"Chennai Declaration": 5-year plan to tackle the challenge of anti-microbial resistance

Antimicrobial Stewardship Program in Critical Care-Need of the Hour

Maximum antibiotic usage within hospitals occurs in critical care areas. Reasons for this usage are the moribund state of patients, invasive devices, and protocol based necessity for empiric antibiotic initiation in most critical conditions. Although unavoidable, prudent use of antibiotics (empiric and therapeutic) should be tailored based on national or if available, unit-based hospital antibiogram. This forms the footstool of every antibiotic policy formulated at tertiary care hospitals. Strict adherence to antibiotic policy formulated based on hospital antibiogram largely benefits patients and hospital-wide antimicrobial stewardship is ensured. The necessity, benefits, key targets, and usefulness of antimicrobial stewardship program (AMSP) in critical care has been elaborated in this review. How to cite this article: Vadala R, Princess I. Antimicrobial Stewardship Program in Critical Care-Need of the Hour. Indian J Crit Care Med 2020;24(9):847-854.

Characteristics of a Nationwide Voluntary Antibiotic Resistance Awareness Campaign in India; Future Paths and Pointers for Resource Limited Settings/Low and Middle Income Countries

Antibiotic resistance has reached alarming proportions globally, prompting the World Health Organization to advise nations to take up antibiotic awareness campaigns. Several campaigns have been taken up worldwide, mostly by governments. The government of India asked manufacturers to append a ‘redline’ to packages of antibiotics as identification marks and conducted a campaign to inform the general public about it and appropriate antibiotic use. We investigated whether an antibiotic resistance awareness campaign could be organized voluntarily in India and determined the characteristics of the voluntarily organized campaign by administering a questionnaire to the coordinators, who participated in organizing the voluntary campaign India. The campaign characteristics were: multiple electro–physical pedagogical and participatory techniques were used, 49 physical events were organized in various parts of India that included lectures, posters, booklet/pamphlet distribution, audio and video messages, competitions, and mass contact rallies along with broadcast of messages in 11 local languages using community radio stations (CRS) spread all over India. The median values for campaign events were: expenditure—3000 Indian Rupees/day (US$~47), time for planning—1 day, program spread—4 days, program time—4 h, direct and indirect reach of the message—respectively 250 and 500 persons/event. A 2 min play entitled ‘Take antibiotics as prescribed by the doctor’ was broadcast 10 times/day for 5 days on CRS with listener reach of ~5 million persons. More than 85%ofcoordinators thought that the campaign created adequate awareness about appropriate antibiotic use and antibiotic resistance. The voluntary campaign has implications for resource limited settings/low and middle income countries.

Global Contributors to Antibiotic Resistance

Introduction:

Antibiotic-resistant infections have become increasingly prevalent nowadays. As a result, it is essential to examine the key socioeconomic and political factors which contribute to the rise in the prevalence of antibiotic resistance in developing and developed nations. This study aims to identify the various contributors to the development of antibiotic resistance in each type of nation.

Methods:

PUBMED was used to identify primary research, systematic reviews, and narrative reviews published before Jan 2017. Search terms included antibiotic resistance, antimicrobial resistance, superbugs, multidrug-resistant organisms, developing countries, developed countries. Publications from different countries were included to ensure generalizability. Publications were excluded if they didn't mention factors causing resistance, focused on the molecular basis of resistance, or if they were case reports. Publicly available reports from national and international health agencies were used.

Results:

In developing countries, key contributors identified included: (1) Lack of surveillance of resistance development, (2) poor quality of available antibiotics, (3) clinical misuse, and (4) ease of availability of antibiotics. In developed countries, poor hospital-level regulation and excessive antibiotic use in food-producing animals play a major role in leading to antibiotic resistance. Finally, research on novel antibiotics is slow ing down due to the lack of economic incentives for antibiotic research.

Conclusion:

Overall, multiple factors, which are distinct for developing and developed countries, contribute to the increase in the prevalence of antibiotic resistance globally. The results highlight the need to improve the regulatory framework for antibiotic use and research globally.

Diagnosis Confirmation Model: A Value-Based Pricing Model for Inpatient Novel Antibiotics

The Diagnosis Confirmation Model (DCM) includes a dual-pricing mechanism designed to support value-based pricing of novel antibiotics while improving the alignment of financial incentives with their optimal use in patients at high risk of drug-resistant infections. DCM is a market-based model and complementary to delinked models. Policymakers interested in stimulating antibiotic innovation could consider tailoring the DCM to their reimbursement systems and incorporating it into the suite of incentives to improve the economics of antibiotics.

Emerging contaminants in Indian environmental matrices - A review

The emergence of issues related to environment from ECs is a topic under serious discussions worldwide in recent years. Indian scenario is not an exception as it is tremendously growing in its rate of production and consumption of compounds belongs to ECs categories. However, a comprehensive documentation on the occurrence of ECs and consequent ARGs as well as their toxic effects on vertebrates on Indian context is still lacking. In the present study, an extensive literature survey was carried out to get an idea on the geographical distribution of ECs in various environmental matrices (water, air, soil, sediment and sludge) and biological samples by dividing the entire subcontinent into six zones based on climatic, geographical and cultural features. A comprehensive assessment of the toxicological effects of ECs and the consequent antibiotic resistant genes has been included. It is found that studies on the screening of ECs are scarce and concentrated in certain geological locations. A total of 166 individual compounds belonging to 36 categories have been reported so far. Pharmaceuticals and drugs occupy the major share in these compounds followed by PFASs, EDCs, PCPs, ASWs and flame retardants. This review throws light on the alarming situation in India where the highest ever reported values of concentrations of some of these compounds are from India. This necessitates a national level monitoring system for ECs in order to assess the magnitude of environmental risks posed by these compounds.

Prevalence and genetic mechanisms of antimicrobial resistance in Staphylococcus species: A multicentre report of the indian council of medical research antimicrobial resistance surveillance network

PURPOSE

Routine surveillance of antimicrobial resistance (AMR) is an essential component of measures aimed to tackle the growing threat of resistant microbes in public health. This study presents a 1-year multicentre report on AMR in Staphylococcus species as part of Indian Council of Medical Research-AMR surveillance network.

MATERIALS AND METHODS

Staphylococcus species was routinely collected in the nodal and regional centres of the network and antimicrobial susceptibility testing was performed against a panel of antimicrobials. Minimum inhibitory concentration (MIC) values of vancomycin (VAN), daptomycin, tigecycline and linezolid (LNZ) against selected methicillin-resistant Staphylococcus aureus(MRSA) isolates were determined by E-test and MIC creep, if any, was determined. Resistant genotypes were determined by polymerase chain reaction for those isolates showing phenotypic resistance.

RESULTS

The prevalence of MRSA was found to be range from moderate (21%) to high (45%) among the centres with an overall prevalence of 37.3%. High prevalence of resistance was observed with commonly used antimicrobials such as ciprofloxacin and erythromycin in all the centres. Resistance to LNZ was not encountered except for a single case. Full-blown resistance to VAN in S. aureus was not observed; however, a few VAN-intermediate S. aureus isolates were documented. The most common species of coagulase negative staphylococci (CoNS) identified was Staphylococcus haemolyticus and Staphylococcus epidermidis. Resistance among CoNS was relatively higher than S. aureus. Most phenotypically resistant organisms possessed the corresponding resistance genes.

CONCLUSION

There were localised differences in the prevalence of resistance between the centres. The efficacy of the anti-MRSA antimicrobials was very high; however, almost all these antimicrobials showed evidence of creeping MIC.

The intersection of antimicrobial stewardship and microbiology: educating the next generation of health care professionals

With the alarming rise of antibiotic resistance, clinical professionals are called upon to manage antibiotic therapies using the most relevant and recent clinical and laboratory data. To this end, antimicrobial stewardship (AMS) programs aim to reduce unnecessary or suboptimal use of antibiotics while maximizing outcomes for the patient. For AMS programs to succeed, the active participation of clinical professionals at all levels of patient care is required. Although programs exist to train established clinicians in AMS, there is a paucity of literature on how and when to integrate AMS concepts and skills in pre-clinical and clinical coursework. Here, we discuss the crucial microbiology concepts and proficiencies that are necessary for building and supporting an AMS program. We provide recommendations for key points to include in clinical curricula in order to develop the necessary microbiology interpretation skills to participate in AMS. The influence of AMS programs on local organism susceptibility patterns is emphasized. The importance of antibiograms, rapid diagnostic testing and the practical interpretations of microbiology laboratory reporting are discussed in regard to prioritization in clinical curricula. We also review the current literature on instructional strategies for introducing AMS into clinical programs, and propose concepts that should be included in didactic coursework in order to provide a foundation for AMS education.

International cooperation to improve access to and sustain effectiveness of antimicrobials

Securing access to effective antimicrobials is one of the greatest challenges today. Until now, efforts to address this issue have been isolated and uncoordinated, with little focus on sustainable and international solutions. Global collective action is necessary to improve access to life-saving antimicrobials, conserving them, and ensuring continued innovation. Access, conservation, and innovation are beneficial when achieved independently, but much more effective and sustainable if implemented in concert within and across countries. WHO alone will not be able to drive these actions. It will require a multisector response (including the health, agriculture, and veterinary sectors), global coordination, and financing mechanisms with sufficient mandates, authority, resources, and power. Fortunately, securing access to effective antimicrobials has finally gained a place on the global political agenda, and we call on policy makers to develop, endorse, and finance new global institutional arrangements that can ensure robust implementation and bold collective action.

Antimicrobial Resistance, Food Safety, and One Health: The Need for Convergence

Antimicrobial resistance is a complex, multifaceted, urgent global health problem. There is increasing concern about the emergence of multidrug-resistant superbugs. These superbugs result in infections responsive to treatment with few if any currently available antimicrobial agents, reviving memories of the preantibiotic era and evoking concerns about a postantibiotic era. Use of antibiotics exerts selective pressure on pathogens as well as on commensal organisms that are part of the normal flora of humans, animals, and the environment; this favors the emergence of resistant strains and sometimes involves the food supply. Addressing this urgent threat requires implementation of a multifaceted strategy that has been articulated in the past few years; implementation will require sustained political will, investment in systems and research, and a One Health approach involving improved communication, cooperation, and collaboration among the many professional disciplines and organizations with important roles to play at the intersection of human, animal, and environmental health. Priorities include strengthened human and animal health surveillance and monitoring for resistant organisms, antimicrobial stewardship programs, infection-control programs, development and approval of new antimicrobial agents, research on innovative therapeutic approaches, development of rapid diagnostic tests and new vaccines, and educational programs that target professional groups and the public.

Maximising access to achieve appropriate human antimicrobial use in low-income and middle-income countries

Access to quality-assured antimicrobials is regarded as part of the human right to health, yet universal access is often undermined in low-income and middle-income countries. Lack of access to the instruments necessary to make the correct diagnosis and prescribe antimicrobials appropriately, in addition to weak health systems, heightens the challenge faced by prescribers. Evidence-based interventions in community and health-care settings can increase access to appropriately prescribed antimicrobials. The key global enablers of sustainable financing, governance, and leadership will be necessary to achieve access while preventing excess antimicrobial use.

A decade of change in susceptibility patterns of Gram-negative blood culture isolates: a single center study

BACKGROUND

Gram-negative bacteremia is one of the leading causes of mortality and morbidity in Indian hospitals. We hereby describe changing trends in Gram-negative isolates from blood cultures from a single center over a ten-year period.

METHODS

Antibiotic susceptibility patterns were collected for a total of 4128 non-repetitive blood culture isolates from 2003 to 2013. We analyzed clinically important Gram-negative isolates (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii) and their susceptibility pattern. A. baumannii was studied between 2009 and 2013 only.

RESULTS

There was a steady increase in extended-spectrum beta-lactamase (ESBL) production in E. coli (56% to 80%) and an even steeper increase in K. pneumoniae (50% to 81%). Susceptibility to carbapenems fell marginally for E. coli (p = .242) but significantly for K. pneumoniae (p = .000) and P. aeruginosa (.0005). All these changes were seen irrespective of the source of the isolate (outpatient, inpatient and critical care unit - CCU), with a statistically significant fall among CCU isolates of K. pneumoniae and P. aeruginosa. P. aeruginosa was more susceptible to carbapenems than beta-lactam /beta-lactamase inhibitors until 2009, but thereafter the pattern reversed. A. baumannii was isolated from the CCU only: 75% were resistant to carbapenems and susceptible only to polymyxin E and tigecycline.

CONCLUSION

There was a progressive increase in antimicrobial resistance in isolates of E. coli, K. pneumoniae, P. aeruginosa and A. baumannii isolated from blood cultures. ESBL production was seen in the majority of isolates of E. coli and K. pneumoniae. Carbapenem resistance in K. pneumoniae and E. coli is increasing rapidly. Resistance to even tigecycline and polymyxin E, antibiotics of last resort, has begun to emerge. There is an urgent need for antimicrobial stewardship and other measures to limit worsening of Gram-negative resistance in India.

Tackling antibiotic resistance in India

Infectious diseases are major causes of mortality in India. This is aggravated by the increasing prevalence of antimicrobial resistance (AMR) both in the community and in hospitals. Due to the emergence of resistance to all effective antibiotics in nosocomial pathogens, the situation calls for emergency measures to tackle AMR in India. India has huge challenges in tackling AMR, ranging from lack of surveillance mechanisms for monitoring AMR and use; effective hospital control policies; sanitation and non-human use of antimicrobial. The Ministry of Health and Family Welfare of Govt. of India has taken initiatives to tackle AMR. Extensive guidelines have been drafted and a model worksheet has been developed as a roadmap to tackle AMR.