Antibiotic stewardship and regulations to rationalise antibiotic usage are the corner stones for implementing national action plans for reducing anti-microbial resistance. How easy is it for a general practitioner in a small town in India to convince his patient with a throat infection that an antibiotic is not necessary in most upper respiratory infections?
All doctors know that viruses, not bacteria, cause most throat infections and that antibiotics do not cure viral infections. But how sure can a doctor be in predicting the cause of his patient’s throat infection? Will this clinical experience be sufficient enough to dissuade them from penning down an antibiotic?
It’s easier to preach than practice.
“In India, I can prescribe a five-day course of antibiotics that costs my patient just under a dollar!”
A general practitioner has to treat dozens of patients every day. It is easier to prescribe a three or even five-day course of antibiotics than take the risk of missing a bacterial infection with the potential for consequent complications at the displeasure of the patient.
Significant changes in antibiotic prescribing behavior by general practitioners in developing countries may not materialise unless technology is developed which will help categorically differentiate between bacterial and viral infections. Doctors need a test that is quick, reliable and affordable.
Here comes the affordability conundrum…
In India, I can prescribe a five-day course of antibiotics that costs my patient just under a dollar! Can you offer me a wonderful test that costs less than this magic number? A real challenge…
Now let us peek into the emergency room of a large Indian hospital and talk to the consultant on call. They are taking care of an elderly diabetic patient with a severe urinary tract infection and dropping blood pressure, who is waiting to be transferred to an intensive care unit. The nurse is rushing treatment with a vial of meropenem – an expensive, very broad-spectrum antibiotic, but not an uncommon choice in hospitals in a country with high rates of drug resistant, Gram-negative bacteria.
Two days later the urine culture report comes back positive for an E. coli bacteria that is sensitive to ALL antibiotics.
In retrospect, using meropenem was an overkill. Two days of meropenem costs the patient an unnecessary amount of money as well as the potential for developing carbapenem-resistant bacteria!
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I would not be surprised if the laboratory report for the E. Coli bacteria was not only sensitive to antibiotics, but entirely resistant to all common antibiotics, including meropenem. In such a scenario, even the potent meropenem will be ineffective. Colistin, the last resort in the antibiotic armamentarium, may need to be used instead. There are also plenty of published reports of otherwise healthy individuals, who were never hospitalised, carrying carbapenem-resistant bacteria in their gut.
The scenario could be similar in patients admitted to intensive care units. Delayed initiation of the right antibiotic at the right time is one of the main determinants of high mortality. Although, empirical usage of high-end antibiotics is justified in patients with severe sepsis. The key, however, is in stepping down to a narrow-spectrum antibiotic when culture reports are available – let us say after 3-4 days.
“Any test that costs more than a course of antibiotics in India is less likely to be successful”
Broad-spectrum antibiotics are very expensive, with 3-4 days of empirical antibiotics in Indian intensive care units costing the patient anywhere between $500-1000 on average. Availability of a rapid, reliable, bedside diagnostic test that can identify the causative bacteria and the right active antibiotic would make a dramatic shift in the rates of expensive broad-spectrum antibiotic usage.
But how affordable should these tests be? Any good test that costs less than the antibiotics we are currently dispensing!
In an outpatient department or in general practice; any test that costs more than a course of antibiotics in India is less likely to be successful, unless it is delivered at a highly subsidised rate.
On the other hand, more expensive and sophisticated point-of-care diagnostics could be successful in a hospital set up, if the test is good enough to help the patient and the doctor in peril.
The author, Dr. Abdul Ghafur, is the primary author and coordinator of the “Chennai Declaration“, a document and initiative to tackle the challenge of antimicrobial resistance from an Indian perspective. He is also a Consultant and Adjunct Associate Professor in infectious diseases and Clinical Microbiology at the Apollo Hospitals, Chennai, India.
This article first appeared in the Longitude Prize Blog.