Experts warned that COVID-19 showed a drastic increase in resistance to several important antibiotics and antifungals. Every clinician is using antibiotics in routine clinical practice and this will practice changing recommendations. 

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Antibiotics have been used by Indians to cure a variety of illnesses, diseases, and infections - often without seeing a physician. Studies have indicated that repeated use of antibiotics reduces a patient's sensitivity, hence developing antimicrobial resistance. In a study done between January 1 and December 31, 2021, the Indian Council of Medical Research (ICMR) discovered that a high proportion of patients no longer benefited from the usage of specific medications due to antimicrobial resistance.

As a result, the Indian Council of Medical Research (ICMR) issued revised guidelines on the prudent use of antibiotics in the country. In addition to advising against the use of antibiotics for diseases such as moderate fever or viral bronchitis, the ICMR has advised physicians to adhere to a timeframe when prescribing antibiotics. The most current recommendations, titled "Treatment Guidelines for Antimicrobial Use in Common Syndromes," are an updated version of the 2017 National Action Plan for Antimicrobial Resistance. (NAP-AMR).

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The worrying rise of antibiotic resistance in India

Due to the unfettered use of antimicrobials, the new recommendations, according to experts, are particularly important in the post-COVID-19 era. According to specialists, COVID-19 has shown a considerably enhanced degree of resistance to various key antibiotics and antifungals. The ICMR performed a multi-centre study to establish the national antimicrobial resistance trend. It revealed that the gram-negative bacterium Acinetobacter baumannii, which causes infections in the urinary system and lungs, among other bodily areas, was resistant to cutting-edge medications. According to the study, 87.5% of the Acinetobacter baumannii samples tested in 2021 were resistant to carbapenems, limiting the treatment choices for patients infected with the disease.

Doctors think that AMR or Antimicrobial Resistance makes it difficult to treat illnesses and raises the danger of disease transmission. AMR arises spontaneously when bacteria, fungi, and viruses mutate and lose the ability to react to drugs. According to specialists, drug abuse and inappropriate use might hasten the process.

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The ways to avoid antibiotic overuse

Antibiotics may not be effective against all illnesses; hence, overuse of these treatments is one of the primary causes of antimicrobial resistance (AMR) in India, according to medical specialists. If healthcare professionals believe a patient may need antibiotics, they should, wherever feasible, test and confirm which one they may require.

Today, even parents give their children medicines for the flu or cold, which is not recommended. Reports indicate that India is one of the nations with the greatest rates of antibiotic resistance, with an estimated 5–10% annual increase rate. Antibiotic resistance is estimated responsible for over 1.3 million fatalities in 2019. The ICMR advised against administering antibiotics for mild fever and viral bronchitis. In addition, the recommendations stipulate that a stop date should be documented to ensure that antibiotics are not administered for longer than indicated. Antibiotics should be recommended for five days for infections of the skin and soft tissues, five days for community-acquired pneumonia, and eight days for hospital-acquired pneumonia.

A research investigation was conducted by a team from Boston University in the United States and the Public Health Foundation of India. It was reported that India is the world's greatest user of antibiotics in terms of absolute volume. In addition, they claimed that Indian research has shown poor prescription quality without proof of bacterial infection.

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In a recent report, ICMR has formulated the following steps -

Step 1: Diagnosing a medical condition

Rather than blindly relying on fever, procalcitonin levels, white blood cell (WBC) counts, cultures, or radiology to make a diagnosis of infection, a clinical diagnosis frequently enables us to predict causative pathogens fitting into a clinical syndrome, thereby allowing us to tailor the correct antibiotic. It is important for us to think about the diagnosis of infection.

• Could it be an infection?
• A risk assessment indicates the patient's likelihood of having an infection.
• What potential non-infectious mimics are there?
• Have the proper cultures been obtained to corroborate the final diagnosis?

Step 2: Restrict empiric antibiotic treatment to actual critically sick patients

In general, empiric antibiotic treatment is only indicated for a restricted set of patients, as outlined below, after the collection of suitable cultures from patients who are really gravely sick.

• Febrile neutropenia
• Severe sepsis and septic shock
• Community-acquired pneumonia
• Ventilator-associated pneumonia
• Necrotizing fasciitis

Therefore, it is essential to begin strategically and then concentrate, i.e., to determine whether empiric treatment may be justified or de-escalated and then to formulate a strategy for the length of therapy.

Step 3: Be aware of your infecting organisms

Approach includes

• Identify the clinical syndrome
• Elucidate possible sources of infection
• Predict possible microbial pathogens
• Predict the local resistance pattern based on institutional antibiogram

Step 4: Select the correct antibiotic

• Based on the antibiotic's spectrum while taking into consideration potential resistance tendencies.
• Utilise the proper dosage, method, and duration.
• Ensure that the selected antibiotic has appropriate tissue penetration at the infection location.
• Optimise PK-PD parameters according to co-morbidities

Step 5: De-escalation/modification

• Revise empiric broad-spectrum antibiotics based on culture and antimicrobial susceptibility reports and patient status.
• Stop polymyxins and glycopeptides if no carbapenem-resistant organisms (CRO) or methicillin-resistant Staphylococcus aureus (MRSA) are identified on cultures.
• Avoid double or redundant gram-negative or anaerobic coverage.
• Discontinue antibiotics if a non-infectious mimic is identified.
• De-escalate combination treatment to a single agent
• Change a broad-spectrum antibiotic to a narrow-spectrum one
• Change antibiotics administered intravenously to those administered orally

De-escalation is safe for all patients, even those with febrile neutropenia and septic shock, and it decreases mortality and hospital stay duration..

Step 6: Avoid antibiotics in these clinical conditions

1. Respiratory tract syndromes

• Viral pharyngitis
• Viral rhinosinusitis
• Viral bronchitis
• Non-infectious cardio-pulmonary syndromes misdiagnosed as pneumonia

2. Skin and Soft Tissue Infections

• Subcutaneous abscesses
• Lower extremity stasis dermatitis

3. Asymptomatic bacteriuria and pyuria including in catheterised patients
4. Microbial colonisation and culture contamination
5. Low-grade fever

Step 7: Shorten the length of the treatment

The following durations are suggested by practice guidelines and recommendations for the optimal length of treatment for different infectious disease syndromes :

Community-acquired pneumonia: 5 days

Hospital-acquired pneumonia: 8 days

Skin and Soft tissue infections: 5 days

Urinary tract infections

• Cystitis: 3-5 days
• Pyelonephritis: 5-14 days
• Catheter-associated: 7 days
• Staphylococcal aureus bacteraemia
• Low risk of complications = 2 weeks
• High risk of complications = 4-6 weeks
• Intra-abdominal infection: 4-7 days
• Surgical antibiotic prophylaxis: 1 dose
• Surgical antibiotic prophylaxis: 1 dose

A cutoff date should be determined and documented in advance to ensure antibiotics are not administered for longer than required.

Step 8: Optimise PK-PD parameters

Optimising Pk-PD parameters include loading doses when needed, therapeutic drug monitoring for toxicity and efficacy and optimisation of drug infusion or administration. For e.g., Loading dose of Colistin 9 million units stat and then followed by 3 million units Q8H or 4.5 million units Q12H [to target Colistin Average Steady-State Plasma Concentration (Css,avg = 2-2.5 mg/L)

Inj vancomycin 1g IV Q12H and dose to be adjusted to maintain a trough level between 15-20 µg/ml [however there are increasing recent data that suggests that AUC/MIC may be a better indicator of clinical efficacy than a trough level]

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.