Common chest infection lands patient in ICU: Doctors reveal how antibiotic misuse is fuelling a crisis

With the problem of antimicrobial resistance on the rise across hospitals, doctors are now taking note. “Ten years ago, antimicrobial resistance was the problem of microbiologists. Now clinicians participate and help in implementing protocols to protect the antibiotics. This is because they face the brunt of it,” says Dr Kamini Walia, who heads ICMR’s Antimicrobial Resistance Research and Surveillance Network. “The sensitivity report of patients show repetitive Rs (resistant), for most common antibiotics. So, when you spot an S, signalling they are sensitive to a drug, we breathe a sigh of relief.”

In patients resistant to multiple antimicrobials, she says doctors have to use combinations of multiple drugs or enhanced doses of drugs. They can also go back to older antibiotics that are no longer in use, to which the patient has never been exposed to.

Why is anti-microbial resistance a challenge

Overuse and misuse of antimicrobials can put undue pressure on pathogens like bacteria, fungi and viruses to mutate and gain the ability to withstand the drugs. This essentially means that these drugs stop working.

Nearly 2.6 lakh deaths in India due to various infections in 2021 were directly attributable to antimicrobial resistance, meaning the people would not have died had the infection responded to treatment. That year, a total of 9.8 lakh people died in India with resistant infections — deaths that would not have occurred had the infection been prevented, according to data from Global Burden of Diseases study. Globally, over a million people die each year because of antimicrobial resistance.

The trend in the number of deaths associated with antimicrobial resistance has also changed over the years. Data from the Global Burden of Diseases study shows that most of these deaths occurred in children under the age of five years in 1990, but the highest number of antimicrobial resistance associated deaths in 2021 was in people above the age of 70 years.

A study across 10 hospitals conducted in 2015 found that people with multi-drug resistance were nearly two times as likely to die as those with infections susceptible to the drugs. This risk went up to three-folds in people with extremely drug-resistant infections.

It all begins with a prescription

Importantly, a survey of antibiotic prescriptions across 20 tertiary care hospitals in India by the National Centre for Disease Control hinted at antibiotic overuse and misuse. It found that nearly three in four patients were prescribed antibiotics, with more than half the prescriptions not meant for the treatment of an infection but a prophylaxis to prevent one — a practice that is discouraged. The survey also found that 57 per cent of the antibiotics used were from the watch group — a group of antibiotics used in sicker patients that are more likely to lead to antimicrobial resistance.

Importantly, only six per cent of these antibiotics prescribed were definitive treatment — meant to attack a diagnosed infection — with the other 94 per cent being empirical prescriptions given by the doctors based on what they thought had caused the infection going by symptoms and prevalence.

Diagnosis vs infection control

“There is no magic bullet,” says Dr Walia. “There has to be good infection control in hospitals so that doctors don’t have to compensate with prophylactic doses and more antibiotic prescriptions. There have to be good diagnostic facilities so that doctors are not left treating infections empirically. There is a need to rationalise the prescriptions — patients should not be put on several antibiotics. And, there is a need for infectious disease doctors in hospitals. They can guide everyone on using the appropriate drug for the appropriate infection — some drugs work best for infection in the kidneys, others work for lungs depending on how they are absorbed by different tissues,” she explains.

Antimicrobial resistance, according to her, is a symptom of behavioural and systemic issues. “Awareness needs to be created, there have to be continuous reminders — these are not easy to do. Already we are seeing declining use of broad-spectrum antibiotics — medicines effective against a wide range of bacteria. But it will take some time to see the impact.”

Dr Chand Wattal, infectious disease specialist from Sir Ganga Ram Hospital, says infection control has become important in most hospitals since Covid-19. “People usually get resistant pathogens in the ICUs. Many hospitals, including newer government hospitals, are working towards better infection control driven by NABH and other quality assurance certification.” On their own, hospitals usually measure indices such as ventilator-associated, catheter associated, or surgical site-related infections as a yardstick for themselves. “They then set targets towards fewer infections. Healthcare systems and governments can fight this by improving infection prevention, control and using surveillance to monitor antimicrobial use,” he says.