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Updated: April 28, 2013 09:20 IST

Bacteria are becoming bolder

Dr. Bala Ramachandran
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Patients should ensure that they don’t medicate themselves and ask for antibiotics only when really needed. Illustration: Sreejith Kumar
Patients should ensure that they don’t medicate themselves and ask for antibiotics only when really needed. Illustration: Sreejith Kumar

Antibiotics are often used as an excuse for poor infection control

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)

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Regrettably, this is one of those ticking time bombs that are very difficult to
control without real understanding, commitment and rigorous implementation
across the entire country and society, a feat which we at least have never pulled off
yet.
Doctors need to treat illnesses with the proper means and need to put the medical aspects ahead of all other ones, patients need to stop demanding antibiotics
without reason and when given antibiotics, they need to take a full course. All this without even considering the monetary side of the business which as we know is decisive in India.
One can only despair. We are now the hub for most of antibiotic-resistant diseases and with a considerable diaspora and large number of travellers, the largest
exporter of these diseases into the wide world.
If things go on like this, we'll soon reach a point where simple cuts and bruises will lead to fatal infections, like in the pre-penicillin era. I fear that it will be so.

from:  Vivek
Posted on: Apr 29, 2013 at 12:39 IST

Hospital-bred or nosocomial infections are many. Dr. Bala Ramachandran has touched on one important aspect. Forget public hospitals, even private hospitals resist investing in disinfection and sterilization equipment. They do not see any immediate "Returns" from such investment.
Awareness among the medical fraternity is shockingly low.

from:  n. satya murti
Posted on: Apr 28, 2013 at 12:11 IST

“So, the next time your doctor prescribes an antibiotic, question him or her whether this is really necessary.”

Do you expect your doctor to say “Sorry, I just wrote it for fun. I will scratch it”?

“If you are hospitalised, please ask whether adequate infection control practices are being adhered to.”

Better ask this before you get hospitalised.

“Ask whether the antibiotic prescribed is approved and ensure that appropriate cultures are performed before it is started.”

Doing a culture and sensitivity is routine in any serious illness. But you may be dead and gone if your doctor waits for the results before starting an antibiotic.

from:  Dr Titus Sankaramangalam
Posted on: Apr 28, 2013 at 11:49 IST

Thanks for writing such an informative article. Quacks are the real responsible persons behind this problem. I have observed this ill informed quacks prescribing brad spectrum antibiotics for influenza (common cough and cold) to the kids as young as two years. The patients/parents, after seeing this tend to purchase the same antibiotic from the chemist shop themselves frequently.This rampant use of antibiotics should be stopped. I am pretty sure that all reading this article would follow the right steps. But what about those millions who do not read this article. More importantly, how to educate those millions who do not understand the consequences. Let us share the article to your near and dear ones and try informing everyone who comes in contact with you.

from:  Rohit Sah
Posted on: Apr 28, 2013 at 11:10 IST

Contrary to the article, most of the doctors especially ones near to homes get irritated if we ask questions and stop treating people. The system needs to be changed by a group of committed people and a forum to complain against these doctors.

from:  Vinoth
Posted on: Apr 28, 2013 at 10:43 IST

Very informative article. must read for all.

from:  Mahesh Vhatkar
Posted on: Apr 28, 2013 at 05:56 IST
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