitals. These guidelines emphasize infection prevention, prudent use of antibiotics, and controlling the spread of resistant pathogens. Key components include:
- Policy Development: Hospitals must establish clear protocols for antibiotic usage and resistance monitoring, supported by an Antimicrobial Stewardship Committee.
- Infection Control: NABH standards require measures like isolation protocols for contagious infections, proper sterilization practices, and mandatory surveillance of infection rates.
- Training and Education: Staff must be trained in rational prescribing practices, and educational programs should be conducted to promote awareness of antimicrobial resistance.
- Monitoring and Feedback: Regular audits of antibiotic prescriptions and feedback mechanisms are essential to ensure adherence to guidelines.
- Infrastructure Requirements: Adequate diagnostic facilities, laboratory support, and an antibiogram system for tracking resistance patterns are necessary for effective implementation.
Hospitals aiming for NABH accreditation must align with these protocols, although resource constraints and workforce limitations pose challenges, particularly in public healthcare settings. These standards are designed to ensure patient safety while reducing the threat of antimicrobial resistance.
Antibiotic stewardship technologies:
Antibiotic stewardship technologies are advancing rapidly to help healthcare institutions optimize antibiotic use, improve patient outcomes, and combat antimicrobial resistance. Here are some key technologies used in antimicrobial stewardship programs:
- Clinical Decision Support Systems (CDSS): Tools like Sentri7 Clinical Surveillance offer real-time alerts to healthcare providers, aiding in timely decision-making for appropriate antimicrobial use. These systems monitor patient data, such as microbiology results, and provide actionable insights for interventions like de-escalation of broad-spectrum antibiotic.
- Data Analytics Platforms: Technologies like those provided by Wolters Kluwer help stewardship teams analyze antibiotic use patterns, adherence to guidelines, and resistance trends. These insights are crucial for informed decisions and continuous improvement in stewardship practices.
- Integration with Electronic Health Records (EHR): Seamless integration with EHR systems enables automated tracking of antimicrobial prescriptions, adherence rates, and clinical outcomes. This reduces manual data entry and facilitates efficient reporting.
- Real-Time Surveillance Tools: Platforms like Sentri7 enable continuous monitoring of patient health parameters to detect infections early and recommend evidence-based interventions.
- Bayesian Dosing Software: This technology assists in optimizing antibiotic dosing by using patient-specific data and pharmacokinetic models to tailor therapies, particularly for critical care scenarios.
World AMR Awareness Week (WAAW):
World AMR Awareness Week (WAAW) is a global campaign to raise awareness, understanding and best practices with the public, One Health stakeholders, and other policymakers. One of WHO’s official health campaigns since 2015, WAAW is celebrated from 18 to 24 November every year.
SOURCE OF INFORMATION: https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance?gad_source=1&gclid
