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Antimicrobial Stewardship: An Indian Perspective

Article  in  Online Journal of Health and Allied Sciences · August 2014

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Online Journal of Health and Allied Sciences
Peer Reviewed, Open Access, Free Online Journal
Published Quarterly : Mangalore, South India : ISSN0972-5997 This work is licensed under a
Volume 13, Issue 2; Apr-Jun 2014 Creative Commons Attribution-
No Derivative Works 2.5 India License

Letter:
Antimicrobial Stewardship: An Indian Perspective.

Authors
Geetha Mani, Kalaivani Annadurai, Raja Danasekaran
Assistant Professors, Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Kancheepuram
District, Tamil Nadu, India.

Address for Correspondence

Dr. Geetha Mani,
Assistant Professor,
Department of Community Medicine,
Shri Sathya Sai Medical College and Research Institute,
Ammapettai village, Thirupporur-Guduvancherry Main Road,
Sembakkam Post, Kancheepuram District-603108,
Tamil Nadu, India.
E-mail: drgeethammc@gmail.com

Citation
Mani G, Annadurai K, Danasekaran R. Antimicrobial Stewardship: An Indian Perspective. Online J Health Allied Scs. 2014;13(2):12.
Available at URL:http://www.ojhas.org/issue50/2014-2-12.html

Open Access Archives

http://cogprints.org/view/subjects/OJHAS.html
http://openmed.nic.in/view/subjects/ojhas.html

Submitted: Jun 30, 2014; Accepted: Jul 21, 2014; Published: Aug 30, 2014

Abstract Antimicrobial stewardship (AMS) is one of the key health care costs for infections and limit the selection for
strategies to prevent the emergence of antimicrobial antimicrobial strains.[1,4] It is one of the key strategies to
resistance and decrease preventable healthcare-associated prevent the emergence of antimicrobial resistance and
infections. But more than 50% of hospitals in India do not decrease preventable healthcare-associated infections.
have an AMS program. The common barriers identified for The antimicrobial stewardship criterion requires that all
implementation of AMS were lack of funding and human healthcare services have an antimicrobial stewardship
resource, lack of information technology, higher priorities, program (ASP) in practice.[1,5] The first global survey by
lack of awareness of administration and prescriber Howard P et al on implementation of antimicrobial
opposition. This paper analyses the possible solutions to stewardship activities worldwide reports 53% coverage in
overcome above barriers and promote effective Asia.[1] A survey of infection control programs in hospitals
implementation of AMS in India. in India revealed that ASP was not available in more than
Key Words: Antimicrobial stewardship, Barriers, India, 50% of the hospitals.[6] This status despite India’s
Solutions. commitment to combat antimicrobial resistance by
Antimicrobial resistance (AMR) has emerged as a global publishing the landmark document “Chennai declaration”
health challenge due to the lack of new antibiotics in the reflects the various challenges to be faced.[7] The common
pipeline and ever-increasing burden of infections caused by barriers as identified by Howard P et al study were lack of
multi-drug resistant pathogens.[1,2] AMR accounts for funding and human resource, lack of information technology,
longer, expensive hospital stays and deaths among infected; higher priorities, lack of awareness of administration and
adverse effects without any clinical benefits and spread of prescriber opposition.[1]
resistant organisms, thereby jeopardizing the health of people Table 1 summarises the potential solutions to the above
who are not even exposed to them.[2] The Centres for barriers in implementation of AMS program in India.
Disease Control and Prevention (CDC) estimates more than Any policy to be successful requires community
two million people are infected with antibiotic-resistant participation. Healthcare professional should commit
organisms, resulting in approximately 23000 deaths themselves to explain the prescription to all the patients
annually.[2,3] Hence, promoting an efficient antimicrobial encountered. The community should be educated with
stewardship (AMS) program at all levels of healthcare is a respect to the following: to use medicines only when
global priority. prescribed by a qualified health care personnel, to complete
Antimicrobial stewardship (AMS) refers to coordinated the full prescription even if symptomatically cured, to never
interventions designed to improve and measure the share antibiotics with others or use leftover prescriptions, to
appropriate use of antimicrobials by promoting the selection always follow up with the clinician to ensure complete
of the optimal antimicrobial regimen, dose, duration of cure.[10] The public should be strictly discouraged from self-
therapy and route of administration. The ultimate aim is to medication practices and from availing and using drugs over-
achieve optimal clinical outcomes related to antimicrobial the-counter (OTC).
use with minimal toxicity and other adverse events; reduce

1
 Table 1: Barriers in implementation of AMS activities in dose, by right route with minimal or no harm to the patient
developing countries and potential solutions and future patients.[1] Efficient AMS program results in
Barriers Solutions sustainable long-term outcomes related to improved
prescription practices for therapeutic and prophylactic
Simple, locally developed clinical purposes, improved quality of patient care, increased
protocols infection cure rates, reduced hospitalisation rates, reduced
Development of indigenously developed treatment costs, improved healthcare savings and a healthy
low-cost diagnostic tools[3] human resource capital.[3]
Formulary restriction[1,3, 8] Concluding, implementation of AMS in all hospitals and
Lack of Early intravenous (IV) to oral community health care facilities is of utmost importance in
funding[1] conversion[1,3,8] India. There is a need for encouraging research to assess
Antibiotic cycling[1,3,8] impact of various components of AMS such as evaluation of
Allotting dedicated resources[9] educational activities, prescription practices, quantitative and
Public-private partnerships to offer qualitative antimicrobial use indicators, newer diagnostic
refresher trainings, share diagnostic tools tools, antimicrobial resistance patterns and health care
and community surveillance studies expenditure.
Approved postgraduate courses in References
Infectious diseases 1. Biomerieux. Practical guide to Antimicrobial
Dedicated infectious disease (ID) Stewardship in hospitals. Biomerieux, France 2013; p 4.
physicians for all hospitals to guide the Accessed from
team[1,3,8] http://sapcconference.za.org/presentations/Monday%20
Lack of human
Public-private partnerships to involve ID 24%20June/Commission%202/Commission%202%20
resource[1]
physicians in remote and resource- %2013h10%20-%2014h25/13h10%20-
constrained settings %2013h30%20Professor%20Andries%20Gous/Profess
Multi-stakeholder engagement[3,8] or%20Andries%20Gous%20-
Active involvement of clinical pharmacist %20Antibiotic%20stewardship%202013.pdf
and clinical microbiologist[3,8] 2. Centers for Disease Control and Prevention. CDC’s
Lack of Easy-to-use computer assisted Top Ten: 5 Health Achievements in 2013 and 5 Health
information programs[3,8] Threats in 2014. 2013; Available at
technology[1] Use of mobile applications[3] http://blogs.cdc.gov/cdcworksforyou24-
Higher Creating awareness among administrators 7/2013/12/cdc%e2%80%99s-top-ten-5-health-
priorities[1] and the health team on AMR and AMS[3] achievements-in-2013-and-5-health-threats-in-
2014/ Accessed on July 3, 2014
Providing necessary information and 3. Centers for Disease Control and Prevention. Core
organising discussions and workshops for elements of antibiotic stewardship programs. Available
hospital administrators[3,9] at http://www.cdc.gov/getsmart/healthcare/implementat
Lack of Involving administrators in educational and ion/core-elements.html Accessed on July 4, 2014
awareness planning programmes 4. Infectious diseases Society of America (IDSA).
among AMS as a requirement for approval and Promoting Antimicrobial stewardship in Human
administrators[1] renewal processes Medicine. Available at
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AMR[9] on June 12, 2014.
AMS as part of accreditation process 5. McNeill V, Cruickshank M, Duguid M. Safer use of
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background with separate modules for usage data. MJA 2010;193(8): S114-S117
undergraduates, postgraduates, practitioners 6. Sureshkumar D, Gopalakrishnan R, Ramasubramanian
and other professionals[1] V. Survey of infection control programs in India. Poster
Refresher training and workshops[3] presentation in ID week 2013 October 2-6; San
Evidence based guidelines[1,3,8] Francisco. Accessed from
Incorporating sections on prescription https://idsa.confex.com/idsa/2013/webprogram/Paper42
guidelines and common prescription errors 762.html Accessed on July 5, 2014.
in journals 7. Hopkins S. Improving antimicrobial stewardship and
Standard Antibiotic prescription chart surveillance: the Chennai declaration. BMJ 2013;346:
incorporating diagnosis and indications for f591
Prescriber
antimicrobials[3] 8. Fishman N. Antimicrobial stewardship. Am J Med.
opposition[1]
Restricting fixed-dose-combinations unless 2006;119(6 Suppl 1):S53-61
approved to be therapeutically beneficial[9] 9. Directorate General of Health Services, Government of
Handbooks and handouts with educational India. National Policy for containment of antimicrobial
materials[1,3] resistance India. Accessed from
Frequent reminders on guidelines through http://nicd.nic.in/ab_policy.pdf Accessed on July 3,
electronic mails (emails) and short 2014
messaging services (SMS)[3] 10. World Health Organization (WHO). Antimicrobial
Prescription audits[1,3,8] resistance- Global report on surveillance 2014. WHO
Use of recent innovative mobile Press. 2014. Accessed from
applications for education, information and http://apps.who.int/iris/bitstream/10665/112642/1/9789
evaluation purposes.[3,8,9] 241564748_eng.pdf?ua=1 Accessed on July 2, 2014.
Successful implementation of AMS requires dedicated
partnership involving all members of AMS team and
community healthcare providers to ensure that right drug is
provided to the right patient, in the right time, in the right

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