ARTIFICIAL INTILLIGENCE e newletter

VOLUME 1 | ISSUE 3 | APRIL 2019INFECTION CONTROL TRENDS
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Volume 1 | Issue 3 | April 2019
Circulation: Quarterly | All-India | e-Copy format
CHIEF EDITOR
Dr. Ranga Reddy
EDITOR
Dr. T V Rao
EDITOR & CONCEPT
Dr. Dhruv Mamtora
TEAM MEMBER
Sister Solbymol
SPECIAL EDITION ON ANTIMICROBIAL STEWARDSHIP
newsletter
INFECTION CONTROL TRENDS

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Respected Infection Preventionist,
Modern science is evolving beyond belief. However, while saving millions of lives through several advanced
healthcare interventions, we also witness an unintended consequence: Healthcare Associated Infection (HAI).
This inaugural edition of Infection Control Trends introduces some important issues regarding healthcare workers,
patients and healthcare infections.
HAI can be avoided, and healthcare workers in particular are critical in making this happen. By better
understanding HAI contributing factors, healthcare professionals can apply measures which will contribute to the
safe care that patients expect and deserve.
It has been amazing to see so many accomplished professionals very passionately supporting this project.
We thank and congratulate one and all for their contributions in making this journal see the light.
Our vision is to bring all latest trends in Infection Control in a simple, straightforward and actionable format.
Please send your comments, suggestions and contributions to help make this journal richer with each passing
edition.
Warm regards,
Dr. Ranga Reddy Burri
Dr. T. V. Rao
Dr. Dhruv Mamtora
Sister Solby
Statutory disclaimer: In no event shall Infection Control Trends be liable for any special, incidental, indirect
or consequential damages of any kind, or any damages whatsoever resulting from loss of use, data or profits,
whether or not advised of the possibility of damage, and on faceword theory of liability, arising out of or in
connection with the use or performance of this information. The ideas and opinions expressed in Infection Control
Trends do not necessarily reflect those of Editorial team members. Infection Control Trends neither endorses
nor takes responsibility for any products, goods or services offered by outside vendors through its services or
advertisements.
PREFACE

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Dr. T V Rao is a former Professor of Microbiology from the Andhra
Medical College, Visakhapatnam (Andhra Pradesh, India). With an MD
in Microbiology, he has chosen the specialty not by accident but with
complete determination with the aim of being a part of the system.
His experiences in Zambia showed him how people lose their lives to
infections and how the lack of resources was a great challenge that
practically forced patients to be treated blindly. He believes that the
onset of the AIDS pandemic was a primary factor in the progress of
Microbiology , ushering in a new era of Diagnostic Microbiology.
His association with scientific microbiologists at ICMR (NICED
Calcutta) taught him how all that we do is not necessarily right and why
it is essential to involve oneself in diagnostic laboratory conditions and
even bedside medicine with dedication and sincerity instead of simply
imparting unpracticed knowledge.
His observation includes the seamless working of Darwin’s
Theory in relation to microbes and how they pose real challenges.
He also believes it is time to rethink one’s role as Medical and Clinical
Microbiologists, especially during a time where it is necessary to
understand that Antibiotics are not magic bullets but soft weapons to
destroy the progress of medicine. During his career, Dr. Rao has created
content that helps many in developing countries and to his satisfaction,
even enjoys a global following of 5 million.
Dr. Ranga Reddy Burri is Health policy enthusiast focused on
public health awareness, education and training. He is committed to
improvement of patient safety in India and other low resource settings.
His vision is to improve professional practice standards for infection
prevention and control across India and the setting of standards and
framework for credentialing of infection control professionals.
Dr. Reddy is Physician, Public Health specialist and Social
Entrepreneur with interest in business verticals of high social impact.
He graduated from Minsk Government Medical Institute, Belarus
with MD (Physician) degree; subsequently he did his PG Diploma in
management from Pondicherry University and Advanced Management
from IESE, Barcelona, Spain with specialization in Strategy & Business
Development.
Dr. Reddy is the founder trustee of Infection Control Academy
of India (IFCAI). The organization is a result of his leadership skills,
knowledge and experience gained from working in both domestic and
international MNCs. Yet, the Academy’s most valuable strength lies in
thestrongsenseofempathyforhumansandtheirhealthimpartedbyDr.
Reddy and his colleague trustees. His effort has translated into creating
several long term programs in IPC segment. His current responsibility
includes leading Sanmed Healthcare, a startup with world class
manufacturing capabilities in external preparations. Additionally, he
supports several non-profit organizations in the capacity of advisor
including Neelam Rajasekhar Reddy Research Center for Social Progress,
e-learning center of Hyderabad Central University & Indian Institute of
Public Health.
His flair for entrepreneurship has led him to mentor through
imparting knowledge to NGO’s, startups & micro-small enterprises.
Dr. Ranga Reddy
President IFCAI and Chief Editor
“Infection Control Trends”
Email: dr.rangareddy@ifcai.in
EDITORIAL TEAM
Dr. T. V. Rao
Former Professor of Microbiology
Email: doctortvrao@gmail.com

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Dr. Dhruv Mamtora is a clinical microbiologist and infection
control officer at S. L. Raheja Hospital, A Fortis associate, Mahim,
Mumbai since 2015. Before joining in private sector, he has worked
with government sector both in Maharashtra state as assistant
professor at RCSM GMC Kolhapur and GMC Latur as assistant
professor and AIIMS, Jodhpur as senior resident.
He has passed out MBBS from L. T. M. Medical College (Sion
Hospital) and done MD in microbiology from Government medical
college, Miraj. He has done his healthcare administration EPGDHA
from TISS, Mumbai and he is a New York state certified infection
control professional.
He is member of multiple professional bodies like IAMM, IATP,
IMA, HIS-MF (institutional), society of clinical microbiologists (SCM)
and ISID (international society of infectious diseases).
He has number of publications in peer reviewed journals, both
national as well as international and he is also faculty and speaker
for various national and international, conferences. He has also
organized many training activities and a national level conference
on “Systemic Approach to Hospital Hygiene and Infection Control”
in Mumbai in year 2018.
He is also a media subject expert on subjects like hospital
acquired infection, infection control and infectious diseases.
He is subject expert on infection control for Clean India journal.
He has also guided as well as multiple projects related
to healthcare which is in field of infection control and clinical
microbiology namely national survey on infection control practices
in collaboration with Clean India journal and POCD in infection
control in collaboration with IITB.
He has been awarded multiple times in his organization and at
national level.
His topics of interest are implementing and improving quality
in healthcare, hospital and laboratory accreditation, clinical
microbiology, infection control, antimicrobial stewardship and
improving medical education to a minimum basic standard which
is suitable for current healthcare scenario in country and on
international level.
Sister Solbymol P S is a PICU Nurse with 19 years of experience.
She has worked as In-charge PICU Rainbow Children’s Hospital,
Hyderabad and Vikrampuri, senior staff at Ernakulam Medical
Centre Kochi. She is now working as Coordinator Quality and
Infection Control Nurse at Kinder Women’s Hospital and Fertility
Centre, Cherthala, Alappuzha.
Dr. Dhruv Mamtora
Consultant Microbiologist
and Infection Control Officer
Email: dhruv_mamtora@yahoo.com
Solbymol P S
GNM, ICCP
Email: solbyps@gmail.com

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Theme is dedicated to Accreditation and its role in infection control. Include NABL, NABH or any other accreditation
related topic.
Articles on current infections of National importance as Tuberculosis, Dengue and any other emerging infectious
diseases are welcome.
Article on laboratory quality control, quality assurance, Antimicrobial stewardship, therapeutic drug monitoring,
critical care, transplant care, immunosuppressive therapy, hand hygiene, isolation precautions, disinfection and
sterilization, housekeeping, laundry and kitchen practices are also welcome.
Article related to nursing best practices, role model and healthcare associated costs are also desired.
Or
Any other topic of relevance can be published with consent of editorial team members.
Thefundamentalruleforcreatinganemailnewsletteristomakeitinteresting,relevantandup-to-dateinformation
that is enjoyable to read and practice.
Hope that it meets the expectations of the knowledge seekers. Motto behind e-newsletter format was to be
informed about things which are otherwise difficult to be able to find out about with general searches. People share
the real time experiences, challenges and solutions through this accessible and free platform.
Stick to the Topic you have chosen and elaborate on the theme in mind for each so idea doesn’t get jumbled.
Authorship is for clinical microbiologists, consultants both medical, surgical and dental fields, teaching
professionals, infection control and prevention experts, clinical pharmacists, hospital quality personnel, administrator
and also members of recognized professional bodies. The person has to be associated with medical field in direct or
indirect way. International authors are also welcome and resource poor settings like African region and other Asia
pacific region low and middle income countries will be given special encouragement for authorship.
1. Allow for some flexibility in the length of the content. After all, this is not a print publication that has to fit on a
certain paper size 500 words mean can be 100 words + or 100 words less.
2.TodaymanyareshortoftimeDevisecreativeandinformativesubjectlinesEnsurecontentiseducational,informative,
and concise.
Article to be written with scientific language and references are to be added in Vancouver style only. Mention all
scientific names in italics. Follow font size of 11 with times new roman style with 1.15 line spacing. Article submission
to be done in MS word format only.
We have not many editorial reviewers yet all the articles to be submitted with scientific spirit to be checked for
plagiarism, spell check and grammatical errors by the authors declaring the CONFLICT OF INTEREST IF ANY?
If any comparative or invasive tests are done on humans or animal studies then the scientific work must accompany
the Ethical committee approval/IRB (institutional review board) approval.
Article can be accepted or rejected for lack of place or not suiting the purpose of the topic chosen and will retuned
at the earliest and decision of editorial members is final in approving or rejecting the articles for publication.
Dr. Dhruv Mamtora
Dr. T. V. Rao MD
OBJECTIVES OF E -NEWSLETTER
ON INFECTION CONTROL TRENDS
MEETING THE OBJECTIVES OF E-NEWSLETTER

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INDEX
Editorial
Dr. Ranga Reddy Burri, Prof. T. V. Rao, Dr. Dhruv Mamtora, Sister Solby
Guest Editorial - Importance of Antimicrobial Stewardship (AMS) Education as a
Key Intervention to Combat Antimicrobial Resistance (AMR)
Dr. Dilip Nathwani
Antimicrobial Stewardship – A “Patient First” Approach
Dr. Anup Warrier
Irrational Use of Antibiotics
Dr. Aparna Ravi, Dr. Sudha M. J.
Role of the Microbiology Lab in Use and Misuse of Antibiotics
Dr. Kavita Raja
Essential Teaching on Antibiotic Stewardship to Medical Students
Dr. T. V. Rao
Role of Microbiologists as Antimicrobial Steward
Dr. Sanjay Singhal
Successful Implementation of Antibiotic Stewardship in Hospitals can only be Done
by Assertive Microbiologists
Dr. H Srinivasa
Carrot and Stick in Antimicrobial Stewardship?
Dr. Sourav Maiti
Implementation and Monitoring of Antimicrobial Stewardship Program for
Healthcare Organization
Dr. Dhruv Mamtora
Encountering Antimicrobial Resistance – Strategies at Various Levels (Review Article)
Dr. Nazia Khanum
07
08
10
13
16
19
20
22
25
27
29

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EDITORIAL
Dear Infection Preventionist,
It is a pleasure to bring the third edition of ICT Newsletter to our large audience across the continents.
In today’s “instant world” and “hyper communication”, everything is expected to be addressed instantly. Society
is in a hurry to get a quick fix for all problems big or small and Medical diagnosis and treatment is no exception to this
instant solution rule. There is a huge pressure on physicians and it is understandable that for healthcare workers to
stay in competition, it has become important to act quickly to satisfy the demands of patients for quick cure and (stay
in competition).
Giving best guess at diagnosis and start empirically a broad spectrum antibiotic is found to be an easy way out of
this demanding situation, but this very easy approach is what precisely brings the set of issues leading to AMR.
The World Health Organization predicts that “without urgent action, the spread of antibiotic-resistant bacteria
will lead to resurgence in deaths from minor injuries and previously benign infections”.
Organizations like CDDEP had been doing extensive work on AMR and recently, they came with an innovative idea
to provide “Subsidies for Infection Control Help Reduce Infection Levels at Healthcare Facilities”. We should have more
of these out of the box ideas to deal with the menace of AMR.
The problem of AMR is multi dimensional and it can be effectively dealt with a concerted 360-degree approach.
Some of the areas to be addressed are: Rapid antimicrobial susceptibility testing technology to reduce the time to
quickly and accurately detect antibiotic resistance, Regulations and policy on prescription of antibiotics, AMR mapping,
reporting and sharing of antimicrobial resistance and antimicrobial monitoring data, Responsible antimicrobial
promotion and usage, Education and practical training for effective AMR stewardship, continuous monitoring and
surveillance of stewardship activities etc.
This current newsletter is intended to cover most of the above raised parameters. We hope the articles by eminent
physicians, ID specialists, and microbiologists would make reading interesting and prove to be useful for your practices.
Best regards
Prof. TV Rao
Dr. Dhruv Mamtora
Sister Solby

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Antimicrobial resistance (AMR) has risen steeply over the past few years and is now recognized as a global crisis.
It is estimated that by 2050, drug resistance would kill ten million people every year at a cost of 100 trillion USD in
lost outputs. The World Health Organization (WHO) has identified Antimicrobial resistance (AMR) as the 3rd leading
cause of morbidity and mortality. Antimicrobial Stewardship (AMS) is a key intervention in combating AMR. AMS, and
the importance of education across the disciplines and key sectors were also top recommendations of the Chennai
Declaration against AMR published in 2012 in India. A recent quantitative and qualitative study from India (Antibiotics
2019, 8(1), 11; doi:10.3390/antibiotics8010011), the largest published of its kind, examined the state of education &
training (E&T] for AMS in Indian hospitals. Only 69% of the respondents received E&T on AMS during undergraduate or
postgraduate training. In the qualitative interviews, three key areas of concern were identified: (1) need for government
level endorsement of AMS activities; (2) lack of AMS programs in hospitals; and, (3) lack of postgraduate E&T in
AMS for staff. Therefore, it is heartening to see such local examples [as outlined in this newsletter] of high quality
educational activity to support infection control and stewardship training. Such activity is also entirely in line with the
recommendations by the WHO multi-professional competency framework for education and training in AMR (WHO
Competency Framework for Health Workers’ Education and Training on Antimicrobial Resistance (http://apps.who.
int/iris/bitstream/handle/10665/272766/WHO-HIS-HWF-AMR-2018.1-eng.pdf?ua=1). Whilst I commend this activity
I would also urge colleagues in India to invest in providing basic AMS training for non-infection specialist prescribers,
the majority, with particular emphasis of those working in the ambulatory or non-inpatient setting. Furthermore,
the critical role and influence of clinical pharmacists and nurses should also be explored much more in the Indian
setting. A global check list for setting up hospital AMS programmes, including education, is available here - https://
www.clinicalmicrobiologyandinfection.com/article/S1198-743X(18)30295-7/pdf
To support traditional face to face learning, there is for a variety of reasons to to augment this with e-learning.
This concept of hybrid or blended learning is deemed a highly effective and cost-efficient of delivering education on
a bigger scale. Indeed, a comprehensive review of global educational resources on AMR highlights that e-learning
resource [websites, on line course, webinars, videos etc.] represent 32% of all mapped educational resource. (Mapping
educational opportunities for healthcare workers on antimicrobial resistance and stewardship around the world, Rogers
Van Katwyk et al. Human Resources for Health (2018) 16:9, https://human-resources-health.biomedcentral.com/track/
pdf/10.1186/s12960-018-0270-3)
Two further surveys of education activity and needs from Africa & Russia (Education and management of
antimicrobials amongst nurses in Africa—a situation analysis: An Infection Control Africa Network (ICAN)/BSAC online
survey https://doi.org/10.1093/jac/dky023; Current stewardship and educational activity in Russia, findings from a
survey, Ivan Palagin http://www.bsac.org.uk/wp-content/uploads/2017/02/BSACMoscow2017-IvanPalagin.pdf) identify
e-learning as an important and cost-effective activity that compliments face to face meetings. The British Society for
Antimicrobial Chemotherapy [BSAC] is a global leader in providing e-learning educational resource in AMR. The info-
graph below
GUEST EDITORIAL
IMPORTANCE OF ANTIMICROBIAL STEWARDSHIP (AMS) EDUCATION AS A
KEY INTERVENTION TO COMBAT ANTIMICROBIAL RESISTANCE (AMR).
Dr. Dilip Nathwani
Physician and Professor of Infection; President BSAC [ 2015-2018]
Ninewells Hospital and Medical School, Dundee, DD19SY
Email: dnathwani@dundee.ac.uk

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{1} highlights the
Massive Open On Line
Courses [MOOC’s] and
the AMS e-book all of
which are high quality
and available resources
that are free at the point
of access. They can be
adapted and adopted
for local needs. The
MOOC since its launch
in 2015 has had more
than 60000 learners
globally. Other resources
available or coming soon
are also illustrated below
is the forthcoming global
JAC-AMR platform.
{2} which is the first knowledge exchange platform JAC-Antimicrobial Resistance (JAC-AMR). JAC-AMR is a novel
venture that is intended to complement the JAC by disseminating knowledge on two intertwining strands: clinical
research and educational resources including news. JAC-AMR is also proud to link up with CIDRAP (http://www.cidrap.
umn.edu), providing a good
example of an online platform
that provides up-to-the-minute
information and news for the
global community in relation
to AMR, AMS and infectious
diseases. The education
component of JAC-AMR is novel
in offering a global online or
e-repository links to educational
resources that are intended to
support learning and increase
knowledge about AMS, AMR,
behaviour change and more, for
a worldwide audience and to
support learners in LMICs, and
be available in more than one language where possible. In addition to the geographic and educational diversity, the
platform will also guide users to access resources best suited to their needs, via a searchable database, by providing
structured reviews of resources written by an international Editorial Board.
As Editor-in-Chief of the new JAC-AMR and Programme Leader for the MOOC’s, I am delighted to support the local
educational ventures such as those developed here by Dr Mamtora and other colleagues in India. I wish to encourage
healthcare professionals in India to raise awareness of the resources available outlined in this newsletter as well as join
us in further in submitting and reviewing existing resources and developing new ones that are bespoke to the needs
of particular health care settings, geographies, cultures and resources. As Hellen Keller said “alone we can do so little,
but together we can do so much”.

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Antimicrobial Stewardship (AMS) is a popular terminology with healthcare professionals today. It is often used in
the context of a proactive strategy to counter antimicrobial resistance. Many healthcare professionals consider AMS
to be implementation of an “antibiotic policy” or adhering to institutional prescription protocols to antibiotics. AMS
indeed could be defined as - “Antimicrobial stewardship is the systematic effort to educate and persuade prescribers
of antimicrobials to follow evidence-based prescribing, in order to stem antibiotic overuse, and thus antimicrobial
resistance.” Or, it could be elaborated as - “Antimicrobial stewardship is a coordinated program that promotes the
appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance,
and decreases the spread of infections caused by multidrug-resistant organisms.” The focus of AMS programs has
been curbing the antimicrobial resistance by reducing antimicrobial consumption. How can you reduce antimicrobial
consumption in healthcare?
All the “antibiotic policies” address management of specific clinical syndromes and bugs (Empiric therapy and
Standard treatment Guidelines), which are relevant only if you make the right diagnosis at the right time. If the clinical
and microbiological diagnosis is either wrong or not established, the institutional antibiotic policy document is pretty
much useless. The hospital Antibiogram is meaningless if it does not address the clinical syndrome you need to
“empirically” treat. A Cochrane Review of “Interventions to Improve Antimicrobial Prescription Practices” – published
in February 2017, demonstrated that the best interventions are those targeted at “prescribers” and those which include
feedback instead of restriction-based policies. So, the basic structure of AMSP is a clinical syndrome based Antibiogram
driving the empiric antibiotic choices, followed by Standard Treatment Guidelines for targeted therapy. The two strong-
arm strategies of AMS – De-escalation and Short Duration – are poorly supported by evidence, while restriction has
been shown to be detrimental in the long run.
Let us consider the case for de-escalation first. This was the favorite strategy for Intensivists who were convinced
and managed to convince the rest of the team that in any critically ill patient, it was wise to start “broad spectrum”
antibiotics (which often meant Carbapenem +/- Vancomycin) and we could “de-escalate” once we have the culture
result on day 2/3. The price to pay for initial inappropriate therapy was high (quoting incremental increase in mortality
in various studies) and there was the hope of a positive culture as the “light at the end of the tunnel” to optimize the
antimicrobial therapy. Is there an alternate version for this fairy tale? There are three main challenges to success with
de-escalation –
1.Broad-spectrum antibiotic initiated with scant attention to clinical diagnosis – Might be unnecessary.
2.Culture positivity rates for sepsis in various centers – between 20 -30%. In up to 70%, no de-escalation is possible.
3.Need good quality Microbiology Lab – Resource intensive
WhatdoestheCochraneReviewpublishedin2013sayaboutDe-escalation?“Thereisnoadequate,directevidence
as to whether de-escalation of antimicrobial agents is effective and safe for adults with sepsis, severe sepsis or septic
shock. This uncertainty warrants further research via RCTs.” There has been only one RCTs after this (Leone et al in Oct
2014) – which is not a positive study. Further, in 2017, a modeling study was published in PLos One titled “Benefits and
unintended consequences of antimicrobial de-escalation –implications for stewardship programs”. It concluded “In
these models, de-escalation reduces the use of high-value drugs and preserves the effectiveness of empiric therapy,
while also selecting for multidrug-resistant strains and leaving patients vulnerable to colonization and super-infection.
Dr. Anup Warrier
Consultant Infectious Diseases and Infection Control
Head of Quality
Aster Medicity, Kochi
Email: dranup.warrier@asterhospital.com
ANTIMICROBIAL STEWARDSHIP – A “PATIENT FIRST” APPROACH

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“The net effect of de-escalation in our models is to increase infection prevalence while also increasing the probability
of effective treatment. Changes in mortality are small, and can be either positive or negative.” In 2016 ECCMID, the
presentation from Jeroen Schouten (available for free download) titled – “De-escalation of Antibiotic Therapy – Much
Ado about Nothing” summarizes the evidence available regarding this much-touted strategy. He concludes – the only
way to modification of antimicrobial use can impact AMR is when you either decrease indications for use or stop early.
Shortening the duration of antimicrobials is the next key strategy. The evidence for short duration of antibiotics
has been only for very specific and well-defined clinical syndromes, (like uncomplicated pyelonephritis/intra-abdominal
infection or community onset pneumonia) in a low-risk population (studies exclude the immune-suppressed, those
with MDR/XDR pathogens etc.). Certainly, it would form a minuscule portion of our ICU population. Identifying the
clinical syndromes in which short duration of antimicrobials has been proven to be efficacious and safe brings us again
to the question of accurate and timely diagnosis. Procalcitonin-based early stop of antimicrobial therapy is again being
evaluated in robust trial conditions. PCT based reduction in antimicrobial duration has been shown to work again in
specific clinical syndromes – most relevant of these could be “occult sepsis” where we do not have cultures neither an
identified focus of infection.
The third and quite an interesting arm of AMS is the pharmacokinetic and pharmacodynamics optimization of
doses and dosing regimens. Targeting the PK/PD requirements, the doses of commonly used antibiotics in critically ill
have moved up several notches. This has brought forth increasing toxicity profiles and impacted the cost of therapy.
Does this strategy bring tangible clinical outcomes? Evidence is still weak for core recommendations such as prolonged
infusions for beta-lactams. One of the key factors, which make it quite hard to generate good quality evidence in
infectious diseases trails/studies, is the inability to manage confounders and bias. My take on these strategies for AMSP
are to go with common sense and basic science (pharmacology/microbiology) knowledge and avoid being dogmatic
about these aspects. What I have attempted to communicate up to now is that for AMSP – the key requirement is
DIAGNOSIS. And diagnosis of an infective syndrome to its etiology is no small matter.
The diagnosis of an illness/clinical syndrome is arrived at by application of sound clinical medicine and adequately
supported by microbiological tests. It is very well accepted that the sensitivity and specificity of the microbiological
tests depends upon the “pre-test probability” - which means the test results are relevant only under relevant clinical
picture. Thus, it is imperative that clinical diagnosis precedes microbiological testing and the microbiological testing
is the result of application of principles of sound clinical medicine. Since antimicrobial use is based on diagnosis of
the infectious syndrome (and its etiology), which in turn depends highly on the clinical diagnosis of the Physician
followed by the quality of microbiological diagnostics available – Therapeutic stewardship can only be done by a
skilled Physician with sound knowledge of interpretation of microbiological diagnostics. It is here that the Clinical
Microbiologist is valuable. The role of a Clinical Microbiologist is in ensuring that the use of diagnostics is appropriate or
as the World Health Organization states “Diagnostic Stewardship”. Diagnostic Stewardship is about using the available
microbiological diagnostic tools in such a way that it “nudges” the Physician into making the right diagnosis. It draws
upon the core strength of the Microbiologist – the utilization of microbiological diagnostics – to direct the Physician
to make the appropriate antimicrobial choices. It stresses upon one of the greatest limitations of Microbiology in
our country – Quality! The focus is on ensuring the right test for the right “condition”, quality of sample collection/
transport, quality of analyses and report; ending with appropriate and timely communication with the Physician to
influence the treatment.
It takes years of bedside assessments to make life changing therapeutic decisions like changing/stopping
antibiotics in response to a diagnostic test – judging its relevance to the patient and clinical syndrome; and weighing
the risk–benefit ratio of those decisions for better clinical outcomes, in a critically ill patient, especially since most of
the crucial decisions are beyond the available “Evidence Based Medicine” (EBM) literature. The primary focus of AMSP
(Diagnostic + Therapeutic) is improved patient/clinical outcomes and not control of antimicrobial resistance (AMR)!
This is a paradigm shift. The evidence for AMR control with AMSP is either non-existent or severely biased – while
there is no doubt that accurate diagnosis and appropriate therapy will improve patient outcomes. This intrusion of
“arm chair” AMS programs (focusing on AMR) into clinical medicine have found poor acceptance with the clinical
teams – the prescribers – without whose buy-in, AMSP will not succeed. The need of the day is that Physicians practice
good clinical medicine, invest in bedside clinical diagnosis and develop close interaction with the clinical microbiologist
in understanding and using the appropriate diagnostics. While what we need from Microbiologist is ensuring the
quality of diagnostics staring from the clinical indication to sampling to analysis and reporting, interact fruitfully with
the clinical teams so as to influence the antimicrobial therapy. This thought was voiced out loud by none other than Dr.
Chugh – one of the senior-most Microbiologists and certainly one of the most respected Microbiologists in India – in a
workshop for Clinical Microbiologists at New Delhi.

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Prevention of community acquired infections by practice of good hygiene and vaccinations AND prevention of
hospital acquired infections by an effective hospital infection prevention and control program (IPCP) is a sure shot
way of curbing antimicrobial usage. The AMS Champions should earnestly take up these programs if AMSP has to find
success. These are again the core strengths of the clinical Microbiologist who has extensive knowledge and training in
the modes of transmission of infections, disinfection and sterilization and management of outbreaks.
Let us understand this clearly – there are only 3 ways to reduce the antimicrobial use: Diagnose infections (accurate
etiology and as early as possible), treat with evidence based antibiotic regimens (Standard Treatment Guidelines) AND
prevent infections. And for these requirements, clinical Microbiologists should focus on their core strengths – diagnostic
stewardship and infection prevention. I would end with this quote from Debra A. Goff, Pharm.D, FCCP – one of the
pioneers and a global leader for AMSP - “The steward’s role is rapidly changing from one who oversees institutional
antimicrobial use to one who evaluates new diagnostic tests, learns how to promote the program as a patient safety
initiative, interacts with information technologist to assist with data collecting, creates a business plan and budget for
the hospital’s chief executive officer, and continues to educate. All of this is done with one person in mind: the patient.”

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“The thoughtless person playing with penicillin treatment is morally responsible for the death of the man, who
succumbs to infection with the penicillin resistant organism. I hope this evil can be averted.” – Sir Alexander Fleming.
HISTORY
The discovery of antibiotics remains one of the most marvelous events in medical history till date. The accidental
discovery of penicillin in the dawn of 1928 by Sir Alexander Fleming changed the entire course of medical history. He
was often described as a careless lab technician, and on that day he had just returned from a two-week vacation, to find
a mould that had developed over an accidentally contaminated staphylococcus culture plate, which on examination
was found to result in the lysis of staphylococcus. An article published by Fleming in 1929 says, “I certainly didn’t plan
to revolutionize all medicine by discovering the world’s first antibiotic, or bacteria killer. But I guess that was exactly
what I did.” The first patient was successfully treated with penicillin in 1942 for streptococcal septicemia. Penicillin
created a dramatic reduction in the number of infection-related deaths. Since World War 2, till date, penicillin remains
the most widely used antibiotic in the world and has saved many lives from fatal conditions. It is very interesting to
learn that usage of penicillin in pneumococcal pneumonia and bacterial endocarditis never underwent any randomized
controlled trial, as the results were so apparent that nobody ever thought or wanted to conduct a research trial for the
usage of the drug.
The discovery of the miracle drug was soon available to the public and other populations, with the war going on,
and many pharmaceutical companies had come forward to take up the manufacture and distribution of the same.
They all played a deaf ear to Sir Alexander Fleming when he tried to warn that the over usage of the drug could
result in mutant bacteria. They were unaware of the fact that bacteria can transfer genes horizontally, from one to
another immediately and become resistant to the drug. Humans have just overused the antibiotics for each and every
disease, from sore throat to pneumonia, for a longer duration. This may be because of the basic human nature to
have it all in the best way possible or this was the kind of awareness given to them by pharmaceutical companies for
the promotion of their drugs and for the benefit of their companies. Later on, this overuse had extended its usage
in to our agricultural systems, animals and animal products, food products etc. The microbes are considered to have
extraordinary genetic features which have been found to be evolving with every new antibiotic introduced clinically,
agriculturally, or otherwise to eliminate drug resistance. The microbes continue to do what they are good at – finding
ways to survive. Bacterial resistance has always existed alongside antibiotics, but not on a large scale as in present
scenario. It’s high time we make desperate changes in order to prevent drug resistant cases and related deaths in the
coming decades.
FACTORS LEADING TO DRUG RESISTANCE
Epidemiological studies have proved a direct relationship between the consumption of antibiotics and the
emergence of drug resistance. In developing countries like India, strict regulations regarding drug dispatch is not
formulated or imposed, leading to easy availability of prescription only drugs over the counter without prescriptions,
leading to irrational and over-usage of antimicrobial drugs. This is one of the important causes of drug resistance.
Incorrect prescription of antibiotics is another important contributor to the growth of resistant bacteria. In most
of the cases, the choice of drug and the duration of antibiotic therapy vary greatly from the treatment indication. The
changes in gene expression increase the virulence of the bacteria which promotes its growth and spread.
The environmental micro biome is affected largely by the agricultural use of antibiotics. The antibiotics given to
livestock are excreted through urine and feces which widely affects the natural micro biome. In addition, antibiotics are
dispersed through fertilizer which eventually affects the ground and groundwater along with it.
IRRATIONAL USE OF ANTIBIOTICS
Dr. Aparna Ravi
Assistant Prof.,
Pharmacology, Azeezia
Institute
of Medical Sciences and
Research
Kollam, Kerala
Dr. Sudha.M.J
Associate Prof.,
Pharmacology, Azeezia
Institute
of Medical Sciences and
Research
Kollam, Kerala
Email: nithinaparna@gmail.com Email: sudhasudhasudha@gmail.com

14
Newer development of antibiotics is no longer considered as an economic investment by the pharmaceutical
companies as antibiotics are taken for a short duration as part of curative therapy, unlike other drugs for chronic
conditions such as diabetes mellitus, hypertension where patients take lifelong drug therapy. The newer drugs available
are usually considered as restraint ones and are used as last-line therapy in conditions irresponsive to other drugs.
Thereby, older agents continue to be prescribed and used normally widely, which contributes to drug resistance.
Lack of strict regulatory measures from the manufacturing of the drug through the trial, marketing and dispatch
of drug has totally altered the system resulting in a dramatic rise of drug resistant cases. Strict regulatory measures to
be adopted to reduce the prevalence of this global burden.
CLINICAL OUTCOME
Anti-microbial resistance affects patient outcome in a great way. The development of resistance genes alters the
microbe to be weak or stronger. Most of the mutations results in weakness of the organism following which there is
compensated mutation that results in regained fitness rise. The resistant strains in clinical setups survive and effectively
multiply in a antibiotic dense environment making them highly resistant and fitter than a random group of resistant
strains. This can lead to a delay in the administration of appropriate antibiotic therapy which when given, will be toxic
or inadequate and can result in adverse outcomes. The use of colistin in the treatment of highly resistant Pseudomonas
is associated with high risk of renal dysfunction.
The increase in resistance to common pathogens has resulted in the wide usage of broad spectrum agents for
many common infections. These broad spectrum agents are found to be more expensive, with more toxic effects on
the normal bacterial flora, and considered to be more toxic than effective. The usage of these agents has exemplified
the usage of narrow spectrum agents, such as penicillin, for common infections.
As a final resolution for patients infected with such organisms, surgical procedure is done to remove the nidus
of infection, and patients not amenable to surgical debridement, have high mortality rates. In short, with increasing
resistance against antimicrobial therapy, will result in a complete failure of anti-microbial drugs or anti-microbial
drugs may not work at all.
The understanding and awareness regarding antibiotic resistant in society, as a whole is limited. The population
demands for effective drug therapy, majority of who believe that maximum antibiotic coverage protects them from
illness. This is resulting in the exhaustion of effective drugs and a multi drug resistance society is alarmingly on the rise.
PREVENTIVE MEASURES
A comprehensive approach need to be adopted for reducing the prevalence of anti-microbial resistance. The
Central Pollution Control Board (CPCB), in March 2018 has prepared a set of draft demands for antibiotic discharge in
pharmaceutical industry effluents that is being awaited for approval by the Environment ministry. It is important to
accomplish stringent standards to eliminate environmental pollution with antibiotics.
The priorities as per NAP-AMR (National Action Plan – Antimicrobial Resistance) are:
1. Adopting effective communication, education and training measures to improve understanding of AMR and to raise
awareness among the general public and farmers
2. Appropriate education to improve knowledge of professionals
3. Strict regulations in human, animal, food and environment sectors
4. Surveillance of antimicrobial resistance.
5. Effective infection control and prevention.
6. Effective healthcare to reduce spread of AMR and antimicrobials through animals and food.
7. To reduce the spread of AMR and antimicrobials in the community and environment.
RECENT ADVANCES
1) Micro-organisms in recent drug discovery– There have been lot of recent research activities happening with
drug discovery utilizing environmental microbes, which has now become one of the leading source of drug discovery.
These are a large number of microbes which were not targeted for drug discovery. With emerging technologies, novel
drugs are harvested from these uncultivable microbes, which are assumed to be more promising than other group of
drugs.
2) Newer drug – Discovery of a newer drug Teixobactin, was announced in January this year. It is considered to
be one of the most significant antibiotics discovered in the last thirty years, and is considered to combat multi drug
resistant bacteria.

15
3) Alternative to antibiotic – The utilization of enzymes of Bacteriophages is considered to be a newer alternative
method to usage of antibiotics. Bacteriophages are small viruses that infect the bacteria, following which they make
copies of themselves, and then leave the bacteria. They release an enzyme before leaving the bacteria, which dissolves
the bacterial cell membrane. It is this mechanism that is being utilized for the development of antibiotic alternative.
4) Proteomics – Proteomics is one of the recent advances that have helped us understand beyond genomics.
Proteomic studies have been used for understanding mechanism of bacterial virulence and important aspects of
interaction of bacteria with human cells, which has helped in newer revelations.
5) Antibiotic stewardship/policy – This refers to a set of coordinated strategies to improve the usage of anti-
microbial medications by reducing adverse outcomes and drug resistance. Various online courses regarding antibiotic
stewardship have been launched for the easy access of medical personnel. WHO have also implemented educational
course of the same for medical personnel mainly targeting medical students and physicians.
References:
1.Penicillin: An accidental discovery changed the course of medicine, History of medicine, Endocrine Today, August 2008
2.Lecia Bushak A Brief History Of Antibiotic Resistance: How A Medical Miracle Turned Into The Biggest Public Health Danger
3.C. Lee Ventola, MS, The antibiotic resistance crisis, P & T Pharmacy and therapeutics 2015 April 40(4) 277-283
4.George M. Eliopoulos, Sara E. Cosgrove Yehuda Carmeli The Impact of Antimicrobial Resistance on Health and Economic
Outcomes, Division of Infectious Disease, Johns Hopkins Hospital, Baltimore, Maryland ,Clinical Infectious Diseases, Volume 36,
Issue 11, 1 June 2003, Pages 1433–1437
5.National Action Plan on Antimicrobial Resistance (NAP-AMR) 2017 – 2021
6.Antibiotic resistance 2019

16
The role of the clinical microbiologist in treatment of infections in a hospital, prevention of infections and judicious
use of antibiotics is very great. There is no other person in a hospital who knows the dynamics between bacteria and
antibiotics so well. Nobody even realizes that the dynamics are so complex. In this article, I will discuss how to go about
proving to be an effective clinical microbiologist who is responsible for the strict quality control of all tests in the lab,
rapidity and timeliness of results and ensures that the treatment occurs according to the result issued.
PRE- ANTIBIOTIC TESTING:
a) Gram reaction guides therapy – Keeping your staining perfect and stains fresh is an essential part of clinical
microbiology, because early treatment is the cornerstone of eradicating infections. A smear, if meticulously done
and reported promptly, can save lives. E.g. Pneumococci in CSF, Staphylococci in pus and gram negatives in urine are
examples where we can give definitive therapy within one hour of receiving the specimen. Gram reaction also guides
the processing of the specimen, with extra selective media added based on gram stain findings. In some cases like
sputum and urine, it is also possible to reject poorly taken specimens based on gram staining.
b) The Genus and species of bacteria isolated – A clear concept of the basics of all branches of microbiology
and especially bacteriology is essential. In a lab with no automation, maximum efforts to identify the bacteria to genus
and species level is needed. This helps in taking note of inherent resistance, e.g. Serratia genus being Colistin resistant,
Pseudomonas being Tigecycline resistant and enterococci being Cephalosporin resistant. It is not always very apparent
on disc diffusion testing and MRSA appearing sensitive to 1st gen cephalosporins is a common error.
c) True pathogen – commensal – opportunistic– On opening a sputum culture plate , the clinical microbiologist
looks for normal flora and then only for the primary pathogens, namely pneumococci, Hemophilus influenzae, followed
by overgrowth of gram negatives. However, in case of a throat swab, Beta lytic streptococci take precedence and it is
very rare to report gram negatives or yeast which may oral thrush.
ANTIBIOTIC TESTING:
a) Which antibiotics do you test and how?
It is the responsibility of the doctor in charge of the lab to draw up the panel of antibiotics to be tested for each
pathogen or group of pathogens. This can be based on CLSI and local availability. In addition, since the testing and
resistance are getting more complicated, the exact method which is most accurate has to be decided, e.g. Gentamicin
testing involves looking for HLAR for enterococci, Colistin cannot be tested by any conventional method other than
micro-plate MIC, Vancomycin is best tested using an e-test and Cloxacillin is now tested by the surrogate Cefoxitin.
There are still many antibiotics that can be tested on a petri-dish using antibiotic discs. The CLSI and EUCAST give us
good guidance on doing this, with disc concentration of antibiotic and zone size tables. However, the lab incharge has
to go through all available methods and design the method that is both accurate and suitable to the needs of the lab.
b) Use standard methods to do Disc diffusion. On deciding which antibiotics are to be tested, the next step is to
standardize the discs, using standard strains. These can be tested every time a new batch of discs are taken out from
the deep freezer. Now it is necessary to decide which discs are put on one plate. Based on the size of the plate, either
five, six or seven discs can be put. It is better if you put the first line, second line and third line antibiotics on different
ROLE OF THE MICROBIOLOGY LAB IN USE AND MISUSE OF ANTIBIOTICS
Dr. Kavita Raja
Professor and Head
Department of Microbiology
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Department of Science and Technology, Govt of India
Thiruvananthapuram -695011, Kerala, India
Email: kavitaraja225@gmail.com

17
plates, so that reading becomes easier. An additional requirement that has come up is the need to determine the
mechanism of resistance. This also requires the planning of certain discs in combination on the sensitivity testing
plates, so that reading of sensitivity goes hand in hand with determining mode of resistance simultaneously. This is
essential in case of D test for Clindamycin and antagonism test for ceftazidime in case of Pseudomonas aeruginosa for
Amp C.
c) Automated methods like VITEK 2 have their own panels. Choose the panels carefully and give proper instructions to
the Technicians on their use. Do not give the printout as a report. Read the sensitivity and then give your own report.
Cefoxitin sensitivity means Cloxacillin and 1st Gen Cephalosporin sensitive and this is how it must be read.
READING THE SENSITIVITY TEST:
a) Basically, the zone size has to be accurately measured using a small scale or zone reader. The diameter is measured
and compared with a pre-prepared standard chart. At the same time, it is also noted whether the inoculum is adequate.
b) The order of reading would be to go from the first line beta lactams, aminoglycosides to the second, beta lactam
lactamase combinations and quinolones and then third line drugs like Colistin and Tigecycline.
c) Alertness to identify resistance through surrogate testing and different patterns like antagonistic straight line
between discs and synergistic merging of zones is necessary. E test and MICs have to be carefully read and recorded.
Genus and species must be considered, e.g. if a non-fermenter turns out to be Stenotrophomonas, only Co-trimoxazole
and Ciprofloxacin are reported. Some bacteria like mucoid variety of Pseudomonas aeruginosa appear more sensitive
than actual in vivo effect, due to the slow growth.
d)Thecluetotheidentityofanorganismalsoliesinthepatternofresistance,e.g.TigecyclineresistanceinPseudomonas
aeruginosa and Colistin resistance in Burkholderia or Serratia.
ANTIBIOTIC REPORTING
a) The clinical microbiologist has a lot of responsibility here. It is in the reporting that the actual worth of a lab is felt.
Make a policy for reporting based on the organism and include in your SOP, so that the same method is followed by all
who do the reporting. CLSI is a good guide to reporting. They have classified antibiotics for each bacterium and give in
detail the criteria for deciding whether an antibiotic has to be reported.
b) Though all available antibiotics are tested routinely, only first line are reported, if sensitive. Clear instructions are
given to the technicians that no reports may be given over phone without the permission of the lab in charge. Testing
of all antibiotics is done for statistics. Mechanism of resistance if phenotypically apparent can also be included in the
statistics. A prime example is Staph. aureus where MSSA is reported as sensitive to Cloxacillin and cephalosporin, but
Vancomycin and Linezolid are kept hidden.
HOW IS AN ANTIBIOTIC PRESCRIBED?
a) Defining the target Infection: When an organism is isolated from specimens like pus, urine and CSF, the exact site
of infection is apparent. However, if it is a blood stream infection, the source has to be determined by further testing.
This is needed because the antibiotic chosen has to be the best for that site and kind of infection. For a non-typhoidal
salmonella from blood culture, the source may be an abscess in the liver. Unless the abscess is drained, drugs alone
may not work.
b) Antibiotic selection: This has to be a regular exercise for the clinical microbiologist. The optimum antibiotic for the
site with a useful combination may be suggested in the report.
c) PK/PD – How the drug behaves inside the body - An idea of the drug behavior is extremely essential while advising
the dosage and frequency. Beta lactams have to be given more frequently than quinolones or aminoglycosides. Do not
expect an aminoglycoside to reach the lungs or Linezolid to treat urinary infection.
d) Route: Bio-availability determines the route. For Salmonella Typhi sensitive to Ciprofloxacin, oral route is needed
to eradicate the intracellular bacteria in the Peyer’s patches. IV Ciprofloxacin merely clears the blood stream with
recurrence after it is stopped. Select the best route for each infection. For deep infections, intravascular route is needed
and may involve getting admitted in a hospital.
e) Duration: There is no fixed duration for any kind of infection. Clinical correlation and repeat cultures may help.
Procalcitonin, especially in children, is of help in determining when to stop antibiotics. For deep seated organ space
infections, a minimum of 2 weeks is needed. UTI can be managed with a 5-day course. However, osteomyelitis needs
parenteral 4 weeks and endocarditis, parenteral bactericidal antibiotics for 6 weeks with surgery wherever necessary.

18
f) It is always wise to speak with the clinician while giving crucial treatment advice, otherwise it may not be followed.
FAILURE OF TREATMENT
Many a time, it is seen that despite the best reports and quality drugs, the patient fails to respond. This may be
due to one of several reasons:
a) Immunosuppressed: Patient’s own immunity, especially cell mediated is essential for complete recovery of infections
caused by intracellular organisms like Salmonella and Brucella.
b) Colonizer vs real infection: A sputum sample from a patient with severe pneumonia may grow only the pharyngeal
flora the colonizers there. In such cases, a Broncho-alveolar lavage specimen may be needed.
c) Source not identified: Central line infections can be managed only by removing the offending line and abscesses
wherever they are have to be drained.
d) Drug penetration into bone and tissue may not be optimum if the blood supply is compromised.
e) Intrathecal route may be needed if the bacteria causing meningitis is sensitive only to aminoglycosides.
HOW TO IMPLEMENT?
Let your final aim be the good outcome of the patient.
Treat each patient individually and talk to the person who has the greatest power to change the management.
Believe yourself and your lab. Be consistent and quick in reporting.
Be scientific in your approach. Use common sense.
CONCLUSION:
The present scenario of extreme antibiotic resistance can be tackled only if the clinical microbiologists are active.
A Clinical Microbiologist is the link between the clinician and the laboratory. They have to persist in active involvement
with treatment of infections. Many hospitals now have ID physicians who can be a great support in implementing quick
and judicious use of antibiotics. Teamwork is very essential. A Medical Microbiologist (Scientist) looks after the quality
control and supervises different sections. The technician does the routine benchwork. The team achieves what an
individual cannot.

19
The present curriculum and syllabus on Antibiotics is taught to our Medical Students as a core subject in
Pharmacology, just mentioning the names of different Antibiotics in Microbiology with more clinical teachings and
applications in Final year of MBBS Yet, there are few topics in integrating the consequences of using, misusing,
and the consequences of Antibiotic use. Major studies including WHO have identified including WHO that little is
taught on Misuse of antibiotics and the consequences, which lead to poor status on Antibiotic prescriptions, lacking
scientific prescriptions. However, the new syllabus coming in force from 2019 (MCI 2018) emphasizes the importance
of integrating therapeutics in clinical care is a major curricular change as we are turning the students to caregivers with
lacuna in use of antibiotics for full-fledged Medical practice. Despite millions of lives being saved by antibiotics, what
if they did not work any longer? What would we do? Unfortunately, we are coming face to face with that problem as
various ‘microbes’ become resistant to major groups of antibiotics. With antimicrobial resistance a growing global
concern, there have been calls for further integration of teaching on this topic at the undergraduate medical level.
NEED FOR ANTIBIOTIC STEWARDSHIP EDUCATION - As Education, as a mainstay feature of these programs,
is considered essential to teaching the knowledge necessary for effective stewardship, and can influence physicians’
prescribing behavior. Several educational interventions have been shown to improve antimicrobial prescribing practices
and infection control.
TEACHING ANTIBIOTIC STEWARD TO STUDENTS TO MAKE BETTER DOCTORS IN CONSERVING
ANTIBIOTICS
In a major study in USA, ninety percent of surveyed fourth-year medical students felt they would like more
education on the appropriate use of antimicrobial; only one-third felt adequately prepared to apply principles of
appropriate antimicrobial prescribing. The authors found significant heterogeneity in how students from the 3 medical
schools accessed appropriate antimicrobial prescribing information. Of concern, the study also identified gaps in
medical students' knowledge regarding antimicrobial management of common infections. However, we still follow
developed countrie's literature as we have poor educational research.
THE INTEGRATED SYLLABUS SHOULD ADDRESS -
1) Improve how we prevent and manage infections in people and in animals; including through better hygiene and
monitoring of bacteria in medical and community settings, and through better farming practices.
2) Improve education and training around the prescribing of antibiotics to reduce inappropriate usage and make sure
patients get the right antibiotics, at the right time and for the right duration.
3) Antibiotics are only needed for treating certain infections caused by bacteria. Antibiotics also won’t help some
common bacterial infections including most cases of bronchitis, many sinus infections, and some ear infections.
4) Collect better data on the resistance of bacteria, so we can track them more effectively, find the most resistant
bacteria and step in earlier where there is resistance to antibiotics.
5) Better documentation practices of Antibiogram and informal Audits of Antibiotic usage and Drug Resistance patterns
can help us know the changing trends on concerns on Antibiotic misuse.
Never forget Antibiotics are no longer the ultimate magic bullets, just drugs to control defined infections. Evidence
based prescriptions of Antibiotics may save many lives and reduce Antibiotic Resistance.
Reference:
1. Antimicrobial Stewardship Education for Medical Students Vera P. Luther Christopher A. Ohl Lauri A. Hicks Clinical Infectious
Diseases, Volume 57, Issue 9, 1 November 2013 clinical Infectious diseases.
2. Curricular changes for Undergraduates MCI 2018.
ESSENTIAL TEACHING ON ANTIBIOTIC STEWARDSHIP
TO MEDICAL STUDENTS
Dr. T. V. Rao
Former Professor
of Microbiology
Email: doctortvrao@gmail.com

20
Microbial resistance to antimicrobial drugs became evident soon after their use was started and the mechanisms
of resistance were either already presents in the microorganisms or they acquired the same through mutations and
plasmids. The dreams of conquering microbial infections with antimicrobial agents were shattered as soon as we
started using them, but we continued inventing newer and newer agents in hope of winning this battle.
Methods of detecting susceptibility/resistance were developed and standardised in 1950s and 60s and physicians
started getting the tests done if the patient was not responding to the prescribed antimicrobial agent. Professor Hans
Erricson, a Swedish researcher, after playing great role in development of susceptibility testing method turned a
manufacturer of antimicrobial susceptibility testing discs and his company, AB Biodisks, developed the E-test strips in
1980s.
By this time, physicians and researchers had understood that bacteria are developing resistance at a much faster
rate than previously thought of and the reason was rampant misuse of antimicrobial agents not only in humans but in
poultry and animal husbandry as well. In the late 1980s, scientists started discussing the rationale use of antimicrobial
agents, and AB biodisks came out with an antimicrobial stewardship program in the early 1990s with the name “ARTIST”.
By now, microorganisms have become resistant to almost all available antimicrobials and development of new
antimicrobial agents is not lucrative for pharmaceutical companies, leading us back to the pre-antibiotic era as hardly
any options are available.
In this era of MDRs and XDRs, therefore, the role of microbiologists becomes externely important. The role of
clinical microbiologists in providing accurate clinical reports for patient’s infection becomes most important apart from
providing data for planning of empirical antimicrobial treatment for life threatening infections. To face the challenge of
resistant microorganisms, the microbiologists should consider the following before reporting.
1) Develop a culture of going from bench-side to bed-side and know your patients
2) Collect appropriate sample and if you think sample has not been collected properly, reject it.
3) Develop SOPs for processing all samples as per standards and stop, compromising for not following them due to
any reasons, be it resource constrain, clinicians pressure or any other. Remember, when you compromise, your report
is compromised. For example, never perform susceptibility testing directly from sample or very young culture to fast
forward your reporting.
4) Do not become over enthusiast to report normal flora contaminating a sample. If you suspect so, always request a
repeat sample that has been carefully collected as per your instructions.
5) Do not report susceptibility result if you are doubtful about pathogenicity of an isolate because the clinician will
have no choice after a culture report is made available. Always ask for a repeat sample. One of my teachers used to tell
us, “If in doubt, report it negative as the clinician will investigate it further”.
6) Keep yourself updated for reporting susceptibility results and keep updating your clinicians too. Be very careful
about intrinsic resistance while reporting.
7) Report the susceptibility results selectively depending upon patient profile, site of infection and CLSI guidelines.
8) Insist on developing and implementing infection control program in your hospital including audits. Do not force
policies on clinicians, if you are in-charge of infection control. Always insist on respective departments to develop their
own policies that shall be endorsed and approved by ICC. This will ensure better compliance.
ROLE OF MICROBIOLOGISTS AS ANTIMICROBIAL STEWARD
Dr. Sanjay Singhal
Prof. and Head,
Department of Microbiology,
ESI PGIMSR, Basaidarapur,
N. Delhi, India
Email: drsanjaysinghal@gmail.com

21
9) Do not perform routine cultures for environmental or personnel for surveillance and convince clinicians and
administration about the cost benefit analysis of such routine screening. They can be asked to provide authentic
guidelines and action to be taken protocols if you are forced to do so.
10) Antimicrobial policy, similarly, should be prepared by respective departments and not by microbiologists, and
approved by hospital administration for better compliance.
11) Microbiologists should provide susceptibility data for updating the antimicrobial policy. You must prepare this data
and share biannually with clinicians and policy planners. Be careful to divide this data into ICU patients, in-patient and
out-patient so that empirical antimicrobial agent can be planned accordingly in policy. The cumulative Antibiogram
should be made as per WHONET or CLSI M39.
12) Remember that antimicrobial stewardship is the responsibility of every healthcare worker and not only yours and
it is the actual prescriber who is responsible for the patient as well as development of resistance; so keep re-educating
but refrain from forcing them.
I hope and wish that if we are able to perform our duty well, we shall become a better steward and be able to fight
the microorganisms or at least co-exist.

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SUCCESSFUL IMPLEMENTATION OF ANTIBIOTIC STEWARDSHIP IN
HOSPITALS CAN ONLY BE DONE BY ASSERTIVE MICROBIOLOGISTS
Dr. H Srinivasa
MD Microbiology
(AIIMS, New Delhi)
Free lance Consultant Microbiologist & Infection Control Bangalore
Email: dr.srinivasa.micro@gmail.com
MICROBIOLOGIST AND HIS WORKING DOMAINS
The present day clinical microbiologist attached to a hospital is expected to work in two domains. One domain is
lab component, another is in hospital area. The first Domain involves accurate lab diagnosis of infections, mainly the
bacterial ones, by reporting on antibiotic sensitivity to clinicians. This he will do as a team, involving technicians and
support Staff. Another domain is role in hospital, the work is supposed to be infection control and antibiotic guidance
going by international guidelines.
He is generally satisfied with his role in the first domain, while in the second domain, he is not satisfied with his
performance, sees many hurdles, many grey areas. So generally, he is not happy, and even starts blaming others or the
system. Many international groups are talking about success of antibiotic prescription guidelines-antibiotic policy or
implementation of it and Antibiotic Stewardship programs, (AS). In our country, he is already given up and convinced
about failure of AS considering high degree of multi drug resistant bacteria.
Concerns of present day clinical microbiologist in infection Control (IC)
1) Feels left out in IC- lack of provision of infection control nurse by the hospital, lack of Structured training in IC
practices etc.
2) Faces non-cooperation of clinicians.
3) Feels that hospital administration is not supporting him in IC activities.
ARE THE CONCERNS OF MICROBIOLOGIST GENUINE?
However, these concerns are sometimes genuine but many a times, due to pessimism built around him by
himself.
Also, he should realize that the two domains of his are interdependent. Synergy is required if he has to achieve
some degree of success in the second domain. First he should relook into the first domain.
Is he getting right samples, is he generating meaningful reports to clinicians, whether he presents his Antibiogram
periodically in clinical forum etc.
Most importantly, does he take feedback from clinicians on sample processing and reporting. Does he practice in
his culture sensitivity report, some sort of restrictions in antibiotic prescriptions?
ANTIBIOTIC STEWARDSHIP SHOULD START FROM HOSPITAL LABORATORY
As one of our international colleague incisively remarked in one of the digital platforms, AMS should Start from
the laboratory. Very well said and time for introspection required by we, the microbiologists.
For this program, there should be actionable AP. Why is there failure of Implementation despite so many excellent
learning materials available?
Why are there many non-starter hospitals in AP and AS?
Is it really impossible?
What attributes should be there in a microbiologist for hospital to succeed in AP & AS.
I will illustrate the stories of five kinds of microbiologists, and then, let us reflect on what has gone wrong with us
and how to improve.

23
MICROBIOLOGIST A
Good in bench bacteriology, serology QC practices. Attends CMEs and conferences on antibiotic policy whenever
opportunity is present..Collects all literature relevant to AP, AS including international guidelines on various IC practices
and systematically files. In the lab, releases the AST as per SOP without any explanatory comments in the Report form.
Spends all working hours in lab Does not part step into hospital premises. Not in the habit of sharing lab information
in clinical Forum.
MICROBIOLOGIST B
Similar to Microbiologist A, collects information on AP, AS, guidelines on IC practices. Attends a CME on antibiotic
Policy. The hospital has no infection Control Nurse. On hearing about high end antibiotic restriction, gets enthused,
comes back to the lab the next day and starts restricting about ten high end antibiotics based on AST meaning not
mentioning in the Report form. Over a period of time, he became so strict that pharmacy started complaining that
many antibiotics in the Shelf are not getting utilized, Clinicians also start airing their concerns that their prescription
freedom is heavily curtailed. Based on clinicians input, Hospital administration got the restriction lifted on all high end
antibiotics. Microbiologist now continues to report sensitivity for all antibiotics.
MICROBIOLOGIST C
Also a good bench microbiologist. Attends CMEs, workshops on antibiotics and bugs but selectively collects
information on various national and international guidelines, but recommends after modification if need be depending
on local AST data available to him from the excel sheet and discussion in the clinical forum. He is also confident to
present AST data to clinicians and administration and when asked, he tries his best to answer queries.
He does not go on infection rounds. Infection Control Nurse is not available in Hospital. He asked for one, but
hospital said to utilize existing Staff nurses for IC purpose. He advises on antibiotics prescription when asked only by
clinicians. Checks with ward in case of doubt about bacteria isolated is pathogen or not by eliciting patient history. He
prepared a protocol for screening patients transferred from other hospital for screening nasal swab for MRSA. He also
prepared an Antibiotic Justification form and sent to hospital administration for acceptance so that clinicians can fill
with justification for high-end antibiotic. Both screening policy and antibiotic justification form were turned down by
administration.
MICROBIOLOGIST D
Good bench microbiologist. Has good knowledge of infection control practices. Experienced, well versed in clinical
pharmacology of antibiotics.
But he finds that instead of interpreting Culture Sensitivity report , some clinicians were practicing irrational
antibiotic therapies. His clarification did not yield any results. Also, doctors were not interested in antibiotic sensitivity
data presentation when he wanted to take a class on sample collection for culture like blood, urine, Even new doctors
did not volunteer saying they are busy in the ward. But the microbiologist, not relenting with hospital administration,
was able to present in well-attended clinical forum sensitivity data of bacteria and stressed the need for Rational
prescribing of antibiotics. He also took a class on need for proper sample collection for Microbiology.
MICROBIOLOGIST E
He is also well trained in bench microbiology techniques. He is having ten years experience in IC practices; he
proactively presents six monthly antibiotics sensitivity in clinical forum, volunteers for investigation and management
of difficult to manage infections.
He issues advisories periodically regarding MRSA /VRE screening, protocols implementation of H1NI categorization
duringoutbreak.SeeingnoICnurseinvolvedintraining;heidentifieswiththehelpofhospitaladministrationamotivated
staff nurse to take up IC. He works in tandem with IC nurse and goes on IC rounds, helps IC nurse in organizing training
program, also participates actively by taking a few classes.
He studies antibiotic prescription practices, prepared an Antibiotic Justification (AJ) form having a list of high end
antibiotics with spaces to fill details by clinician on justification, clinical diagnosis, culture, sensitivity data to support.
He was also active in monitoring antibiotic therapy of ward patients and to alert clinicians when to stop antibiotics. He
is also involved in quality assurance practices of not only lab but also Hospital and developing Standards
DISCUSSION
Microbiologist A and B are not proactive and nonstarters and administration was not helpful. They have no IC
nurse. But what is lacking is lack of assertive attitude. Maybe by constant persuasion of higher ups in Hospital, these
Microbiologists would have implemented AS &IC practices. In Antibiotic Stewardship programs, the Microbiologist

24
should be the driving force. He may face various hurdles in Implementation of AS but should be patient enough to
persuade the administration and clinical Heads by repeated representations. It may take time but ultimately, he will be
successful as seen in Microbiologists D and E. Microbiologist C is also proficient, but having received a single negative
reply from the administration, he was content to give up! This type of scenario is commonly seen, but they also can
scale up the ladder by repeated representation to administration of Hospital. This skill comes by experience and
not willing to give up attitude. Note that Category D and E are having some degree of experience. I am not stating
all freshers are non starters but experience and interaction with peers teaches a lot of lessons and helps in problem
solving in difficult scenarios. So, let us be assertive and optimistic to achieve success In AS.
CONCLUSIONS
The time has come for us to should shed pessimism and recognize ourselves more as a clinical specialty. This
attitude helps to work towards persuading hospital administration, mobilize clinician opinion towards achieving
success. Microbiologists should seize the opportunity towards giving more time to clinical areas, do IC rounds and win
clinician's confidence. Such proactive microbiologist will go a long way in executing AS in a way appropriate to the local
problems and in an evidence-based approach. I am confident such pool of microbiologists with their team as a new
department rightly called as Infection and prevention Advisory Services (IPA), will definitely help to mitigate AMR and
offer best advice in AS. Also, by constantly reading getting updated in the field of clinical pharmacology of antibiotics,
including use of judicious combinations, new antibiotics etc. they will be able to offer ultimately the best management
of infections even with highly antibiotic resistant bacteria.

25
Bentham’s principle of reinforcement tells that to make a donkey work one has to put a carrot in front of it as well
as jab with a stick from behind. That works as the carrot acts as reward for forward progress while stick ensures that
progress is dynamic and unidirectional. Unfortunately, when putting antimicrobial stewardship into practice, despite
theoretical soundness and expected fluency, either we behave like donkeys or collide with some of them.
Thinkingfromtheotherendofthetable,onepersonperformshisdutiesreligiouslyandhewilldoitmoreefficiently
if he knows what he does is right to do. However, situations of non-performances do arise by own reluctance or by
external functionalities where a punishment might improve personal attributes or expose the functional hindrance.
Basically, medical service is nothing but behavioural science at large. Only reward will not drive our inherent resilience,
neither continuous punishments would improve the work flow. It is imperative to keep in mind that punishment would
be effective in behaviour modulation if an individual switches on to a desirable alternative behaviour. In case it is not,
then the original behaviour is going to reappear as soon as the punitive period is suspended. So, the punishment works
best at the time of actual performance of an undesirable behaviour. Human nature is difficult and punishment may be
utilized as reward for an undesirable behaviour; care has to be cautioned there to have the positive effect of motivation.
There are many ways to implement antimicrobial stewardship in hospitals and healthcare sectors. Majority focuses
upon formulary restriction and pre-authorization of antimicrobials. However, in a given clinical situation, such things
might cause inconvenience to the grass-root healthcare providers and may cause restraint which may be disastrous at
moments.
Schuts EC et al (2016) performed a systematic review and meta-analysis on hospital antimicrobial stewardship
objectives to see whether they have any effect on clinical outcomes, adverse events, costs and bacterial resistance
rates. After studying 145 studies, they found that guideline-based empirical therapy, de-escalation, IV-to-PO switch,
therapeutic drug monitoring, use of restricted antibiotics and bedside consultation showed statistical significant
benefits for one or more of the four outcomes. Guideline-based empirical therapy was associated with a relative risk
reduction for mortality of 35% (relative risk 0.65, 95% CI 0.54–0.80, p<0.0001) and for de-escalation of 56% (0.44,
0.30–0.66, p<0.0001). Evidence of effects was less clear for adjusting therapy according to renal function, discontinuing
therapy based on lack of clinical or microbiological evidence of infection, and having a local antibiotic guide. These
findings are meaningful to us despite the low quality of evidence and moderate to high heterogeneity between the
studies. However, I did not find the answer of the query from one clinical colleague that do these rituals really help and
if so, why does the resistance rate not come down. There remains an under-discussed issue in all these researches that
is lack of positive clinical feedback. Herein lies the importance of building rapport and functional stewardship planning.
In my hospital settings, one Clinical Microbiologist and one Critical Care Consultant manage all the antimicrobial
issues. However, this cannot be sustained 24x7 and therefore privileges have been given to certain key personnel of
appropriate hierarchy. Although, whatever the patient has been prescribed is critically judged on the next meeting
opportunity which is usually the morning meeting/round. Any unjustified advice is assessed down to the root cause
analysis and is corrected. This approach does not irritate the other side, rather motivates them to follow rational steps.
For example, one new neurosurgeon got surgical site infection case and was frustrated. We approached, performed
the root-cause analysis and it appeared that one of the root causes might be very early timing of the pre-operative
prophylactic antibiotic dosing. When he realized its true importance, he himself went on to check the same for the
next cases. Here, our sympathetic and emotionally scientific approach acted as carrot and post-operative infection case
as the stick. Being a high turnover staffed hospital, this approach suits all strata of the staff. Similarly, we are there in
every difficult post-operative infection cases to guide therapy. This multi-disciplinary and mutually-cohesive approach
CARROT AND STICK IN ANTIMICROBIAL STEWARDSHIP?
Dr. Sourav Maiti
Chief Consultant Clinical Microbiologist & In-Charge,
Department of Infection Prevention & Control,
Institute of Neurosciences Kolkata
Email: smaiti76@gmail.com

26
is beneficial for both the parties and obviously for the patient. What we gathered as experience over the years is that
we were successful in gradual but sustained decrease in antibiotic consumption. Lately, we realized, it is also associated
with decrease in Days of Therapy (DOTs).
Long been searching and researching for articles on antimicrobial stewardship programs, one study came into my
notice which is somewhat similar to our indigenous approach. It is a 2016 study by a Pharmacist Hurst AL at Children’s
Hospital, Colorado who named it Handshake Stewardship. This involves an active stewardship team that participates in
clinical round and delineates care plans instead of pre-authorising antibiotics or imposing ban on restricted formularies.
Handshake stewardship is distinguished by: (1) lack of restriction and preauthorization, (2) review of all prescribed
antimicrobials and (3) a rounding-based, in-person approach to feedback by a pharmacist–physician team. What it
resulted is that the overall antimicrobial use decreased by 10.9% during the 4 years significantly. Vancomycin use
decreased by 25.7% (105 to 78 DOT/1000 PD, P < 0.01). Meropenem use decreased by 22.2% (45 to 35 DOT/1000 PD,
P = 0.04) without a compensatory increase of other antipseudomonal agents. Similar resonance did we elicit.
As we have done away with physical handshake, we can still utilise handshake at antimicrobial stewardship. Away
from the complexities of ego, shame and humiliation, handshake of knowledge and authority should produce good soil
for appropriate work culture to seed in. If a surgeon understands that a surgical site infection is not due to his fault but
an opportunity to explore possibilities, it ultimately helps in the long run. Yes, we do believe, a stitch in time can save
nine or even more!
Reference:
1. Hurst AL, Child J, Pearce K, et al. Handshake stewardship: a highly effective rounding-based antimicrobial optimization service.
Pediatr Infect Dis J 2016; published online May 31. DOI:10.1097/INF.0000000000001245.
2. Schuts EC, Hulscher ME, Mouton JW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic
review and meta-analysis. Lancet Infect Dis 2016;16: 847–56.

27
The current era is an era of rampant drug resistance. For organization like high end tertiary care that are performing
high end surgeries, transplants and oncology related work where there is immunosuppressive therapies, probably the
challenges are multiplying with times. On the other end, there are chronic diseases and morbidities due to diseases
e.g. diabetes are increasing due to high population, eating habits and other social and economic factors. One of the
frequent complications in diabetes is infections which require antibiotics therapy and they need repeated antibiotics
therapy due to repeated admissions due to one or other reasons. Similar is scene of hematology and oncology related
patients who need frequent admissions in hospitals.
Antibiotic use is not only common in medical industry but also in pharmaceutical, research, veterinarian and food
industry where they are used as growth promoters and suppress any impending threats due to infections, whether in
poultry, dairy industry or other animal related industries.
Stewardship comprises a common list of processes which are implemented as an accountable and responsible
care giver by anyone who is involved in prescribing, dispensing or administering antibiotics. It is a complex process
which involves multiple stakeholders starting from prescribing consultants, resident doctors, dispensing units like
pharmacy whether in hospital or in community and nurses who are administering antibiotic doses or DOTS observer
or any one like patient themselves or their keens. It is multimodality and multidisciplinary efforts to be responsible
for actions which are related to antibiotics. Other important stakeholders are government policies, FDA policy on
sanctioning new discoveries and overall control of pharmaceutical industry and perspective of pharmaceutical industry
that are manufacturing antibiotics and supply chain for antibiotics. Pharmaceutical role is major because the quality,
quantity and pharmacokinetic parameters like bioavailability are very important for medicines like antimicrobials.
Clinical microbiologist can just not remain as laboratory consultant but may act as overall in charge for implementation
of antimicrobial stewardship program. They can be one point of contact between multiple stakeholders and probably
guide the program. Similar help can be provided by intensive care expert and senior physicians.
When it comes to decision making for dosing practices, it is important to understand pharmacokinetic and
pharmacodynamic properties of antibiotics, type of antibiotic, preferred route, suitable dose appropriate for age, route
by which is excreted and dose adjustments in conditions like renal insufficiency, liver disease, chronic or acute care
settings, pregnancy, children and neonates, certain special conditions like obesity and elderly age. Probably, here the
institution has to spend more for hiring an appropriate expert for same who is clinical pharmacist.
The pillar for guiding empiric therapy will be the available hospital specific guidelines which are available from
microbiology data which is system wise and systematically showing major bugs, their sensitivity pattern and site of
infection. Usually policy must include guidance for surgical prophylaxis, urinary tract infections (UTI), Respiratory tract
infections (RTIs), Blood stream infections (BSIs), Skin and soft tissue infections (SSTIs) and intra abdominal infections
(Desirable).
Microbiologylaboratorymustbeequippedwithbasicidentificationandsusceptibilityinstrumentsandthereshould
be appropriate provision for doing broth micro dilution test for colistin as the automated systems are not validated for
colistin results. Some of indirect markers of infectious diseases like ESR, CRP levels, PCT levels etc. should be available.
Serum markers for fungal infections are desirable in view of increased mortality and delayed diagnostic confirmation
in view of invasive fungal infections. However, it all depends upon scope of services of organization to decide what
to include as diagnostic modality as per patient population which they are catering to. Antibiotic sensitivity data has
become more reliable with systematic procedures and reproducible results. Another important thing is standardized
IMPLEMENTATION AND MONITORING OF ANTIMICROBIAL
STEWARDSHIP PROGRAM FOR HEALTHCARE ORGANIZATION
Dr. Dhruv Mamtora
Consultant Microbiologist infection control officer
S. L. Raheja Hospital, A fortis associate, Mahim, Mumbai.
Co-editor and designer “Infection control trends”
Email: dhruv_mamtora@yahoo.com

28
guidelines are available for performing susceptibility testing like CLSI and EUCAST which are updated on regular basis
thus helping and integrating with clinical decision making.
Some recent advances in diagnostics are really tools which can improve laboratory performance drastically which
are PCR based techniques, sequencing and PNA-FISH. The turnaround times are drastically reduced if any of new
methods are introduced. This can significantly bring down costs of empirical therapy which are broad spectrum and
high end or reserved antibiotics. Long term effect of such diagnostic modality may be that they even reduce drug
resistance which may be happening due to wider use of antibiotics and exposure of antibiotics in acute care settings.
Once confirmed, there is de-escalation step wherein a specific drug is given as per sensitivity pattern, which is
narrow range and as per culture susceptibility test targeting pathogen causing infection. Another word of caution is
dealing with contamination and colonizers. Clinicians’ role is important in deciding appropriate samples to be sent for
culture and sensitivity and other ancillary tests like acute phase reactants. Many times, there is ambiguity in diagnosis,
so multiple tests are ordered which reduces probability of detection. Another important thing is sending cultures
before initiation of antibiotic therapy which improves detection rates. Role of point of care testing is important in this
era. However, there are challenges which are high cost, performing quality control and assurance of test results when
performed in acute care settings. Danger of misdiagnosis is abuse and misuse of precious medicines like antimicrobial
agent which should be prevented in any given settings as important part of stewardship program.
Antimicrobial stewardship in an organization needs attention by all stakeholders such as clinicians, pharmacists,
administrators, patients, nurses and supporting teams. There should be a committee for antimicrobial stewardship. If
no definitive committee can be formed, then infection control committee can act as parenting committee or may be
combined together as the majority of stakeholders are similar. Committee can formulate antibiotic policy, put formulary
restriction for use of specific use of antibiotics and pre authorization whether needed or not for issuing antibiotics.
There will be supportive framework from nursing, pharmacy and information technology end for regular scrutiny of
dispensed, administered and issued antibiotics which can be tracked and analyzed specialty wise, consultant wise,
department wise and unit wise. Restricted antibiotics can be alerted to antimicrobial stewardship committee and
appropriate authorization if obtained by members of committee, and then only antibiotics should be administered. In
many emergencies, these can never be possible; in such cases, explanation can probably be given by ordering physician
for use of antibiotics which are restricted.
Role of administrators is in providing appropriate resources i.e. manpower, money and material so that teams
can perform effectively. Also, administrator can evaluate performance indirectly by looking at cost saving like reduced
length of stay and reduced consequences of antibiotic misuse like antimicrobial resistance by introduction of systems
related to antimicrobial stewardship implementation.
There is also an important role of nurses who are mostly involved in direct patient care. They can literally act as
means of education for patients and relatives, foresee the adverse effects of antibiotics administration and improve
pharmacovigilance and additionally can act as point of contact for AMS team and consultants. They are important also
in implementation of barrier nursing techniques and isolation precautions for the patients who are harboring multidrug
resistant organisms (MDROs). The nurses can supervise doses and can actually supervise duration of therapy. Also,
serve as important personnel in switching from intravenous to per oral route. They can undergo special training and
can be designated as AMS (Antimicrobial Stewardship) Nurse. The nursing supervisor or incharge can act as link of
communication between AMS team and administration also. It all depends upon administration how much credentials
and privileges are given to senior nursing staff. They are best candidates for OT implementation of surgical prophylaxis
and also for improvising and supervising same.
This is the era of documentation. This is the era of evidence based practice so probably all efforts needs
documentation. There should be Standard Operating Procedures.

29
ENCOUNTERING ANTIMICROBIAL RESISTANCE – STRATEGIES AT VARIOUS LEVELS
(REVIEW ARTICLE)
Antimicrobial resistance is not an issue of hospitals alone, it prevails and originates in community as well. In community,
it causes colonization of healthy population, who are most common source of infection and major cause of spread of
MDROs in a community, both healthy and sick. These colonized organisms/individuals are also major source of MDROs
in hospital.
In order to control the antimicrobial resistance, it is very important to have data on antimicrobial resistance.
IMPORTANCE OF ANTIMICROBIAL RESISTANCE DATA:
1. To improve our understanding of endemic resistance (MDR, XDR, PDR) for deciding on emperic therapy.
2. To improve judicious use of antimicrobial agents with the aim of preserving available agents.
3. To slow or prevent the emergence of resistance among commonly acquired or colonized bacteria.
4. To use trends of resistance as an outcome measure for the success of antimicrobial stewardship programs (ASPs)
Reported data suggests that almost 2 million cases of infection with resistant bacteria have been reported in the United
States (US) every year leading to $20 billion incremental direct healthcare cost. Estimates of European Medicines
Agency (EMA) and European Centre for Disease Prevention and Control (ECDC) reported a toll of 25,000 deaths per
year as a direct consequence of a MDR infection with total cost of €1.5 billion. In Canada, hospitalization caused by
resistant infections resulted in higher economic burden with excess cost of $9–$14 million. Study by Indian Network
for Surveillance of Antimicrobial Resistance
(INSAR) group, India reported prevalence of 41%
with methicillin resistant Staphylococcus aureus
(MRSA). High prevalence of gram–negative
bacterial resistance has also been reported
in India. World Health Organization (WHO)
estimates that worldwide, 3.7% of new cases and
20% of previously treated cases are estimated to
have MDR-TB.
TheglobalthreatofAMRcallsforthecollaborative
action for developing effective strategies in
combating AMR. CDC recommends 12 steps to
prevent antimicrobial resistance in a healthcare
setting.
1) Unoptimized, indiscriminate, widespread use of antibiotics
by physicians and quacks for all or any kind of infections, most
of the times its emperical and not culture based.
2) Uncontrolled dispatch of drugs by pharmacies.
3) Poor antibiotic-taking behavior of patients: In a study done by
Kardas et al.[1], a review of antibiotic misuse in the community
reported that at community level, more than one third of
patients were non-compliant to the antibiotic regimen and
one quarter kept the unused antibiotics for use in future. CONTRIBUTING FACTORS FOR NON PRESCRIPTIONAL SALE OF ANTIMICROBIAL
AGENTS IN DEVELOPING COUNTRIES
Causesfordevelopmentofantimicrobialresistanceincommunity:
Dr. Nazia Khanum
M.D (Microbiology); MHA (SMU)
Clinical Microbiologist & Assistant consultant Infection
Control Infection Prevention & Control Department
KSMC Riyadh
Email: drnaz.khan@gmail.com

30
EFFECTIVE STRATEGIES FOR COMBATING AMR:
The collaborative approach directed at international, national, community, hospital, individual and patient level is
required for combating anti microbial resistance.
1. INTERNATIONAL MEASURES
In the year 2011, WHO used the theme “combating antimicrobial resistance” in order to draw international attention
and need of combined efforts to alleviate the problem of AMR.
Some of the WHO recommended approaches are listed below:
• Increasedcollaborationbetweengovernments,non-governmentalorganizations,professionalgroupsandinternational
agencies
• New networks that undertake surveillance of antimicrobial use and AMR
• International approach for control of counterfeit antimicrobials
• Incentives for the research and development of new drugs and vaccines
• Forming new, and reinforcing existing programmes to contain AMR.
2. NATIONAL STRATEGIES
2.1 National committee with intersectoral coordination and regulatory actions
WHO recommends that a national committee which monitors impact of antibiotic resistance and provides
intersectoral co-ordination is required. Functions of such committee would be:
a. To formulate AMR policy;
b. To provide guidance on standards, regulations, training and awareness on antibiotic use and AMR.
c. To Develop indicators to monitor and evaluate the impact of AMR prevention and control strategies at national
level.
d. To have a registration scheme for all dispensing outlets, making prescription-only availability of antimicrobials, legal
binding on all manufacturers to report data on antimicrobial distribution and incentives for rational use of antimicrobials
can help contain AMR.
e. To Establish and implement national standard treatment guidelines, having essential drug list (EDL), enhancing coverage
of immunization are other essential strategies desired at national level.
2.2 National Antimicrobial Resistance Policy, India – Introduced in 2011
The policy aims to understand emergence, spread and factors influencing AMR, to setup antimicrobial program
which includes establishing AMR surveillance system, strengthening infection prevention and control measures and
educate, train and motivate all stakeholders in rational use of antimicrobials and to encourage the innovation of newer
effective antimicrobials.
3. ACTION AT COMMUNITY LEVEL
As the increasing rate of resistance among community acquired infections are not matched by development of
newer antibiotics, there is urgent need for action at community level for managing Anti Microbial Resistance.
3.1 Rational use of antibiotics
Irrational use of medicines is a serious global problem. In developing countries, at primary level, more than 60%
patients in public sector and more than 70% patients in private sector are not treated as per standard treatment
guidelines. This indicates the need for mandatory public and professional education towards rational use of antibiotics.
3.2 Over-the-Counter (OTC) antibiotics
A study done by Morgan et al, reported that non-prescription use of antimicrobials varied from as low as 3%
in northern Europe studies to 100% in African studies. This implies urgent need for regulatory control on OTC use of
antibiotics.
3.3 Guidelines for use of antibiotics at local levels
In common situations, based on the clinical condition of the patient, prevalent pathogen and resistance pattern
in a locality empirical therapy should be started, and later, appropriate change in antibiotic is required as per the
sensitivity of microbe. Therefore, antibiotic guidelines are a must to optimize antibiotic selection with their dosing,
route of administration and duration of therapy.
3.4 Standards of hygiene
Use of alcohol-based hand rubs or washing hands has proven efficacy in prevention of infection. This factor can
restrict the spread of infection and thereby the AMR.

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