Join Indian initiative for management of antibiotic resistance (IIMAR)

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Friday, June 13, 2008

Discussion Forum

Your views are invited on the following. At the end of all contributions look for comments and click on that and write.

Aims and Objectives

Naveen Thomas of Bangalore suggests following aims and objectives with the comment that the strategies are evident in the objectives given below

  1. To study the extent (differential rates) of antibiotic resistance prevalent in various parts of the country.
  2. To create a forum for reporting of antibiotic resistance by practitioners.
  3. To sensitise practitioners and users about the extent, causes and effects of antibiotic resistance.
  4. To encourage and engage with practitioners, pharmaceutical producers and policy makers to take pro-active steps to manage antibiotic resistance.
  5. To work on the issue of antibiotic resistance, in the larger context of access to medicines and treatment in India.

Dr. R. D. (Atul) Kulkarni of Dharwad adds the following

  • Training of fresh clinicians and creating awareness among them (both private and institutional) about antibiotic resistance management.
  • To hold refresher workshops for both junior and senior clinicians on antibiotic resistance management to particularly make them aware that a thought on resistance build up is necessary before writing an antibiotic prescription.
  • To dissuade the clinicians from learning about antibiotics from Medical Representatives.

AUROBINDO ROY of Pune suggests following strategies

  1. Govt. of India and different Voluntary organizations (NGOs) should be induced to organize Workshops for the Physicians who are at the PHC level on the topic of antibiotic management.
  2. IIMAR should make efforts for banning of illogical use of antibiotics in the livestock.
  3. IIMAR should encourage efforts to isolate natural compounds which in conjunction with the known antibiotic could reduce the resistance level (as it may be act on the eflux pumps and may also increase uptake of the antibiotics.
  4. IIMAR should try to impress on Physicians that they should stop the following practice. Physicians (working privately or in Govt. hospitals) due to their immense pressure of work do not want to see the patient second time, so they prescribe a cocktail of antibiotics with very high dose even to children. This results in complicating the antibiotic resistance problem.
  5. There should be a constant renewal of reminders for following ethics and good practices.

From Dr. Siddappa Sujatha (Bangalore)

  • Dissemination of information and education with regards to dangers of indiscriminate use of antibiotics e.g. how commensals will become pathogenic should be given to all levels functioning in the state from a PHC to a TERTIARY CARE provider
  • IIMAR should take up with the government for stringent Laws to regulate drug dispensing.
  • Universal lab sensitivity testing protocol attached to a referral institute.
  • Establishing a centralized antibiotic board The main hurdle would be to notify the diseases and anti biotic sensitivity current trends to one and all for e.g. cross sensation to other prevalent diseases in the state endemically e.g. chicken gunia, malaria, kala, azar, these disease when treated with indiscriminate use of drugs from general practitioners mask the signs and give rise to so called atypical presentations due to which there is delay in control measures due to delay in diagnosis. The list is endless!!

Dr. Shanthi Bhanukumaar From Kanchipuram, Tamilnadu writes…..I am sending the Aim & Objectives of the Indian Initiative of management of antibiotic resistance & strategies to be followed to acheive the set aims.

Aim & Objective - To use reliable lab procedures to detect resistance as an aid to manage infected patient .

  • To monitor changing resistance trends among clinically relevant bacteria .
  • To reliably detect all resistance processes with current lab procedures taking care not to misinterpret the criteria so that this processes is either reverted or slowed down.
  • To reduce pool of patients who habour multidrug resistant organisms , when they inturn are hospitalised these new patients recontaminate the hospital environment .
  • Prevention of other most dangerous drug resistant forms like tuberculosis, gonorrhoea, & necrotizing pneumonia apart from sharp increase of fluroquinolones resistant P. aeroginosa, new 'Super bug' MRSA , causing pneumonia & vancomycin RESISTANT MRSA which are observed in last 5 yrs.

STRAGIES: To be followed in lab -

  1. Susceptible pathogen identification by standard procedures.
  2. Antibigram of commonly encountered isolates should be done by the ATC\DDD system .
  3. Trends in antimicrobial prescribing - Deescalation to be followed .
  4. Detected antimicrbial resistance pattern must be informed to clinicians .
  5. Microbiologist should survey the outbreak of newer organism in the hospital set up .
  6. Microbiologist need to know the regional data by interacting with local reginal hospital lab .
  • To be followed in hospital -
  1. Improoved Hospital infections control & prevention measures.
  2. Screening of infections associated with catheter, SSI, monitor associated infections ,centralised A.C , ventilator & endotracheal aspirates.
  3. Create awarness of the ward personal about new outbreaks occuring in hospital - bimonthly analysis of infection rates.
  4. Baseline antibiotic therapy for commonly encountered isolates should be formulated with inputs from clinicians .
  5. These should be reviewed 6 monthly or yearly for risk areas like ICU.
  6. Each hospital should have good local surveillance programme & data to develope appropriate therapeutic guidlines .
  7. Regulatory bodies & phamaceutical industry need to work together to ensure a steady supply of new antimicrobials .
  8. Health minister ( government ) , the medical professional , & public must be informed & educated periodically.
  9. Urgent need for pharmaceutical companies to develope newer drugs that are active against multidrug resistant gram negetives.

Dr Nandan T M, KIMS, Bangalore contributes the following…
Here are my opinions about the aims and strategies for preventing antibiotic resistance.

  • To win over pathogens
  • To continue antibiotic era
  • To involve microbiologists in patient care to the fullest extent
  • To eradicate over-the-counter antibiotic vending
  • To educate the general public including the government authorities about the importance of rational antibiotic prescriptions


  1. Regulating prescriptions including compulsory C&S
  2. Regulating pharmacies
  3. Bringing in state of the art technology to all microbiology labs to speed up reporting
  4. Making clinical microbiology a pure clinical subject at the post graduate level to help close communication with the patient and other clinicians
  5. Establishing a research organization to monitor resistance all over the country

June 17, 2008
Dr.Mullai Venkatachalam From MMCH& RI, Kancheepuram proposes the following:

  • Constant Monitoring/ surviellance of the sensitivity pattern of the pathogens.
  • Deescalation of the empiric therapy , once the sensitvity pattern is available-Rotation of antibiotics could save some of the antibiotics
  • Clinicians should be aware of the local/hospital sensitivity pattern before deciding on the empirical antibiotic usage.
  • A regional antibiotic policy will really help us to put a check against these super bugs.
  • The mortality rate due to antibiotic resistance/failure can be recorded region wise and can be highlighted to the Government of India, to enforce a law to Frame & follow a regional / state/ nation wide antibiotic policy
  • If there is a chance to prevent the ready availability of antibiotics over the counter, resistance rate could be cut off at least by 25%
  • I have a strong notion that natural products / compounds will really have best effects on these notorious creatures. Some of our traditional medicines will really help us.
  • Once in six months or in a year/ a regional survey of the sensitivity pattern can be recorded and presented which will help us to have a birds eye view on our country's sensitivity pattern and this survey will really help us in the usage of antibiotics.

You can also see following

Need for national/regional guidelines and policies in India to combat antibiotic;year=2008;volume=26;issue=2;spage=105;epage=107;aulast=Lakshmi

June 24, 2008
From Dr. Asit Ranjan Ghosh, Vellore
Dear Dr.Tamhankar
Thank you very much for taking a serious initiative to SAVE OURSELVES. As a researcher in the field of infectious diseases, alarming rate of increse of antibiotic resistance among microbial population including pathogens is a matter of utmost concern. The initiative may look for following AIMS & OBJECTIVES:

  1. To develop a complete and NATIONAL databank of antimicrobial resistant microorganisms including pathogens and non-pathogens
  2. To develop a complete and NATIONAL databank of spatial, temporal distribution of ESBL and AmpC-beta lactases-producing organisms of anthropocentric environments.
  3. To develop a e-network sytem to enter the authentic reports on antibiotic resistance following standard methods, NCCLS etc. from different parts of the country on real-time basis
  4. The initiative may look for a start of Journal on antibiotic resistance and awarness; it may have several chapters in different parts of educational and research institute and hospitals; It may offer suggestions to the national policymakers for stream lining the antibiotic use
  5. To study the moleecular insight of resistance development among microbial populations
  6. To study the normal flora and process of developement of drug resistance
  7. To study the hospital environ ments ( biotic and abiotic) to combat nosocomial infections
  8. To educate our clinicians and practitioners for appropriate applications of this life saving drugs
  9. To control and regulate the mechnisms of antimicrobial abuse in agriculture and veterinary system
  10. To incorporate this initiative in the form of MOVEMENT with MASS with the help of NGOs
Indian Antibiotic Resistance Scenario - 2008 (by A.J. Tamhankar)

From the Scientific Journals


-Antibiotic resistance calls for better diagnostic labs.
-Antibiotic resistance in pathogens causing urinary tract infections in India.
-Antibiotic resistance pattern of group-a beta-hemolytic streptococci isolated from north Indian children.

-Emerging antibiotic resistance in bacteria with special reference to India.
-Incidence of metallo beta lactamase producing Pseudomonas
aeruginosa in ICU patients.
-Estimation of faecal carriage of Clostridium difficile in patients
with ulcerative colitis using RT-PCR.

-Detection of extended spectrum beta-lactamase from clinical isolates in Davangere.
-A study on nosocomial pathogens in ICU with special reference to multiresistant Acinetobacter baumannii harbouring multiple plasmids.
-Enterococcal infections & antimicrobial resistance.
-Changing pattern of Clostridium difficile associated diarrhoea in a tertiary care hospital: A 5 year retrospective study.
-Antibiotic sensitivity pattern in cases of enteric fever.
-Functional assignment to JEV proteins using SVM.
-High rate of mutation K103N causing resistance to nevirapine.
-Increased prevalence of extended spectrum beta lactamase producers in neonatal septicaemic cases.
-Correlation between biofilm production and multiple drug resistance in imipenem resistant clinical isolates of Acinetobacter baumannii.
-Detection of Pseudomonas aeruginosa isolates producing VEB-type extended-spectrum beta-lactamases.
-Drug susceptibility testing of Mycobacterium tuberculosis against second-line drugs using the Bactec MGIT 960 System.
-Expression, purification, crystallization and preliminary X-ray diffraction studies of glyceraldehyde-3-phosphate dehydrogenase 1 from methicillin-resistant Staphylococcus aureus (MRSA252).
-Study of metallo-beta-lactamase production in clinical isolates of Pseudomonas aeruginosa.
-Occurrence of ESBL & Amp-C b-lactamases & susceptibility to newer antimicrobial agents in complicated UTI.
-Pneumonia in a traveller coming back from Asia.
-Rising prevalence of enteric fever due to multidrug-resistant Salmonella.
-Risk factors for antibiotic-resistant E. coli in children in a rural area.
-Status of high level aminoglycoside resistant Enterococcus faecium and Enterococcus faecalis.
-Synergy of gatifloxacin with cefoperazone and cefoperazone-sulbactam against resistant strains of Pseudomonas aeruginosa.
-The cost-effectiveness of typhoid Vi vaccination programs.
-The influence of glucose added urine on the in vitro antimicrobial activity of various antibiotics.
-Trend of antibiotic resistance of Vibrio cholerae strains from East Delhi.
-Triple therapy-based targeted nanoparticles for the treatment of Helicobacter pylori.
-Tigecycline in-vitro susceptibility and antibiotics' fitness for gram-negative pathogens.
-Antibiotic resistance pattern of group-a beta-hemolytic streptococci isolated from north Indian children.
-Detection and identification of methicillin resistant Staphylococcus aureus.
-Changing characteristics of Vibrio cholerae: emergence of multidrug resistance and non-O1, non-O139 serogroups.
-Dental therapeutic systems.
-Incidence of metallo beta lactamase producing Pseudomonas aeruginosa in ICU patients.
-Antibiotic prescribing practices in primary and secondary health care facilities in Uttar Pradesh, India.
-Mycobacterium tuberculosis interactome analysis unravels potential pathways to drug resistance.
-TEM & SHV genes in extended spectrum beta-lactamase producing Klebsiella species beta their antimicrobial resistance pattern.
-TargetTB: a target identification pipeline for Mycobacterium tuberculosis through an interactome, reactome and genome-scale structural analysis.
-Detection of virulence genes in Vibrio cholerae isolated from aquatic environment in Kerala, Southern India.
-Bacterial persistence: some new insights into an old phenomenon.
-Down regulation of gyrase A gene expression in E. coli by antisense ribozymes using RT-PCR.
-Novel mutations in emb B gene of ethambutol resistant isolates of Mycobacterium tuberculosis: a preliminary report.
-A potential plasmid-curing agent, 8-epidiosbulbin E acetate, from Dioscorea bulbifera L. against multidrug-resistant bacteria.
-RpoN gene, RAPD profile, antimicrobial resistance and plasmids of Vibrio anguillarum isolates from vibriosis infected Penaeus monodon.
-Novel and potent oxazolidinone antibacterials featuring 3-indolylglyoxamide substituents.
-Enhancement of the efficacy of erythromycin in multiple antibiotic-resistant gram-negative bacterial pathogens.
-Zinc and antibiotic resistance: metallo-beta-lactamases and their synthetic analogues.
-Changing trends in bacteriology of peritonsillar abscess.
-Incidence of bacterial enteropathogens among hospitalized diarrhea patients from Orissa, India.
-Moonlighting function of glutamate racemase from Mycobacterium tuberculosis: racemization and DNA gyrase inhibition are two independent activities of the enzyme.
-Substituted 3-((Z)-2-(4-nitrophenyl)-2-(1H-tetrazol-5-yl) vinyl)-4H-chromen-4-ones as novel anti-MRSA agents: synthesis, SAR, and in-vitro assessment.
-Antimicrobial stewardship in institutions and office practices.
-Tigecycline: a critical update.
-Cefoxitin disc diffusion test for detection of meticillin-resistant staphylococci.
-In-vitro antimycobacterial drug susceptibility testing of non-tubercular mycobacteria by tetrazolium microplate assay.
-Differential expression of ompC and ompF in multidrug-resistant Shigella dysenteriae and Shigella flexneri by aqueous extract of Aegle marmelos, altering its susceptibility toward beta-lactam antibiotics.
-Comparative bacteriology of acute and chronic dacryocystitis.
-Extensively drug-resistant tuberculosis: current challenges and threats.
-Prevalence of inducible clindamycin resistance in gram positive organisms in a tertiary care centre.
-Assessment of pheromone response in biofilm forming clinical isolates of high level gentamicin resistant Enterococcus faecalis.
-Incidence of carbapenem-resistant Pseudomonas aeruginosa in diabetes and cancer patients.
-Evaluation of rapid MTT tube method for detection of drug susceptibility of Mycobacterium tuberculosis to rifampicin and isoniazid.
-Phenotypic detection of inducible clindamycin resistance among Staphylococcus aureus isolates by using the lower limit of recommended inter-disk distance.
-Prevalence of extended spectrum beta lactamase and AmpC beta lactamase producers among Escherichia coli isolates in a tertiary care hospital in Jaipur.
-Empiric antibiotic therapy in children with community-acquired pneumonia.
-Comparison of the radiometric BACTEC 460 TB culture system and Löwenstein-Jensen medium for the isolation of mycobacteria in cutaneous tuberculosis and their drug susceptibility pattern.
-Molecular cloning, overexpression and biochemical characterization of hypothetical beta-lactamases of Mycobacterium tuberculosis H37Rv.
-Molecular characterization of multidrug-resistant Shigella species isolated from epidemic and endemic cases of shigellosis in India.
-Epidemiological evidence of multidrug-resistant Shigella sonnei colonization in India by sentinel surveillance in a Japanese quarantine station.
-Aminoglycoside-resistance mechanisms in multidrug-resistant Staphylococcus aureus clinical isolates.
-Antimicrobial resistance pattern of Neisseria gonorrhoeae isolates from peripheral health centres and STD clinic attendees of a tertiary care centre in India.
-Novel structural analogues of piperine as inhibitors of the NorA efflux pump of Staphylococcus aureus.
-Salmonella enterica Serotype typhi in Kuwait and its reduced susceptibility to ciprofloxacin.
-Synthesis and antimycobacterial activity of 4-[5-(substituted phenyl)-4, 5-dihydro-3-isoxazolyl]-2-methylphenols.
-Observations on carbapenem resistance by minimum inhibitory concentration in nosocomial isolates of Acinetobacter species: an experience at a tertiary care hospital in North India.
-A simple and effective approach for the treatment of chronic wound infections caused by multiple antibiotic resistant Escherichia coli.
-Cefepime and its role in pediatric infections.
-Antimicrobial susceptibility profile of resistance phenotypes of Neisseria gonorrheae in India.

-Stationary phase induced alterations in mycobacterial RNA polymerase assembly: A cue to its phenotypic resistance towards rifampicin.
-Epidemiology, etiology, and diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia in Asian countries.
-Involvement of O8-antigen in altering beta-lactam antibiotic susceptibilities in Escherichia coli.
-Prevalent phenotypes and antibiotic resistance in Escherichia coli and Klebsiella pneumoniae at an Indian tertiary care hospital: plasmid-mediated cefoxitin resistance.
-Cellphones as reservoirs of nosocomial pathogens.
-A case of fatal acute pyogenic meningitis in a neonate caused by extended-spectrum beta-lactamase producing Salmonella group B.
-Significance of isolation and drug susceptibility testing of non-Candida albicans species causing oropharyngeal candidiasis in HIV patients.
-Small and lethal: searching for new antibacterial compounds with novel modes of action.
-On detection and assessment of statistical significance of Genomic Islands.
-A study of typhoid fever in five Asian countries: disease burden and implications for controls.
-Vibrio cholerae non-O1, non-O139 strains isolated before 1992 from Varanasi, India are multiple drug resistant, contain intSXT, dfr18 and aadA5 genes.
-Emerging resistance to newer antimicrobial agents among Shigella isolated from Finnish foreign travellers.
-Antimicrobial protein from Streptomyces fulvissimus inhibitory to methicillin resistant Staphylococcus aureus.
-Modified PAP method to detect heteroresistance to vancomycin among methicillin resistant Staphylococcus aureus isolates at a tertiary care hospital.
-Detection of Enterobacteriaceae producing CTX-M extended spectrum beta-lactamases from a tertiary care hospital in south India.
-Need for national/regional guidelines and policies in India to combat antibiotic resistance.
-ESBLs detection in clinical microbiology: why & how?
-Detection of extended spectrum beta-lactamase production in clinical isolates of Klebsiella spp.
-Detection of extended-spectrum beta-lactamase in Pseudomonas aeruginosa.
-Sequence analysis of bla CTX-M-28 , an ESBL responsible for third-generation cephalosporin resistance in Enterobacteriaceae, for the first time in India.
-Spectrum of microbial flora in diabetic foot ulcers.
-Incidence of metallo-beta-lactamase-producing Pseudomonas aeruginosa in diabetes and cancer patients.
-Emergence of highly fluoroquinolone-resistant Salmonella enterica serovar Typhi in a community-based fever surveillance from Kolkata, India.
-Enteric fever in Mumbai--clinical profile, sensitivity patterns and response to antimicrobials.
-Diarrhoeal outbreak of Vibrio cholerae 01 Inaba in Delhi.
-The role of antibiotic prophylaxis in mesh repair of primary inguinal hernias using prolene hernia system: a randomized prospective double-blind control trial.
-Antimycobacterial activities of novel 2-(sub)-3-fluoro/nitro-5,12-dihydro-5-oxobenzothiazolo[3,2-a]quinoline-6-carboxylic acid.
-Staphylococcus aureus ocular isolates from symptomatic adverse events: antibiotic resistance and similarity of bacteria causing adverse events.
-Quinolone resistance among Shigella spp. isolated from travellers returning from India.
-Pneumocephalus as a complication of multidrug-resistant Klebsiella pneumoniae meningitis.
-Occurrence and detection of AmpC beta lactamases among clinical isolates of E. coli and K. pneumoniae causing UTI.
-Low recovery rates of high-level aminoglycoside-resistant enterococci could be attributable to restricted usage of aminoglycosides in Indian settings.
-Stomatococcus mucilaginosus meningitis in a healthy 2-month-old child.

-Emergence of tetracycline-resistant Vibrio cholerae O1 serotype Inaba, in Kolkata, India.
-Emergence of fluoroquinolone-resistant Neisseria meningitidis--Minnesota and North Dakota, 2007-2008.
-Dissemination of clonally related Escherichia coli strains expressing extended-spectrum beta-lactamase CTX-M-15.
-Metallo beta lactamases in Pseudomonas aeruginosa and Acinetobacter species.
-Inhibition of DNA gyrase activity by Mycobacterium smegmatis MurI.
-Role of beta-lactamase inhibitors in enterobacterial isolates producing extended-spectrum beta-lactamases.
-High nasopharyngeal carriage of beta-lactamase-negative ampicillin-resistant Haemophilus influenzae in north Indian school-going children.
-The yejABEF operon of Salmonella confers resistance to antimicrobial peptides and contributes to its virulence.
-Pre-admission antibiotics for suspected cases of meningococcal disease.
-Resistance in gram-negative bacilli in a cardiac intensive care unit in India: risk factors and outcome.
-Microbiological profile of donor corneas: a retrospective study from an eye bank in north India.
-Preparation & characterization of solid inclusion complex of cefpodoxime proxetil with beta-cyclodextrin.
-High level ciprofloxacin resistance in Salmonella enterica isolated from blood.
-Changing patterns of Vibrio cholerae in sevagram between 1990 and 2005.
-Piperine analogs as potent Staphylococcus aureus NorA efflux pump inhibitors.
-Rising standards for tuberculosis drug development.
-Transcriptional activation and increased mRNA stability contribute to overexpression of CDR1 in azole-resistant Candida albicans.
-High rate of detection of high-level aminoglycoside-resistant enterococci from urinary tract specimens in South India.

-Metallo beta lactamases in Pseudomonas aeruginosa and Acinetobacter species.
-Orthodox and unorthodox clavulanate combinations against extended-spectrum beta-lactamase producers.
-Prevalence and clonality of extended-spectrum beta-lactamases in Asia.

Non-Human and General-2008.

-Evaluation of the probiotic characteristics of newly isolated lactic acid bacteria.
-Antibiotic Resistance Pattern of Shiga Toxin-producing Escherichia coli Isolated from Diarrheic Calves in Gujarat,India.
-Detection of conjugative plasmids and antibiotic resistance genes in anthropogenic soils from Germany and India.
-Need for guidelines and policies in India to combat Antibiotic Resistance
-Diversity of root associated microorganisms of selected medicinal plants and influence of rhizomicroorganisms on the antimicrobial property of Coriandrum sativum.
-Multiple antibiotic resistance patterns of rhizospheric bacteria isolated from Phragmites australis.
-Antibiotic use, environment and antibiotic resistance: A qualitative study among human and veterinary health care professionals in Orissa, India.
-Multiple antibiotic resistance patterns of rhizospheric bacteria isolated from Phragmites australis growing in constructed wetland for distillery effluent treatment.
-In vitro activity of eugenol, an active component from Ocimum sanctum, against multiresistant and susceptible strains of Neisseria gonorrhoeae.
-Synergism between natural products and antibiotics against infectious diseases.
-Phosphinothricin resistance in Aspergillus niger and its utility as a selectable transformation marker.
-Utility of lytic bacteriophage in the treatment of multidrug-resistant Pseudomonas aeruginosa septicemia in mice.
-Conjugative plasmids in multi-resistant bacterial isolates from Indian soil.
-Selection of genes of Mycobacterium tuberculosis upregulated during residence in lungs of infected mice.
-Contamination of potable water distribution systems by multiantimicrobial-resistant enterohemorrhagic Escherichia coli.
-Antibacterial activity of some medicinal plant extracts.
-Prevalence and characterization of Salmonella enterica serovar Weltevreden from imported seafood.
-Utilization of Bombyx mori larvae as a surrogate animal model for evaluation of the anti-infective potential of oxazolidinones.