# RKS: ANTIMICROBIALS GALORE (III) - Antimicrobial Availability, Prescribing & Recommendations

 

# RKS: ANTIMICROBIALS GALORE (III)

ANTIMICROBIAL AVAILABILITY, PRESCRIBING & RECOMMENDATIONS


RKS / 2024-2025 / Ser 6 / Blog 5


1st February 2025

ANTIMICROBIAL GALAXY

ANTIMICROBIAL STATISTICS


Dear Reader,

Antimicrobials are shunned by the layman. For any prescription given the standard question asked by a patient is which is the antibiotic and how strong is it and what are the side effects. Surprising since the very same antimicrobial is prescribed to cure him and even save his / her life or, at the least, prevent from being hospitalized.

Strong ingrained adverse perception for antimicrobials is the root cause of patient's longer suffering duration and, many a times, leading to hospitalization. Mind you, an infection detected within the first 48 hours of hospitalization was actually acquired doctor (Dr.) as an out patient department (OPD) consultation and could have been cured if antimicrobials were prescribed appropriately and consumed as instructed.

This blog endeavors to educate regarding antimicrobials' requirement, prescribing patterns and the basis on which the doctors opt for the same.


NEED FOR ANTIMICROBIALS

The antimicrobials prescribed are for the following situations:

[Singh SK et al. J Hosp Infection 2019; 103(3): 280-283]

  1. Community Acquired Infections (CAI): 26.9% of antimicrobials are prescribed for day-to-day infections in routine consulting practice.
  2. Hospital Acquired Infections (HAI): 19.2% in hospitalized patients.
  3. Surgical prophylaxis: 28.7% of operated patients or those undergoing any procedure are advocated preventive antimicrobials.
  4. Medical prophylaxis: 17.3% of outpatients require antimicrobial coverage for a non-infective illness.
  5. Unknown indication: 8.0% of patients prescribed antimicrobials are for an unknown precise diagnosis.

The more common infections which require antimicrobials include:

[Singh SK et al. J Hosp Infection 2019; 103(3): 280-283]

  1. Lower Respiratory Tract Infections (LRTI): 25.8%
  2. Skin & Soft Tissue Infections (SSTI): 7.6% 
  3. Infections of Central Nervous System (CNS): 6.6%
  4. Cardiovascular System (CVS) infections: 5.5%
  5. Intra-abdominal sepsis: 4.9%
  6. Obstetric / Gynecological infections: 1.7%
  7. Upper Respiratory Tract Infections (URTI): 1.1%
  8. Bone & Joint infections: 1.1%


ANTIMICROBIAL PRESCRIBING PATTERN

PREFERRED CLASS OF ANTIMICROBIALS

Approximately 40% of outpatients are prescribed antimicrobials and 40% of those advocated in India are from the chemical classes mentioned.  

[Kotwani A & Holloway K. BMC Infectious Diseases 2011; 11: Article No 99]

  • Quinolones: Public Hospital OPDs, 9.0%; Private Drs., 13.7%
  • Cephalosporins: Public Hospital OPDs, 5.7%; Private Drs., 11.6%
  • Penicillins: Public Hospital OPDs, 10.2%; Private Drs., 8.7%
  • Macrolides: Public Hospital OPDs, 6.6%; Private Drs., 3.8% 
  • Co-trimoxazole: Public Hospital OPDs, 4.4%; Private Drs., 2.6%
  • Tetracyclines: Public Hospital OPDs, 3.4%; Private Drs., 2.2%
  • Aminoglycosides: Public Hospital OPDs, 0.0%; Private Drs., 0.8%

Overall, in India, cephalosporins (29.5%) is the most frequent class prescribed followed by penicillins (17%) and macrolides (16.5%) and these 3 constitute to 63% of the antimicrobials consumed. 

(Koya SF et al. Lancet 2022; 4: 100025)


COMMONLY PRESCRIBED ANTIMICROBIALS

The most common antimicrobials consumed globally in 2023 include: 

(https://www.definitivehc.com/resources/healthcare-insights/most-prescribed-antibiotics)

  1. Amoxicillin: 24.0%
  2. Co-amoxiclav [Amoxicillin + Clavulanic acid (CA)]: 13.6%
  3. Azithromycin 11.6%
  4. Cephalexin: 10.0%
  5. Clindamycin: 6.1%
  6. Co-trimoxazole: 6.1%
  7. Metronidazole: 5.2%
  8. Ciprofloxacin: 4.4%
  9. Ofloxacin: 2.8%

In India, 12 drugs constitute to more than 80% of the total number of antimicrobials prescribed in OPD practices - being prescribed for day-to-day illnesses: 

(Kotwani A & Holloway K. BMC Infect Dis 2011; 11: 99)

    1. Co-amoxiclav - 17.6%
    2. Ofloxacin - 16.2%
    3. Cefuroxime - 11.0%
    4. Cefixime - 7.3%
    5. Ciprofloxacin - 6.7%
    6. Levofloxacin - 5.6%
    7. Doxycycline - 5.4%
    8. Azithromycin - 4.5%
    9. Roxithromycin - 4.1%
    10. Amoxicillin + Cloxacillin - 3.8%
    11. Cefixime + CA - 3.5%
    12. Amoxicillin - 2.8%


    ANTIMICROBIAL PRESCRIBERS

    WHO PRESCRIBES ANTIMICROBIALS?

    Antimicrobials consumption pattern is: 

    (Kotwani A & Holloway K. BMC Infect Dis 2011; 11: 99)

    • Community (OPD patients): 80%
    • Hospitals (In-patients): 20%

    Antimicrobials prescribed by various specialist doctors in admitted patients include: 

    [Sheikh S et al. Infection Prevention in Practice 2022; 4(4): 100253]

    • Obstetricians & Gynecologists: 75% of patients require antimicrobials
    • Intensivists: 58% of patients require antimicrobials
    • Physicians: 51% of patients require antimicrobials
    • Surgeons: 45% of patients require antimicrobials
    • Orthopedicians: 35% of patients require antimicrobials
    • Pediatricians: 33% of patients require antimicrobials
    • ENT Surgeons: 30% of patients require antimicrobials
    • Oncologists: 28% of patients require antimicrobials

    Overall, 42% of 'in-patients' receive antimicrobials.


    HOW MANY ANTIMICROBIALS PRESCRIBED?

    On an average, 1.62 antimicrobials are being prescribed per patient in the Indian subcontinent. In hospitalized patients, approximately 2 per patient inwards and roughly 3 antibiotics per day in ICU has been recorded.

    [Sheikh S et al. Infection Prevention in Practice 2022; 4(4): 100253] 


    BASIS OF ANTIMICROBIALS PRESCRIBING

    Are antimicrobials are being empirically prescribed or on basis of confirmed effectiveness by way fo a positive antimicrobial culture and sensitivity (C/S) report? 

    [Sheikh S et al. Infection Prevention in Practice 2022; 4(4): 100253]  

    Overall, the basis of prescribing antimicrobials in India is:

    • Empirical: 40.1%
    • Prophylactic: 37.1%
    • Based on C/S: 22.8%

    In hospitalized patients:

    • Empirical: 72.1%
    • Prophylactic: 19.9%
    • Based on C/S: 7.9% 


    ANTIMICROBIAL PRESCRIBING GUIDELINES

    There are guidelines laid down internationally for prescribing antimicrobials and these include:

    • WHO (World Health Organization): Infection Prevention and Control (IPC) guidelines
    • America: Infectious Diseases Society of America (IDSA) Clinical Practice guidelines
    • Africa: African Antibiotic Treatment Guidelines for Common Bacterial Infections and Syndromes
    • Australia: Australian Guidelines for the Prevention and Control of Infection in Healthcare
    • Europe: European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guideline
    • Canada: Infection Prevention and Control (IPC) guidelines
    • India: National Treatment Guidelines for Antimicrobial Use in Infectious Diseases
    • Japan: JAID (Japanese Association of Infectious Disease) / JSC (Japanese Society of Chemotherapy) Guide to Clinical Management of Infectious Diseases
    • Malaysia: National Antimicrobial Guideline (NAG)
    • Netherlands: SWAB (Stichting Werkgroep AntibioticaBeleid or Dutch Working Party on Antibiotic Policy) Therapy for Empirical Antibacterial Therapy for Sepsis in Adults 
    • New Zealand: bpacnz Primary Care Antibiotic Guide
    • Saudi Arabia: National Antimicrobial Guidelines for Community and Hospital Acquired Infections in Adults
    • Singapore: Infection Prevention and Control (IPC) Guidelines and Standards

    The medical professionals of various countries by and large adhere to prescribing as per the guidelines for a particular infection being treated. Adherence to guidelines has been documented as:

    • Medical Ward: 70.2%
    • Surgical Ward: 70.0%
    • ICU (Intensive Care Unit): 79.5%

    [Singh SK et al. J Hosp Infection 2019; 103(3): 280-283]

      

    WHO & ANTIMICROBIAL CLASSIFICATION

    The 2019 World Health Organization (WHO) AWaRe Classification Database was developed on the recommendation of the WHO Expert Committee on Selection and Use of Essential Medicines. It includes details of 180 antimicrobials classified as Access, Watch or Reserve, their pharmacological classes.

    1. ACCESS GROUP: This group includes 48 antibiotics that have activity against a wide range of commonly encountered susceptible pathogens whilst also demonstrating lower resistance potential than antibiotics in the other groups.
    2. WATCH GROUP: This group includes 110 antibiotics that have greater resistance potential and includes most of the highest priority agents among the Critically Important Antimicrobials for Human Medicine and/or antibiotics that are at relatively high risk of selection of bacterial resistance.
    3. RESERVE GROUP: This group includes antibiotics and antimicrobial classes that should be reserved for treatment of confirmed or suspected infections due to multidrug resistant (MDR) organisms and should be employed as “last resort” options.

    ACCESS includes narrow-spectrum antibiotics recommended as first-line or second-line antibiotics; WATCH includes broad-spectrum antibiotics with a high chance of resistance to be used only for specific indications; and RESERVE includes antibiotics to be used only as a last resort.

    (Koya SF et al. Lancet 2022; 4: 100025) 


    CONCLUSIONS

    For a layman, antibiotic is a generic terminology to treat infections. However, in medical parlance, the science of antimicrobials is much more intricate and complexities are involved in judiciously advocating the same. NO two patients, even with the same diagnosis, is similar and  best placed to unleash his / her antibug arsenal based on previous experiences in a geographical location as well as past knowledge of that patient's responses.

    The regulators all sit pretty at the helm of affairs and try proclaiming dictates on antimicrobial usage restrictions inspite of ZERO clinical experience and sans assuming any accountability for adversities that could arise if the pathogens responsible for attacking the patient's tissues are not adequately decimated. In all fairness for the Dr., and in the best interest for the patient's welfare, love the antimicrobials and don't castigate these magic bullets.

    The concluding upcoming blog will dwell on the real reasons for antimicrobial resistance (AMR) and what are the tips to minimize the same and guidance for the same for the patient and Dr. alike.


    DR R K SANGHAVI

    Prophesied Enabler

    Experience & Expertise: Clinician & Healthcare Industry Adviser




    -------------------------------------------------------------------------------------

    POWERED BY -

    # fuzionnutra.com

    Location: Mumbai, Maharashtra, India

    Comments

    Post a Comment

    Popular posts from this blog

    # RKS: INTERMITTENT FASTING CULT FOR WEIGHT LOSS - A Passerby Or Here-To-Stay

    Image
        # RKS: INTERMITTENT FASTING CULT FOR WEIGHT LOSS A PASSERBY OR HERE-TO-STAY RKS / 2024-2025 / Ser 6 / Blog 2 1st November 2024 INTERMITTENT FASTING ALL SET TO RULE THE SCIENCE BEHIND Dear Reader, Fasting is the act of refraining from eating, and sometimes drinking. Fasting practices may have first emerged around 1,500 BC in the Vedic, Hindu and Jainism religions.  Prophet Adam was the first person to ever fast in human history. It is believed that the first fasting (done by Prophet Adam) was after his descent to earth and God’s acceptance of his prayers and repentance. It is also believed that he fasted 3 days each month during the entire year; they are the 13th, 14th and 15th. Fasting was commonly practiced in earlier times on 'holy' days to reduce the harm to plants and  animals caused by harvesting and eating.  Fasting has also been used for therapeutic  purposes since at least the 5th century BCE. Greek physician Hippocrates recommended  that p...
    Read more

    # RKS: EXERCISE CAN SPELL HEALTHY MORTAL LIVING OR MORTALITY - Be Warned Of The Fitness Fanaticism

    Image
      # RKS: EXERCISE CAN SPELL HEALTHY MORTAL LIVING OR MORTALITY BE WARNED OF THE FITNESS FANATICISM  1st April 2024 DISSECTING THE ART OF PHYSICAL FITNESS - A FINE-TUNED CRAFT THE PITFALLS ANALYZED BEHIND RECENT CALAMITIES  Dear Reader, Over the past decades, we have witnessed an increasing proportion of society engaging in ultra-endurance events, which are well in excess of the health-promoting exercise recommendations.  Table: Names of some popular celebrities who passed away whilst gymming. In recent times, there has been a hue and cry regarding the reported drastic rise in gym-related deaths each year, with the majority being attributed to sudden cardiac arrest (SCA). In fact, 80-85% of all sudden deaths are heart-related - sudden cardiac deaths (SCD). In today's context, SCD is become the most common cardiac concern amongst all heart ailments. Graph: Incidences of SCD vs other cardiac maladies. It would be intriguing to analyze the bare underlying reasons for s...
    Read more

    # RKS: SANTIZING & SANITIZERS - More Than Meets The Eye

    Image
     # RKS: SANTIZING & SANITIZERS  - More Than Meets The Eye 1st October 2020 Dear Reader, I always remember how I was pulled up in yesteryears for washing my hands - a wee bit too frequently - by family, friends, and even Dr colleagues. After touching each patient, even for checking mere BP or pulse (including a socially visiting relative or friend), always washed hands; before touching any eatable and always after finishing food washed hands with water.  In AI flights there is yet wet wipes given but the practice has stopped in other airlines but I continued washing my hands even as seated in a plane - guess how?!!  Sanitizing is the rule today and sanitizers are ruling today. Umpteen manufacturers have entered the fray and because of COVID-19 fear I feel better hygienic environment prevailing when in close apposition to someone's else flesh-brushing - rare handshake and the like. But why do we buy, use, advocate and amply store sanitizers? What is their actual ro...
    Read more