Message from the Regional Director This year, World Health Day focuses on the problem of antimicrobial resistance, or AMR. Simply put, the microbes that cause many diseases are becoming resistant to the drugs that are the mainstay of treatment of communicable diseases. The development of resistance is a natural process, because organisms evolve ways to adapt to threats. But we have vastly accelerated the emergence and spread of resistance by careless, unwise and profligate use of antibiotics for everything from the common cold (which they cannot cure) to “preventive” uses in livestock. The medical management of communicable diseases was revolutionized some seven decades ago with the advent of antibiotics. These “wonder drugs” prevented deaths and reduced the duration of illness, and became the mainstay in the battle against communicable disease. Other modern advances in health care, such as complex surgeries, organ transplants and care for people living with HIV and cancers, have benefited tremendously from the effective use of antibiotics. But the wonder of the wonder drugs has worn off, and the cavalier use and abuse of these precious medical tools is now presenting a serious menace to public health. People start taking antibiotics but stop once they begin to feel better, abandoning the prescribed course of treatment; doctors prescribe them under pressure from patients, relatives, or suppliers, often without adequate evidence showing that they are indicated; and patients hoard unused medicine for a rainy day—in effect, prescribing for themselves the next time illness comes around (this is known as “self-medication”). In 2 | Health in South-East Asia || March 2011 many developing countries, pharmacies—and sometimes even ordinary stores and shops— sell antibiotics over the counter without a prescription. All of these actions tend to favour the development of antibiotic resistance. The consequences are severe—economically, socially and personally. Resistance in microorganisms costs money, livelihoods and lives, and threatens to undermine the effectiveness of health delivery programmes. Recent decades have seen the development of pharmacological treatments for deadly diseases such as malaria, TB and HIV.The first two are curable and HIV is now a manageable condition—but AMR could erode or even erase these achievements. Were that to happen it would be catastrophic not only for millions of people, but would have larger social consequences, including hampering efforts to reduce poverty and improve quality of life for people all over the world. When infections become resistant to first-line antimicrobials, treatment has to be switched to second- or third-line drugs, which are nearly always much more expensive and sometimes more toxic as well. For example, the drugs needed to treat MDR-TB are over 100 times more expensive than the first-line drugs used to treat the non-resistant form. In some countries, this high cost is prohibitive, with the result that some of these cases can no longer be treated. That means that patients become victims. Resistant organisms can move across and between countries through travel and trade. Therefore, antimicrobial resistance is a global problem, and combating it will require concerted efforts at the national and global levels to preserve the efficacy of the available antibiotics. The emergence and spread of antimicrobial resistance are complex problems intertwined with the knowledge, expectations, and
interactions of prescribers and patients, as well as the regulatory environment. Patient compliance with recommended treatment is a major problem. Easy access to antimicrobials in developing countries and myths about their effectiveness in all conditions that give rise to fever also have an important influence on the emergence of resistance. Several problems continue to plague prevention and containment of antimicrobial resistance, which continues to be neglected despite of its profound impact on health and the economy. National approaches to combating AMR are generally lacking, and regulatory mechanisms are weak. There is also a lack of education, whether for prescribers or for patients. Incentives for pharmaceutical manufacturers to undertake the enormously costly development of new drugs is insufficient as well. Infection control practices in health-care facilities in developing countries are often deficient, and these too play a role. Finally, collaboration between stakeholders is weak at best, and often entirely lacking, The global pattern of misuse, in both developed and developing countries, has offered an undue advantage to microorganisms and needlessly
depleted humanity’s arsenal in its battle against disease. To catalyze national actions, a regional strategy to combat AMR has already been developed by WHO. It gives particular attention to the introduc tion of legislation and policies governing the use of antimicrobial agents, establishment of laboratory-based net works for the surveillance of resistance, and ensuring the rational use of these drugs at all levels of health-care settings. The global community can no longer take antibiotics for granted, nor ignore the emergence of AMR. The good news is that not only policy-makers, but also individuals, can make a difference. Coordination and involvement of all stakeholders is key, however; the time for sustained, global action is now, since we are slowly but surely drifting towards a reversion to the dreadful pre-antibiotic era. That would be disastrous. In fact, it would represent the biggest threat to global poverty alleviation and efforts to make this world a better and more healthy place. Hence we must save antibiotics to save human lives
Dr Samlee Plianbangchang Regional Director
© World Health Organization 2011 All rights reserved. Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – can be addressed to Publishing and Sales, World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Marg, New Delhi 110 002, India (fax: +91 11 23370197; e-mail: publications@searo.who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed.
Inside: • Message from the Regional Director.................2 • Perceptions and usage of antimicrobials in South-East Asia. .........................................4 • Antimicrobial resistance in India. ...................6 • Containing antimicrobial resistance in Sri Lanka: use of national antibiotic policy and infection control practices.......................11 • Perceptions of communities and physicians in use of antibiotics. ......................................17 • Recent publications from SEARO on antimicrobial resistance...............................................19
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Perceptions and usage of antimicrobials in South-East Asia Vanvisa Warachit, Uppasala, Sweden
An “antimicrobial” is a chemical compound killing or inhibiting the growth of bacteria without causing the host (human or animal) significant damage. Antimicrobials can be naturally produced by a mold or bacterium, or synthetically made. Antibiotics are the antimicrobials most familiar to the general public. Antibiotics are used to treat illnesses caused by bacteria and, in some cases, preventively--prior to surgery, for example. Resistance occurs when an antibiotic has lost its ability to effectively control or kill bacterial growth; in other words, the bacteria continue to multiply even in the presence of therapeutic levels of an antibiotic. There are many factors influencing antimicrobial resistance (AMR) in South-East Asia--for instance, patients who stop taking the medicine before the end of the dose period, or use it for a viral infection (antibiotics don’t kill viruses). Another cause is too easy access to medicines (sometimes without a prescription),
and there are indirect factors such as economic pressure. Patients sometimes save some of their medicine to use again the next time they get sick, or because of cost they go to a hospital too late and require more expensive antibiotic treatment. Antimicrobials have enabled us to combat and control some of the most devastating diseases known to humanity, including tuberculosis, malaria, and HIV/AIDS. The rise of AMR presents a very real possibility that these gains could be lost. Action is necessary by all stakeholders in the process, from the manufacturer down to the level of the patient/user. Patients are one of the most important factors in AMR, due to frequent lack of knowledge of the nature and treatment of their infection. One study found that some patients tended to exaggerate their symptoms to get a prescription, and patients’ expectation of being prescribed anti-microbials significantly influenced doctors and pharmacists to prescribe or dispense them1 (Jean, 2001). Therefore, it is important to educate people about which symptoms are caused by viral infections and which do not necessarily need to be treated with antibiotics. One study in India found that of the survey sample, 69.4% of patients received antimicrobial prescriptions2. A Thai study revealed that 53% of those surveyed stopped taking their antibiotics before the course was ended, for such reasons as that they felt better Jean CP. Patients’ interviews and misuse of antibiotics. Clinical Infectious Diseases. 2001; 33(Suppl 3):S170-173. 2 Kumari IK et al. Antimicrobial prescription patterns for common acute infections in some rural and urban health facilities of India. Indian J Med Res, 2008; 128:165-171. 1
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or had experienced some negative side effect3. Thus, patient attitudes lead to self-medication and uninformed decisions about the use of medication.
Pharmacists and chemists may dispense antibiotics to patients without a prescription. It has been documented that chemists sometimes do not explain possible dangers of using these medicines, do not ask for details of Manufacturers also have a role, because the symptoms, or sell the medicines without substandard antimicrobials contribute to providing even the name or information on AMR. Regulations on controlling the quality using it. This might be explained by insufficient of antimicrobials should be initiated where training of the pharmacy employees and lack of they are absent and enforced in the future. enforcement of regulations. To train chemists Incentives for the pharmaceutical company to to be aware of the dangers improve the AMR situation of AMR and the impact are also important. To of for dispensing medicine encourage companies to It is important to educate without a prescription and improve and develop new people about which appropriate information is kinds of drugs, or to develop symptoms are caused by essential. a testing kit to distinguish viral infections and which between a viral or bacterial But even educating chemists do not necessarily need to be infection, are examples of and pharmacists is not treated with antibiotics. such measures. In this way, enough, because in many antimicrobials would be countries antibiotics can be used less than at present, obtained elsewhere. The Indonesian government which would improve both the AMR situation has launched an important regulation allowing and the clinical failure rate. only licensed medical shops to dispense antibiotics. However, the regulation does not Policy-makers are clearly pivotal in addressing mention other types of outlets, and the gap AMR. A key aspect is how we look at control in regulation has resulted in the selling of programmes for infectious diseases. Nonantibiotics in general shops4. Both policy and pharmaceutical measures—such as hand enforcement need to be enhanced throughout hygiene or isolation precautions—need to be the Region to combat AMR. promoted as being among the best strategies to slow the development of resistance. And Doctors need, first of all, to be trained in just as there is a burden of disease, there is a the accurate diagnosis and management of “burden of resistance” due to AMR, which infectious disease. One study found that only should be included in any calculation related a small number of stool cultures were used in to disease control programmes. This burden of the diagnosis of infectious diarrhoea5. To use a resistance includes the cost of substitution of the antimicrobial, cost of implementing a new 3 Jean CP. Patients’ interviews and misuse of antibiotics. Clinical Infectious Diseases. 2001; 33(Suppl 3):S170-173. kind of antimicrobial, cost of infection control 4 Usman Hadi et al. Cross-sectional study of availability and cost of morbidity and mortality. and pharmaceutical quality of antibiotics requested with or without prescription (over the counter) in Surabaya, Indonesia. BMC Infectious Diseases, 2010; 10:203. 5 L Rand Carpenter et al. Stool cultures and antimicrobial prescriptions related to infectious diarrhea. The Journal of Infectious Diseases, 2008; 197:1709-1712.
laboratory test before prescribing the antibiotic is a crucial measure in containing AMR. Doctors also need to be sensitized to the threat of AMR in order to resist social and economic pressures to overprescribe antimicrobials.
The cost of indiscriminate use is not just loss of effectiveness; it also means loss of life. Action is long overdue to meet the challenge of AMR. Health in South-East Asia || March 2011 | 5
Antimicrobial resistance in India Mohuya Choudhuri, New Delhi
If you’re sick for a couple of days, nose running that the scale of resistance is extensive but few with a splitting headache and fever racking your steps, such as stricter supervision of the use and body and you pop some antibiotics for relief sale of antibiotics, have been taken. But with an without taking medical advice, then you are one increasing number of people not responding to of millions who use antibiotics indiscriminately. a spectrum of drugs, can India afford to ignore Taking antibiotics without a doctor’s diagnosis antibiotic resistance any longer? This debate and prescription has led to widespread was placed centre stage in August 2010, when The Lancet published the antibiotic resistance in India. study on NDM1 (New Delhi However, the problem is not With few new drugs in metallo – B lactamase 1), or restricted to India; globally, the pipeline, the options for the “Superbug”. This enzyme, antimicrobial resistance hosted by the E-coli bacteria (AMR) is growing. A broad treatment are getting limited. and Klebsiella pneumonia, was spectrum of antibiotics is no found to be non-responsive longer able to treat routine infections because of the rise in the number to carbapenems — the most potent antibiotics of antibiotic-resistant microbes. Some of the available currently and usually used for microorganisms that have drug-resistant strains emergencies. Both these bugs can cause urinary are those that cause, tuberculosis, typhoid fever tract infections and blood poisoning, leading to death. So far, patients infected by NDM1 and pneumonia. are untreatable. Over the years, popular drugs like penicillin, tetracycline used for treating respiratory This discovery put AMR in the public eye. infections, and quinolones like ciprofloxacin People are worried. For the first time, the (second generation) used for typhoid fever quality of infection control in intensive care have become less effective. With few new drugs settings such as ICUs, CCUs and NICUs is in the pipeline, the options for treatment are being raised. Even though the community is getting limited. Several studies have established generally aware of antibiotic resistance in their 6 | Health in South-East Asia || March 2011
day-to-day life, there is little knowledge about its own role in creating it.
So what is AMR? It is the process by which bacteria become resistant to known drugs by Sometimes, in low-income areas, chemists genetic mutation. There are several reasons do give antibiotics to customers because they why resistance occurs but the key driver in cannot afford to pay a doctor’s fees. A chemist India is ignorance. Cutting across all sections in a South Delhi slum plays the resident of society, antibiotic abuse is doctor. He hands out ciplox common, both by patients and tetracycline liberally, and Cutting across all sections of and by pharmacies. Since when a customer asks him society, antibiotic abuse is medical care is expensive, how long he should take the people end up indulging drug, the chemist tells him common, both by patients in self-medication. General to take the pills till he feels and by pharmacies. practitioners are a disappearing better. breed. So unless the condition Such gross misuse of is considered “serious”, people fall back antimicrobials has led to a proliferation of drugon their neighbourhood pharmacist. After resistant pathogens. The “Superbug” showed discussing the symptoms over the counter, how a group of bacteria are now resistant to often antibiotics are handed out liberally multiple classes of drugs. In India, pathogens without a prescription. Madhushree Sinha, that cause tuberculosis, pneumonia and 34, says she takes antibiotics whenever she has malaria are showing resistance to drugs. There fever with cough and cold, a toothache or a are three key factors. One is micro-biological; stomach infection. “I am a single mother and when bacteria are under stress or pressure (as I cannot afford to be ill. It’s simpler to ask the from chemotherapy), they are forced to carry local chemist and he usually gives me the right out novel mutations in their genetic structure medicines. Usually I get better on the second which are responsible for neutralizing the or the third day. But these days, it takes longer impact of antibiotics. to fix. At times, I do not complete the course if I am feeling better.” Sinha said she did not When penicillin was discovered in the have time to visit a doctor. “These are regular beginning of the twentieth century, the use of illnesses and can be handled at home,” she chemotherapeutics to kill bacteria was a brand said. Here’s where the trouble begins. Irrational use of antibiotics, faulty dosages, counterfeit drugs, truncated treatment and above all, use of antibiotics for infections not caused by bacteria are a recipe for disaster. But some chemists disagree. They say not all of them hand out antibiotics to customers without prescriptions because there is growing awareness among pharmacy owners about the misuse of drugs. Surinder Singh, who runs a pharmacy in South Delhi, blames doctors for over prescribing antimicrobials. He says as the cold sets in, coughs and colds are usual, but Health in South-East Asia || March 2011 | 7
doctors routinely prescribe heavy doses of highend antibiotics even to newborns, though there is no real need. Why blame chemists alone?
new concept. It saved many lives and remained a miracle drug for quite a while — till resistance began to emerge. But with long-term, widespread use the bug was no longer vulnerable to penicillin. So it is with a large number of pathogens including MRSA1, which causes skin infections, because bacteria are extremely resilient and versatile. Once exposed to a particular drug over a period of time, it initiates changes in its genes, which makes it possible to survive in a chemo-hostile environment. Some strains of TB have also been found to be resistant to the primary drug, rifampacin, while another group with a different genetic mutation does not respond to isoniazid. And if a strain is resistant to both these compounds, then the person who is infected is suffering from multidrug-resistant TB, an increasing phenomenon in India, which has one of the largest burden of TB cases in the world. Second is the quality of medications. In India, there is a thriving counterfeit or spurious drug market. Hundreds of factories churn out copies of drugs that end 1
Methicillin Resistant Staphylococcus aureus – these are resistant to multiple antibiotics.
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up in pharmacies. Since inspection or raids of phar-macies or pharmaceutical factories never take place, the market is flooded with suboptimal medications that lead to poor recovery and provide a window of opportunity for the pathogen to devise a strategy against the antibiotic.
standardization of hospital services and only a few facilities follow best practices for infection control and patient safety. Hospitals are breeding grounds for bugs, and when these are exposed to bulk doses of a cocktail of antibacterials, resistance results. For instance, the level of resistance found in outpatients is lower than that of those who are admitted for treatment. The third and very critical cause of AMR is the However, there are other risks involved. Since role of the community and outpatient departments tackle the environment. Apart from a large volume of patients, Sometimes patients suffering irrational use of antibiotics by drug resistant germs can from viral fever are put on patients themselves, doctors be transferred from one to an antibiotic regimen even (many of them unqualified) the other, even though the prescribe antibiotics though it has absolutely no person may be asymptomatic. frequently, even though it may impact on the pathogen. Doctors should therefore not be indicated. Sometimes impress upon families not to patients suffering from viral come to hospitals in groups fever are put on an antibiotic regimen even for visits, in order to control the spread of though it has absolutely no impact on the drug-resistant microbes. pathogen. In cities, where multiple infections can occur simultaneously such as dengue, But the real danger lies in ICU settings, where malaria, chikungunya and influenza, thousands the levels of AMR are much higher. In some of people are forced to take several rounds of cases, patients have stopped responding to antibiotics, whether they need it or not. most antibiotics. Most of the drug-resistant bugs found in ICUs are gram negative Samridhhi is only three years old but she has microorganisms that are pan-resistant. They had repeated courses of antibiotics though she do not respond to most of the available line of did not need it. Her parents still do not know medications. The fear of them spreading why her paediatrician gave antibiotics each time from patient to patient is real, since most she had cough and cold. She was diagnosed ICUs in India are open, with patients with asthma later. Clearly, her treatment was suffering from different infections not only faulty but could lead to resistance to a kept together. Their consultants certain class of antibiotics at a later date. prescribe their preferred Social behaviour can also lead to resistance. antibiotic (sometimes highDuring outbreaks, people tend to pop end, extremely potent ones) antibiotics as prophylaxis. During the SARS and thereby push up the risk and later avian influenza outbreaks, people of antimicrobial resistance. rushed to stores to buy antibiotics out of panic. Since there is no clear policy on the use of antibiotics, multiple However, the biggest antibiotics are used in ICUs. source of antibiotic Patients infected with resistance is in drug-resistant hospital settings. strains Over 80% of health care is provided by the private sector in India. There is no Health in South-East Asia || March 2011 | 9
are therefore likely to pass on the infection to patients, hand-washing, minimizing the use others who share a room with them. Another of cleaners, detergents and antibacterials have route that leads to AMR is poor waste disposal also helped immensely. But in India, the fight at hospitals. Discharges containing urine is going to be on many more levels. and faeces of sick patients also contain large Antibiotic abuse occurs all around us in amounts of antibiotics. When this mixes with nonmedical conditions as well. In the field the sewage water containing of agriculture, farmers use colonies of bacteria, resistance antibiotics to prevent fruits and Antibiotic abuse develops. vegetables from rotting. Those occurs all around To overcome this, some countries engaged in animal husbandry us in nonmedical follow a strict antibiotic policy. are also liberally using conditions as well. Waste is treated and ICUs have antibacterials to induce growth antibiotic “holidays”, during in cattle and prevent infections which no anti-biotics are given, in poultry. With avian influenza thus limiting the risk of building resistance. In and Ranikhet disease posing an active threat, fact, doctors say that if an antibiotic is not used poultry owners do not want to risk losing their for a long time, then the bacteria no longer stock. Hence an assortment of antimicrobials has any “memory” of it. Chloramphenicol are finding their way through the food chain was considered the gold standard for treating into the environment. typhoid in the 1970s and 1980s. But after The threat of AMR is real. With no law to the bug, Salmonella typhi, stopped responding regulate the use and abuse of antimicrobials, to it, second-generation drugs like ofloxacin/ the lives of millions of people are at stake. With ciprofloxacin began to be used. But these too no new drugs available to combat newer strains are also showing lower sensitivity. Surprisingly, of bacteria, the best bet is to use antibiotics doctors have now found that choloramphenicol optimally. First, the government must frame is once again showing good results. Experts stringent regulations on the use of antibiotics. believe that this occurs because the drug was Doctors must prescribe judiciously — only not in use for nearly three decades, and the when it is really required — and not give low bacteria has mutated several times since then doses. Patients must not demand antibiotics and has no systemic reference to sidestep it. at any cost, and should take them according In countries like Sweden, antibiotic holidays to the regimen. Chemists must only sell them and strict infection control measures have when it is prescribed by a doctor, and audits shown that AMR can be brought down. But must be done on all pharmacies. Only then simple practices like segregating infected will the misuse of antibiotics be reduced.
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Containing antimicrobial resistance in Sri Lanka: use of national antibiotic policy and infection control practices S.D. Atukorala, Consultant Clinical Microbiologist, Colombo, Sri Lanka
An antibiotic is a substance that inhibits growth of bacteria or selectively kills them. Since bacteria infect humans and are also living cells that multiply inside the human body, the drug must act on the bacterial cell and cause no harm to human cells. This selective action is achieved by getting the drug to act on sites present on bacterial cells and absent on the human cells, such as the cell wall. When the antibiotic acts on biochemical pathways like protein synthesis, a selective advantage is obtained because the ribosomal components taking part in protein synthesis differ in bacterial cells, as compared with human cells.
This phenomena of antibiotic resistance showed the medical world that they were dealing with a population of living organisms which had immense powers of adaptability for survival. The discovery of the antistaphylococcal penicillin group (like methicillin) followed. Since the killing power of cloxacillin and fluorinated cloxacillin-flucloxacillin was superior, they were used in preference to methicillin, which was the standard or prototype anti- staphylococcal penicillin.
Around this time, another group of bacteria (gram negative bacilli or rods) were posing problems of urinary tract infections and also When the first antibiotic diarrhoeal diseases. A broadpenicillin was discovered and spectrum penicillin group, the Poverty, ignorance introduced into the world, the ampicillins, were then developed. inadequate access to main bacteria causing health Alongside this development of drugs, poor health care problems were those that caused the broad-spectrum ampicillin delivery, have limited the respiratory tract infections family, the anti-pseudomonal control of infections. and skin and soft tissue sepsis. penicillins and other groups This prototype penicillin saved of antibiotics (macrolides, millions of lives. aminoglycosides, cephalosporins and tetracyclines) were developed for clinical But alongside this beneficial effect, one of the use. The cephalosporins give broad spectrum problems encountered was that the ubiquitous cover against several bacteria. Staphylococcus aureus started producing the enzyme penicillinase, which destroyed the prototype benzyl penicillin. This was the start of Management of antimicrobial the development of antibiotic or antimicrobial resistance resistance (AMR). This also initiated the development of various types of antibiotics Antimicrobial resistance is one of the biggest against the changing types of disease-causing challenges facing health care globally. bacteria. Health in South-East Asia || March 2011 | 11
Although antibiotics have saved millions of lives, poverty, ignorance inadequate access to drugs, poor health care delivery, especially in developing countries, have limited the control of infections. Sometimes we cannot provide reliable susceptibility data on which rational use of antibiotics can be based. Management of antimicrobial resistance requires many skills. Infection control measures would place barriers on the exchange of resistant bacteria from patient to patient, patient to health-care worker (HCW) and HCW to the patient. Skills are needed in the effective use of antibiotics, taking into consideration their pharmacokinetics and pharmaco-dynamics. Laboratory skills are required to identify bacteria, measure their antibiotic resistance and monitor the spread in hospital and in the community. These require integrated teamwork. Attention has to be paid to control the addition of antibiotics to animal feeds as growth promoters, as this also helps in the selection of resistant bacteria.
It is not only drug use but also the dose and duration of use which plays a role in antibiotic resistance. Appropriate antimicrobial use is the use that maximizes therapeutic impact while minimizing toxicity and development of resistance. The appropriate use is facilitated by promoting the use of informed guidelines by clinicians, improving diagnostic techniques, and also informing consumers about the proper use and the limitations of antibiotics.
Development of antibiotic policy in Sri Lanka In Sri Lanka, at the request of the Ministry of Health, guidelines were prepared for rational use of antibiotics. They were presented in tabular form for easy reading and distributed by the ministry to medical officers. Recently, at the request of the Sri Lanka Medical Association, we developed an updated set of guidelines for which contributions were made by specialists in each field. Although guidelines are available,
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good microbiological laboratory backup is not available in many peripheral hospitals. A strict antibiotic policy is not in place at present. An antibiotic policy would not only prevent the development of antibiotic resistance but also guide the clinician to use the antibiotic only when necessary e.g. the cause of upper respiratory infections is mainly viral and antibiotics are not necessary and symptomatic measures would suffice. Further, the antibiotic policy would help prevent the side effects related to antibiotics and reduce treatment costs. It has been shown that the second-highest expenditure item after payment of salaries of staff is antibiotics. The type of policy could be restrictive – where doctors are not permitted to use reserve antibiotics for minor infections. A restrictive policy would also not permit the use of glycopeptide antibiotics meant for resistant bacteria like methicillin-resistant Staphylococcus aureus (MRSA). Some countries rotate antibiotic use, i.e. use a certain antibiotic for a particular period and replace this with another during the successive period. This type of cyclic policy is not favoured. Some doctors do not like policies in which their prescribing rights are curbed by a set of guidelines drawn by a chosen set of doctors. In developing countries, the availability of over the counter (OTC) antibiotics has been a tremendous impediments to rationalizing antibiotic use. It is felt that an antibiotic policy should be for
a particular hospital or a group of hospitals in a province where there is a consultant microbiologist available, and adherence to this policy has to come through consensus. An antibiotic policy committee needs to be appointed to take decisions on antibiotic use and also to implement the decisions of the committee. Review of the antibiotic-resistance patterns need to be done periodically to change the antibiotics of the guideline accordingly. The provincial committee could monitor the antibiotic use in satellite hospitals in the province. In developed countries each hospital has its own antibiotic policy.
Role of laboratories in generating evidence The information needed to manage resistance comes from the microbiologist and the
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Hand-washing An extract from a poster advocating for hand-washing in health-care facilities at five key moments in patient care. Good hand hygiene helps prevent antimicrobial resistance.
Produced by the Infection Control Unit of NHSL (Sri Lanka) and WHO.
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microbiology laboratory. The laboratory will at acquiring genes that code for drug resistance, isolate bacteria from clinical samples and particularly in the presence of antibiotic identify them to species level. Antibiotic selection pressure. They have available a range sensitivity testing need be performed to check of resistance mechanisms against the same antimicrobial resistance. The microbiology antibiotic, or a single mechanism to affect laboratory could generate the information and multiple antibiotics. use a resistance-monitoring programme like Since HAI cannot be totally eliminated, all WHONET to store the data. The laboratory hospitals in Sri Lanka have embarked on can be linked to other WHO Collaborating methods to control HAI. This is done through Centres. Improved diagnostic testing will an Infection Control Committee, which not only help detect resistance is headed by the hospital’s but also enhance correct microbiologist and would antibiotic use and patient care. By far the single most have infection control nurses The microbiology laboratory important aspect of (ICN) and other consultants. would need to address controlling of HAI is Pharmacists are also included to appropriate specimen collection, hand washing. help in implementing antibiotic performance of accurate testing policies. interpretation, and reporting of antibiotic sensitivity (susceptibility) tests Among the main measures is the reduction of the done on clinical samples. There has to be close “bio-burden” or the quantum of microorganisms communication between the microbiologist in all areas of the hospital. General measures and clinicians to interpret the significance of would include hand-washing, safety precautions isolates, choosing the appropriate antibiotic, made up of universal precautions plus body investigation of infectious disease outbreaks substance isolation (BSI), patient isolation and infection control measures. policies and laundry care. By far the single most important aspect of controlling of HAI is hand washing. Whenever we speak of curtailing Impact on patient care and the spread of resistant bacteria like MRSA or hospital-associated infections multidrug resistant (MDR) gram negative rods, hand-washing will hold top position. Although (AAI) An HAI is an infection which the patient hand-washing with soap was the time-tested acquires after 72 hours of hospital stay and method, alcoholic rubs have made this task which he did not have at the time of admission easier. Posters have been developed at the to hospital. HAI is a challenge to patient safety. National Hospital of Sri Lanka (NHSL) as per If a patient acquires an infection while in WHO guidelines to insist on the five moments hospital it is going to increase his hospital stay for hand hygiene (see page 16). There is little or make him more ill, or he may even die of doubt that hand-washing is at the top of list of the HAI. Gram negative bacteria have features priorities in a health care setting; it is a simple, which are of main concern to health care effective way to reduce HAI and combat the providers. These organisms are highly efficient development and spread of antibiotic resistant bacteria.
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Perceptions of communities and physicians in use of antibiotics WHO/SEARO commissioned a preliminary study in and around New Delhi to generate some data regarding perception of communities and physicians on use of antibiotics. The initial findings are summarized here. The sample size was 150 members of community and 150 physicians. The survey is being expanded to other geographical areas and populations to make it truly representative.
Q: Should antibiotics be discontinued by 25% of responders said Yes
the patient when he starts feeling better, even before completion of recommended course?
But stopping antibiotics before the course is finished leads to antibiotic resistance
Q: Should antibiotics be given to a child with any fever?
25% said Yes But antibiotics have no effect on viral fevers
Q: Will you wish to change your doctor 47% of patients said Yes But antibiotics cannot cure the common cold!
if he fails to prescribe antibiotics for your common cold?
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Will you save unused antibiotics for later use by yourself or by other family members?
Q:
18% of people said Yes Re-using medicines prescribed for previous illnesses can be dangerous and leads to antibiotic resistance
Q: Would you prescribe antibiotics for your own use or that of your family members? antibiotics
53%
of people would self-prescribe
Self-medication leads to antibiotic resistance
Would physicians prescribe antibiotics for non-specific fever, cough, purulent ear discharge and diarrhoeas?
Q:
16%
of physicians will prescribe antibiotics to a patient with non-specific fever
17% of physicians feel that all patients with cough need antibiotics
18% of physicians recommend antibiotic therapy for diarrhoea
49% of physicians treat purulent ear discharge with antibiotics Overprescribing and overuse of antibiotics leads to antibiotic resistance.
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Recent publications from SEARO on antimicrobial resistance Antimicrobial resistance (AMR) has assumed serious proportions. The life-saving impact of antimicrobial agents, as well as considerable economic benefits, are being negated by increasing resistance to these “wonder drugs”. AMR can be minimized by collective action by all — physicians, health administrators, regulators, manufacturers and the general public, especially patients. These FAQs explain in simple terms the reasons for the emergence of AMR and possible mechanisms by which it can be prevented and contained. AMR has assumed greater importance in health-care settings. Preserving the efficacy of antimicrobial agents is considered a critical step in fighting communicable diseases. One of the approaches is to have evidence-based antibiotic usage policy in hospital and standard treatment guidelines for common infectious diseases. This document focuses on the mechanism to develop a practical hospital antibiotic policy and standard treatment guidelines. It also contains information on various effective strategies for implementation of standard treatment guidelines. A suggested model hospital STG for community-acquired pneumonia in adults is included.
The World Health Assembly and the WHO Regional Committee for South-East Asia have endorsed several resolutions on antimicrobial resistance (AMR). These resolutions reflect the commitment of all Member States and also provide a roadmap for combating AMR. The resolutions contained in this compilation provide guidance for initiating activities to prevent and contain AMR.
Antimicrobial resistance has been an unrecognized and neglected problem which is not only cross cutting but also has far reaching implications as an emerging public health problem with huge risk to international health security. The consequences of resistance are severe and several. Resistance in microorganisms costs money, livelihood and lives and threatens to undermine the effectiveness of health delivery programmes. The emergence and spread of antimicrobial resistance are complex problems fuelled by the knowledge, expectations, and interactions of prescribers and patients, and regulatory environment. A strategic approach has been described in this document to combat this burgeoning problem. Health in South-East Asia || March 2011 | 19
For more information visit the website at: www.searo.who.int/worldhealthday2011 Editorial Board : Dr Poonam Khetrapal Singh, Deputy Regional Director, WHO-SEARO Dr Rajesh Bhatia, Regional Advisor, BLT/WHO-SEARO Mr Bruce Murphy, Reports Officer, DOC/WHO-SEARO Ms Vismita Gupta-Smith, Information Officer, PIA/WHO-SEARO Produced by : Reports and Documents Unit and Public Information and Adovacy Unit, WHO-SEARO Photo credit : WHO/SEARO
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