Advancing Antimicrobial Stewardship in India

In late November, the Global Antibiotic Resistance Partnership-India (GARP-India) co-sponsored a 2-day “train-the-trainers” workshop for Indian healthcare professionals on antimicrobial stewardship in hospitals, followed by a policy forum focusing on antibiotic resistance and stewardship in Indian hospitals. The workshop was led by the British Society of Antimicrobial Chemotherapy and organized by the Public Health Foundation of India. Workshop activities were taught by Indian and international experts. Many of the attendees were already involved with antibiotic stewardship in both public and private hospitals.

At the policy forum, stakeholders from many sectors presented their viewpoints to 170 participants. CDDEP Director Professor Ramanan Laxminarayan chaired the event and Professor NK Ganguly, chairman of the GARP-India national working group, was the guest of honor.

The presenters, in addition to Professor Ganguly, were:

·      Professor Ranjit Roy Chaudhury, a leading clinical pharmacologist, medical education professional and highly-reputed researcher

·      Professor Abhay Chowdhary, Professor at Grant Government Medical College, Head of Microbiology at Sir JJ Hospital in Mumbai and Director and Head of Virology at the Haffkine Institute for Training, Research and Testing in Mumbai

·      Dr. Abdul Ghafur, author and coordinator of “The Chennai Declaration” and consultant in infectious diseases and clinical mycology, Apollo Specialty Hospital, Chennai

·      Dr. Ankur Gupta, Associate Director for Antimicrobial Stewardship for Emerging Markets, MSD Pharmaceuticals

·      Ms. Rekha Khanna, Managing Director, bioMérieux India Pvt. Ltd.

·      Professor Dilip Nathwani, President, British Society for Antimicrobial Chemotherapy and Professor of Infection, Ninewells Hospital and Medical School, Dundee, Scotland

During the inauguration of the workshop, Dr. Ganguly remarked on the importance of working together to identify steps to control resistance and change current prescribing practices in India. Potential steps include mandatory reporting of emerging resistance in hospitals, providing uniform training on infection control for healthcare practitioners, establishing a surveillance network, creating a national prescription database and regular pharmacy audits.

Professor Laxminarayan declared that it is time to seize the opportunity to track data, show that stewardship is possible and define stewardship in the Indian context.

At the policy forum, Professor Chaudhury stressed the need to address antibiotic resistance in India with Indian solutions. He noted that as the drug regulatory authority, the Ministry of Health and Family Welfare is increasingly involved in tackling the issue of antibiotic resistance and that efforts are being made to restrict the entry and availability of antibiotics by limiting certain antibiotics to specific levels of the health facility.

Dr. Gupta noted that the pharmaceutical industry is often seen as part of the problem of antibiotic resistance, rather than as part of the solution. MSD Pharmaceuticals sees itself in the latter role. They use evidence-based research to develop local treatment guidelines for physicians and administrators who can then make informed choices about the drugs they prescribe. Other MSD Pharmaceutical work, such as their collaboration on CDDEP’s Drug Resistance Index, has helped pave the way for understanding trends in resistance before and after the establishment of antimicrobial stewardship programs.

Dr. Ghafur called for the implementation of the national antibiotic policy and for every Indian hospital to adopt an appropriate local antibiotic policy. Dr. Chowdhary noted that difficulties creating antibiotic policies in local hospitals often emerge from disagreements within the microbiology and clinical pharmacology departments of hospitals and stressed the need to follow the national antibiotic policy. He also remarked on the dearth of infectious disease specialists and microbiologists in India and indicated that antibiotic surveillance cannot be conducted well where these professionals are absent. In these cases, stewardship has an important role to play in limiting antibiotic resistance, as does restricting the supply of antibiotics at different levels of the public health care system. Ms. Khanna spoke of the bureaucratic limitations of efforts to foster public-private partnerships, in response to which Dr. Chowdhary expressed Haffkine Institute’s willingness to work with bioMérieux India on future courses.

Dr. Nathwani highlighted the importance of developing and integrating rapid diagnostic tests to guide treatment decisions. He noted the importance of data collection, and in particular, the value of point prevalence surveys. He also noted that India is at the forefront of innovation in information technology and should increase investment in this area. Dr. Nathwani observed that the national antibiotic policy can be implemented only after people acquire the skills needed to implement it, and added that while the hospital focus is important, we should not ignore inappropriate prescribing and misuse of antibiotics in the community.

Participants discussed the importance of auditing prescribers and giving them feedback to improve stewardship, the greater educability of younger doctors compared with their seniors, calling for a national campaign on antibiotic resistance, regularly revising the essential drug list at the hospital level and implementing stewardship programs in states with an uneven distribution of microbiologists or infectious disease specialists.

The stewardship course and the forum opened the door for greater collaboration among all sectors in India. GARP-India will follow up to build and maintain the momentum created by these events.