ANTIBIOTIC PROTOCOLS AND AMR

Source: DownToEarth

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Context

• The rise of healthcare-associated infections (HAIs) caused by drug-resistant bacteria presents a critical challenge for hospitals worldwide.
• These infections, which include central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated pneumonia, are difficult to manage due to antimicrobial resistance (AMR).
• There is an urgent need for hospitals to implement antibiotic protocols to address this growing threat effectively.

Details

Current Challenges

• High-Risk Hospital Environments: Patients, especially those in intensive care units (ICUs), are vulnerable to infections due to weakened immune systems and extensive antibiotic use, which fosters resistance. In India, ICUs reported 2,622 healthcare-associated bloodstream infections and 737 healthcare-associated urinary tract infections between May 2017 and October 2018.
• Superbugs: The frequent administration of multiple antibiotics in the hope that one will be effective against resistant bacteria leads to the development of superbugs. Superbugs like MRSA and VRE are becoming increasingly common in hospital settings.
• Global and Local Statistics: Data from the International Nosocomial Infection Control Consortium indicates that catheter-associated urinary tract infections and central line-associated bloodstream infections are three to six times higher in ICUs in low- and middle-income countries compared to the US. WHO's 2022 report notes that the risk of acquiring HAIs is up to 20 times higher in relatively poor countries.

Surveillance and Data

• Surveillance Studies: Surveillance studies show significantly higher rates of HAIs in low- and middle-income countries. For instance, the pooled rates of catheter-associated urinary tract infections and central line-associated bloodstream infections were notably higher compared to those in US ICUs.
• Specific Pathogens in India: A report in The Lancetfrom September 2023 highlights high resistance levels in pathogens causing HAIs in India. For instance:
  • Klebsiella spp.: 72.4% resistance in bloodstream infections, 76.3% in UTIs.
  • Escherichia coli: 58% resistance in bloodstream infections, 62% in UTIs.
  • Acinetobacter spp.: 77.2% resistance in bloodstream infections, 75.7% in UTIs.
  • Pseudomonas spp.: 63.7% resistance in bloodstream infections, 71.9% in UTIs.
• Vancomycin-Resistant Enterococcus (VRE): In Indian ICUs, the prevalence of VRE is five times higher than the global average, according to a study by the Global Antibiotic Research and Development Partnership and One Health Trust.

Importance of Antibiotic Protocols

• Antibiotic Stewardship Programs: These programs ensure the right antibiotics are used at the right doses for the right duration, minimizing misuse and overuse. Antibiotic stewardship programs can reduce the incidence of drug-resistant infections and improve patient outcomes.
• Antibiograms: Regular use of antibiograms helps track resistance patterns and guide empirical antibiotic therapy, crucial for managing HAIs effectively. With advancements in automated systems, the generation of antibiograms has become more efficient and accurate.
• Continuing Medical Education: Updating practicing doctors on the latest susceptibility patterns and breakpoints is essential for informed decision-making. Medical education should include regular updates on AMR trends and effective antibiotic use.

Government Initiatives in India

• ICMR Pilot Project: The Indian Council of Medical Research has initiated antibiotic stewardship programs in 20 tertiary care hospitals to curb misuse and overuse of antibiotics.
• National Programme on AMR Containment: Coordinated by the National Centre for Disease Control, this program enhances the capacity of hospitals to generate and monitor AMR surveillance data.
• National AMR Surveillance Laboratory Network (NARS-Net): This network includes laboratories across states and Union territories to provide comprehensive surveillance data. As of March 2023, NARS-Net included 40 laboratories in 31 states and Union territories.
• National Action Plan on AMR (NAP-AMR): Launched in April 2017, the plan focuses on improving awareness, surveillance, infection prevention, optimizing antimicrobial use, promoting research, and enhancing international collaboration. The Union Health Ministry is now preparing a National Action Plan on AMR 2.0.

Recommendations

• Uniform Implementation of Protocols: Ensuring that all hospitals, including smaller centers, have infection control teams and follow standardized protocols. Smaller centers often lack the resources and training to effectively manage infection control, and enhanced government support is crucial.
• Education and Training: Incorporating AMR and infection control into medical curricula and providing ongoing training for healthcare professionals. This includes updating doctors on the latest breakpoints and susceptibility patterns.
• Government Support: Increased support for hospitals, especially smaller ones, to establish and maintain effective infection control measures. Government initiatives should provide resources and training to ensure uniform implementation across all healthcare settings.
• Collaboration: Encouraging collaboration between doctors, hospitals, and non-governmental organizations to enhance data collection and awareness efforts. NGOs can play a crucial role in creating awareness and supporting data collection initiatives.
• One Health Approach: Integrating human, animal, and environmental health strategies to combat AMR comprehensively. This holistic approach recognizes the interconnectedness of health across different sectors.
• Technological Advancements: Leveraging automated systems and technological advancements to improve the accuracy and efficiency of antibiograms. This can help in real-time tracking of resistance patterns and prompt decision-making.

Various Drug-Resistant Bacteria

• Methicillin-Resistant Staphylococcus aureus (MRSA)
  • Characteristics: MRSA is a type of Staphylococcus aureus that has developed resistance to methicillin and other beta-lactam antibiotics.
  • Mechanisms of Resistance: MRSA produces an altered penicillin-binding protein (PBP2a) that has a low affinity for beta-lactam antibiotics.
  • Infections: MRSA can cause skin and soft tissue infections, pneumonia, bloodstream infections, and surgical site infections.
  • Prevalence: Common in hospitals (hospital-acquired MRSA) and community settings (community-acquired MRSA).
• Vancomycin-Resistant Enterococci (VRE)
  • Characteristics: Enterococci bacteria that are resistant to vancomycin, often Enterococcus faecium and Enterococcus faecalis.
  • Mechanisms of Resistance: VRE produces altered cell wall precursors that prevent vancomycin from binding effectively.
  • Infections: Can cause urinary tract infections, bloodstream infections, wound infections, and endocarditis.
  • Prevalence: Frequently encountered in healthcare settings, particularly in immunocompromised patients.
• Carbapenem-Resistant Enterobacteriaceae (CRE)
  • Characteristics: A family of Gram-negative bacteria that includes Klebsiella pneumoniae and Escherichia coli, resistant to carbapenem antibiotics.
  • Mechanisms of Resistance: CRE produces carbapenemases (enzymes that break down carbapenems) such as KPC, NDM, and OXA-48.
  • Infections: Cause severe infections including pneumonia, bloodstream infections, urinary tract infections, and wound infections.
  • Prevalence: Increasingly reported in hospitals worldwide, leading to high morbidity and mortality.
• Multidrug-Resistant Tuberculosis (MDR-TB)
  • Characteristics: Mycobacterium tuberculosis strains resistant to at least isoniazid and rifampicin, the two most potent TB drugs.
  • Mechanisms of Resistance: Mutations in genes associated with the target sites of these drugs.
  • Infections: Causes pulmonary tuberculosis that is difficult to treat.
  • Prevalence: Particularly prevalent in countries with high TB burdens, posing a significant challenge to TB control programs.
• Extended-Spectrum Beta-Lactamase (ESBL)-Producing Enterobacteriaceae
  • Characteristics: Bacteria such as E. coli and Klebsiella spp. that produce enzymes called ESBLs, which break down a wide range of beta-lactam antibiotics.
  • Mechanisms of Resistance: Production of ESBL enzymes that hydrolyze antibiotics such as penicillins, cephalosporins, and aztreonam.
  • Infections: Can cause urinary tract infections, bloodstream infections, and intra-abdominal infections.
  • Prevalence: Increasingly common in both community and healthcare settings.
• Drug-Resistant Pseudomonas aeruginosa
  • Characteristics: A Gram-negative bacterium with intrinsic resistance to multiple antibiotics and the ability to acquire additional resistance mechanisms.
  • Mechanisms of Resistance: Efflux pumps, beta-lactamases, and mutations in antibiotic target sites.
  • Infections: Causes infections in immunocompromised patients, including pneumonia, urinary tract infections, and surgical site infections.
  • Prevalence: Common in hospitals, particularly in ICUs and among patients with cystic fibrosis.
• Drug-Resistant Acinetobacter baumannii
  • Characteristics: A Gram-negative bacterium that can survive in various environments and develop resistance to many antibiotics.
  • Mechanisms of Resistance: Produces enzymes like carbapenemases, and possesses efflux pumps and permeability changes.
  • Infections: Causes pneumonia, bloodstream infections, urinary tract infections, and wound infections.
  • Prevalence: Often associated with healthcare settings, particularly in ICUs and war zones.

Types of drug-resistant TB

• Mono-resistance:resistance to one first-line anti-TB drug only
• Poly-resistance:resistance to more than one first-line anti-TB drug, other than both isoniazid and rifampicin
• Multidrug resistance (MDR):resistance to at least both isoniazid and rifampicin
• Extensive drug resistance (XDR):resistance to any fluoroquinolone, and at least one of three second-line injectable drugs (capreomycin, kanamycin and amikacin), in addition to multidrug resistance
• Rifampicin resistance (RR):resistance to rifampicin detected using phenotypic or genotypic methods, with or without resistance to other anti-TB drugs. It includes any resistance to rifampicin, in the form of mono-resistance, poly-resistance, MDR or XDR.

Conclusion

Drug-resistant bacteria represent a formidable challenge to modern medicine. Effective management requires a multifaceted approach, including robust antibiotic stewardship, stringent infection control practices, continuous surveillance, innovative research, and comprehensive education and awareness campaigns. By implementing these strategies, we can mitigate the impact of drug-resistant bacteria and protect public health.

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Sources:

DownToEarth