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Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 110-112

Antibiotic stewardship: So near yet so far

Department of Pediatric Intensive Care, Advanced Pediatric Critical Care Centre, Wanless Hospital, Miraj, Maharashtra, India

Date of Submission19-Apr-2020
Date of Acceptance22-Apr-2020
Date of Web Publication25-May-2020

Correspondence Address:
Dr. Vinayak Patki
Department of Pediatric Intensive Care, Advanced Pediatric Critical Care Centre, Wanless Hospital, Miraj, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPCC.JPCC_67_20

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How to cite this article:
Patki V. Antibiotic stewardship: So near yet so far. J Pediatr Crit Care 2020;7:110-2

How to cite this URL:
Patki V. Antibiotic stewardship: So near yet so far. J Pediatr Crit Care [serial online] 2020 [cited 2022 Jan 22];7:110-2. Available from: http://www.jpcc.org.in/text.asp?2020/7/3/110/284942

Use of antibiotics as a common medicine in intensive care units (ICUs) is a known fact. It applies equally to adult and pediatric ICU (PICU) setups.[1] Patients in ICUs are critically ill and they have a very high chance of getting health-care-associated infections. These two reasons force the treating doctors to prescribe multiple antibiotics for prolonged period. The study results indicate that 30%–60% of antibiotics prescribed in ICUs are unnecessary, inappropriate, or suboptimal.[2]

This inappropriate use results in increase in treatment cost, duration of therapy, poor clinical outcome, and antibacterial resistance. The causative effect of misuse and abuse of antibiotics with emergence of resistance and also dissemination of resistant strains in hospitals and ICUs has been well proven by epidemiological studies. There is hardly any development in new antibacterial molecule in recent years, but antibiotic resistance to almost all new and broad-spectrum antibiotics is emerging in a very fast way.[3]

Recently, the terminology “superbugs” has been coined. These are multidrug-resistant organisms which can be treated with very high-end antibiotics. “ESKAPE” group of organisms is good example of these superbugs. “ESKAPE” means Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species.[4]

In 2010, India was one of the countries to have the highest antibiotics consumption in the world, recorded a deeply shocking 12.9 billion units of antibiotic consumption.[5] Then onward, this trend continued. In the last few years, there is an increase in the consumption of carbapenems, lincosamides, glycopeptides, linezolid, and daptomycin, as reported in one study.[6]

Why do we have this situation of such high antibiotic consumption? Various factors can be contributed. First, the microbiology laboratory service for cultures and antibiotic susceptibility testing are either not available or even if available, not utilized up to the mark. Then, we have varying approach of treating doctors, anxiety among treating doctors of missing a bacterial infection or covering for secondary bacterial infection as safeguard. Empirical but incorrect use of antibiotics, simultaneous use of more than a single antibiotic when actually not necessary, not de-escalating when possible, and inefficiency in the review of the response to antibiotics are some contributing factors. This can be attributed to the fact that they lack up-to-date knowledge on the current revised guidelines and algorithms for antibiotic usage. Finally, a very important factor is no control by the regulatory authorities.

There are very limited data about how the antibiotics are utilized in children admitted to PICU in India and subcontinent. The prevalence of antibiotic use in Indian PICUs in tertiary care centers is reported from 44% to 97%.[7],[8],[9],[10] Abbas et al. in their study from Pakistan have reported that all (100%) of the total 240 patients admitted in PICU during the study period received antibiotics.[11] The pattern of antibiotic use in India remains almost similar. The most common antimicrobials prescribed were third-generation cephalosporins, namely, ceftriaxone, then aminoglycosides (amikacin), co-amoxiclav, followed by carbapenems (imipenem/meropenem), vancomycin and oxazolidinones (linezolid) followed by colistin.[7],[8],[9],[10]

Various efforts were made to address the issues at international level. Antibiotic stewardship was launched in 2007 by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Antibiotic stewardship in ICUs includes rapid identification and optimal treatment of bacterial infections based on pharmacokinetic–pharmacodynamic characteristics of antibiotics. It also improves the ability to avoid administering unnecessary broad-spectrum antibiotics, to shorten the duration of their administration, and to reduce the number of patients receiving undue antibiotic therapy.[12]

The World Health Organization adopted a new method of classifying antibiotics into three categories: access, watch, and reserve in the 20th Essential Medicine List classification. The access group antibiotics should be made available at all times and are commonly used to treat many infections such as amoxicillin. The watch group includes antibiotics, which are reserved as “drug of choice” for certain infections such as rifampicin for the treatment of tuberculosis and the reserve group includes antibiotics, which should be reserved for use in managing life-threatening, multidrug-resistant infections, for example, colistin.[13]

India also addressed this problem at various platforms. In 2012, the Indian Council of Medical Research launched the program on Antimicrobial Stewardship Prevention of Infection and Control in collaboration with other institutions. India's National Action Plan for Antimicrobial Resistance (AMR) was released in April 2017 by the Union Ministry of Health and Family Welfare to improve awareness, enhance the surveillance measures, strengthen infection prevention and control, research, and development, and also to promote investments and collaborative activities to control AMR.[14] It will be very interesting to see the results of these efforts on the implementation of antibiotic policies at various hospitals. Few published studies from various PICUs give a promising hope for the future.

In this current issue of Journal of Pediatric Critical care, Sharma et al., in their retrospective study of around 1700 patients, found a high level of rational antibiotic usage at their center and concluded that strategies such as following an evidence-based antibiotic policy and empowering the designated persons for every antibiotic prescription ensure rational antibiotic usage in PICU.[15] Similarly, Bhullar et al. in their study found a significant overall decrease in antimicrobial usage after the introduction of a justification form before prescribing antimicrobials or at the time of deferring de-escalation.[16]

To initiate antibiotic stewardship measures, physicians and microbiologists need to play a major role to frame the guidelines for infectious disease treatment. There is a need to perform regular audits, to provide positive feedbacks to proper authority, to measure antibiotic consumption, and to carry out therapeutic drug monitoring for effective implementing antibiotic stewardship measures. Moreover, this can be achieved by a collaborative teamwork of physicians, nurses, and clinical pharmacists specialized in infectious diseases, a dedicated team, staff time, and leadership support.

There are two ways ahead of us for the future, either we will be able to implement such a policy sincerely or we and our patients will look toward an unmanageable burst of very difficult-to-treat pathogens. Choice is ours!

  References Top

van Houten MA, Luinge K, Laseur M, Kimpen JL. Antibiotic utilisation for hospitalised paediatric patients. Int J Antimicrob Agents 1998;10:161-4.  Back to cited text no. 1
Kollef MH. Optimizing antibiotic therapy in the intensive care unit setting. Crit Care 2001;5:189-95.  Back to cited text no. 2
Luyt CE, Bréchot N, Trouillet JL, Chastre J. Antibiotic stewardship in the intensive care unit. Crit Care 2014;18:480.  Back to cited text no. 3
Santajit S, Indrawattana N. Mechanisms of antimicrobial resistance in ESKAPE pathogens. Biomed Res Int 2016;2016:2475067.  Back to cited text no. 4
Van Boeckel TP, Gandra S, Ashok A, Caudron Q, Grenfell BT, Levin SA, et al. Global antibiotic consumption 2000 to 2010: An analysis of national pharmaceutical sales data. Lancet Infect Dis 2014;14:742-50.  Back to cited text no. 5
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:e0204805.  Back to cited text no. 6
Baidya S, Hazra A, Datta S, Das AK. A study of antimicrobial use in children admitted to pediatric medicine ward of a tertiary care hospital. Indian J Pharmacol 2017;49:10-5.  Back to cited text no. 7
[PUBMED]  [Full text]  
Mali NB, Deshpande SP, Tullu MS, Deshmukh CT, Gogtay NJ, Thatte UM. A Prospective Antibacterial Utilization Study in Pediatric Intensive Care Unit of a Tertiary Referral Center. Indian J Crit Care Med 2018;22:422-6. doi:10.4103/ijccm.IJCCM_365_17.  Back to cited text no. 8
[PUBMED]  [Full text]  
Sindhu S, Ahmed SM. Prescription pattern analysis of antibiotic use in a paediatric intensive care unit of a tertiary care teaching hospital in South India. Int J Basic Clin Pharmacol 2018;7:1094-9.  Back to cited text no. 9
Sharma M, Damlin A, Pathak A, Stålsby Lundborg C. Antibiotic prescribing among pediatric inpatients with potential infections in two private sector hospitals in central India. PLoS One 2015;10:e0142317.  Back to cited text no. 10
Abbas Q, Ul Haq A, Kumar R, Ali SA, Hussain K, Shakoor S. Evaluation of antibiotic use in Pediatric Intensive Care Unit of a developing country. Indian J Crit Care Med 2016;20:291-4.  Back to cited text no. 11
[PUBMED]  [Full text]  
Dellit TH, Owens RC, McGowan JE Jr., Gerding DN, Weinstein RA, Burke JP, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159-77.  Back to cited text no. 12
WHO. WHO Model Lists of Essential Medicines; WHO. Available from: http://www.who.int/medicines/publi cations/essentialmedicines/en/. [Last accessed on 2019 Mar 12].  Back to cited text no. 13
Ranjalkar J, Chandy SJ. India's National Action Plan for antimicrobial resistance – An overview of the context, status, and way ahead. J Fam Med Prim Care 2019;8:1828-34.  Back to cited text no. 14
Sharma PK, Kumar M, Aggarwal GK, Kumar V, Srivastava RD, Aggarwal PK, et al. Evaluation of antibiotics use in a tertiary care pediatric intensive care and high dependency unit. J Pediatr Crit Care 2020;7:131-5.  Back to cited text no. 15
  [Full text]  
Bhullar HS, Shaikh FA, Deepak R, Poddutoor PK, Chirla D. Antimicrobial justification form for restricting antibiotic use in a pediatric intensive care unit. Indian Pediatr 2016;53:304-6.  Back to cited text no. 16


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