Antimicrobial resistance and inappropriate use of antimicrobials: Can we rise to the challenge?

The human race has witnessed several wars during its existence. Most wars stop within a specific time period, but one of these - the war against microbes - goes on and on. Humans thought they had won the war against microbes with the discovery of antimicrobials in the earlier part of the 20th century. The advent of antimicrobial resistance (AMR) has now brought about the realization that antimicrobials may have given humans only a transient victory.

AMR has risen to alarming proportions and is truly a global public health issue. Surveillance systems in high-income countries have revealed that the problem exists not just in hospitals, but in the community too.[1] Low- and middle-income countries (LMIC) like India have not been spared too, with AMR reaching high levels in urban and rural areas.[2]

There are different factors associated with rising AMR. Among these, important contributive factors include individual and collective antimicrobial use.[3] Relatively few studies have been conducted in India on antimicrobial use. These have revealed high[4] and inappropriate use of antimicrobials,[56] posing grave implications for public health in India.

Stakeholders in antimicrobial use include physicians, nurses, pharmacists, patients, their relatives, medical representatives, distributors, pharmaceutical companies, regulators, and policy makers. There are also stakeholders involved in nonhuman use in the animal and agricultural industry. Since stakeholders are responsible in different ways toward inappropriate use,[7] all groups should make an effort toward appropriate use of antimicrobials.

On behalf of various stakeholders, the World Health Assembly (WHA) in May 2014 tasked the World Health Organization (WHO) to develop a plan to tackle AMR.[8] As a consequence, multiple stakeholder meetings and consultations were held, culminating in a resolution on AMR in the WHA in May 2015 and the release of a global action plan (GAP). In another development, civil society organizations representing healthcare, agricultural, and development sectors launched the Antibiotic Resistance Coalition to tackle AMR. Countries are also taking the initiative. Sweden has long been in the forefront with organizations such as STRAMA and ReAct taking the lead in reducing AMR. In the USA, the Presidential Council of Advisors in Science and Technology is implementing a plan for containing AMR. In India, there have been attempts through various quarters to contain AMR. These include policies by the government such as bringing antimicrobial prescriptions under schedule H1 and efforts through the Chennai Declaration, Global Antimicrobial Resistance Partnership, National Centre for Disease Control's policy on containment of AMR and ICMR's Antibiotic Stewardship, Prevention of Infection and Control program.[9] However, for all these initiatives to be truly effective in long-term containment of AMR, there needs to be a sustained, multipronged strategy involving all stakeholders. The GAP of WHO provides an ideal platform for a fresh impetus involving all countries and stakeholders in the fight against AMR.

Member countries of WHA have been urged to implement the GAP and integrate and contextualize it with their national priorities through a national action plan on AMR. This national plan, to be initiated within the next 2 years on the lines of the GAP, should encourage the appropriate use of antimicrobial medicines in agriculture, animal, and human health. The main objectives of the WHO GAP[8] are to: (i) Improve awareness and understanding of AMR (ii) strengthen surveillance and research (iii) reduce the incidence of infection (iv) optimize the use of antimicrobial medicines (v) ensure sustainable investment in countering AMR.

Toward achieving these objectives, strategies in various domains to tackle global AMR have been suggested:[8]

Communication: Increased awareness and understanding about AMR and its consequences would greatly assist efforts in changing the behavior of stakeholders toward improving antimicrobial use. Different approaches may be needed for various stakeholders. However, the underlying message should be that appropriate antimicrobial use could help to contain rising AMR

Insight: Acquiring knowledge through information and data analysis, and building evidence through research and innovation would help develop relevant strategies to contain AMR. Important components would include research cum surveillance of AMR and antimicrobial use, and capacity building for laboratories

Infection prevention and control (IPC): Reducing the incidence of infections would help decrease antimicrobial use. Strategies for IPC should cover not only healthcare facilities but the community also. Awareness and practice of basic hygiene and focused programs like hand hygiene would be essential

Optimizing antimicrobial use: Appropriate antimicrobial prescribing, dispensing and administration, as well as monitoring the quality and availability of antimicrobials would be essential. Workable regulations should be considered that provide access but prevent excess antimicrobial use

Sustainability: The economic impact of AMR on health systems and individuals and the cost of alternative solutions need to be looked into. Sustainability of research and development models of newer antimicrobials, vaccines, and diagnostics need to be strengthened.

In LMIC and in India too, many of the above domains would need strengthening. A national AMR program would greatly help, but needs to be integrated into the health system structure and universal health coverage for real impact. Areas such as research and development are often industry based and need substantial financial investment. There are other areas, where health professionals like pharmacologists could take the lead in cost effective interventions. In this context, hand hygiene, antimicrobial stewardship, and education are important strategies to be implemented on an urgent basis across India.

Antimicrobial stewardship is one area where pharmacologists could play a major role. Pharmacologists need to be actively involved with microbiologists, infectious disease physicians, and others, in forming an antimicrobial policy within the hospital. Such a working group would be essential in developing and implementing guidelines for antimicrobial use. Pharmacologists could also use their knowledge in activities such as prescription audits, feedback, and monitoring antimicrobial use throughout the hospital. Another area would be in interpreting minimum inhibitory concentrations values when difficult treatment decisions have to be made due to AMR.

Education and training are core fields where pharmacologists should use their experience and vantage position in molding future prescribers with the right attitude. Teachers of pharmacology and other relevant disciplines in the medical, pharmacy, and nursing curriculum should devote sufficient time and emphasis on the approach to antimicrobial use and choice of therapy. Such an approach would go a long way in giving future health professionals a fundamental basis to practice responsible use of antimicrobials. Needless to say, the assessment mechanism needs to adapt accordingly.

The role of the pharmacologist need not be restricted to the hospital. Raising AMR awareness, improving appropriate antimicrobial use, and developing monitoring systems in the community are important. Research on antimicrobial use in the local context would be essential in formulating local guidelines. Affordability and accessibility being major issues in India, pharmacoeconomic studies would help to decrease the burden on health system finances and less privileged patients. Pharmacologists can also assist with continuing education programs so that physicians, pharmacists, and nurses are up to date with evidence-based practices. Pharmacologists, with their knowledge of pharmacodynamics and kinetics, could be ideal facilitators between physicians and the pharmaceutical industry for translational research in antimicrobials.

In summary, all stakeholders have their part to play in containing AMR. Pharmacologists in particular, have a great responsibility as teachers, researchers, and subject experts to be true stewards of antimicrobial use within the hospital and outside in the community. The current initiative provided by the launch of the WHO GAP, provides pharmacologists with the opportunity to take the lead in collaboration with other disciplines toward implementing the relevant aspects of the plan. If embraced with sincerity and perseverance, efforts in improving antimicrobial use in hospitals and the community would go a long way in containing rising AMR. Can we rise to this challenge, go beyond our call of duty, and save antimicrobials and society?