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ICMR guidance document spotlights rampant antibiotic overuse in dermatology, dentistry and ENT; experts rap OTC sales
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Arun Sreenivasan, New Delhi
November 24 , 2018
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Obtaining cultures to identify the offending microorganism before prescribing antibiotics, use of early diagnostic kits, quantifying therapy as per World Health Organisation norms and implementing effective standard treatment guidelines validated by a peer-review process at hospitals are some of the measures mooted by the Indian Council of Medical Research (ICMR) to check growing antimicrobial resistance (AMR) in the country, which has made it tough to treat many bacterial infections.
The new guidelines for Antimicrobial Stewardship Programme (AMSP) released by the council, expected to be followed voluntarily by hospitals and clinicians in India, observe that irrational prescription of broad-spectrum antibiotics, poor sale regulations, self-medication and lack of education regarding responsible use are the key factors driving the AMR menace.
The comprehensive 63-page guidance document emphasises hospital-based programmes that are helpful in improving patient safety through increased infection cure rates.
Inappropriate antimicrobial use and treatment failures expose the general population to the risk of contracting a resistant strain of microorganisms. As they become resistant to first-line antimicrobials, the forbidding high cost of the second-line drugs may result in difficulty to treat these illnesses. Most alarming are the diseases caused by multidrug-resistant microbes, which are virtually non-treatable and contributes to a ‘post-antibiotic era.’
Senior medical practitioners and doctors’ associations say that despite numerous campaigns by the ICMR, National Centre for Disease Control and various non-profit groups, indiscriminate use of antimicrobial medications is continuing unabated in the country. They primarily blame self-medication and unregulated over-the-counter sale for the growing menace. “We are fully aware of this issue and have been asking our members to mandatorily restrict the usage of antibiotics for treatment of proven bacterial infections. We have a policy on anti-microbial resistance and are circulating a booklet on this. But we can only offer guidance to raise awareness, and it is entirely up to a doctor’s discretion whether to follow it,” Secretary General of Indian Medical Association Dr RN Tandon told Pharmabiz.
Highlighting the frequent overuse of antibiotics in specialised fields such as ENT, dermatology and dentistry, the ICMR proposes concrete steps to promote rational use. “Antibiotic prescription is common dental practice for conditions like caries, gingivitis, pulpitis and chronic apical inflammation which could be managed by dental procedures, suggesting irrational use. Globally, dentists were reported to prescribe up to 11.3 per cent of all antibiotics. Dentists tend to prescribe broad spectrum antibiotics empirically either to prevent or manage infections,” the guidance document, compiled and reviewed by top microbiologists and clinicians, observed.
Upper respiratory tract infections including rhino pharyngitis, tonsillitis and otitis media are the most common reasons for which patients seek treatment in ENT outpatient department. The main causes of acute upper respiratory tract infections - virus infections - do not need antimicrobial agent. However, such infections are the reason for 75 per cent of the antibiotic prescriptions each year. This occurs despite the fact that in most cases, antibiotic gives little or no benefit.
The guidelines cite dermatologists prescribing potent steroid–antibacterial–antifungal topical combinations to treat superficial fungal infections on patients’ face for an extended duration. Compared to topical corticosteroids, rapid 'feel-good' effect and ignorance about harmful effects lead to continuation of treatment beyond the prescribed duration. It is much easier to prescribe a systemic immunosuppressive than prescribe, educate and motivate a patient to use topical steroids though there is good quality evidence to use the latter as first-line therapy. The problem is compounded by the fact that everyone can prescribe dermatological medications, particularly the topical applications. “Dermatologists' prescriptions account for a minor proportion of sales of topical medications – other specialists including paediatricians, internists, general practitioners, over-the-counter sales, pharmacists and self-prescription account for the major percentage of procurement of these products,” the document noted.
The ICMR underscores the role of sophisticated and error-free tests in reducing irrational antibiotic prescription. “Rapid diagnostic tests for distinguishing between viral and bacterial infection greatly facilitate the decision of whether or not to prescribe antibiotics. With the advent of new rapid diagnostics, time frame can be reduced dramatically,” the guidelines stated.
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