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Minding the gap: Rethinking implementation of antimicrobial stewardship in India
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Journal Article
Minding the gap: Rethinking implementation of antimicrobial stewardship in India
2019
Overview
By conservative estimates, 700,000 deaths this year will be attributable globally to antimicrobial-resistant bacteria, and this number will rise to 10 million deaths by 2050 if trends in antimicrobial resistance do not change.1 Reversing trends in antimicrobial resistance could have the biggest impact in India, which has the highest infectious disease burden in the world.2 Recent India-wide estimates of Escherichia coli resistance demonstrate 77% resistance to third-generation cephalosporins, 84% resistance to fluoroquinolones, and up to 59% resistance to carbapenems for Klebsiella pneumoniae isolates.3 The concept of antimicrobial stewardship can be hard to reconcile in this setting—particularly with overwhelming barriers including inadequate sanitation, unrestricted access to antibiotics in the community, antibiotic use in agriculture, and antibiograms that warn of a post-antibiotic era. Applying a tiered framework like the Centers for Disease Control and Prevention (CDC) Core Elements of Human Antibiotic Stewardship Programs in Resource-Limited Settings points out how deploying antimicrobial stewardship in India necessitates revision of constructs that have been used commonly in the United States due to the vastly different healthcare infrastructure.4,5 In this issue of Infection Control and Hospital Epidemiology, Rupali et al6 describe incorporating stewardship principles into infectious disease consultation in a South Indian hospital.6 They focused on the intensive care unit and found that 73.3% of antibiotic prescriptions were inappropriate, indicating that an effective inpatient antimicrobial stewardship program would make substantial impact. Selected Contributing Barriers to Antimicrobial Stewardship in India and Tactics that May Help Barriers Proposed Tactics Unregulated antibiotic use in the community National policy change (eg, the Red Line Campaign) Few existing hospital antimicrobial stewardship programs Build stewardship into hospital accreditation standards Lack of infectious diseases (ID)–trained pharmacists and ID physicians Build capacity for infectious diseases fellowship programs and construct infectious disease pharmacy training programs in large academic centers/pharmacy schools; involve medical microbiologists Lack of empowerment of pharmacists Socioadaptive tactics, employing multidisciplinary stewardship teams Disconnected process for inpatients obtaining antibiotics (eg, families will often buy antibiotics from a separate pharmacy while patient is inpatient) Engage insurance and pharmacy stakeholders in cost-related stewardship interventions (eg, narrow-spectrum antibiotics should be priced lower than broad-spectrum antibiotics) Author for correspondence:
Publisher
Cambridge University Press
Subject
