DOI: 10.7860/JCDR/2014/8925.

4529
Review Article

Strategies to Combat Antimicrobial

Internal Medicine
Section

Resistance

Rajesh R Uchil1, Gurdeep Singh Kohli2, Vijay M Katekhaye3, Onkar C Swami4

ABSTRACT
The global burden of antimicrobial resistance is rising and is associated with increased morbidity and mortality in clinical and community
setting. Spread of antibiotic resistance to different environmental niches and development of superbugs have further complicated the
effective control strategies. International, national and local approaches have been advised for control and prevention of antimicrobial
resistance. Rational use of antimicrobials, regulation on over-the-counter availability of antibiotics, improving hand hygiene and improving
infection prevention and control are the major recommended approaches. Thorough understanding of resistance mechanism and innovation
in new drugs and vaccines is the need. A multidisciplinary, collaborative, regulatory approach is demanded for combating antimicrobial
resistance.

Keywords: Antimicrobial resistance, Antibiotic, Control and prevention, Infection, Rational use

Introduction We herein discuss the effective strategies for combating AMR.

Antimicrobial resistance (AMR) including multidrug resistance The collaborative approach is required at different levels. Different
(MDR), is on the rise among many microorganisms in health-care measures for combating AMR can be directed at international,
facilities as well as in community [1]. Reported data suggests that national, community, hospital, individual and patient level. [Table/
almost 2 million cases of infection with resistant bacteria have Fig-1] summarizes these approaches.
been reported in the United States (US) every year leading to $20
billion incremental direct healthcare cost [2]. Estimates of European
Medicines Agency (EMA) and European Centre for Disease
Prevention and Control (ECDC) reported a toll of 25,000 deaths per
year as a direct consequence of a MDR infection with total cost
of €1.5 billion [3]. In Canada, hospitalization caused by resistant
infections resulted in higher economic burden with excess cost
of $9–$14 million [1]. Study by Indian Network for Surveillance of
Antimicrobial Resistance (INSAR) group, India reported prevalence
of 41% with methicillin resistant Staphylococcus aureus (MRSA)
[4]. High prevalence of Gram–negative bacterial resistance has
also been reported in India [5]. World Health Organization (WHO)
estimates that worldwide 3.7% of new cases and 20% of previously
treated cases are estimated to have MDR-TB [6].
The path of antibiotic development is challenged at every step
by the emerging microbial resistance. Emergence of MRSA, [Table/Fig-1]: Approaches for combating of antimicrobial resistance
resistant Pseudomonas aeruginosa have already compromised Std.: Standard, R & D Research and Development, OTC: Over-the-Counter
the most effective treatments [7]. Recent reports have witnessed
changing susceptibility pattern and spreading trend in AMR [8-10].
Development of superbug like New Delhi metallo-β-lactamase 1 1. International Measures
(NDM-1) positive Enterobacteriaceae have further complicated the As a global problem, AMR is now well accepted by various
management of such infections [11]. stakeholders. In the year 2011, WHO theme was on combating
antimicrobial resistance. It was one of the major attempts to draw
Urgent threats with Clostridium difficile, carbapenem-resistant
international attention and need of combined efforts to alleviate the
Enterobacteriaceae (CRE) and drug-resistant Neisseria gonorrhoeae
problem of AMR [13]. Some of the WHO recommended approaches
have been reported by US Centers for Disease Control and
are listed below: [14]
Prevention (CDC) [2]. Thus AMR is a major point of concern as it
is associated with high death rates and fear of progression to the • Increased collaboration between governments, nongover­
pre antibiotic era; also has potential to hamper infectious disease nmental organizations, professional groups and international
control programmes; increase in health care costs and diminish agencies
health-care gains achieved so far [6].This review discusses various • New networks that undertake surveillance of antimicrobial use
measures that can be taken to combat AMR with major emphasis and AMR
on antibiotics resistance. • International approach for control of counterfeit antimicrobials
Call for action • Incentives for the research and development of new drugs and
The global threat of AMR calls for the collaborative action for developing vaccines
effective strategies in combating AMR. CDC recommends 12 steps • Forming new, and reinforcing existing programmes to contain
to prevent antimicrobial resistance in a healthcare setting [12]. AMR.

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2. National Strategies 3.3 Guidelines for use of antibiotics at local levels

2.1 National committee with intersectoral coordination and About use of antibiotics in common situations, Bhagwati A.
regulatory actions discussed that an empirical antibiotic therapy should be started
Establishment of national committee to monitor impact of antibiotic considering the clinical condition of the patient and prevalent
resistance and provide intersectoral co-ordination is required. WHO pathogen and resistance pattern in a locality. Appropriate change
recommends that such committee would formulate AMR policy; in antibiotic is required as per the sensitivity of microbe. Antibiotic
provide guidance on standards, regulations, training and awareness guidelines are therefore must to optimize antibiotic selection with
on antibiotic use and AMR. Developing indicators to monitor and their dosing, route of administration and duration of therapy [21].
evaluate the impact of AMR prevention and control strategies would 3.4 Standards of hygiene
be amongst priority objectives at national level [15].Further WHO Use of alcohol-based hand rubs or washing hands has proven
advises that having a registration scheme for all dispensing outlets, efficacy in prevention of infection [12,23]. This factor can restrict the
making prescription-only availability of antimicrobials, legal binding spread of infection and thereby the AMR. Willingness to put up with
on all manufacturers to report data on antimicrobial distribution and high standards of hygiene is the need of an hour.
incentives for rational use of antimicrobials can help contain AMR
[15]. 3.5 Other approaches
These include identifying residents with MDR infections and use
Establishing and implementing national standard treatment
of standard treatment regime for their management, vaccination,
guidelines, having essential drug list (EDL), enhancing coverage of
infection prevention strategies and ban on OTC sale of antimicrobials
immunization are other essential strategies desired at national level
[12,16].
[14].
2.2 National Antimicrobial Resistance Policy, India 4. At Hospital or health care setting
A national policy for containment of AMR was introduced in 2011. A person or a patient in a health care facility is at higher risk of
The policy aims to understand emergence, spread and factors infection with common pathogens. For control and containment
influencing AMR, to setup antimicrobial program, to rationalize the of AMR, experts recommend some of the measures as discussed
use of antimicrobials and to encourage the innovation of newer herein.
effective antimicrobials. In addition, some major action points 4.1 Infection prevention and control within health-care facilities
identified in national policy were; establishing AMR surveillance [1,24]
system, strengthening infection prevention and control measures Infection prevention and control measures are designed to reduce
and educate, train and motivate all stake holders in rational use the spread of pathogens including resistant ones within healthcare
of antimicrobials [16]. WHO estimates that less than 50% of all facilities and to the wider community. This can prevent further
countries are implementing basic policies for appropriate use of infections and AMR spread [1]. Recommended measures to prevent
medications [17]. and control infection in a health-care facility [1,12,16,24-26].
3. Action at Community Level • Establishing an infection prevention and control committee
Globally, infectious diseases still continue to be significant cause of (IPC).
morbidity and mortality, affecting more the countries where health • Good hand hygiene practices.
services are not sufficiently accessible [18]. Kardas et al., in a review • Effective diagnosis and treatment of infection.
of antibiotic misuse in the community reported that at community
• Rational antimicrobial use.
level, more than one third of patients were non-compliant to the
antibiotic regimen and one quarter kept the unused antibiotics for • Surveillance of antibiotic resistance and antibiotic use.
use in future [19]. This indicates a poor antibiotic-taking behavior • Improving the antimicrobial quality and supply chain.
[19]. Review on population perspective of AMR by Lipsitch et al., • Good Microbiology Practices.
suggests that prevention of AMR in an individual suffering from
infection is one of the basic method to prevent further spread of Surveillance of Antibiotic resistance and antibiotic use
resistance to the wider community [20]. The increasing rate of All over the world, surveillance is considered as strength of the
resistance among community acquired infections like upper and programmes directed towards AMR. The objective of surveillance
lower respiratory tract infections, bacterial diarrhea, typhoid fever is to facilitate the containment of antibiotic resistance. It is a useful
are not matched by development of newer antibiotics [21]. Thus tool that generates data on antimicrobial use and AMR which is
there is urgent need for reforms at community level for curtailing essential in updating national EDLs and formulating infection control
AMR. Different measures directed to control and prevent AMR at policies. It may also help in improving antimicrobial prescribing and
community levels are the need of an hour. development of empirical therapy or standards treatment guidelines
[25,26].National policy on AMR in India recommend three types of
3.1 Rational use of antibiotics
surveillances which include comprehensive surveillance, sentinel
Irrational use of medicines is a serious global problem. In developing
surveillance, and point prevalence [16].
countries, at primary level, less than 40% patients in public sector and
less than 30% patients in private sector are treated in accordance
Good Microbiology Practices
with standard treatment guidelines [17].This mandates public and
From accurate collection, handling of specimens to the speedy
professional education towards rational use of antibiotics.
reporting with standard microbiology practices may help in
3.2 Over-the-counter (OTC) antibiotics prevention of AMR spread. Testing with international standards,
Measures that preserve efficacy of antimicrobials are mainly directed reporting of resistance pattern to IPC and monitoring the sterilization
towards the hospitals and drug providers and missing antibiotic and disinfection activities underlie the good microbiology practices
use without prescription. In systematic review of non-prescription [16,24].
antimicrobial use, Morgan et al., reported that non-prescription
use of antimicrobials varied from as low as 3% in northern Europe 5. At Personal / Patient level
studies to 100% in African studies [22]. This implies urgent need for 5.1 Role of Physician
regulatory control on OTC use of antibiotics. Along with providing direct patient care, complying with local
infection control and antibiotic use policies and timely notifying

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www.jcdr.net Rajesh R Uchil et al., Strategies to Combat Antimicrobial Resistance

resistant cases to IPC, the physician can play a major role in the treatment of infections and contribute to the control of AMR
combating AMR [24]. Identifying and preventing situations that may [32].
act as nidus for infection may help curtail unnecessary infections
6.4 Innovation in new drugs and technology
and thereby AMR [12].
Concerns of increased antibiotic resistance lead to the urgent
5.2 Role of Nurses/health care providers need of concentrating on the issue of new drugs and vaccines
Since nurses/health care providers are in direct contact with the development to combat AMR. Collaborated efforts of national,
patients, they are amongst those related in either spread or control international, government and academic networks are needed to
of infection and AMR. Educating nurses and health care providers identify new classes of antibiotics and diagnostic technologies [15].
about the AMR and aseptic practices may help in control of spread Providing research funding for development of new antimicrobials to
of infections. Moongtui et al., have reviewed the role of nurses in pharmaceutical companies for diseases of public health importance
preventing AMR and reported the initiatives by Thailand like having can advance the new drug development.
Master’s programme in infection control nursing with other short In summary, it is necessary to enforce essential actions to be taken
training courses and involvement of nurses in AMR prevention and by government to inspire change by all stakeholders related to AMR
control programme [27]. as described in WHO policy package for combating AMR [13]. This
5.3 Role of Pharmacist policy package refers to:
McCoy et al., in their review discussed the Pharmacist-directed • Dedicate to a comprehensive, financed national plan with
antibiotic stewardship programs (ASPs) as an approach to improve accountability of each one involved and engagement of civil
the utilization of antibiotics. Pharmacists can counsel patients with societies
viral infections about the ineffectiveness of antibacterials and can • Improve and strengthen surveillance and laboratory capacity
recommend appropriate OTC medication for supportive care. and facilities
Referral to physician is must if a bacterial infection is suspected.
• Make sure uninterrupted wide access to essential medicines
Above all, most importantly, addressing patient and clinician
of assured quality
concerns related to antimicrobial and understanding of the
appropriate use of these agents, pharmacist can be an essential • Regulate and encourage rational use of medicines, even in
arm in preventing AMR [28]. Pharmacist is the key person to educate animal husbandry, and ensure proper patient care
patients about antimicrobial use and the importance of complying • Improvise on infection prevention and control
with the prescribed treatment regime. This may help to reduce the • Promote and pursue innovations and research and development
unnecessary use of antibiotics. for new tools
5.4 At patient level
(a) Aseptic protocol for any procedures. Conclusion
Antimicrobial resistance is a complex problem with many diverse
Parameswaran et al., reported that MDR microbes caused 30.2% of
contributing factors. It is major cause of health concerns adding cost
the catheter-related blood-stream infections and empirical treatment
to oneself and to the community, directly or indirectly. Prevention is
had no role in prevention of such infections [29]. This mandates
still the best tool to reduce the infection spread and thereby AMR.
use of aseptic protocol to minimize local or systemic infections
Along with rational use of existing antimicrobial drugs, development
associated with any procedures.
of new effective compounds and new diagnostic technology is
(b) Breaking the chain of infectivity [12]. the need. Joint efforts from patients, prescribers and individuals
By simple means like covering mouth while coughing or sneezing, to international regulators and policy makers are needed to fight
infection spread can be reduced. against the globally spreading antimicrobial resistance.
(c) Compliance to the antimicrobial regime and antibiotic.
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PARTICULARS OF CONTRIBUTORS:
1. Consulting Physician, Department of Medicine, Holy Family Hospital, Bandra (W), Mumbai, India.
2. Director and Consultant Physician, Department of Medicine, Joy Nursing Home, Rajouri Garden, New Delhi, India.
3. Assistant Manager, Department of Medical Services, Unichem Laboratories Ltd. Unichem Bhavan, Jogeshwari (W), Mumbai, India.
4. Head, Department of Medical Services, Unichem Laboratories Ltd. Unichem Bhavan, Jogeshwari (W), Mumbai, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Onkar C Swami,
Head, Medical Services, Unichem Laboratories Ltd. Unichem Bhavan,
Prabhat Estate, SV Road, Jogeshwari (W), Mumbai – 400 102, India.
Date of Submission: Feb 14, 2014
Phone: +91-22-66888333, Fax: +91-22-26780303/+91-22-26785198, E-mail: [email protected]
Date of Peer Review: Mar 24, 2014
Financial OR OTHER COMPETING INTERESTS: None. Date of Acceptance: Apr 05, 2014
Date of Publishing: Jul 20, 2014

4 Journal of Clinical and Diagnostic Research. 2014 Jul, Vol-8(7): ME01-ME04