Arjun (name changed) is an 8-year-old boy who was being treated for breathing difficulty in a hospital in one of the southern cities. He had suffered on and off with cough/cold since infancy and had been treated multiple times with antibiotics. His parents were not highly educated and hoped that he would get better as he grew older. This time, he became much sicker and was admitted to hospital. Since his problem was quite complicated, he was referred to us. We investigated and continued to treat him. He was diagnosed with a complicated birth defect of the breathing passages.
However, one of the investigations performed here showed that he was colonised with a dangerous bacterium that is acquired only from hospitals. Moreover, this bacterium was resistant to most of the commonly used antibiotics. The child then developed pneumonia and had to be admitted to the Intensive Care Unit. He was treated with high doses of a toxic antibiotic. Thankfully, he recovered and was successfully discharged.
Why did Arjun suffer so much? Who is to blame?
The problem of getting infections in hospitals is not new. However, over the past many years, doctors have noticed that the bacteria are becoming more resistant, making it much harder to treat these infections. Moreover, we are seeing infections with resistant bacteria being acquired from the community, in children who have never been admitted to hospitals. The problem was noticed many years ago as bacteria gradually became resistant to commonly used antibiotics.
No problem — the pharmaceutical industry had bigger, better (and more expensive!) drugs. They had a field day marketing various antibiotic formulations (many of which are unapproved, but continue to be available in the Indian market). However, bacteria are very smart and have developed resistance to these new drugs. Now, there are groups of bacteria that are resistant to almost all antibiotics, leaving doctors with little choice but to use older drugs, like Colistin, that were given up decades ago due to high toxicity.
Bacteria will eventually develop resistance to even these agents. Currently, there are no new agents in the pipeline and we will soon have no means of treating these bacteria. The cause of this problem is complex, but the main issue is rampant abuse of antibiotics, by both doctors and the public. Patients often demand antibiotics, even for viral infections (where antibiotics have no role). In addition, antibiotics are freely available without prescription, leading to self-medication. A huge amount of antibiotics is also used in the veterinary industry, and eventually this finds its way into the general resistance chain.
Pharmaceutical companies produce huge amounts of antibiotics, including many unapproved ones, and promote them aggressively to doctors. Effective infection control is very difficult and these practices are not up to the mark in most Indian hospitals. Antibiotics are often used as an excuse for poor infection control practices. The most cost-effective way of preventing cross infection is to encourage good infection control. When a patient gets a hospital-acquired infection, the result is increased morbidity (and sometimes mortality), increased length of hospital stay and a huge increase in costs.
What can be done to remedy this issue? Both patients and doctors must cooperate. Patients should ensure that they don’t medicate themselves and ask for antibiotics only when really needed. When prescribed, the full course must be taken. There has to be a huge change in the way doctors use antibiotics, starting with rational prescription only when needed. Antibiotic use should be guided by appropriate cultures done in a reliable microbiology laboratory. When required, the narrowest spectrum drug should be used for the shortest duration possible — why use a mallet when a hammer will suffice! Hospitals have to spend adequate resources in training of personnel and enforce good infection control practices to reduce the chances of cross infection. In developed countries, doctors are not allowed to use powerful antibiotics when a simpler one is adequate, unless they can convince the Infection Control team otherwise. In the U.S., hospitals are required by law to publicise their infection rates and insurance companies will not reimburse people for hospital acquired infections — both of these are strong stimuli to reduce infection rates. The Indian government should regulate the marketing of unapproved, unproven or irrational formulations. Antibiotics should strictly be available only on prescription.
So, the next time your doctor prescribes an antibiotic, question him or her whether this is really necessary. If you are hospitalised, please ask whether adequate infection control practices are being adhered to. Ask whether the antibiotic prescribed is approved and ensure that appropriate cultures are performed before it is started.
( The writer is a senior paediatrician specialising in Paediatric Intensive Care. The views expressed in this article are his own. His email:mdpicu@hotmail.com )
