Changing patterns in bugs and drugs in hospital

Antimicrobial Resistance (AMR) is a  universal problem. Its spread does not recognize country borders. The emergence and spread of drug-resistant pathogens threaten our ability to treat common infections and to perform life-saving procedures including cancer treatment,  organ transplantation and other surgeries.

Antimicrobials – including antibiotics, antivirals, antifungals, and antiparasitics – are medicines used to prevent and treat infectious diseases in humans, animals and plants.

AMR is a natural process that happens over time through genetic changes in pathogens. Its emergence and spread is accelerated by human activity, mainly the misuse and overuse of antimicrobials to treat, prevent or control infections in humans, animals and plants.

Who is smart- we or bacteria  –  let’s find

Bacteria is single celled structure without any brain and we (humans) have brain and well developed organ system but still bacterias are stronger  and brainy than us .

In 1928, Alexander Fleming discovered the first antibiotic, penicillin, and by the 1930s, the first antibiotic had become commercially available but became resistant in 1941 . Today, after less than a century  later, we are facing  health crisis as many high class of drugs that have commonly been used are no longer effective  and not available for treatment. End result is “superbugs “ Superbugs are strains of bacteria that are resistant to all or almost all antibiotics, including last-resort drugs called carbapenems.

• Carbapenem-Resistant Enterobacteriaceae are nightmare bacteria. They pose a triple threat.
• First, they’re resistant to all or nearly all antibiotics.
• Second, they have high mortality rates. They kill up to half of people who get serious infections with them.
• Third, they can spread their resistance to other bacteria.

In the study of national AMR surveillance conducted by ICMR and NCDC, Enterobacterales and non-fermenting Gram-negative bacilli (Pseudomonas aeruginosa and Acinetobacter baumannii) were reported to be most common Gram-negative pathogens. Over 50% of the infections in most ICUs in tertiary care centres in India are caused by difficult-to-treat (DTR) Gram-negative pathogens. In India, a sharp increase in carbapenem resistance in Gram-negative pathogens is seen, which leaves patients with limited treatment options and increases the risk of AMR attributed mortality in patients. Further, the declining effectiveness of antibiotics imposes potentially large health and economic burden.

Below is the table which summarizes the data on susceptibility of key antibiotics (modified from ICMR and NCDC data of 2023). It clearly conveys the message that carbapenem resistance is very high in Acinetobacter Baumannii (close to 90%), Klebsiella Pneumoniae (close to 50-75%).

Some of the main drivers of AMR?

One of the primary driver is the overuse and misuse of antibiotics in both human medicine and agriculture. In many cases, antibiotics are prescribed when they are not necessary or are not used correctly. This can lead to the survival and proliferation of resistant bacteria.

Message for everyone—

Antimicrobial resistance is a serious threat to public health globally. It is a slower-moving pandemic than COVID-19, so we are fast running out of treatment options. To  some extent we all are responsible for this situation as we have been using antibiotics for all disorders , may it be viral or fungus.. Remember—

You will be alright after 7 days without antibiotics. You will be alright after one week with antibiotics. Choice is yours!

1.   Antibiotics have no effect on viral illness.
2.   Overusing   antibiotics  causes  resistance.
3.   If your doctor decides you need an antibiotic  , make sure you take them as  prescribed .
4. Your body’s immune system can often protect   against  infection  without the need for antibiotics. Do not expect your doctor to prescribe antibiotics every time you are ill.
5. Even  if you start to feel better , always complete the full course.
6.  Never save antibiotics for later use or share them with other people.

Message for prescribers

Everytime antibiotics are Prescribed —

• Order recommended cultures before antibiotics are given .
• Make sure indications,dose and expected duration are specified in the patient record .
• Reasses within 48 hrs and de-escalate / escalate according to sensitivity  report or stop if not required .
• Clearly distinguish whether your patient is suffering from community acquired infection or hospital acquired infection.
• Community acquired bacterial infections can be easliy managed by using cephalosporins, aminoglycosides, macrolides and tetracyclines depending on indications, Carbepenems, polymyxins and combination therapies should be restricted to the treatment of hospital acquired infections
• We should also remember that India is a TB endemic country so antibiotics like Levofloxacin and Linezolid should not be used indiscriminatoly as these are important drugs to manage Drug resistant TB.

Message for Everyone

• Follow good infection control practices like clean hands, food safety
• Vaccinate yourself for vaccine preventable diseases like Typhoid, pneumococcus and influenza (even adults need vaccines)

Message for Health care professionals and health care Institutions

• Follow hospital infection control practices with utmost diligence
• Vaccinate yourself and encourage your patients to take vaccines (reduce hospital admission and hence antibiotic use)
• Every health care facility should have antibiotic policy and monitor pattern of bugs within the Institute.
• Every hospital should have infection control committee. Any outbreak of infection within hospital or community should be investigated.

Guest Editor-Dr.Neelam Sachdeva- Chief of Microbiology, Head CSSD & Infection control Officer,RGCIRC

Co-Author-Dr.A.K.Dewan-Director-Surgical Oncology,RGCIRC