Restricted antibiotic policy: Rational approach towards antibiotic resistance

Dr M C Joshi, Tariq K and Ejaj A

Because of increasing concern and awareness of antibiotic resistance problems worldwide and frequent inappropriate use of antimicrobial agents in hospitals, these drugs have often been the target of attempts to restrict and control their use. Disease-causing microbes that have become resistant to drug therapy are increasing public health problem. Tuberculosis, gonorrhea, malaria and childhood ear infections are just a few of the diseases that have become hard to treat with antibiotic drugs. Part of the problem is that bacteria and other micro-organisms that cause infections are remarkably resilient and can develop ways to survive drugs meant to kill or weaken them.

This antibiotic resistance, also known as antimicrobial resistance or drug resistance, is largely due to inappropriate use of antibiotics. Unless antibiotic resistance problems are detected as they emerge, and actions are taken to contain them, the world could be faced with previously treatable diseases that have again become untreatable, as in the days before antibiotics were developed.

Epidemiology of Antibiotic Resistance

According to the Centers for Disease Control and Prevention (CDC) statistics, nearly two million patients in the United States get an infection in the hospital each year. Of those patients, about 90,000 die each year as a result of infection. More than 70 percent of the bacteria that cause hospital-acquired infections are resistant to at least one of the drugs most commonly used to treat them.

Persons infected with drug-resistant organisms are more likely to have longer hospital stay and require treatment with second or third choice drugs that may be less effective, more toxic, and expensive.

Majority of MRSA infections occur among patients in hospitals or other healthcare settings; however, it is becoming more common in the community setting. Data from a prospective study in 2003, suggests that 12 per cent of clinical MRSA infections are community-associated, but this varies by geographic region and population. In India, antibiotic resistance to penicillin was detected in 11.6 per cent of pneumococcal strains, to erythromycin and chloramphenicol in 1.8 per cent and to cotrimoxazole in 24 per cent of cases.

Most of the organisms causing enteric infections are already resistant to old antibiotics, among shigella an overall resistance of 63.6 per cent; 58.1 per cent 16.3 per cent observed for Nalidixic acid, cotrimoxazole, furazolidone and 5 per cent resistant to ciprofloxacin. Among vibrio cholera 77.8 per cent resistant to cotrimoxazole and among non-typhoid salmonella 18.5 per cent of ciprofloxacin resistant noted by a study done in north India.
In short, antimicrobial resistance is driving up health care costs, increasing the severity of disease, and increasing the death rates from certain infections.

Restricted Antibiotic Guidelines

Restricted antibiotics are those antimicrobial agents, which should not be used or which are restricted by the hospital formulary to be used in the empirical therapy of any infection. The purpose of enlisting of restricted antibiotic is to keep certain antibiotics in reserve only to be used if culture and cross sensitivity reports are positive for that specific antibiotic. These restricted antibiotics are mainly the newer molecules in the market and certain old molecules specified for certain specific use.

These restricted antibiotics are never used as a first line therapy. Since the drug resistant and the drug sensitivity of microorganisms differ in different regions, the list of restricted antibiotics for hospitals in different geographical regions differ. Therefore every hospital has to frame its own list of restricted antibiotics. This will not only help in overcoming drug resistance problem but also a good patient prognosis in various life threatening infections.

The restricted antibiotic guidelines are a step towards the upgradation in the antibiotic policies of hospitals. To solve the purpose of reducing antibiotic resistance, antibiotic policies are framed by many multispeciality and tertiary healthcare centers. Policies are thought to be more rigorous and fixed in their suggestions whereas guidelines are more flexible and acknowledge that some patients will fall out of the recommendations. There are also legal aspects to consider: it is more difficult to justify action outside of policies than guidelines. In spite of these distinctions between policies and guidelines, however, they will be used interchangeably in this article.

The most important preparation before antibiotic policy framing is the rational use of antimicrobial agents. The conference of experts on the rational use of drugs, convened by the World Health Organisation in Nairobi in 1985 defined that “Rational use of drugs requires that patients receive medications appropriately to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, at the lowest cost to them and their community”

Guidelines for Antibiotic Policy

• Improve patient care by promoting the best practice in antibiotic prophylaxis and therapy. n Make better use of resources by using cheaper drugs wherever possible.
• Retard the emergence and spread of multiple antibiotic-resistant bacteria. n Improve education of junior doctors by providing guidelines for appropriate therapy.
• Eliminate the use of unnecessary or ineffective antibiotics and restrict the use of expensive or unnecessarily powerful ones.

A “Hospital Antibiotic Committee” should frame restricted antibiotic policy. This might be a subcommittee of the hospital drugs and therapeutics committee or of the infection control committee. Membership of an antibiotic committee may vary according to local conditions and needs.

If possible, the following key persons should be included in the committee:

• The Pharmacist who will report back to the antibiotic committee at each meeting on drug utilisation and cost.
• The microbiologist, who will report on antibiotic susceptibility patterns of bacteria are isolated from major infections.
• Clinical doctors and nurses responsible for direct patient care who provide a link between clinical practice and the antibiotic committee. n Manger(s) who will ensure the resources are available for implementation of the antibiotic policy.
• Reciprocal membership between the infection control committee and the drugs committee should be ensured.

The antibiotic committee will have to make rational choices amongst “equivalent drugs” and classes of drugs in order to select the least expensive, most effective agents for the empirical therapy of different type of infections. Cost should determine the selection, when microbiological, pharmacological, and other relevant properties are similar.

The Antibiotic Committee and the Infection Control Committee should receive regular updates on antibiotic susceptibility of bacterial isolates from the local area. This will assist the Committees in producing effective guidance for the local patient population. The laboratory should also alert the Committees to the emergence of widespread resistance to certain agents so that the inclusion of those agents in the guidelines can be reviewed. When no local microbiology laboratory exists, antibiotic policy should be based upon a basic formulary, if possible established after consultation with regional or national groups. When resources for microbiology are scarce, priority should be given to examination of samples from nosocomial, life-threatening cases, or arrangements should be made for microbiology tests with a referral hospital. Culturing of the environment or screening of staff should be discouraged and only done after authorization by the Infection Control Team11.

The principal aim of an antibiotic policy is to improve the quality of prescribing. This should lead to a reduction of resistance, decreased cost and improved patient care. Before embarking upon the development, dissemination and subsequent implementation of an antibiotic policy, clinicians and key decision-makers need to be clear on how they plan to evaluate its impact. Quality indicators need to be identified. The number and complexity of these indicators will be dependent on local resources. They must be specific to the organization, simple, measurable and meaningful. Panel 2 shows the key components of antibiotic policies.

The restricted antibiotic guidelines implementation in certain hospital reports resulted in a marked reduction in overall antimicrobial costs. But the inappropriate antibiotic usage may persist for some drugs despite restricted access. This result emphasizes the need for combined interventions using education and expert counseling, targeted to classes of antibiotic for which inappropriate usage is most common12.

Surveillance on antibiotic resistance rates is essential to help doctors choose appropriate antibiotics and to detect local outbreaks. Good quality local data will also provide a basis for national and international surveillance. It is also important to know the patterns of antibiotic prescriptions so as to identify where clinical practice needs to be improved13. To reduce antibiotic consumption, a multifaceted approach has been proposed that includes education of doctors, widely accepted recommendations for good clinical diagnosis and treatment, and a follow-up of compliance by audit. Restrictive policies, such as the requirement for written justification or automatic stop orders, are also useful inclusions to a policy in hospital settings. Such integrated strategies have reduced antibiotic use or curtailed antimicrobial resistance14, 15,16.

Conclusion

The restricted antibiotic policy is an important part of strategies to reduce the antibiotic resistance and to reduce the cost of treatment, which has grown a lot in the recent past because of the use of newer costly antibiotics. But the effectiveness of policy depends on the antibiotics used in the primary care. There should be a line listing of antibiotics to be used in primary care setting, as antibiotic resistance starts from the primary care level because of the injudicious use of antibiotics. It is of great importance that policies developed should also be applicable and acceptable for use in primary care. Monitoring the usage of antibiotics in primary care is more difficult strategically but is crucial to the containment of antibiotic resistance. Liaison between the hospital microbiology department and primary care clinicians will be of paramount importance.

Dr Joshi is a clinical pharmacologist and Tarik K and Ejaj A are clinical pharmacists at Indraprastha Apollo Hospital, New Delhi