Time to rationalise, audit antibiotic use

Nusrat Shafiq

SCENARIO 1: Mrs A's five-year-old child has been running cold and a low-grade fever for two days. She takes out amoxicillin syrup from her refrigerator and administers two teaspoonfuls to her daughter.

Scenario 2: Mr B has been diagnosed as a case of dengue and admitted to a private hospital for a decreasing  platelet count. He is started on ceftriaxone by the treating consultant.

Scenario 3: Dr C, posted in the emergency unit of a tertiary care centre, receives a patient referred from another hospital. The patient's condition is serious because of sepsis. The doctor notes the antibiotics that the patient had been receiving (tigecycline, colistin, teicoplanin, amphotericin) for nine days prior to the referral. The discharge summary with the patient does not give any other details pertinent to the use of above antibiotics

The underlying problem in all the above scenarios is “inappropriate use of antibiotics”. Till some time ago, we were battling with resistant malaria and tuberculosis, now the list is much longer. Diseases like typhoid, which could be managed fairly decently in the majority, are leaving clinicians grappling with resistant organisms.

While the first one of the above scenarios addresses the problem of self-medication, that is the patient (here, the mother) decides himself or herself that a condition needs medication and makes a choice of medicine. In the above instance, little did the mother know that the cold was probably due to a viral illness and the antibiotic would do more harm to the child than any benefit. 

The harm an antibiotic may cause, if not used when needed and the one needed (antibiotics are not all the same), in the dose that is appropriate and for the duration that it ought to be given, runs beyond the usual harm caused by any other group of drugs. The additional burden of inappropriate use of antibiotics is that of fostering antibiotic resistance amongst organisms causing infection. The worst thing is that these resistant organisms spread by various means.

It is not uncommon practice to walk up to the chemist and ask for an antibiotic for cough, cold and or fever. Over the counter (OTC or permission to be sold without prescription) availability of antibiotics, though it has now been restricted for antibiotics, on the ground the practice is not followed to a great extent. Further, despite the fact that it is now mandatory for packaging containing an antibiotic to bear a “red line,” also known as laal lakeer, the procurement of the same without a prescription is not very difficult.  

There is a flip side to this policy. In rural areas, where chemist is the only source of medical advice to a patient, it may be unwise to withhold an antibiotic for a needy patient. Education of chemists and pharmacists about the rational use of antimicrobials should perhaps also be a priority. While it is encouraging to know that the harm caused by self-medication or over-the-counter sale of antibiotics has been addressed to some extent, a lot more needs to be done in order to implement the same.

Now, we come to scenarios 2 and 3. Herein both the patients were prescribed antibiotics by a medically qualified person. For the second case, it was a viral infection, not requiring an antibiotic, even if the treating physician deemed it to be serious. In the third case, it needed to be known why the patient was receiving antibiotics which are generally reserved for infections due to resistant organisms. Perhaps, some of them were indeed needed considering the fact that organisms causing serious infections are not a rarity anymore, but certainly not all. However, the discharge summary should have carried the details of laboratory reports for susceptibility patterns of organisms, justification, if any, for use of the mentioned antibiotics.  It is likely that administration of some of the mentioned antibiotics could have led to further deterioration of the patient's condition. The fallout of compounding the problem of antibiotic resistance goes without saying.

Are we trying to question the ability of the treating medical person to make decisions regarding appropriateness of antibiotics for a particular situation? There is indeed a gap, which needs to be addressed. Somehow our medical curriculum does not give the due emphasis that rational use of antibiotics deserves. The devastating implications of irrational use of antibiotics and the skills for making right decisions about antimicrobials has to be instilled right from the beginning in the medical curriculum and reinforced repeatedly. 

It is important that trained academicians undertake this training process and it is not left to pharmaceutical companies to educate clinicians about rational use of antimicrobials. Antimicrobial stewardship programmes can be very useful in this regard.

We need to give a closer look to our prescriptions for antibiotics. The time tested modality is that the prescriptions are audited by a trained person on the basis of standard parameters and a feedback is given. In the medical parlance, it is called “prescription audit and feedback”. The feedback is given with a view to improving practices. This exercise also serves for providing data about the pattern of use of antibiotics and identifying key targets for designing the training modules. It is not uncommon in developed countries, where hospitals/clinics receive a letter for finding out why the use of a supposedly reserved antibiotic has increased and can something be done? In a country with a poor doctor to patient ratio, absence of electronic record systems, a heavy load of patients, this may seem Herculean and by no means, it is too. However, a pilot exercise may be initiated in less-burdened setups. Such setups could be identified within government and private hospitals/clinics. The resources this may entail would eventually prove to be cost-effective.

Besides logistics, the important issue is of changing the mindset. The idea of letting prescriptions be scrutinised may not gel well with several medical practitioners. In informal discussions and in actual practice as well, the pleasant surprise is that many senior colleagues, many of whom are international authorities, are more than ready for training, prescription audit and feedback. An example could be set up by having them on board.

Training doctors to facilitate the judicious use of antibiotics and a continuous cycle of prospective audit and feedback are needed to enabling success of the campaign: “Antibiotics: handle with care.”

The writer is an Additional Professor, PGIMER, Chandigarh.