India's National Action Plan for antimicrobial resistance - An overview of the context, status, and way ahead

Emerging trends in antimicrobial resistance in bloodstream infections: multicentric longitudinal study in India (2017-2022)

Background

Antimicrobial resistance (AMR) has escalated to pandemic levels, posing a significant global health threat. This study examines the patterns and trends of AMR in Bloodstream Infections (BSIs) across India, aiming to inform better surveillance and intervention strategies.

Methods

Six-year data from 21 tertiary care centers in the Indian Council of Medical Research's AMR Surveillance Network (IAMRSN) were retrospectively analyzed to estimate cluster-robust trends in resistance. Time-series analysis was used to discern lead/lag relationships between antibiotic pairs and the directional influence of resistance in community and hospital-acquired BSIs(CA/HA BSIs). A data-driven Bayesian network ensemble averaged over 301 bootstrap samples was modelled to uncover systemic associations between AMR and Sustainable Development Goals (SDGs).

Findings

Our findings indicate significant (p < 0.001) monthly increases in Imipenem and Meropenem resistance for Klebsiella, E. coli, and Acinetobacter BSIs. Importantly, Carbapenem resistance in HA-BSIs preceded that in CA-BSIs for Klebsiella and Acinetobacter (p < 0.05). At a national level, Cefotaxime resistance emerged as a potential early indicator for emerging Carbapenem resistance, proposing a novel surveillance marker. In Klebsiella BSIs, states with higher achievement of SDG3 goals showed lower Imipenem resistance. A model-based AMR scorecard is introduced for focused interventions and continuous monitoring.

Interpretation

The identified spatiotemporal trends and drug resistance associations offer critical insights for AMR surveillance aligning with WHO GLASS standards.The escalation of carbapenem resistance in BSIs demands vigilant monitoring and may be crucial for achieving SDGs by 2030. Implementing the proposed framework for data-driven evidence can help nations achieve proactive AMR surveillance.

Funding

No specific funding was received for this analysis.

Antimicrobial resistance in China across human, animal, and environment sectors - a review of policy documents using a governance framework

Antimicrobial resistance (AMR) poses a multifaceted threat to the human, animal, and environment sectors. In response, China has formulated a series of policies since the 2000s. Thus far, there has been no comprehensive assessment of these policy documents. This study aims to review the content of AMR policy documents at the national level using a governance framework covering three areas: Policy Design; Implementation Tools; and Monitoring and Evaluation. We identified 44 AMR documents from 2003 to 2022 sourced from government agency websites. Our findings have revealed noticeable discrepancies across the three governance areas. The Policy Design and Monitoring and Evaluation areas should be strengthened, particularly in the domains of 'Coordination', 'Accountability', 'Sustainability', and 'Effectiveness'. From a 'One Health' perspective, the environment sector has received less attention compared to the human and animal sectors. Effectively addressing these challenges requires a stronger commitment and widespread support from diverse stakeholders.

Global insight into the occurrence, treatment technologies and ecological risk of emerging contaminants in sanitary sewers: Effects of the SARS-CoV-2 coronavirus pandemic

The SARS-CoV-2 pandemic caused changes in the consumption of prescribed/non-prescribed drugs and the population's habits, influencing the detection and concentration of emerging contaminants (ECs) in sanitary sewage and harming environmental and health risks. Therefore, the present work sought to discuss current literature data on the effects of the "COVID-19 pandemic factor" on the quality of raw sewage produced over a five-year period (2018-2019: pre-pandemic; 2020-2022: during the pandemic) and biological, physical, chemical and hybrid treatment technologies, influencing factors in the removal of ECs and potential ecological risks (RQs). Seven hundred thirty-one publications correlating sewage and COVID-19 were identified: 184 pre-pandemic and 547 during the pandemic. Eight classes and 37 ECs were detected in sewage between 2018 and 2022, with the "COVID-19 pandemic factor" promoting an increase in estrogens (+31,775 %), antibiotics (+19,544 %), antiepileptics and antipsychotics (+722 %), pesticides (+200 %), analgesics, anti-inflammatories and anticoagulants (+173 %), and stimulant medications (+157 %) in sanitary sewage. Among the treatment systems, aerated reactors integrated into biomembranes removed >90 % of cephalexin, clarithromycin, ibuprofen, estrone, and 17β-estradiol. The absorption, adsorption, and biodegradation mechanisms of planted wetland systems contributed to better cost-benefit in reducing the polluting load of sewage ECs in the COVID-19 pandemic, individually or integrated into the WWTP. The COVID-19 pandemic factor increased the potential ecological risks (RQs) for aquatic organisms by 40 %, with emphasis on clarithromycin and sulfamethoxazole, which changed from negligible risk and low risk to (very) high risk and caffeine with RQ > 2500. Therefore, it is possible to suggest that the COVID-19 pandemic intensified physiological, metabolic, and physical changes to different organisms in aquatic biota by ECs during 2020 and 2022.

Combating antibiotic resistance using wastewater surveillance: Significance, applications, challenges, and future directions

The global increase of antibiotic resistance (AR) and resistant infections call for effective surveillance methods for understanding and mitigating (re)-emerging public health risks. Wastewater surveillance (WS) of antibiotic resistance is an emerging, but currently under-utilized decision-support tool in public health systems. Recent years have witnessed an increase in evidence linking antibiotic resistance in wastewaters to that of the community. To date, very few comprehensive reviews exist on the application of WS to understand AR and resistant infections in population. Current and emerging AR detection methods, and their merits and limitations are discussed. Wastewater surveillance has several merits relative to individual testing, including; (1) low per capita testing cost, (2) high spatial coverage, (3) low requirement for diagnostic equipment, and (4) detection of health threats ahead of real outbreaks. The applications of WS as an early warning system and decision support tool to understand and mitigate AR are discussed. Wastewater surveillance could be a tool of choice in low-income settings lacking resources and diagnostic facilities for individual testing. To demonstrate the utility of WS, empirical evidence from field case studies is presented. However, constraints still exist, including; (1) lack of standardized protocols, (2) the clinical utility and sensitivity of WS-based data, (3) uncertainties in relating WS data to pathogenic and virulent bacteria, and (4) whether or not AR in stools and ultimately wastewater represent the complete human resistome. Finally, further prospects are presented, include knowledge gaps on; (1) development of low-cost biosensors for AR, (2) development of WS protocols (sampling, processing, interpretation), (3) further pilot scale studies to understand the opportunities and limits of WS, and (4) development of computer-based analytical tools to facilitate rapid data collection, visualization and interpretation. Therefore, the present paper discusses the principles, opportunities, and constraints of wastewater surveillance applications to understand AR and safeguard public health.

Understanding Knowledge and Attitude of Farmers towards Antibiotic Use and Antimicrobial Resistance in Jhunjhunu District, Rajasthan India

The misuse of antibiotics in veterinary practices by farmers is harming livestock production and food safety and leading to the rise of antibiotic resistance (AMR). This can also transfer resistant bacteria from animals to humans, posing a serious public health threat. However, we have not paid enough attention to understanding how farmers behave in this regard. Our study aims to explore farmers' behaviors and identify the factors that influence their choices. To conduct this study, we used a questionnaire with 40 questions and surveyed 208 farmers in Jhunjhunu district, Rajasthan. We analyzed the data using SPSS. Here are the key findings: About 58.3% of the farmers have some awareness of antibiotics, and 49.5% are aware of antimicrobial resistance (AMR). Notably, as the level of education increases, so does awareness of antibiotics. Unfortunately, 63.9% of the farmers are not aware of the withdrawal time, and 64% have no idea about the presence of antibiotic residues during this period. Around 75% of farmers vaccinate their animals, but approximately 56.9% of individuals have never undergone an antibiotic sensitivity test (ABST) for milk. Around 48.6% of farmers are unaware of government testing centers. Several factors hinder farmers from implementing proper animal management practices, such as the high fees of veterinarians. When their animals become sick, their first choice is home remedies, followed by using old prescriptions. Additionally, 63.9% stop treatment once the animal looks better. A significant portion (83.8%) of farmers rely on local pharmacists for medicine. It has been determined that there is no significant correlation between education, experience, age, and the level of awareness concerning withdrawal periods, the existence of government antibiotic sensitivity test (ABST) centers, and entities responsible for sending samples for ABST. In our qualitative analysis, focus groups identified significant barriers to following best farm practices and spreading awareness about AMR. These findings suggest that addressing AMR in livestock requires a comprehensive approach. This should include targeted education and awareness programs for farmers, as well as improved access to veterinary services.

Impact of Antimicrobial Stewardship on Reducing Antimicrobial Resistance

Antimicrobial resistance has become a serious global issue, posing a significant threat to public health and healthcare professionals. Since the advent of penicillin, many antibiotics have lost their effectiveness in combating microbes simply due to inappropriate, irrational, unnecessary, and unrestricted use. The ineffectiveness of an increasing number of antibiotics necessitates the utilization of more potent antimicrobial agents for combatting uncomplicated infections. In response to the escalating prevalence of multidrug-resistant pathogens and the imperative to curtail the demand for novel antibiotics, the Antimicrobial Stewardship Program was conceived and implemented. This initiative is characterized by a lead physician, ideally possessing expertise in infectious diseases, alongside a pharmacist serving as a secondary leader and a microbiologist with defined responsibilities to achieve several objectives. These objectives include reducing indiscriminate usage of antimicrobial agents, promoting selective antimicrobial utilization based on culture results, de-escalating therapy from broad-spectrum to targeted antimicrobial agents, and transitioning from parenteral to oral administration when feasible. These objectives are pursued through a combination of pre-prescription and post-prescription strategies. While the Antimicrobial Stewardship Program is widely established in developed nations, a pressing need exists for its more comprehensive implementation in less developed regions. This review aims to examine the strategies used in antimicrobial stewardship programs to evaluate their effectiveness in preventing the development of multidrug-resistant organisms (MDROs) based on existing research studies. Under the Antimicrobial Stewardship Program, education of healthcare professionals and continuous disposal of information about antimicrobial resistance have helped to restrict the emergence of multidrug-resistant organisms.

Implementation of 'One Health' approach in Kerala state, India - A systematic review

With humans, animals and the environment being as interconnected as they are, the science describing their interactions needs to cut across disciplinary boundaries. Systems research at the interface between the three goes by several names, such as 'Eco-Health' and 'Planetary Health', each with a varied focus, but the concept of 'One Health' (OH) has stood out as the most popular one. COVID-19 has reiterated the importance of OH in response to health challenges. This review aimed to assess the OH approach integration and implementation level in Kerala state, India, in the context of emerging zoonotic diseases. A systematic literature review was conducted by searching for relevant articles with specific keywords across six electronic databases. This involved screening the initial hits for titles and abstracts, then systematic sorting to identify the ones that met the criteria, followed by more thorough scrutiny to finally shortlist the six studies to be included in the review. We found that OH in Kerala has made good progress, as evident from a few recent examples, but has a long way to go with significant challenges. In line with the study's aim, identifying and analysing what is already done, what is missing and what needs to be done can have wider implications for future OH implementation. Relevant threats and opportunities were identified, with lessons for Kerala and India and broader applications.

Bibliometric Analysis of Global Research Output on Antimicrobial Resistance among Pneumonia Pathogens (2013-2023)

Antimicrobial resistance (AMR) is a pressing global concern, posing significant challenges to the effective treatment of infections, including pneumonia. This bibliometric analysis aims to investigate the research output on AMR among pneumonia pathogens from 2013 to 2023. Data were extracted from the Web of Science Core Collection (WOS-CC) using an inclusive search strategy. The analysis included 152 relevant studies published in 99 different sources, involving 988 authors and yielding an average of 16.33 citations per document over the past decade. The findings reveal a notable increase in research on AMR among pneumonia pathogens, indicating a growing awareness of this critical issue. Collaborative studies were prevalent, with the majority of authors engaging in joint research efforts. Bradford's Law identified twelve core journals that were instrumental in disseminating research in this field, with "Medicine" emerging as the most prolific journal. The USA and China emerged as the leading contributors, while Germany displayed a strong inclination towards collaborative research. Intermountain Medical Center, Saitama Medical University, and Udice-French Research Universities were the most productive institutions, and Yayan J. and Rasche K. were the top authors. Furthermore, the analysis identified commonly encountered microorganisms such as Acinetobacter baumanii and Klebsiella pneumoniae in the context of AMR. Time-based analysis of keywords highlighted the significance of terms like "community-acquired pneumonia" and "ventilator-associated pneumonia". Overall, this comprehensive study sheds light on the global research landscape of AMR among pneumonia pathogens. The insights gained from this analysis are essential for guiding future research priorities and collaborative efforts to combat AMR effectively and improve treatment outcomes for pneumonia and related infections. As the frequency of reports concerning resistance among pneumonia pathogens, notably A. baumannii and K. pneumoniae, continues to rise, there is an immediate requirement for pharmaceutical manufacturers and healthcare providers to respond proactively and ready themselves for the forthcoming implications of this matter. It also underscores the importance of knowledge dissemination and evidence-based interventions to address this growing public health challenge. However, the study acknowledges the limitations associated with using a single publication database and encourages the inclusion of data from other sources in future research.

An overview on the prevalence and potential impact of antimicrobials and antimicrobial resistance in the aquatic environment of India

India at present is one of the leading countries in antimicrobial drug production and use, leading to increasing antimicrobial resistance (AMR) and public health problems. Attention has mainly been focused on the human and food animals' contribution to AMR neglecting the potential contribution of the perceptibly degraded aquatic environment in India. The paper reviews the available published literature in India on the prevalence of antimicrobial residues and their dissemination pathways in wastewater of pharmaceutical industries, sewage treatment plants, hospitals, riverine, community pond water, and groundwater. The prevalence of antimicrobial residue concentration, pathogenic and non-pathogenic bacteria antimicrobial resistant bacteria (ARB), their drug resistance levels, and their specific antimicrobial resistant genes (ARGs) occurring in various water matrices of India have been comprehensively depicted from existing literature. The concentration of some widely used antimicrobials recorded from the sewage treatment plants and hospital wastewater and rivers in India has been compared with other countries. The ecotoxicological risk posed by these antimicrobials in the various water matrices in India indicated high hazard quotient (HQ) values for pharmaceutical effluents, hospital effluents, and river water. The degraded aquatic environment exhibited the selection of a wide array of co-existent resistant genes for antibiotics and metals. The review revealed improper use of antibiotics and inadequate wastewater treatment as major drivers of AMR contaminating water bodies in India and suggestion for containing the challenges posed by AMR in India has been proposed.

Biosynthesized Silver Nanoparticles Derived from Probiotic Lactobacillus rhamnosus (AgNPs-LR) Targeting Biofilm Formation and Quorum Sensing-Mediated Virulence Factors

In recent years, bacterial pathogens have developed resistance to antimicrobial agents that have created a global threat to human health and environment. As a novel approach to combating antimicrobial resistance (AMR), targeting bacteria's virulent traits that can be explained by quorum sensing (QS) is considered to be one of the most promising approaches. In the present study, biologically synthesized silver nanoparticles derived from Lactobacillus rhamnosus (AgNPs-LR) were tested against three Gram-negative bacteria to determine whether they inhibited the formation of biofilms and triggered the virulence factors controlled by QS. In C. violaceum and S. marcescens, a remarkable inhibition (>70%) of QS-mediated violacein and prodigiosin production was recorded, respectively. A dose-dependent decrease in virulence factors of P. aeruginosa (pyocyanin, pyoverdine, LasA protease, LasB elastase and rhamnolipid production) was also observed with AgNPs-LR. The biofilm development was reduced by 72.56%, 61.70%, and 64.66% at highest sub-MIC for C. violaceum, S. marcescens and P. aeruginosa, respectively. Observations on glass surfaces have shown remarkable reductions in biofilm formation, with less aggregation of bacteria and a reduced amount of extra polymeric materials being formed from the bacteria. Moreover, swimming motility and exopolysaccharides (EPS) was also found to reduce in the presence of AgNPs-LR. Therefore, these results clearly demonstrate that AgNPs-LR is highly effective in inhibiting the development of biofilms and the QS-mediated virulent traits of Gram-negative bacteria. In the future, AgNPs-LR may be used as an alternative to conventional antibiotics for the treatment of bacterial infections after careful evaluation in animal models, especially for the development of topical antimicrobial agents.

Hospital-based antimicrobial stewardship, India

Objective

To establish a framework for implementing antimicrobial stewardship in Indian tertiary care hospitals, and identify challenges and enablers for implementation.

Methods

Over 2018-2021 the Indian Council of Medical Research followed a systematic approach to establish a framework for implementation of antimicrobial stewardship in Indian hospitals. We selected 20 Indian tertiary care hospitals to study the feasibility of implementing a stewardship programme. Based on a questionnaire to lead physicians before and after the intervention, we assessed progress using a set of process and outcome indicators. In a qualitative survey we identified enablers and barriers to implementation of antimicrobial stewardship.

Findings

We found an improvement in various antimicrobial stewardship implementation indicators in the hospitals after the intervention. All 20 hospitals conducted monthly point prevalence analysis of cultures compared with three hospitals before the intervention. The number of hospitals that initiated formulary restrictions increased from two to 12 hospitals and the number of hospitals that started practising prescription audit and feedback increased from six to 16 hospitals. Respondents in 15 hospitals expressed their willingness to expand the coverage of antimicrobial stewardship implementation to other wards and intensive care units. Six hospitals were willing to recruit the permanent staff needed for antimicrobial stewardship activities.

Conclusion

Antimicrobial stewardship can be implemented in Indian tertiary hospitals with reasonable success, subject to institutional support, availability of trained manpower and willingness of hospitals to support antimicrobial stewardship-related educational and training activities.

Man vs Microbes - The Race of the Century

The complexity of the antimicrobial resistance (AMR) crisis and its global impact on healthcare invokes an urgent need to understand the underlying forces and to conceive and implement innovative solutions. Beyond focusing on a traditional pathogen-centric approach to antibiotic discovery yielding diminishing returns, future therapeutic interventions can expand to focus more comprehensively on host-pathogen interactions. In this manner, increasing the resiliency of our innate immune system or attenuating the virulence mechanisms of the pathogens can be explored to improve therapeutic outcomes. Key pathogen survival strategies such as tolerance, persistence, aggregation, and biofilm formation can be considered and interrupted to sensitize pathogens for more efficient immune clearance. Understanding the evolution and emergence of so-called 'super clones' that drive AMR spread with rapid clonotyping assays may guide more precise antibiotic regimens. Innovative alternatives to classical antibiotics such as bacteriophage therapy, novel engineered peptide antibiotics, ionophores, nanomedicines, and repurposing drugs from other domains of medicine to boost innate immunity are beginning to be successfully implemented to combat AMR. Policy changes supporting shorter durations of antibiotic treatment, greater antibiotic stewardship, and increased surveillance measures can enhance patient safety and enable implementation of the next generation of targeted prevention and control programmes at a global level.

Pharma-cartography: Navigating the complexities of antibiotic supply to rural livestock in West Bengal, India, through value chain and power dynamic analysis

Antibiotic resistance threatens provision of healthcare and livestock production worldwide with predicted negative socioeconomic impact. Antibiotic stewardship can be considered of importance to people living in rural communities, many of which depend on agriculture as a source of food and income and rely on antibiotics to control infectious diseases in livestock. Consequently, there is a need for clarity of the structure of antibiotic value chains to understand the complexity of antibiotic production and distribution in community settings as this will facilitate the development of effective policies and interventions. We used a value chain approach to investigate how relationships, behaviours, and influences are established during antibiotic distribution. Interviews were conducted with key informants (n = 17), value chain stakeholders (n = 22), and livestock keeping households (n = 36) in Kolkata, and two rural sites in West Bengal, India. Value chain mapping and an assessment of power dynamics, using manifest content analysis, were conducted to investigate antibiotic distribution and identify entry points for antibiotic stewardship. The flow of antibiotics from manufacturer to stockists is described and mapped and two local level maps showing distribution to final consumers presented. The maps illustrate that antibiotic distribution occurred through numerous formal and informal routes, many of which circumvent antibiotic use legislation. This was partly due to limited institutional power of the public sector to govern value chain activities. A 'veterinary service lacuna' existed resulting in livestock keepers having higher reliance on private and informal providers, who often lacked legal mandates to prescribe and dispense antibiotics. The illegitimacy of many antibiotic prescribers blocked access to formal training who instead relied on mimicking the behaviour of more experienced prescribers-who also lacked access to stewardship guidelines. We argue that limited institutional power to enforce existing antibiotic legislation and guide antibiotic usage and major gaps in livestock healthcare services make attempts to curb informal prescribing unsustainable. Alternative options could include addressing public sector deficits, with respect to both healthcare services and antibiotic provision, and by providing resources such as locally relevant antibiotic guidelines to all antibiotic prescribers. In addition, legitimacy of informal prescribers could be revised, which may allow formation of associations or groups to incentivise good antibiotic practices.

One Health approaches adapted in low resource settings to address antimicrobial resistance

Inter-disciplinary collaborations are now considered as key factors for integrated health system strengthening. Its application in the domain of One Health needs more milestones to achieve. Other than the human health sector, the antimicrobials are used in food animals and aquaculture for therapy, prophylaxis and growth promotion which significantly contributes to the development of antimicrobial resistance. It is the high time to develop a sustainable collaboration between the concerned sectors of One Health for a resilient health system. The domain of One Health not only mitigates the emergence of antimicrobial resistance but also helps in realizing the surveillance and epidemiology of zoonotic diseases, and the control of public health emergencies such as COVID-19. The review identified the key One Health strategies adapted by India, the exemplary low resource settings, to address antimicrobial resistance and zoonosis.

Rapid growth of antimicrobial resistance: the role of agriculture in the problem and the solutions

Abstract

The control of infectious diseases has always been a top medical priority. For years during the so-called antibiotic era, we enjoyed prolonged life expectancy and the benefits of superior pathogen control. The devastating failure of the medical system, agriculture and pharmaceutical companies and the general population to appreciate and safeguard these benefits is now leading us into a grim post-antibiotic era. Antimicrobial resistance (AMR) refers to microorganisms becoming resistant to antibiotics that were designed and expected to kill them. Prior to the COVID-19 pandemic, AMR was recognised by the World Health Organization as the central priority area with growing public awareness of the threat AMR now presents. The Review on Antimicrobial Resistance, a project commissioned by the UK government, predicted that the death toll of AMR could be one person every 3 seconds, amounting to 10 million deaths per year by 2050. This review aims to raise awareness of the evergrowing extensiveness of antimicrobial resistance and identify major sources of this adversity, focusing on agriculture’s role in this problem and its solutions.

Keypoints

• Widespread development of antibiotic resistance is a major global health risk.

• Antibiotic resistance is abundant in agricultural produce, soil, food, water, air and probiotics.

• New approaches are being developed to control and reduce antimicrobial resistance.

Qualitative Study on Antimicrobial Usage and Resistance in the Dairy Chain: A Situation Analysis and Solutions by Stakeholders from Punjab, India

The rising prevalence of antimicrobial resistance in animal foods and injudicious antibiotic use in the dairy sector pose significant threats to public health. Focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with a strategic sample of four stakeholder groups (114 participants) associated with antibiotic usage in the dairy sector of Punjab. The FGDs were conducted among veterinarians (n = 56), para-veterinarians (n = 28), and KIIs were conducted among chemists (n = 18) and dairy quality managers (n = 12) during 2020-2021. FGDs and qualitative interviews of various stakeholders depict existing risk practices in the fields that may promote antimicrobial resistance. The present study revealed that widely prevalent quackery (treatment practices carried out by unauthorized persons without any recognized diploma/degree) and self-treatment by farmers, over-the-counter availability of antibiotics, low veterinarian per animal ratio, and lack of awareness among the society about the potential public health effects of antimicrobial resistance were the main risk factors for injudicious antibiotic use in the dairy sector. The present study involved a comprehensive approach targeting the stakeholders in the dairy sector and their reflections on judicious antimicrobial usage and antimicrobial resistance adapted to the dairy farming of Punjab. There is an urgent need for the advocation of policies that consider the specific challenges faced by the dairy sector to simultaneously improve access to veterinary services as well as strengthen antibiotic stewardship.

Country data on AMR in India in the context of community-acquired respiratory tract infections: links between antibiotic susceptibility, local and international antibiotic prescribing guidelines, access to medicine and clinical outcome

Background

Antimicrobial resistance (AMR) is one of the biggest threats to global public health. Selection of resistant bacteria is driven by inappropriate use of antibiotics, amongst other factors. COVID-19 may have exacerbated AMR due to unnecessary antibiotic prescribing. Country-level knowledge is needed to understand options for action.

Objectives

To review the current situation with respect to AMR in India and initiatives addressing it. Identifying areas where more information is required will provide a call to action to minimize further rises in AMR and to improve patient outcomes.

Methods

National AMR initiatives, antibiotic use and prescribing in India, and availability of susceptibility data, in particular for the key community-acquired respiratory tract infection (CA-RTI) pathogens (Streptococcus pneumoniae and Haemophilus influenzae) were identified. National and international antibiotic prescribing guidelines for specific CA-RTIs (community-acquired pneumonia, acute otitis media and acute bacterial rhinosinusitis) commonly used locally were also reviewed, plus local antibiotic availability. Insights from a local clinician and clinical microbiologist were sought to contextualize this information.

Conclusions

Many initiatives have been launched since AMR was recognized as a national priority and organizations such as the Indian Academy of Paediatrics and the Global Antibiotic Resistance Partnership have worked to build awareness. The Indian Ministry of Health and Family Welfare published a 5 year national action plan on AMR. However, the burden of infectious disease and consumption of antibiotics in India is high. There have been national surveillance studies generating local data along with international studies such as Survey of Antibiotic Resistance (SOAR) and Antimicrobial Testing Leadership and Surveillance (ATLAS). For common RTIs, clinicians use a range of international and national guidelines. However, a more standardized inclusive approach to developing local guidelines, using up-to-date local surveillance data from community-acquired infections, could make guidelines more locally relevant. This would encourage more appropriate antibiotic prescribing and improve adherence. This would, in turn, potentially limit AMR development and improve patient outcomes.

What are the Tuberculosis Care Practices of Informal Healthcare Providers? A Cross-Sectional Study from Eastern India

India is the highest Tuberculosis (TB) burden country, accounting for an estimated 26 % of the global burden of disease. Systematic engagement of the private sector is a cornerstone of India's National Strategic Plan (NSP) for TB elimination (2017-2025). However, Informal Healthcare Providers (IPs), who are the first point of contact for a large number of TB patients, remain significantly underutilised in the National TB Elimination Program (NTEP) of India. Non-prioritisation of IPs has also resulted in a limited understanding of their TB care practices in the community. We, therefore, undertook a descriptive study to document IPs' TB care practices, primarily focusing on their approach to screening, diagnosis, treatment, and referral. This cross-sectional study was carried out from February to March 2020 in the Birbhum District of West Bengal, India. Interviews were conducted utilising the retrospective case study method. A total 203 IPs participated who reported seeing at least one confirmed TB patient in six months prior to the study. In that duration, IPs reported interacting with an average of five suspected TB cases, two of which were later confirmed as having TB. Antibiotic use was found to be common among IPs (highest 69% during the first visit); however, they were prescribed before the patient was suspected or confirmed as having TB. We noted the practice of prolonged treatment among IPs as patients were prescribed medicines until the second follow-up visit. Referral was the preferred TB case management approach among IPs, but delayed referral was observed, with only one-third (34%) of patients being referred to higher health facilities during their first visit. This study presents important findings on IPs' TB care practices which have consequences for achieving India's National Goal of TB elimination.

Antibiotic Use and Bacterial Infection in COVID-19 Patients in the Second Phase of the SARS-CoV-2 Pandemic: A Scoping Review

This scoping review aimed to explore the prevalence and patterns of global antibiotic use and bacterial infection in COVID-19 patients from studies published between June 2020 and March 2021. This review was reported in line with the Preferred Reporting of Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews, and the protocol is registered with the Open Science Framework. Compared with our previously-published review of the period (December 2019-June 2020), the antibiotic prescribing rate for COVID-19 patients (June 2020-March 2021) was found to have declined overall (82.3% vs. 39.7%), for mild and moderate patients (75.1% vs. 15.5%), and for severe and critical patients (75.3% vs. 48.3%). The seven most frequently prescribed antibiotics in COVID-19 patients were all on the "Watch" list of the WHO AWaRe antibiotics classification. The overall reported bacterial infection rate in COVID-19 patients was 10.5%, and the most frequently reported resistant pathogen in COVID-19 patients was Staphylococcus aureus, followed by Pseudomonas aeruginosa, Escherichia coli, and Klebsiella pneumoniae. There is an urgent need to establish comprehensive and consistent guidelines to assist clinicians in selecting appropriate antibiotics for COVID-19 patients when needed. The resistance data on the most frequently used antibiotics for COVID-19 patients for certain resistant pathogens should be closely monitored.

Genomic insights of beta-lactamase producing Klebsiella quasipneumoniae subsp. similipneumoniae belonging to sequence type 1699 from retail market fish, India

Klebsiella quasipneumoniae is a recently described species and often misidentified as Klebsiella pneumoniae. Here, we report the genomic characterization of Klebsiella quasipneumoniae subsp. similipneumoniae (India238 strain) isolated from fish. The annotated genome acknowledged the presence of bla_CTX-M-15, bla_OKP-B-1, fosA5, oqxAB and virulence genes. The strain with ST1699 and serotypes KL52 and OL103 also harboured insertion sequences (ISs): ISKpn26 and ISEc9. Three complete phage genomes were identified in contigs 1 and 6 of the bacterial genome, enhancing the prospects of genome manipulation. The study highlights the pitfall of conventional microbiological identification methods to distinguish K. pneumoniae and K. quasipneumoniae. This is the first Indian study documenting the incidence of extended-spectrum beta-lactamase (ESBL)-producing K. quasipneumoniae subsp. similipneumoniae from a non-clinical environment, equipped with virulomes and associated mobile genetic elements. Given that fish can act as a potential vector for transmission of antimicrobial resistance genes, our findings have paramount importance on human health.

Comparing the Effectiveness of Different Approaches to Raise Awareness About Antimicrobial Resistance in Farmers and Veterinarians of India

Background

Antimicrobial resistance (AMR) is a global public health threat. The indiscriminate use of antibiotics in the animal health sector contributes to increasing rates of AMR and studies involving dairy farmers in India have found knowledge levels regarding antibiotics and AMR to be very low. The purpose of this study was to assess different methods to raise awareness and knowledge about AMR and antibiotic use among dairy farmers, paravets (veterinary assistants), and veterinarians.

Materials and Methods

The study was conducted in September-December of 2018 in some parts of Haryana, Assam, Karnataka, and West Bengal. It had two parts: an intervention meeting (September–October 2018) which consisted of focus group discussions (FGD) with farmers, key informant interviews (KII) with veterinary professionals along with distribution of information packages, and then a follow-up survey (November–December 2018). The villages were randomly allocated to either one of the four intervention approaches (1-FGD/KII and information package on AMR; 2-FGD/KI and information on animal health; 3- FGD/KII and information package on animal health plus information on AMR; or 4- only the FGD/KII). A follow-up survey was done to assess the effect of interventions.

Results

In total, 274 dairy farmers and 51 veterinary professionals (21 veterinarians and 30 paravets) participated in the follow-up survey. Many of the farmers and veterinary professionals who participated in the follow-up survey had been part of the intervention meetings. The average knowledge score of farmers was 7.8. It was found that the knowledge score was higher amongst farmers who had participated in the intervention meetings (p &lt; 0.05), had received intervention approach 2 (p = 0.03) or approach 3 (p = 0.01), and amongst female farmers (p = 0.03) compared to male. The veterinary professionals had good knowledge but lacked interest in training the farmers about antimicrobial resistance.

Conclusion

Our research demonstrated that a higher percentage of farmers and veterinary professionals who attended the intervention meeting had improved knowledge. Dairy farmers should be regularly educated on antibiotic usage and how to avoid misusing them. Also, veterinary experts should be provided with tools and strategies to educate farmers on the use of antimicrobials.

Audits of Antimicrobial Usage in a Tertiary Care Center in Hyderabad

Background

Irrational prescriptions have an ill effect on health as well as on healthcare expenditure. Prescription auditing is an important tool to improve the quality of prescriptions, which in turn improves the quality of health care provided. Regular and timely audits of antibiotic prescriptions can prevent irrational antibiotic usage.

Introduction

The inappropriate use of drugs is a global health problem, especially in developing countries like India. In 2015, during the 68th World Health Organization (WHO) Regional Committee for Southeast Asia, all Member States of the region, including India, endorsed the “Regional Strategy for Patient Safety in the WHO Southeast Asia Region (2016-2025)” aiming to support the development of national quality of care and patient safety strategies, policies, and plans and commit to translating those objectives of the Regional Strategy into actionable strategies at country level.

Methodology

A retrospective observational study was conducted in a 330-bedded, National Accreditation Board for Hospitals & Healthcare Providers (NABH)-accredited tertiary healthcare center. The study period was six months, from January 2019 to June 2019.

Results

Ninety-five point four-five percent (95.45%) of the doctors attended the sensitization program and all accepted following the standard prescribing protocols. Sixty-nine point seven percent (69.7%) of the doctors were aware of the availability of drugs in the hospital pharmacy stores. Seventy-four point two-four percent (74.24%) of the doctors were aware of the ongoing prescription audits. Seventy-two point two-seven percent (72.27%) of the treating doctors were of the opinion of selecting the appropriate antibiotics based on hospital antibiogram. The importance of antibiograms from cultures and environmental surveillance was followed well only after sensitizing all the treating doctors. Ninety-five point four-five percent (95.45%) of the doctors were of the opinion of taking the permission of a higher authority to start high-end antibiotics. Seventy-seven point one-zero percent (77.10%) doctors recommended sample collection prior to antibiotic administration. Sixty-three percent (63%) of the patient’s clinical condition improved with the antibiotics prescribed prior to the culture report.

Conclusion

By judicious use of antibiotics, we can reduce the evolution of antibiotic resistance in bacteria and extend the useful life of antibiotics that are still effective. Antibiotic use patterns must be studied to address complications resulting from a large number of antibiotics.

Genotypic and Phenotypic Characterization of Novel Sequence Types of Carbapenem-Resistant Acinetobacter baumannii, With Heterogeneous Resistance Determinants and Targeted Variations in Efflux Operons

Acinetobacter baumannii has emerged as one of the dominant nosocomial human pathogens associated with high morbidity and mortality globally. Increased incidences of carbapenem-resistant A. baumannii (CRAB) have resulted in an enormous socioeconomic burden on health-care systems. Here, we report the genotypic and phenotypic characterization of novel ST1816 and ST128 variants in A. baumannii strains belonging to International clone II (GC2) with capsule types KL1:OCL8 and KL3:OCL1d from India. Sequence analysis revealed the presence of diverse virulome and resistome in these clinical strains, in addition to islands, prophages, and resistance genes. The oxacillinase bla _OXA-23 detected in the genomic island also highlighted the coexistence of bla _OXA-66 /bla _OXA-98 , bla _ADC73 /bla _ADC-3 , and bla _TEM-1D in their mobile scaffolds, which is alarming. Together with these resistance-determining enzymes, multidrug efflux transporters also harbored substitutions, with increased expression in CRAB strains. The hotspot mutations in colistin resistance-conferring operons, PmrAB, LpxACD, and AdeRS, were additionally confirmed. Phenotype microarray analysis indicated that multidrug-resistant strains A. baumannii DR2 and A. baumannii AB067 preferred a range of antimicrobial compounds as their substrates relative to the other. To our knowledge, this is the first comprehensive report on the characterization of A. baumannii variants ST1816 and ST128, with different genetic makeup and genome organization. The occurrence of CRAB infections worldwide is a severe threat to available limited therapeutic options; hence, continued surveillance to monitor the emergence and dissemination of such novel ST variants in A. baumannii is imperative.

Antimicrobial prescription patterns among oral implantologists of Kerala, India: A cross-sectional survey

Background and Objectives:

Antimicrobial resistance is a grave public health concern, and it is important to optimize the use of antimicrobials in dental surgeries. Antimicrobial prescriptions in dental implant placements are often empiric and not guided by consensus or specific guidelines. The aim of this study was to elucidate antibiotic prescribing patterns among oral implantologists. The objectives were to identify the frequency of antimicrobial usage and preferences regarding the perioperative timing of prescriptions, type of antibiotic, dosage, and duration in different implant placement scenarios.

Subjects and Methods:

An anonymized web-based survey was carried out. Participants were drawn from the lists of oral implantologists from all local branches of the Indian Dental Association in the state of Kerala, India, until the required sample size was met. Responses were recorded using an Internet-based validated questionnaire sent via e-mail to the participants. The questionnaire contained five sections with both open-ended and closed-ended questions.

Results:

Among the 93 participants, 59% of the dental implantologists preferred 0.2% povidone-iodine as a preprocedural mouth rinse in the backdrop of the COVID-19 pandemic, and 68% prescribed 0.12%–0.2% chlorhexidine as the postoperative mouth rinse. The majority of the participants (73%) routinely prescribed systemic antibiotics perioperatively during implant placement surgery. Interestingly, while none of the participants preferred a solely preoperative regimen, 92.4% of the dentists in our survey prescribed both pre- and postoperative antibiotics. Antibiotics of choice as the preoperative agents were amoxicillin and amoxicillin plus clavulanic acid. The most preferred postoperative agent was amoxicillin plus clavulanic acid. The popularly reported rationale behind a preoperative antibiotic was to decrease or eliminate local or systemic infections (79%), and the majority of the participants (60%) prescribed postoperative antibiotics to prevent postoperative infection.

Conclusions:

Systemic antibiotic prescriptions in implant placement surgery are not based on currently available evidence. Most oral implantologists who participated in the survey prescribed systemic antibiotics to prevent perioperative infection, even in simple and straightforward implant placements. Specific guidelines need to be generated in complex implant placement situations and implant placement in medically compromised patients to prevent excessive prescriptions.

Review on Multiple Facets of Drug Resistance: A Rising Challenge in the 21st Century

With the advancements of science, antibiotics have emerged as an amazing gift to the human and animal healthcare sectors for the treatment of bacterial infections and other diseases. However, the evolution of new bacterial strains, along with excessive use and reckless consumption of antibiotics have led to the unfolding of antibiotic resistances to an excessive level. Multidrug resistance is a potential threat worldwide, and is escalating at an extremely high rate. Information related to drug resistance, and its regulation and control are still very little. To interpret the onset of antibiotic resistances, investigation on molecular analysis of resistance genes, their distribution and mechanisms are urgently required. Fine-tuned research and resistance profile regarding ESKAPE pathogen is also necessary along with other multidrug resistant bacteria. In the present scenario, the interaction of bacterial infections with SARS-CoV-2 is also crucial. Tracking and in-silico analysis of various resistance mechanisms or gene/s are crucial for overcoming the problem, and thus, the maintenance of relevant databases and wise use of antibiotics should be promoted. Creating awareness of this critical situation among individuals at every level is important to strengthen the fight against this fast-growing calamity. The review aimed to provide detailed information on antibiotic resistance, its regulatory molecular mechanisms responsible for the resistance, and other relevant information. In this article, we tried to focus on the correlation between antimicrobial resistance and the COVID-19 pandemic. This study will help in developing new interventions, potential approaches, and strategies to handle the complexity of antibiotic resistance and prevent the incidences of life-threatening infections.

Antibiotic resistance in agriculture: Perspectives on upcoming strategies to overcome upsurge in resistance

Antibiotic resistance is a massive problem rising constantly and spreading rapidly since the past decade. The major underlying mechanism responsible for this problem is an overuse or severe misuse of antibiotics. Regardless of this emerging global threat, antibiotics are still being widely used, not only for treatment of human infections, but also to a great extent in agriculture, livestock and animal husbandry. If the current scenario persists, we might enter into a post-antibiotic era where drugs might not be able to treat even the simplest of infections. This review discusses the current status of antibiotic utilization and molecular basis of antibiotic resistance mechanisms acquired by bacteria, along with the modes of transmittance of the resultant resistant genes into human pathogens through their cycling among different ecosystems. The main focus of the article is to provide an insight into the different molecular and other strategies currently being studied worldwide for their use as an alternate to antibiotics with an overall aim to overcome or minimize the global problem of antibiotic resistance.

Antibiotic Use and Misuse in Dentistry in India-A Systematic Review

Background: Infections caused by antibiotic resistance pose a serious global health threat, undermining our ability to treat common infections and deliver complex medical procedures. Antibiotic misuse, particularly in low-–middle-income countries, is accelerating this problem. Aim: The aim of this systematic review was to investigate the use and misuse of antibiotics in dentistry in India. Method: We included studies carried out on Indian populations evaluating the prescription of prophylactic or therapeutic antibiotics by dental practitioners or other healthcare providers, along with antibiotic self-medication by the general population. The primary outcome measure was prescription rate/use of antibiotics for dental/oral problems. The secondary outcome measures included indications for antibiotic use in dentistry, their types and regimens, factors influencing practitioners’ prescription patterns and any differences based on prescriber and patient characteristics. Multiple databases were searched with no restrictions on language or publication date. The quality assessment of all included studies was carried out using the AXIS tool for cross-sectional studies and the Joanna Briggs Institute checklist for qualitative studies. Results: Of the 1377 studies identified, 50 were eligible for review, comprising 35 questionnaire surveys, 14 prescription audits and one qualitative study (semi-structured interviews). The overall quality of the included studies was found to be low to moderate. The proportion of antibiotic prescriptions amongst all prescriptions made was found to range from 27% to 88%, with most studies reporting antibiotics in over half of all prescriptions; studies also reported a high proportion of prescriptions with a fixed dose drug combination. Worryingly, combination doses not recommended by the WHO AWaRe classification were being used. The rate of antibiotic self-medication reported for dental problems varied from 5% to 35%. Conclusions: Our review identified the significant misuse of antibiotics for dental diseases, with inappropriate use therapeutically and prophylactically, the use of broad spectrum and combination antibiotics not recommended by WHO, and self-medication by the general population. There is an urgent need for targeted stewardship programmes in this arena.

Factors Predicting Blood Culture Positivity in Children With Enteric Fever

BACKGROUND

Blood culture, despite low sensitivity, is the gold standard for enteric fever diagnosis. Understanding predictors of blood culture positivity may help design strategies to optimize enteric fever diagnosis.

METHODS

A cohort of 6760 children aged 0.5-15 years was followed for 3 years for enteric fever with blood cultures in an automated system, for fevers >3 days. Factors affecting test positivity in fevers and participant-level predictors for culture refusals were analyzed using regression models.

RESULTS

Overall, 6097 suspected typhoid/paratyphoid fever (STF) episodes were reported, of which 5703 (93.5%) STFs had sampling for blood cultures, with 394 (6.5%) refusals. Salmonella enterica serovar Typhi/Paratyphi positivity was culture-confirmed in 3.8% (218/5703) of STF episodes. Older children (odds ratio [OR], 1.96 [95% CI, 1.39-2.77]), larger blood volume inoculated (OR, 2.82 [95% CI, 1.71-4.66]), higher temperatures during fever (OR, 3.77 [95% CI, 2.89-4.91]), and fevers diagnosed as suspected typhoid or acute undifferentiated fever (OR, 6.06 [95% CI, 3.11-11.78]) had a higher probability of culture positivity. Antibiotics before culture did not decrease culture positivity. Blood culture refusals were higher for children from wealthier households or with milder illness.

CONCLUSIONS

Performing blood cultures in older children with fever, especially those fevers with toxic presentation and increasing blood volume for inoculation are strategies to improve enteric fever detection in surveillance settings.

Impact of an Anti-Microbial Stewardship Program on Targeted Antimicrobial Therapy in a Tertiary Care Health Care Institute in Central India

Introduction Antimicrobial resistance (AMR) has become a global pandemic. In order to identify this menace, World Health Organisation (WHO) has developed the Global Action Plan on AMR (GAP AMR). Antimicrobial stewardship programs (AMSP) have been identified as a decisive tool for combating AMR. One of the most efficient measures of these programs has been the implementation of point prevalence surveys (PPS) of antibiotic usage and subsequent audit feedback. The present study was undertaken to identify the impact of AMSP on curtailing of empirical usage of antibiotics and the augmentation of targeted therapy.  Methods It is an observational, cross-sectional study comprising 1396 patients. The microbiology culture details and anti-microbial-sensitivity results were recorded. Antibiotic prescriptions were recorded in each patient during their hospital stay. Result Out of 1396 patients treated over four quarters (Q1-Q4), 711 (50.9%) patients were on antibiotics, and among them, only 415 patients were subjected to any microbiological cultures with an overall bacterial culture rate (BCR) of 58.3%, and 296 patients (41.6%) were treated with antibiotics empirically without sending any samples for bacterial culture. There was a statistically significant rise in BCR from 47.3% in the first quarter to 77.6% in the fourth quarter. Sending specimens for blood culture increased significantly from 29.2% in Q1 to 37.6% in Q4. After receiving culture reports, 72.3% of cases continued with the same antibiotic, the antibiotic was changed in 19.9% of cases, and the antibiotic was stopped in 7.8% of cases. Conclusion There was a strong positive impact of AMSP in curtailment of empirical usage of antibiotics and augmenting targeted therapy as evidenced by the significant rise in BCR over Q1-Q4 PPS as well as a significant rise in ordering for blood culture over the same time period.

India's National Action Plan on Antimicrobial Resistance: a critical perspective

Antimicrobial resistance (AMR) is widely recognised as a global health threat, which is projected to account for more deaths than cancer by 2050. The Government of India has formulated a National Action Plan to tackle AMR (NAP-AMR), largely modelled on the World Health Organization's Global Action Plan on AMR. While the NAP-AMR successfully mirrors the Global Action Plan and lays out ambitious goals, we find that the lack of financial allocation across states, poor enforcement and inadequate multisectoral co-ordination have hampered progress. A broader focus on improving infrastructure for water and sanitation, linking the issue of AMR to existing vertical health programmes for human immunodeficiency virus (HIV) and tuberculosis (TB), prioritising infection prevention and control, strengthening the frontline healthcare workforce in rural and peri-urban settings to reduce reliance on antibiotics, leveraging point-of-care testing and mobile app-based health interventions for diagnosis and surveillance, and adopting a socioecological approach to health and development would help to create an enabling environment for concrete action on AMR in India.

Genotypic characterization of carbapenem resistant Enterobacterales in clinical isolates from western Maharashtra

PURPOSE

To study distribution of carbapenemase genes namely; New Delhi metallo-beta-lactamase (blaNDM), Oxacillinase-48 (blaOXA48), Verona Integron-Encoded Metallo-beta-lactamase (blaVIM) and Imipenemase (blaIMP) in carbapenem resistant Enterobacterales (CRE), isolated from clinical samples.

METHOD

This cross-sectional study was conducted at a tertiary care hospital of western Maharashtra over six months period. CREs were identified by conventional disc diffusion and modified carbapenem inactivation method (mCIM). A total of 50 consecutive CRE isolates from clinical samples were subjected to home brewed polymerase chain reaction (PCR) for detection of carbapenemases.

RESULTS

Out of the 50 CRE isolates, at least one of the four carbapenemase genes was detected in 49 (98%) isolates. The frequency of distribution of these genes were NDM 90% (n = 45), OXA48 60% (n = 30) and VIM 12% (n = 6). Dual combination of blaNDM and blaOXA48 (50%) was the commonest pattern observed, which was frequently associated with Klebsiella pneumoniae.

CONCLUSIONS

The study indicate high prevalence of NDM warranting strict anti-microbial stewardship practices. Surveillance of CRE and resistance mechanism is essential to monitor the trend and take informed decision for appropriate anti-microbial therapy.

Understanding Antibiotic Usage on Small-Scale Dairy Farms in the Indian States of Assam and Haryana Using a Mixed-Methods Approach-Outcomes and Challenges

The use and misuse of antibiotics in both humans and animals contributes to the global emergence of antimicrobial resistant (AMR) bacteria, a threat to public health and infection control. Currently, India is the world’s leading milk producer but antibiotic usage within the dairy sector is poorly regulated. Little data exists reflecting how antibiotics are used on dairy farms, especially on small-scale dairy farms in India. To address this lack of data, a study was carried out on 491 small-scale dairy farms in two Indian states, Assam and Haryana, using a mixed method approach where farmers were interviewed, farms inspected for the presence of antibiotics and milk samples taken to determine antibiotic usage. Usage of antibiotics on farms appeared low only 10% (95% CI 8–13%) of farmers surveyed confirmed using antibiotics in their dairy herds during the last 12 months. Of the farms surveyed, only 8% (6–11%) had milk samples positive for antibiotic residues, namely from the novobiocin, macrolides, and sulphonamide classes of antibiotics. Of the farmers surveyed, only 2% (0.8–3%) had heard of the term “withdrawal period” and 53% (40–65%) failed to describe the term “antibiotic”. While this study clearly highlights a lack of understanding of antibiotics among small-scale dairy farmers, a potential factor in the emergence of AMR bacteria, it also shows that antibiotic usage on these farms is low and that the possible role these farmers play in AMR emergence may be overestimated.

Antimicrobial resistance and the post antibiotic era: better late than never effort

Introduction: Antimicrobial resistance (AMR) is a multi-layered problem with a calamitous impact on humans, livestock, the environment, and the biosphere. Initiatives and action plan to preclude AMR remain poorly implemented in India.Area covered: This review highlights essential factors contributing to AMR, epidemiology of the resistant bacteria, current treatment options, economic impact, and regulatory efforts initiated by the Indian government to tackle AMR.Expert opinion: Health-care professionals, hospitals, and the general public must understand and cooperatively implement the 'One Health approach,' which entails judicious use of antibiotics in humans, animals, and the environment. Neglecting the AMR problem predicts the expansion of the 'Post-antibiotic era' characterized by drying antibiotic discovery pipelines, overuse of 'Watch' and 'Reserve' groups, coupled with underuse of 'Access' antibiotics, increased daily defined doses, increased healthcare cost, rise in morbidity, mortality, and environmental degradation. The Indian case study elucidates a looming international crisis that demands global attention and commitment for envisaging and implementing locally relevant solutions.

Adopting an intersectoral One Health approach in India: Time for One Health Committees

Following the several episodes of zoonotic disease outbreaks and the more recent COVID-19 pandemic, the Indian policy initiatives are committed to institutionalize One Health (OH) approaches and promote intersectoral, transdisciplinary collaboration and cooperation. The OH principle needs to be visualized beyond the scope of zoonoses. While conservation, ecological and veterinary professions are getting increasingly engaged with OH, most of the medical/clinical and social sciences professions are only peripherally aware of its nuances. The OH initiatives, by their essentially multidisciplinary nature, entail working across ministries and navigating tacit institutional hierarchies and allocating leadership roles. The logical operational step will be the constitution of One Health Committees (OHC) at the State and district levels. Here, we outline the key foundational principles of OHC and hope that the framework for implementation shall be deliberated through wider consultations and piloted and adopted in a phased manner.

Antimicrobial Stewardship and Its Impact on the Changing Epidemiology of Polymyxin Use in a South Indian Healthcare Setting

Polymyxins being last resort drugs to treat infections triggered by multidrug-resistant pathogens necessitates the implementation of antimicrobial stewardship program (ASP) initiatives to support its rational prescription across healthcare settings. Our study aims to describe the change in the epidemiology of polymyxins and patient outcomes following the implementation of ASP at our institution. The antimicrobial stewardship program initiated in February 2016 at our 1300 bed tertiary care center involved post-prescriptive audits tracking polymyxin consumption and evaluating prescription appropriateness in terms of the right indication, right frequency, right drug, right duration of therapy and administration of the right loading dose (LD) and maintenance dose (MD). Among the 2442 polymyxin prescriptions tracked over the entire study period ranging from February 2016 to January 2020, the number of prescriptions dropped from 772 prescriptions in the pre-implementation period to an average of 417 per year during the post-implementation period, recording a 45% reduction. The quarterly patient survival rates had a significant positive correlation with the quarterly prescription appropriateness rates (r = 0.4774, p = 0.02), right loading dose (r = 0.5228, p = 0.015) and right duration (r = 0.4361, p = 0.04). Our study on the epidemiology of polymyxin use demonstrated favorable effects on the appropriateness of prescriptions and mortality benefits after successful implementation of antimicrobial stewardship in a real-world setting.

Antibiotics Use in Food Animal Production: Escalation of Antimicrobial Resistance: Where Are We Now in Combating AMR?

The use of antibiotics has been very beneficial to human health, animal wellbeing, and food production, however, there are no alternatives to antimicrobials in treating infectious diseases. Their use can contribute to the development of antimicrobial resistance, but the world has realized the need to combat antimicrobial resistance in recent decades due to the continued escalation of the problem jeopardizing human and veterinary medicine and food and environmental safety. Understanding the AMR and judicious use of antimicrobials are critical, and one health approach involving several sectors and multiple disciplines is important to tackle the problem. National, regional, and global action plans have been instigated to tackle the escalation of AMR. Antimicrobials are frequently used in food animal production. Therefore, food animal producers are important participants to prevent overuse and misuse of antimicrobials. Recent regulations to address the challenges have not been perceived well in animal farming communities. More awareness regarding these action plans and understanding the impact of AMR are needed. A nationwide survey of perceptions of food animal producers regarding AMR mitigation approaches should be conducted to evaluate the effectiveness of the current policies regarding antibiotics use and AMR. These outcomes should be incorporated in future policies and awareness campaigns targeting food animal producers.

Antibacterial activity of medicinal plants against ESKAPE: An update

Antibiotic resistance has emerged as a threat to global health, food security, and development today. Antibiotic resistance can occur naturally but mainly due to misuse or overuse of antibiotics, which results in recalcitrant infections and Antimicrobial Resistance (AMR) among bacterial pathogens.

These mainly include the MDR strains (multi-drug resistant) of ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species). These bacterial pathogens have the potential to “escape” antibiotics and other traditional therapies. These bacterial pathogens are responsible for the major cases of Hospital-Acquired Infections (HAI) globally. ESKAPE Pathogens have been placed in the list of 12 bacteria by World Health Organisation (WHO), against which development of new antibiotics is vital. It not only results in prolonged hospital stays but also higher medical costs and higher mortality. Therefore, new antimicrobials need to be developed to battle the rapidly evolving pathogens. Plants are known to synthesize an array of secondary metabolites referred as phytochemicals that have disease prevention properties. Potential efficacy and minimum to no side effects are the key advantages of plant-derived products, making them suitable choices for medical treatments. Hence, this review attempts to highlight and discuss the application of plant-derived compounds and extracts against ESKAPE Pathogens.

A road-map for addressing antimicrobial resistance in low- and middle-income countries: lessons learnt from the public private participation and co-designed antimicrobial stewardship programme in the State of Kerala, India

BACKGROUND

The global concern over antimicrobial resistance (AMR) is gathering pace. Low- and middle-income countries (LMICs) are at the epicentre of this growing public health threat and governmental and healthcare organizations are at different stages of implementing action plans to tackle AMR. The South Indian state of Kerala was one of the first in India to implement strategies and prioritize activities to address this public health threat.

STRATEGIES

Through a committed and collaborative effort from all healthcare related disciplines and its professional societies from both public and private sector, the Kerala Public Private Partnership (PPP) has been able to deliver a state-wide strategy to tackle AMR A multilevel strategic leadership model and a multilevel implementation approach that included developing state-wide antibiotic clinical guidelines, a revision of post-graduate and undergraduate medical curriculum, and a training program covering all general practitioners within the state the PPP proved to be a successful model for ensuring state-wide implementation of an AMR action plan. Collaborative work of multi-professional groups ensured co-design and development of disease based clinical treatment guidelines and state-wide infection prevention policy. Knowledge exchange though international and national platforms in the form of workshops for sharing of best practices is critical to success. Capacity building at both public and private institutions included addressing practical and local solutions to the barriers e.g. good antibiotic prescription practices from primary to tertiary care facility and infection prevention at all levels.

CONCLUSION

Through 7 years of stakeholder engagement, lobbying with government, and driving change through co-development and implementation, the PPP successfully delivered an antimicrobial stewardship plan across the state. The roadmap for the implementation of the Kerala PPP strategic AMR plan can provide learning for other states and countries aiming to implement action plans for AMR.

Antibiotic stewardship from a decision-making, behavioral economics, and incentive design perspective

Antibiotic-resistant infections cause over 20 thousand deaths and $20 billion annually in the United States. Antibiotic prescribing decision making can be described as a "tragedy of the commons" behavioral economics problem, for which individual best interests affecting human decision-making lead to suboptimal societal antibiotic overuse. In 2015, the U.S. federal government announced a $1.2 billion National Action Plan to combat resistance and reduce antibiotic use by 20% in inpatient settings and 50% in outpatient settings by 2020. We develop and apply a behavioral economics model based on game theory and "tragedy of the commons" concepts to help illustrate why rational individuals may not practice ideal stewardship and how to potentially structure three specific alternate approaches to accomplish these objectives (collective cooperative management, usage taxes, resistance penalties), based on Ostrom's economic governance principles. Importantly, while each approach can effectively incentivize ideal stewardship, the latter two do so with 10-30% lower utility to all providers. Encouraging local or state-level self-managed cooperative stewardship programs thus is preferred to national taxes and penalties, in contrast with current trends and with similar implications in other countries.

India to envision One Health movement for confronting emerging health threats: From concept to approach toward institutionalization

The author's key role in advocating and leading One Health (OH) initiatives in India (especially in Kerala), review the need for and progress of OH from concept to approach and proposes its institutionalization as the way forward. India is currently facing many health threats such as antimicrobial resistance, environmental health hazards, and food safety risks and most importantly, zoonotic diseases such as Nipah, Avian Influenza, Scrub typhus, Congo fever, Kyasanur forest disease, COVID-19, and leptospirosis that grossly impact country's economy. The recent pandemics had exposed the gaps in public health policy and government is prepared to commit on the OH approach and to invest more on public health infrastructure. Further, as challenges have increased in recent years, OH approach was clearly advocated by the experts not only to cope up the pandemic but also to manage the infodemic by promoting the timely dissemination of accurate information. Right from the endorsement of OH in 2007 by India's Prime minister to the present fight against COVID-19 pandemic, the actions to control and manage the disease was ideally oriented toward a collaborative approach. Last year (2019), the representatives from relevant ministries and department had a ground-breaking dialog to develop charter and constitute a National policy on OH. Recently, Health Ministers of the Member States of the World Health Organization South-East Asia signed "Delhi declaration" where the key essence was to implement intersectoral coordination mechanisms following the "OH" approach. India's future policy intervention will emphasize on strengthening of integrated public health labs and contributing to building a national institutional platform for OH to boost research initiatives. Taking stock of OH happenings, resources, challenges, and priorities, the implementation strategy has been proposed across human, animal and environmental health. The article further highlights the key areas that need OH intervention in India, the country's progress in OH and the success stories of OH for a sustainable action to confront emerging health threats.

Current Surgical Antibiotic Prophylaxis Practices: A Survey of Orthopaedic Surgeons in India

BACKGROUND

Surgical antibiotic prophylaxis (SAP) has become the standard of care in orthopaedic surgery. Inappropriate usage of antibiotics (dosage, strength, and/or administration time and duration) can inadvertently result in superadded infections and antimicrobial resistance. The purpose of this study was to document and analyse the prescription patterns for SAP, and to investigate the factors associated with divergence from standard guidelines.

METHODS

We conducted an online cross-sectional questionnaire-based study to collect information about the SAP practices of the members of the Indian Orthopaedic Association (IOA) using Google forms. A link to the questionnaire was sent by e-mails.

RESULTS

The overall response rate was 5.73%. While 97.3% respondents practised SAP routinely, the practice was not aligned with standard guidelines' recommendations. There was heterogeneity in the use of SAP in terms of choice of antibiotic(s), number of co-prescribed drugs, single- versus multiple-dose regimens, and the duration of therapy. The prescription practice patterns showed that orthopaedic surgeons almost always used broad-spectrum antibiotics for long durations, regardless of the type of surgery.

CONCLUSION

While Orthopaedic surgeons in India are practicing SAP, the pattern of antibiotic usage is heterogeneous. Variations were noted in the choice of antibiotics for different types of surgeries, time of administration, duration of usage in the postoperative period as well as co-prescriptions. This study highlights the urgent need for a comprehensive, rational, and robust national SAP policy for orthopaedic surgeries.

Antibiotic prescribing patterns and knowledge of antibiotic resistance amongst the doctors working at public health facilities of a state in northern India: A cross sectional study

Objectives:

The aim of the study is to understand antibiotic prescribing patterns and to understand knowledge of antibiotic resistance amongst the doctors working at public health facilities of a northern Indian state.

Methodology:

A cross-sectional study among doctors of the civil hospitals of Haryana state of India was conducted 2019. Data were collected by self-administered questionnaire from a total of 215 doctors posted at the 22 district hospitals.

Results:

The response rate was 98%. Doctors (66%) perceived antibiotic resistance as a very important global problem, a very important problem in India (68%) and as an important problem in their hospital (31%). Experience in years was significantly associated with considering hand hygiene (OR, 5.78; 95% CI, 1.6420.3; P = 0.005) and treatment of bacteria as per susceptibility report of the organism (OR, 0.54; 95% CI, 0.310.93; P = 0.03). Surgeons reported piperacillin-tazobactam (17%), cloxacillin (17%), and cephazolin (12.05%) and others (54.2%) as the first choice of antibiotics for infection after surgery. Doctors (52.3%) reported that they started antibiotics 12 hours before surgery; 15 (17%) prescribed antibiotics 6 hours before surgery; and 23 (27%) 1 day before the surgery. Time for stopping antibiotics after surgery, as reported by participants, was 1 day (15%), 23 days (35%), 57 days (44%), respectively. A total of 71 (83%) doctors thought that surgical incision could lead to post-surgical site infection.

Conclusion:

Findings of study can be utilized to enhance education on antimicrobial prescribing, antimicrobial surveillance, and prescribing patterns among doctors in our settings.

A review of animal health and drug use practices in India, and their possible link to antimicrobial resistance

BACKGROUND

Livestock production, particularly the dairy sector, is important for food and nutritional wellbeing of communities in India, it supports livelihoods of many farmers, and contributes to the economy of the country. India is a high consumer of antibiotics and antimicrobial resistant (AMR) bacteria are a major public health concern.

OBJECTIVES

Our objectives were to identify animal health and drug use practices that may contribute to emergence and spread of AMR in the country, review previous AMR- mitigation strategies, and discuss "theory of change" as an approach to informing the choice of interventions.

METHODS

We undertook a desk review of literature to identify practices with potential to contribute to emergence and spread of antimicrobial resistance in India. Searches were done in PubMed, Google scholar, and Google. Data were synthesized and discussed by themes.

RESULTS

Animal disease surveillance is less developed and infrastructure to support delivery of services is inadequate. Several groups are known to offer animal health services. The untrained "animal health workers" and para-veterinarians are more popular with farmers as they charge less for consultations (compared to veterinarians who are few and charge more). Over-the-counter access of antibiotics, without prescription, and direct marketing of drugs to farmers are common. Because of this, farmers are able to treat their animals and only consult when cases become non- responsive to treatment. Antibiotics are mostly used in management of mastitis cases. Drug withdrawal periods are rarely observed and occurrence of antibiotic- contaminated milk has been reported. Awareness on AMR is low and antimicrobial stewardship in livestock is yet to be developed. Initiatives such as the National programme for containment of AMR, National Action Plan on AMR, and the National Health policy point to government's commitment in addressing the problem of AMR in the country.

CONCLUSION

Several animal health and drug use practices, with potential to cause AMR, have been described, and their contribution can be discussed further by engaging stakeholders in a "theory of change" exercise. Interventions that address AMR from the animal health perspective should be promoted, and incentives to increase their adoption explored.

The Clasp of CLABSI

How to cite this article: Gopal PB. The Clasp of CLABSI. Indian J Crit Care Med 2020;24(1):3–5.

Antibiotic abuse during endodontic treatment: A contributing factor to antibiotic resistance

Antibiotic resistance is one of our most serious global health threats. The adverse effects of overusing and misusing antibiotics are highly publicized in the health professional literature. Antibiotic abuse occurs during routine endodontic treatment and there are deficiencies in knowledge regarding prescribing antibiotic and appropriate prophylactic antibiotic use. Multidisciplinary coordination and cooperation among dentists, pharmacists, and patients is needed to curb antibiotic abuse. As endodontists, we can become part of the solution to the antibiotic resistance crisis and deal with it conclusively. This review article discusses antibiotic resistance resulting from antibiotic abuse during endodontic treatment, various factors contributing to it, and measures required for stopping antibiotic abuse in endodontic treatment. A web-based research on MedLine was performed with terms Review Articles published in the last 10 year's dental journals in English for literature researching, extracting, and synthesizing data. Relevant articles were shortlisted. Important cross-reference articles were also reviewed.