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In an urgent appeal to all doctors in medical colleges, the Indian government has advised to mandatorily mention the exact indication/reason/justification for antibiotic prescription. In a swift move to address the threat of Antimicrobial Resistance (AMR), the director general of health services, Ministry of Health, Government of India has issued this communication.
Currently, the novel move is to implement it in medical colleges. The letter adds that, the medical colleges not just provide tertiary health care in the country but are also hubs for education.
It is estimated that bacterial AMR was directly responsible for 1.27 million global deaths. Increased air pollution levels are also linked to AMR.
Antibiotic prescription: Justify the reason
“All the doctors to make it a mandatory practice to write indication/ reason justification while prescribing antimicrobials,” reads the letter written by Director General of Health Services (DGHS), Prof Atul Goel which is sent to all medical colleges in India. He further adds that, “Misuse and overuse of antimicrobials is one of the main drivers in the development of drug-resistant pathogens. With few new antibiotics in the Research & Development pipeline, prudent antibiotic use is the only option to delay the development of resistance.”
In another communication to pharmacists, Prof Goel has directed for the strict implementation of the schedule H and H1 of the Drugs and Cosmetic Rules and sell antibiotics only on valid prescriptions.
Antibiotics and wise usage: Culture test a must
Dr Asima Banu, professor of microbiology and principal of Bangalore Medical College welcomes the move adding that this can help young doctors be aware of the right usage of antibiotics. “When we have to indicate the reason for prescribing antibiotics, we must do antibiotics sensitivity test. Upon knowing the organism and its drug sensitivity, a specific antibiotic is identified and prescribed. We first give empirical antibiotics, which is the first line of antibiotics as per the syndromic management guidelines,” Dr Banu said.
When the first line antibiotic treatment is going on, parallelly the person’s body fluid sample is taken for culture test within 48 hours. “Once the culture report comes, we can check if the same antibiotic prescribed is sensitive for the organism, if not and if it is resistant, then the antibiotic has to be changed accordingly,” Dr Banu told Happiest Health.
Dr Banu adds that the antibiotics have to be given for a specified time period of 5 or 7 days, based on the clinical evaluation and the person must be told to complete the course and not stop abruptly or to continue longer than the specified days of usage.
The advisory from DGHS has led to discussion among medical professionals, especially as it mandates only to medical colleges and not for the private healthcare industry.
Prescription audit to control AMR
Dr Anup R Warrier, consultant, infectious diseases and infection control, Aster Medcity, Kochi says that many such advisories are already there but haven’t made impact yet. “There is quality of prescription audit, which assesses the prescription of antibiotics against their set standards and compares it with best practices. There are sets of prescribed standards against which a doctor’s prescription is compared. Whether an indication of the usage of the drug has been mentioned is one such standard. If there is a requirement for a doctor to prescribe an antibiotic, it will stimulate one to think once again,” said Dr Warrier. Unless there is an evaluation system built to check on this, such advisories hardly work, says Dr Warrier.
Speaking to Happiest Health, Dr Rajeev Jayadevan, chairman, research cell, Kerala state IMA said that a major reason for AMR is widespread over the counter use of antibiotics, which do not involve a doctor. “This move is to remind practitioners about the clinical processes behind prescribing antibiotics, so that they use it judiciously. But there is a huge elephant (AMR) in the room that needs to be tackled with a multi-dimentional approach. Asking doctors to specify the reason for prescribing an antibiotic is only a small part of it,” he said.
Experts also cite the widespread use of antibiotics in the agriculture, veterinary and fishery industry, where the drugs enter water and soil on a large scale.
Kerala’s novel move to curb AMR
It can be recalled that recently in the first week of January 2024, the Kerala Drug Control Department launched operation AMRITH (Antimicrobial Resistance Intervention for Total Health) and started making surprise raids to pharmacies to check on the antibiotics sold over the counter, without prescriptions. The state government also mandated that the pharmacies must put out a disclaimer stating ‘antibiotics not sold without doctor’s prescription.’
While over the counter sale of antibiotics is a problem, another problem area is the mindset among the public to question the doctor’s advice, when antibiotics are not prescribed. “For example, some with viral fever who visit the doctor demand antibiotics. They are not satisfied with the doctor’s scientific advice to take only paracetamol as necessary, along with fluids and rest. Some even complain that it was not worth the doctor’s consultation fee as such advice and fever medicines, they could have had on their own at home,” says Dr Jayadevan, adding that there is a need to create awareness among the public too. “In addition, after hearing the discussions on AMR, some people are afraid to take antibiotics even when required, this is also dangerous,” he pointed out.
He adds that the Indian Medical Association has been conducting awareness sessions for doctors on diligent use of antibiotics for a long time. “However, a doctor’s antibiotic prescription is not the biggest concern when it comes to the huge canvas of AMR. The real problem is when the prescription and clinical thinking is bypassed,” Dr Jayadevan said, talking about the threat of antimicrobial resistance.
Takeaways
While antimicrobial resistance has been a matter of global public health concern, a recent communication from the director general of health services says that medical colleges must indicate the reason for prescribing an antibiotic. However, this advisory is only for medical colleges and not for the private healthcare industry. According to experts the need is to first tackle the over-the-counter sale of antibiotics.
