An NCDC study noted around 57% of prescribed antibiotics belong to a group of drugs highly susceptible to antimicrobial resistance (AMR).
The NCDC underscores the need to establish clear antibiotic policies favouring 'Access' group antibiotics. (Creative Commons)
Antibiotics stand as indispensable warriors against infections that target various parts of the body — be it the respiratory system, nervous system, gastrointestinal system, skin, ears, urinary tract, etc.
Their role involves either vanquishing microorganisms or stalling their growth. Yet, when these antibiotics are misused or overused, they cast shadows on a phenomenon known as antimicrobial resistance (AMR). In simpler terms, AMR signifies the ability of microorganisms to withstand the effects of medications, rendering once-potent treatments ineffective.
The emergence of AMR significantly hampers our ability to combat infections, leading to prolonged illnesses, escalating healthcare costs, and soaring mortality rates.
A recent study published by India’s National Centre for Disease Control (NCDC) spotlights a concerning statistic— approximately 57 percent of prescribed antibiotics in India belong to a group of drugs highly susceptible to antimicrobial resistance, prompting a call for vigilant monitoring to prevent misuse/overuse.
Compounding the issue is the disconcerting revelation by recent surveys that antibiotics are often administered not as a remedy for infections but as a preventive measure, fuelling fears of escalating resistance to these drugs.
Equally disquieting is the fact that a whopping 94 percent of patients receive antibiotics before a precise medical diagnosis pinpoints the root cause of their infection.
The study, conducted by the National Centre for Disease Control under the Union Health Ministry, unfolded over six months from November 2021 to April 2022.
“This is delving into the AMR problem which we are about to face. It’s not a huge sample data finding on antibiotics prescription habits, but we are starting here and will keep moving forward and building better data about the silent pandemic — AMR,” Dr Ranga Reddy, President of Infection Control Academy of India, told South First.
Hyderabad-based Infection Control Academy of India was one of the organisations that made policy documents for AMR, which was presented during the G20 Summit in India.
The survey, involving 9,652 patients and 12,342 antibiotic prescriptions across 20 tertiary care institutes in 15 states and two Union territories, reveals a substantial range in prescription rates, varying from 37 percent to a full 100 percent.
Out of 11,588 admissions and 9,652 eligible patients, an alarming 72 percent received antibiotic prescriptions — meaning three out of four patients walk away with a prescription.
Antimicrobial resistance. (Wikimedia)
Digging deeper, it becomes evident that a mere 45 percent of these prescriptions were for therapeutic purposes, intended to combat infections or diseases. The remaining 55 percent were prophylactic, aiming to preempt infection occurrence or spread. A scanty 6 percent received antibiotics after confirming the specific bacteria responsible for their illness, known as definitive therapy.
In stark contrast, a whopping 94 percent embarked on empirical therapy, relying on the clinician’s judgement to assess the likely cause of the illness.
“The hospital environment faces a definite threat due to the prescription of antibiotics. Hospitals must optimise their diagnostic procedures to facilitate the targeted selection of antibiotics tailored to individual patient needs, rather than simply dispensing antibiotics without a precise assessment of the patient’s requirements,” said Dr Reddy.
“Around 26.4 percent of patients undergoing antibiotic treatment were simultaneously targeted by two types of antibiotics to combat gram-negative bacteria. The data revealed that over half of these patients were given antibiotics preventively and, notably, 91 percent received surgical prophylaxis for more than a single day,” the study noted.
“Among the chosen institutes, a mere 6 percent of patients receiving antibiotics were placed on definitive therapy, and a stop or review date for the prescriptions was documented in just 10.4 percent of cases. Additionally, it was found that only eight out of the 20 institutes had a defined antibiotic policy established,” the study said.
The World Health Organization (WHO) has developed the AWaRe classification system to strategically categorise antibiotics into three groups: Access, Watch, and Reserve.
The Access group comprises essential antibiotics vital for treating prevalent and severe infections, emphasising their affordability and lower resistance potential to ensure widespread availability.
Antibiotics in the Watch group possess a higher propensity for resistance and require cautious and selective use, necessitating monitoring to curb the emergence of antibiotic resistance. Conversely, the Reserve group consists of last-resort antibiotics, serving as the final line of defence against infections when other treatments fail.
AWaRe classification system. (ResearchGate)
The AWaRe system aims to encourage appropriate antibiotic usage, mitigate the development of antimicrobial resistance, and preserve the efficacy of crucial antibiotics for combating serious infections.
In the study, out of the total antibiotic prescriptions, 57 percent fell within the category labelled as “Watch”, indicating a higher level of concern regarding their potential for misuse and resistance.
Meanwhile, 38 percent of these prescriptions belonged to the “Access” group, comprising antibiotics with a lower likelihood of misuse. These “Access” group antibiotics are more widely available and are employed in treating a broad spectrum of infections.
Only around two percent of the prescribed antibiotics, categorised as the “Reserve” group, were considered last-resort options used for severe infections caused by multidrug-resistant pathogens.
“It is noteworthy that about 3 percent of the prescriptions were in the ‘not recommended’ group by the WHO. However, the high use of ‘Watch’ group antibiotics is of concern as these antibiotics have a higher potential to develop antibiotic resistance,” the study noted.
“The initial choice should be antibiotics from the ‘Access’ group, with a shift to ‘Watch’ group antibiotics in uncommon situations, and only resorting to ‘Reserve’ group antibiotics when necessary. This approach is an ongoing process. Presently, an increasing number of hospitals are becoming cognisant of this and are formulating policies regarding appropriate antibiotic prescriptions for infections,” said Dr Reddy.
Examining 9,652 patients, the study unveils that 71.9 percent received antibiotic prescriptions, with usage rates ranging from 68.6 percent in paediatric departments to 78.9 percent in intensive care units — highlighting a notably high prevalence of antibiotic administration.
Remarkably, around 4.6 percent of patients were prescribed four or more antibiotics concurrently. More than half of the patients on antibiotics — 53 percent to be exact— used more than one antibiotic simultaneously. Single antibiotic usage predominated in general medicine (60 percent), while obstetrics and gynaecology departments commonly prescribed three or more antibiotics (26.9 percent).
Third-generation cephalosporins emerged as the most frequently prescribed class of antibiotics, accounting for 33.1 percent of prescriptions. Key antibiotics included ceftriaxone, metronidazole, and amikacin, categorised according to the WHO-Anatomical Therapeutic Chemical Class.
“The key issue revolves around prioritising patient care, especially during surgeries or medical procedures, by emphasising stringent hygiene practices for infection prevention and control. Implementing high-level hygiene standards is crucial, not only within healthcare facilities but also extends to community-level practices,” said Dr Reddy.
He added, “Proactive hygiene measures and prevention strategies are more effective than reactive measures. The foremost step involves ensuring infection prevention, which can significantly reduce the occurrence of infections— a crucial yet often overlooked aspect of managing what could be termed a ‘silent pandemic’.”
The NCDC underscores the need for institutes to establish clear antibiotic policies favouring ‘Access’ group antibiotics, minimising the use of ‘Reserve’ group drugs, and monitoring their external sources.
The survey highlights widespread polypharmacy, indicating a risk of adverse effects and drug interactions. To address this, institutions are advised to adopt standard treatment guidelines and conduct periodic surveys to monitor antibiotic consumption, with results shared to modify physicians’ prescribing behaviours.
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