New Delhi: India’s apex bio-medical research agency, the Indian Council of Medical Research (ICMR), is working to develop the country’s first ever set of guidelines on the empirical use of antibiotics for upper respiratory infections, fever and community-acquired pneumonia—the conditions for which they are most overused—ThePrint has learnt.
This comes in the wake of the growing concern around antimicrobial resistance (AMR), which has emerged as a major public health challenge in India.
In 2019, an estimated 2,97,000 deaths in the country were attributed (directly linked) to AMR, while 10,42,500 deaths were associated (indirectly linked) with it.
Empirical use of antibiotics is when they are given to a patient before the specific pathogen causing an infection is identified. AMR occurs when various pathogens, such as bacteria, viruses, fungi and parasites, no longer respond to existing medicines, making people sicker and increasing the risk of illnesses, deaths and spread of infections that are difficult to treat.
Antibiotic misuse is seen as the leading cause of AMR in the country.
“Through the initiative, our aim is to create evidence-based guidelines on empirical use of antibiotics for some common conditions for which the exact cause or pathogen has not been diagnosed,” a senior ICMR scientist, who did not wish to be named, told.
This is particularly important, the scientist added, as the country saw massive abuse of antibiotic azithromycin during the Covid pandemic, when it was used for a large number of patients who did not need it.
ThePrint reached out to ICMR Director General Dr Rajiv Bahl for a comment via phone. This report will be updated if and when a response is received.
According to a document inviting researchers to aid the development of the rules, the guidelines for antibiotic use in case of upper respiratory infections, acute undifferentiated fevers and community-acquired pneumonia will entail the compilation of systematic reviews and meta-analyses from existing medical literature, focusing on well-defined review questions.
These review questions will include when to start the empirical antibiotics, which class of antibiotics to start empirically, when to stop empirical antibiotics and when to change antibiotics.
According to the AWaRe classification of antibiotics developed by the World Health Organisation (WHO) in 2017, there are three classes of antibiotics: Access, Watch and Reserve.
The antibiotics classified as ‘Watch’, which includes azithromycin, generally have a higher potential for antimicrobial resistance and are more commonly used in sicker patients in medical facilities. These medicines, according to WHO, should be prescribed carefully to avoid misuse.
‘Access’ antibiotics are those with a narrow spectrum of activity, generally with fewer side-effects, and a lower potential for antimicrobial resistance and lower cost. These are recommended for the empirical treatment of most common infections.
The third group of antibiotics—‘reserve’—on the other hand, includes last-resort medicines and should only be used to treat severe infections caused by multidrug-resistant pathogens.
“Through the guidelines, our aim is to develop algorithms that can guide clinicians on which situations to prescribe antibiotics in and keep it limited to only ‘access’ class of antibiotics to a large extent because they work in most clinical cases,” the scientist quoted above said.
Experts say that in up to 95 percent of cases of upper respiratory infections—commonly manifested as cold and throat infection—antibiotics may not be required at all.
“It is very unfortunate to see physicians recommending antibiotics for every chest infection or every throat infection because the majority of these are actually viral infections, which do not need antibiotics,” Dr Arjun Khanna, head of department of pulmonary medicine at Amrita Hospital in Faridabad.
Antibiotics should only be used if there is a proven bacterial infection, he explained, failing which there is a chance of developing resistance to the antibiotics.
“It is a very welcome move by the ICMR because in India, we see a lot of over-the-counter prescriptions of antibiotics, which should be discouraged,” Khanna said.
Dr Aravind Reghukumar, head of department of infectious diseases with the Government Medical College in Thiruvananthapuram, pointed out that antibiotics are randomly prescribed in out-patient settings even though many times, physicians don’t have access to a rapid diagnostic test in the OPD, and cases are not subjected to culture and susceptibility tests to establish the pathogen.
“During Covid-19 period, we saw that azithromycin became the most selling drug in India for several months even though the doctors knew very well that it was a viral disease and most patients did not need any antibiotic for this,” he said.
It is probably in this context that the ICMR has decided to aid doctors in OPDs in selecting the right antibody, Reghukumar, who is the convenor of the Kerala Antimicrobial Strategic Action Plan, told ThePrint.
He pointed out that health agencies in developed countries, such as the Centre for Disease Control in the US, already have these algorithms to guide the primary case physicians.
Reghukumar also stressed that for most cases of upper respiratory infections, such as pharyngitis, sinusitis or rhinitis, it is important to actually look at the severity of the symptoms and the patient profile, to see whether they are immunocompetent or immunocompromised.
“There is a categorisation based on the severe dose symptoms into category A, b1, b2 and C, following which the physician can determine if testing is required or if there is a need to start an antiviral, but antibiotics may not be needed at all in such cases,” he said.
Likewise, for an undifferentiated fever, a similar approach may help, the specialist pointed out.
For example, in areas where dengue is prevalent and a patient reports fever, joint pain, myalgia, headache and excessive fatigue, the doctor should suspect a dengue fever.
“In such cases, a diagnosis should be asked for and supportive care should be given to the patient, but there is no need for antibiotics at all,” Reghukumar said.
