Inappropriate use of antibiotics results in antibiotic resistance, the most common cause being its improper use in viral infections. The over-prescribing of antibiotics may also be due to pressure on the physician by the patient party for writing antibiotics, self-medications, and taking left-over antibiotics from the previous prescription.   

USE OF ANTIBIOTICS IN COMMON INFECTIONS

Antibiotics are crucial for successfully managing various bacterial infections, such as acute bacterial sinusitis, tuberculosis, pneumonia, bacterial gastroenteritis, septicemia, etc. 

The most common condition for prescribing antibiotics includes upper respiratory tract infections, acute bronchitis and cough, accounting for almost two-thirds of the total prescriptions. Interestingly, 80% of these prescriptions are not according to the standard guidelines for prescribing antibiotics and often exceeds the recommended period.

India is the largest consumer of antibiotics globally. The share of BRICS countries in global antibiotic consumption was 76% between the period 2000 to 2010, of which India's contribution was 23%. There has been a 22% increase in per-capita antibiotic consumption in India between 2008 to 2012. India has witnessed an increased use of lincosamides, 3rd generation cephalosporins, carbapenems, and glycosides in the recent past.   

ANTIBIOTIC USE IN NOSOCOMIAL INFECTIONS

Nosocomial infections or hospital-acquired infections are common in developing countries, accounting for 75% of the global cases. It resulted in an increased overall cost of treatment, antibiotics use and improved hospital stay. 

The most common nosocomial infections site includes urinary tract infections (UTI), respiratory tract infections, surgical and soft tissue infections, gastroenteritis and meningitis. 

The common organisms include S. pneumonia, Enterococcus, S. aureus, E. coli, Pseudomonas, and Acinetobacter. 

The use of inappropriate broad-spectrum antibiotics in healthcare settings is a leading cause of nosocomial infections globally. Penicillin-resistant pneumococci, multi-drug-resistant tuberculosis, methicillin-resistant and S. aureus (MRSA) are the most common antibiotic-resistant bacteria examples in hospital settings.

For example, in a study among 3439 patients in a maternity hospital in Saudi Arabia, over 90% of the bacterial isolates were multi-drug resistant. The same study reported an antibiotic misuse rate as high as 57%. 

Hospitals need to adopt various control programs through which infection rates can be compared and controlled with a well-managed surveillance team. Healthcare workers, especially nurses, should be well-trained to adopt best practices to avoid the spread of nosocomial infections. 

Until the arrival of a culture report, physicians generally prescribe empirical therapy to prevent the infection's progression. Once the information is received, physicians should prescribe the most effective antibiotic, It will help in preventing antibiotic resistance. Suppose the culture is negative, and the physician still suspects it, they may implement bacterial infection, PCR and data sequencing techniques to determine the infection's aetiology.

CUSTOMIZED TREATMENT OF INFECTION

An increasing trend of personalized medicine is observed in almost all the therapeutic categories, including infection management. Delivering personalized medications reduces the incidences of antibiotic resistance. While developing the strategy for treating bacterial infections, the physicians should assess the risk of developing a particular condition and forms a tailor-made treatment plan. The duration of therapy may be determined by using biomarkers. Therapeutic drug monitoring also helps in ensuring the success of treatment and reducing antibiotic resistance. The standard drug categories used in managing infections are Cephalosporin and Aminoglycoside, fluoroquinolones, and glycopeptide antibiotics.

GUIDANCE ON PRESCRIBING ANTIBIOTICS

Antibiotics are considered life-saving agents in managing various bacterial infections. However, there is an unmet need to curb the inappropriate, ineffective, and unnecessary antibiotics use. Different international guidelines are in place to monitor antibiotics' use and reduce the development of antibiotic resistance.  Following are some of the rules outlined by global guidelines that need to be followed while prescribing antibiotics:

Need: As antibiotics are available at low cost and are relatively safer, these are the most misused drugs. The physicians need to understand that antibiotics are for treating infection and significantly reducing the duration of illness. Physicians should not prescribe antibiotics without comprehensively evaluating the patient’s symptoms. 

Cause of infection: The doctor should recommend diagnostic testing to determine the cause of infection. Antibiotics do not work in viral infections. 

Narrow spectrum antibiotics: The doctors should aim to prescribe the antibiotics with a narrow spectrum. It will prevent antibiotic resistance and have fewer effects on normal flora. 

Recommended duration: The duration of antibiotic treatment should be according to the international and local guidelines. 

Reason for prescription: The doctors should set out the reason for prescribing a particular antibiotic. 

INAPPROPRIATE PRESCRIBING AND ITS CONSEQUENCES

Inappropriate antibiotic prescriptions are one of the major driving factors for developing antibiotic resistance. In the developed economies, the approximately improper antibiotic prescription rate ranges from 30% to 50%. Almost half of the antibiotics prescribed aim to treat upper respiratory tract infections such as rhinosinusitis and pharyngotonsillitis. Thus, there is a high onus on ENT specialists and pulmonary specialists to reduce antibiotics' inappropriate use. Inappropriate use of antibiotics involves two crucial aspects, i.e., Prescribing the antibiotics without following the recommended guideline and prescribing correct antibiotics with over or sub-optimal duration. 

Following are some of the consequences of inappropriate antibiotic prescriptions:

Antibiotic resistance: Inappropriate antibiotic prescription increases the risk of antibiotic resistance and the emergence of more powerful and drug-resistance pathogens.

Increased infection severity: Inappropriate use of antibiotics may not effectively treat the infection. The infection, thus, progresses into a more severe form. 

The increased cost of treatment: Antibiotic misuse may result in increased disease length and duration of hospital stay. It increases the cost of treatment. 

Side effects: Antibiotic misuse results in side effects because of the imbalance in the normal flora. It may also result in super-infection. 

Re-hospitalization: Patients administered with inappropriate antibiotics are at increased risk of re-hospitalization. 

REFERENCES

• Louie JP, Bell LM. Appropriate use of antibiotics for common infections in an era of increasing resistance. Emerg Med Clin North Am. 2002 Feb;20(1):69-91.
• Pouwels KB, Hopkins S, Llewelyn MJ, Walker AS, McNulty CA, Robotham JV. Duration of antibiotic treatment for common infections in English primary care: cross-sectional analysis and comparison with guidelines. BMJ. 2019 Feb 27;364:l440.
• Farooqui HH, Selvaraj S, Mehta A, Heymann DL. Community-level antibiotic utilization in India and its comparison vis-à-vis European countries: Evidence from pharmaceutical sales data. PLoS One. 2018;13(10):e0204805.
• Danish Health and Medicines Authority. Guidelines on prescribing antibiotics. Available at: https://www.sst.dk/-/media/Udgivelser/2019/Guideline-on-prescribing-antibiotics.ashx?la=da&hash=5AD3BEEB829F508CD25C02C0730017EE371D053F. Accessed on 21st February 2021.
• Center for Infectious Disease Research and Policy. Overuse and overprescribing of antibiotics. Available at: https://www.cidrap.umn.edu/asp/overuse-overprescribing-of-antibiotics#:~:text=Risks%20of%20antibiotic%20overuse%20or,problems%20that%20previously%20may%20have. Accessed on 21st February 2021.
• Khan HA, Ahmad A, Mehboob R. Nosocomial infections and their control strategies. Asian Pacific J Trop Biomed. 2015;5(7):509-14.
• Bilal NE, Gedebou M, Al-Ghamdi S. Endemic nosocomial infections and misuse of antibiotics in a maternity hospital in Saudi Arabia. APMIS. 2002 Feb;110(2):140-7.

FAQs

1. . What are the steps to prevent the inappropriate use of antibiotics?

There are various ways to prevent the inappropriate use of antibiotics. The patients should take the antibiotics strictly as directed. Avoid antibiotic self-medication and do not pressurize the physicians to prescribe antibiotics. Physicians should prescribe the antibiotics only when it is required.   

2. What food producers can do to prevent antibiotic resistance?

The food producers, including the poultry owners and crop producers, should reduce the use of antibiotics. Further, they should dispose of the left-over antibiotics according to specific guidelines. They should also help in preventing the spread of infection by following hygiene guidelines. 

3. What is antibiotic stewardship?

Antibiotic stewardship is the process to ensure the optimum use of antibiotics. The antibiotics should be used only when required for effectively managing the infection. 

4. What is the role of the pharmaceutical industry to curb antibiotic resistance?

Top pharmaceutical companies and drug manufacturers in India and the world should develop new antibiotics to treat antibiotic-resistant pathogens. The development of new vaccines also reduces the dependency on antibiotics. Only 5% of the drugs under pharmaceutical research and development are antibiotics. The industry should try to increase this number.   

5. What the World Health Organization is doing to combat antibiotic resistance?

World Health Organization has launched various programs for creating awareness and reducing the incidences of antibiotic resistance. Global Strategy for Containment of Antimicrobial Resistance provides interventions that reduce the emergence of resistance. It also advises the countries to draft policies to regulate the use and monitoring of antibiotics.