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.
Aims

• 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

Strategies

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

http://www.ijmm.org/article.asp?issn=0255-0857;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