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Indian Journal of Medical Microbiology, Vol. 28, No. 3, July-September, 2010, pp. 189-190 Editorial National antibiotic resistance surveillance and control D Raghunath Principal Executive, Sir Dorabji Tata Centre for Research in Tropical Diseases, Innovation Centre, Indian Institute of Science Campus, Bangalore 560 012, India While it is known that resistance determinants were present in bacterial populations before therapeutic use of antibiotics, the current widespread prevalence is certainly due to the selection pressure that human activity has generated. The prokaryotes evolve rapidly to counter fresh challenges demolishing established dogmas along the way, e.g., the emergence of community-associated versions of the archetypical nosocomial pathogen-methicillin-resistant S. aureus[2] and likewise, the belief that floroquinolone resistance is chromosomally determined has been revised following the discovery of horizontally transmitted plasmid-mediated resistance. [3] Those of us who started clinical bacteriology in the mid-twentieth century used to be excited when we saw a significant isolate of Acinetobacter sp. or Stenotrophomonas (Pseudomonas earlier) maltophilia. At present the situation is different. The spectrum of pathogens handled by a large modern hospital has really widened, and it often becomes difficult to dismiss an unusual isolate as irrelevant. Thus, the job of the clinical microbiologist appears to be secure in the foreseeable future and would probably become more interesting! As persons occupying the pivotal positions vis-à-vis infections, their responsibilities have also increased. Antibiotic therapy is no longer empirical. It requires to be evidence-based. Medical microbiologists need to be proactive in this field. Conserving antibiotic resources, diminishing the antibiotic stress in the environment and decreasing the opportunities for microbial interaction have become important responsibilities of our speciality. These are discharged through the antibiotic policy and hospital infection control committees. These corporate activities require collective action, but are largely on the basis of inputs from the microbiology laboratory. The operation of the responsibilities requires dedication, innovation, persistence, and an ability to operate as a member of the team. It goes beyond receiving specimens, performing laboratory procedures, and issuance of reports. It requires hard work and a degree of stoicism. The various methods by which rational antibiotic use and infection control can be achieved are well publicized. What is not widely appreciated is the fact that these methods developed in various milieus cannot be transposed to our environments mindlessly. A constant evaluation of the efficacy of the modalities is essential, and only those that are useful in the specific situation should be adopted. Thus, it has been seen that the popular seminar/meetings type of activity does not change behavior outside the walls of the seminar hall. Likewise, extensive contact with the pharmaceutical industry skews the practices. A number of modalities need to be tried, and the best suited to the institution adopted. Active involvement of the executive authorities will ensure success. They can be convinced if the benefit to the organization and the patients is demonstrated. Improving antimicrobial use involves ensuring optimal selection, adequate dosage for right duration. It requires appropriate monitoring and attention to toxicity in addition to minimising environmental impact. [4] In fact, there would be the need to standardize treatment modalities and laying down the principles of treatment that would lead to rational and minimal antibiotic treatment. "Surveys have shown that as much as 50% of all antimicrobial use is inappropriate." [5] A well-run institutional programme can decrease this considerably, resulting in decreased antibiotic pressure and consequent improvement in resistance rates. This approach to the running of a hospital is largely alien to this country. The only way this can be inculcated is by ensuring efficient, timely, and responsive laboratory support. The shortfall in clinical microbiological service in the average Indian hospital forces the treating physicians to adopt empirical practices. It is possible to change the trend when the microbiologist becomes a part of the medical effort. Widespread skepticism not withstanding, this is the best way of conserving our antibiotic resources. It is in the outpatient setting that the issues are complicated. Countries that have good records demonstrate a wide variation in community antibiotic usage. France uses four time the amount used by the Netherlands. The variation is particularly steep in the case of antibiotic usage in respiratory infections. This translates to an increased level of antibiotic resistance in pneumococci. Interestingly, the lower consumption of antibiotics by the Netherlands does not have any effect on overall morbidity and mortality figures. [6] Changing prescribing habits in this environment is difficult even in regulated societies. In the Indian context, there is hardly any regulation of antibiotic prescription and at the same time these drugs are used (often totally empirically) by the large segment of practitioners of alternate medicine, quacks, and even pharmacies directly. It is, therefore, not surprising to find most antibiotic usage inappropriate. While it would probably be simplistic to attribute rising community antibiotic resistance solely to this aspect, it certainly plays a large part. Added to this is the poor state of hospital waste management. The net result is an environment with a high antibiotic stress seeded by multiresistant hospital generated organism-a bleak situation to say the least. The question that now arises is what can we do about this? Isolation of bacterial pathogens and determining their antibiotic susceptibility is common enough throughout the country. However, the quality of the test and veracity of the isolate varies substantially. In many cases, the results are hardly worth the papers on which they are reported. Institutional record keeping is certainly there, but not generally prevalent. It is difficult to enforce an institutional antibiotic policy, let alone a regional, state, or countrywide policy. While reviewing the emergence of drug-resistant HIV strains, Bennet [7] comments on our chaotic state, which is also true as far as other infections such as tuberculosis, leprosy, leishmaniasis, etc. (all of which have spun off difficult-to-treat strains). Practically, every issue of this Journal contains papers on antibiotic resistance and molecular studies on the organisms. In fact, practically every variety of resistance determinants has been reported. Although sophisticated molecular studies on resistant factors such as extended spectrum b-lactamases have collection in this country most of the information has come from foreign laboratories. Despite good sophistication in the country in molecular technology, little concerted work on the phenomenon is being carried out in an organized fashion. There is a need for a Central Institution devoted to antibiotic resistance as seen in India. Much smaller countries have such institutions, why can′t we? Another major problem in India is the easy availability of antibiotics over-the-counter. This practice needs regulation. In summary, this country needs to
This is not a tall order when one considers the cost effectivity. Being involved in antibiotic technology for the past three decades, one cannot but feel helpless at the "relentless and Dizzying Rise of Antimicrobial Resistance" [8] and start preparing for the Post-Antibiotic Era. There are possibilities there, but, left for a later editorial, perhaps! References
Copyright 2010 - Indian Journal of Medical Microbiology |
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