NMC says no antibiotics before diagnostic tests: Will its norms control antimicrobial resistance?

What is AMR?

This is a condition when microbes, which are exposed to high-grade antibiotics, become used to them over time and become resistant to them. This makes treating common infections difficult, increasing the risk of severe illness and death. This resistance also makes them ineffective for preventing secondary infection during “surgeries, chemotherapy and managing chronic infections,” say the guidelines. In short, the microbes become superbugs.

Why the need for guidelines?

Since infections can be bacterial, viral, fungal or parasitic, the guidelines say that “identification of the clinical problem and making a differential diagnosis at the bedside will help in deciding whether to start or not to start any antimicrobial. The history should assess the risk of infection based on the symptoms and signs and the common patterns of presentation of different diseases such as upper respiratory tract infections (URTI), lower respiratory tract infection (LRTI), urinary tract infection (UTI), meningitis, diarrhoea, skin and soft tissue infections.”

How should assessment be done?

The guidelines suggest a “syndromic approach” at first to classify patients. These include those with acute febrile illness and rash — for example, viral infections like dengue or malaria, bacterial infection like scarlet fever, other infections like Lyme disease, drug reactions and autoimmune diseases. The category called acute febrile illness with jaundice, applies to viral infections like hepatitis, bacterial infection like typhoid and biliary tract infections. The acute febrile illness with neurological involvement includes meningitis while acute febrile illness with respiratory syndrome includes flu and pneumonia. On the last category, the guidelines say, “Most of the respiratory illnesses do not require antimicrobials. Viral infections are self-limiting and treated symptomatically. However, if a patient of respiratory symptoms presents with expectoration and signs of septicaemia, pneumonia should be suspected. Sputum sample should be sent to the laboratory and empirical antibiotic may be initiated.”

In case of urinary tract infections, the guidelines recommend that “antimicrobials may be initiated empirically in situations like pregnancy, diabetes etc and can then be modified as per available reports.”

What are steps of diagnosis?

Apart from a detailed history of presenting infection, the guidelines say the clinician should go through history of any surgical, medical disorders and co-morbidities like diabetes as these may predispose an individual to infections. “Previous use of antibiotics in such situations may predispose for AMR in current illness,” the guidelines add.

The module emphasises the virtues of a detailed physical examination. “Finding a murmur on examination of cardiovascular system examination can point towards an infective endocarditis. Urinary tract infections (UTI) and skin infections like foot ulcers develop in diabetic patients. The collection of mid-stream urine samples in suspected UTI cases should be done.” For respiratory illnesses, “the decision to treat with antibiotics should be made by the presence of severity and laboratory report of sputum and culture examination,” says the new module.

The NMC also urges doctors to understand the proper technique of blood culture sampling and proper communication with the microbiology laboratory. “The positive culture reports must be conveyed rapidly to prescribers so that the therapeutic interventions can be made in desired time frame,” it says. “The empiric antibiotic therapy must be limited to seriously ill patients. This choice should be based upon institutional/local antibiograms (these map how susceptible a series of organisms are to different antimicrobials). Choose the appropriate antibiotic based on clinical evaluation and most likely pathogen keeping the antibiogram in mind,” say the guidelines.