Slowing down AMR with Stewardship
Microbes have been producing antimicrobials for millions of years for their survival. It was the serendipitous discovery of Penicillin that opened the avenue of treating infectious diseases in humans. Since then, many new antimicrobials have been discovered and scientific advancements have enabled us to mass-produce these life-saving drugs. But the flipside to this is that we are also on the brink of losing the utility of antimicrobials. We are at the brink of dealing with the antimicrobial resistance [AMR] catastrophe.
The antimicrobials themselves aren’t the core issue of the emerging AMR crisis, it is the way they are used. Overuse and misuse have been a driving factor of this public health crisis worldwide.
Unregulated use of antimicrobials
In a recent European survey, half of the patients consulting for cough and cold were prescribed antibiotics. These decisions weren’t evidence-based and were borne out of concerns of developing severe symptoms. No major indicator corroborated that the antibiotic treatment had a significant impact on preventing the severe symptoms.[i]
In a study published in 2019 on private care prescriptions, approximately one-fifth of antibiotic prescriptions were dispensed for upper respiratory infections, which rarely require antibiotic therapy. The trend of over-prescription is more notable in LMICs. [Low-Middle Income Countries] [ii]
As per WHO recommendation, not more than 30% of outpatients are advised to receive antibiotics, however a study published in 2020 revealed that the proportion of patients in LMICs to whom antibiotics were prescribed was over 50%.[iii]
Another issue is access to antimicrobials without a prescription. A study in India reported 94.65% of pharmacies distributed antibiotics for a sore throat or diarrhea without a prescription. At the same time, a lack of awareness among the public as indicated by non-adherence to treatment protocols, self-prescription and repeated use of old prescriptions for obtaining antimicrobials is further aggravating the problem. [iv] [v]
Stewardship can play a major role in addressing these issues.
Stewardship is the need of the hour
Stewardship in essence is overseeing the optimal usage and management of antibiotics. The main objective is to warrant the use of antimicrobials for a longer duration of time and reduce the chances of microbes developing resistance, thereby rendering them ineffective against their target pathogens. Over time, an effective stewardship programme can help us reduce health care costs and improve health outcomes without compromising efficacy and quality. Stewardship includes the antimicrobial choice, dosage, administration route, prescription duration, adherence to the prescription. At a wider level, Stewardship also addresses responsible disposal, effluent management and other factors that come into play at the human-animal-interface.
Barriers to Stewardship
To implement stewardship guidelines in place, there may be several barriers like:
· Lack of awareness about the issue among the public
Education and training play a vital role in successful stewardship implementation. Public aren’t aware about the severity of AMR crisis and continue to use antibiotics carelessly and not complete the course.
· Lack of communication among healthcare providers
Communication gap between the different healthcare sectors leads to disjointed efforts and hinders effective implementation of stewardship. Key players need to co-ordinate efforts as working in silos will not help.
· Poor infrastructure and administrative support for stewardship intervention
Although the stewardship policies and strategies are outlined, due to lack of infrastructure or administrative support, these strategies cannot be adopted and there could be no mechanisms to monitor enforcement.
· Limited diagnostics/microbial testing
Testing and lab-facility limitations proves to be a major obstacle. Delayed reports of tests or no proper diagnosis contributes to the practice of misuse/overuse of antimicrobials. Accurate diagnosis is crucial for optimal prescription of antimicrobials.
· Insufficient data of antimicrobial prescribing trends and prevalence of AMR in the community
IT infrastructure isn’t embedded in all hospitals across the country particularly in remote places. Lack of sufficient data in a central database prevents us from tracking trends and prevalence of resistance patterns. This results in an inability to carry out appropriate interventions.
Multistakeholder effort towards Stewardship
The WHO [World Health Organisation] has introduced AWaRe [Access, Watch and Reserve] classification of antibiotics to emphasize on their optimal and safe use. Access antibiotics are those used to treat some of the common infections, antibiotics classified as Watch are used sparingly for which resistance cases have been occurring and antibiotics under Reserve category are used as a last resort, only when other antibiotics aren’t effective.
WHO is also collaborating with FAO [Food and Agriculture Organisation] and OIE [World Organisation for Animal Health] to tackle AMR and enforce effective stewardship guidelines across all sectors.
For effective stewardship, strategies need to be adapted to address local barriers and challenges. The stewardship guidelines must trickle down from global to grass-root level participation spanning healthcare and community settings alike.
To oversee that the stewardship guidelines are implemented across all settings and appropriate human resources are deployed, a strong leadership and administration is needed at the national level. At community health settings, the core AMS team must comprise doctors, nurses, pharmacists, microbiologists and public health experts to drive the initiatives at the grassroot level.
Awareness programs must be organised to enlighten the public about the severity of the issue and educate them on using antibiotics appropriately. In India, ICMR [Indian Council for Medical Research] has initiated AMS activities by developing curriculums and designing workshops to train healthcare workers in prescribing appropriate antimicrobials and awareness programs for the public.
To understand if the stewardship interventions are effective, feedback is fundamental. JPIAMR [Joint Programming Initiative on Antimicrobial Resistance] is developing an open-web based system to audit and obtain feedback on antibiotic use in outpatient settings which they propose to expand across health systems, countries, and sectors in coming years.
Along with safeguarding the existing antimicrobials, efforts should also be put forward in ensuring that new antimicrobials that are entering the market are effective for the long term. In India, Centre for Cellular and Molecular Platforms [C-CAMP] is leveraging its deep-science expertise to nurture entrepreneurs and start-ups working on developing new antimicrobials.
CARB-X in collaboration with several of its cross-sector stakeholders including the Wellcome Trust, the Bill & Melinda Gates Foundation (BMGF), the Global Antibiotic Research and Development Partnership (GARDP), the Access to Medicine Foundation (ATMF), the US Department of Health and Human Services Biomedical Advanced Research and Development Authority (BARDA), and the UK Department of Health and Social Care’s Global Antimicrobial Resistance Innovation Fund (GAMRIF), has outlined a comprehensive first-of-its-kind Stewardship and Access Plan Development Guide that outlines a general roadmap for new products in the AMR space to support sustainability in the market and faster, broader access to products. The guide outlines a series of questions to prompt people who are developing new drugs/innovations to draft out their plan and identify obstacles and constraints to stewardship and access, and how they can develop strategies.
Considering the complexity of the AMR challenge, it is imperative that all stakeholders work together at all levels of intervention taking the One Health approach. Stewardship is a continuous and dynamic process addressing local and global AMR challenges alike, across human health, animal health and environment. Having a systemic focus can help mitigate the progression of resistance more effectively.
[ii] Outpatient antibiotic prescription rate and pattern in the private sector in India: Evidence from medical audit data (nih.gov)
[iii] Antibiotic prescription practices in primary care in low- and middle-income countries: A systematic review and meta-analysis (nih.gov)
[iv] Medication misuse in India: a major public health issue in India | Journal of Public Health | Oxford Academic (oup.com)
Disclaimer: The blog is a compilation of information on a given topic that is drawn from credible sources; however this does not claim to be an exhaustive document on the subject. It is not intended to be prescriptive, nor does it represent the opinion of C-CAMP or its partners. The blog is intended to encourage discussion on an important topic that may be of interest to the larger community and stakeholders in associated domains.