Kerala leads the way, innovates a system to combat antimicrobial resistance

Kerala's GMCH has conceptualised and piloted this novel antimicrobial stewardship tool which is expected to improve patient outcomes.

ByDileep V Kumar

Published Jun 02, 2024 | 9:00 AMUpdatedJun 02, 2024 | 9:00 AM

Combat antimicrobial resistance

In a groundbreaking move, Kerala has become the first state in India to roll out an AWaRe-based bacteriological culture susceptibility reporting format.

This pioneering initiative aims to revolutionise the way antibiotics are prescribed in the state by familiarizing physicians with the World Health Organization’s (WHO) AWaRe classification of antibiotics and thereby reduce the burden of antimicrobial resistance (AMR) in the long run.

The Government Medical College Hospital in Thiruvananthapuram (GMCH) has conceptualised and piloted this novel antimicrobial stewardship tool which is expected to improve patient outcomes.

It is learnt that health institutions within and outside the state are reaching out to the GMCH to implement this reporting format at their respective centers.

Related: What is antimicrobial resistance? Which is touted as the silent pandemic by doctors

What’s the tool all about?

Talking to South First, Dr Aravind R, Head of Infectious Diseases at the GMCH and the convener of the working committee for implementing the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP) said, “A patient arrives with certain symptoms. Suspecting an infection, a physician will send specimens (either blood or urine or pus) for bacterial culture. The result of the same will now arrive in this new format. Based on this antibiotics will be prescribed.”

The reporting format developed by the Department of Microbiology of the GMCH has been integrated with eHealth, a centralized healthcare Aadhar-based system in which citizens will have unique identification and unified healthcare records.

The new reporting format

Those who work behind this said that the system, which is an innovative one, replaces the traditional antibiotic categorization of first, second, and third lines with a clearer framework based on the World Health Organization’s (WHO) AWaRe classification.

This classification categorizes antibiotics into three groups:

Access: These are the preferred antibiotics for most infections, as they are effective, affordable, and have a low risk of resistance development.

Watch: These antibiotics should be used with caution and only when Access drugs are not suitable or applicable.

Reserve: These are last-resort antibiotics for life-threatening infections and should only be used under strict guidance due to their high potential for resistance development.

“The AWaRe-based reporting format includes clear footnotes defining these categories, acting as a constant reminder to doctors to prioritise ‘Access’ antibiotics whenever possible. This continuous reinforcement is expected to significantly improve antibiotic stewardship practices in the state,” said Dr Aravind.

He further added, “This format will ensure the selection of ‘Access’ category antibiotics if found susceptible. This will help the state to achieve the target set by the WHO – that out of total antibiotics used in a year,  60 percent should be from the Access category.”

According to officials at the Department of Microbiology, GMCH, this tool has been designed to help physicians in selecting the right antibiotic that will pose the least threat of collateral damage and thereby AMR.

Also read: Hospital associated infections — a missing piece in Kerala’s antimicrobial resistance puzzle

A positive impact

In November 2023, a group of experts from the GMCH published an article in the German Medical Science Infectious Diseases (GMS ID), an e-journal, on ‘AWaRe-based culture reporting format: a novel tool for antimicrobial stewardship.’

It was stated in the article that the new approach “has the potential to significantly optimize the current prescription practices with a positive impact on antimicrobial stewardship and thereby patient outcomes in the field of infectious diseases.”

Highlighting the new antibiotic stewardship tool, the article stated that “instead of the conventional format in which antibiotics are sorted into first, second and third line, clear footnotes have been included with definitions of Access, WATCH, and RESERVE drugs to ensure optimization of antimicrobial stewardship by prescribers.”

It added further that, “In this reporting format, each positive culture report will act as a continuous reminder to the prescribers to select susceptible antibiotics from the Access category. These incessant reminders and the cascade reporting associated with positive culture reports will enhance the knowledge, attitudes, and practices of healthcare professionals and thereby augment antibiotic stewardship practices.”

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Five advantages of the new tool

  • The format serves as a platform for the dissemination of knowledge regarding optimal antibiotic prescription practices. Each positive culture report will be like a revision of the AWaRe tool for the prescriber and hence each culture report becomes a stewardship tool.
  • The inclusion of the list of antibiotics in the Access, Watch, and Reserve classes enables healthcare professionals to make quick decisions regarding antibiotic selection while considering antimicrobial stewardship policies and patient safety.
  • All healthcare professionals indirectly participate in antimicrobial stewardship programs.
  • It establishes a foundation for antimicrobial prescription audits, allowing healthcare professionals to be questioned about their choices if susceptible Access antibiotics are not prescribed.
  • It helps to dispel misconceptions, such as the belief that Vancomycin is superior to Penicillin/Ampicillin.

According to Dr Aravind, who is also a co-author of the article, integrating the AWaRe-based culture reporting format into microbiology culture and antibiotic susceptibility reports will revolutionize antibiotic stewardship practices and might have a significant impact on antimicrobial resistance rates.

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In 2017, the AWaRe Classification of antibiotics was developed by the WHO Expert Committee on Selection and Use of Essential Medicines. It’s a tool to support antibiotic stewardship efforts at local, national and global levels.

Under this, antibiotics are classified into three groups – Access, Watch and Reserve – taking into account the impact of different antibiotics and antibiotic classes on AMR to emphasise the importance of their appropriate use.

In 2021, an update was made on the AWaRe classification as 78 antibiotics, not previously classified, were included bringing the total to 258.

According to the WHO, AWaRe Classification is a useful tool for monitoring antibiotic consumption, defining targets, and monitoring the effects of stewardship policies that aim to optimize antibiotic use and curb AMR.

Referred to as a silent killer by WHO, AMR occurs when bacteria, viruses, fungi, and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness, and death. As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others.

(Edited by Neena)