An app to aid fight against microbial resistance
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Mumbai: Finding an effective solution to microbial resistance to antibiotics has emerged as one of the most daunting medical challenges in the modern world.
Now, the US drug firm Merck and Co. Inc, the same firm that helped distribute the world’s first antibiotic, penicillin in 1942, has made another major contribution to take on this new challenge.An electronic antimicrobial stewardship (AMS) programme, which promotes rational and judicious use of antibiotics in hospitals, has been designed and initiated by MSD Pharmaceuticals Pvt. Ltd, the India unit of Merck. The programme is followed by hundreds of doctors attached with at least 140 large hospitals in India—home to the highest number of microbial resistance cases, according to World Health Organisation (WHO).
Antimicrobial resistance is the immunity of microorganisms, including bacteria, virus, fungi and parasites that cause infection in the human body, against antibiotics. This occurs mainly because of wrong use of antibiotics, including improper identification of the bug that caused the infection, wrong selection or suboptimal dosage of antibiotics, and failure to complete the course of treatment.
The issue of infectious bugs’ resistance to existing antibiotics emerged as a cause of serious concern in the light of very slow or almost no progress in the discovery of newer antibiotics.
An initiative by a large pharmaceutical company to control the use of medicines naturally raised doubts among critics.
But, MSD India’s president and managing director K.G. Ananthakrishnan says, “I was asked by many in the past whether this is part of the group’s corporate social responsibility or does it have a business strategy behind it?”
“It is neither. In all the therapeutic areas where we operate, we’ve always tried to keep the patient at the centre and have introduced very comprehensive solutions to ensure better results and the comfort of patients, and this (AMS) was one such initiative that has made a large impact in countering a big crisis in the area of infectious diseases,” he adds.
The objectives of the AMS programme includes gaining an overall understanding of all class of antibiotics and related issues of resistance. With this, it tries to build a consensus among different stakeholders in a hospital, including clinicians, microbiologists, pharmacy and the management, to frame an institution-specific antibiotic protocol.
A regular review and audit of maintenance of these protocols is another part of the programme.
The initiative was developed in 2008 in India with the aim of preparing hospitals for practising rational use of antibiotics.
The programme, which was first developed as a pocket book reference manual for doctors working in intensive care units (ICUs) to help them take decisions on the right drug for the right bug, was made available digitally early this year.
“We found that doctors often forget to carry the ready reference book or even to look at the referral points pasted on the walls of the ICU ward (as part of the programme) at the time of emergency, which became a big barrier in maintaining protocol under the stewardship programme,” says Gourav Laroia, senior director (specialty care) at MSD India. “But, the mobile phone is one device that everyone carries every time today, and that ignited the whole idea of making the programme compatible to this device,” Laroia says.
The digital programme (e -AMS), which works through an app installed on the mobile phones of doctors at the enrolled hospitals, is now backed by the Indian Society of Critical Care Medicine (ISCCM). In September, the initiative was also recognised by the prestigious British Medical Journal.
Most relevant to India
In a country like India, the resource-limited hospitals and unregulated healthcare settings pose a serious challenge for implementing antimicrobial stewardship.
The major challenges include lack of trained infectious disease physicians, clinical pharmacists and epidemiologists, a paucity of local microbiology surveillance data and over-the-counter availability of antibiotics. This makes following an antimicrobial protocol designed for developed countries difficult.
“It needs indigenous solutions with customization of global guidelines,” says Swashraya Shah, senior director (medical affairs), MSD India. Moreover, it makes the role of microbiologists in these hospitals, whose report ultimately identifies the bug causing the infection, important in formulating the treatment decisions in the hospital, and it also encourages the interaction between the doctors and microbiologists for better decisions, which was not the practice in the country until now, says Shah.
How it works
Formulation of clinical pathways and infection-site specific guidelines for the hospitals based on local microbiological data was cornerstone of MSD’s e-AMS programme, which has now been introduced in other countries such as Russia, Colombia, Vietnam and the Philippines.
The hospital-specific antibiotic protocols and guidelines have mainly four basic principles: appropriate antibiotic to be recommended depending on the site of infection and hospital’s own “antibiogram”; the risk analysis for the presence of multi-drug resistant pathogens to be taken into consideration along with local microbiology for deciding on antibiotics; de-escalation of the antibiotic options based on the culture and sensitivity results and the patient’s clinical condition; and dose optimization of antibiotics.
All these recommendations are available on the app that is enabled in the mobile phone.
Critical care physicians and infectious disease specialists with good knowledge and an interest in antibiotics have been entrusted with leading the programme in the hospitals along with clinical microbiologists.
Since most Indian hospitals do not have clinical pharmacists and trained physicians to provide expert opinion on critical clinical decisions on antibiotics, the protocol app acts as a ready reference manual.
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