Statements in the Article Response
My strong feeling is that we Microbiologists, especially those with MBBS, MD hold joint responsibility for this sorry state of affairs.
They also should own the responsibility.
The drug resistant strains develop in the community and are transported to the hospital where they concentrate. Use of antibiotics as a reflex without logic, at all levels including (and mainly) the peripheral, private health care setting are the factories of drug resistant pathogens.
It is never taught in the medical colleges during the medicine lectures or clinics that not only the infections but the antibiotic also should be diagnosed. Choice of antibiotic is a logical and analytical process. But unfortunately most of the clinicians including the busy academicians learn about the antibiotics from the pharmaceutical houses.
Microbiologists in the lab are certainly responsible but are not the culprits. The one, who write antibiotic prescriptions for material gains like foreign trips, plush cars, free conference registrations, pleasure trips under the banner of academics etc. are the once who have created the menace.
The MD or MBBS microbiologists’ contribution is their ignorance and apathy to the problem. They consider that it is not their responsibility to act. They are satisfied only to preach, not practice.
Most Microbiologists are safely ensconced in their labs with no inkling of what is going on in the wards.
A lot of importance is given to making an impeccable report that cannot be proved wrong by anybody.
Most microbiologists do not feel that it is important to take pains in preparing an impeccable report. The common assumption is that most clinicians do not understand and try to understand anything about the report and microbiology.
Gram-negative bacilli in two samples of blood is a dire emergency.
The problem of drug resistance can hardly be related to blood culture. This is an investigation performed only in the big hospitals of the metropolitan cities. Most tertiary care centers also do this investigation rarely. Forget PUO, blood culture is hardly ever ordered for diagnosis of typhoid fever. The biggest practice of medicine is in the community; and not in elite hospitals, where the drug resistant pathogens are generated. In the elite hospitals and academic institutes also protocols and policies are used cosmetically only as a façade.
Generally the report is given only after a thorough identification (this may be important in case of Stenotrophomonas maltophilia-very rare).
Yes it is important to provide the report after through identification.Stenotrophomonas maltophilia or Haemophilus or brucella or E. coliwill be identified only after through identification and the treatment varies as per the pathogen. All are Gram-negative bacilli from blood culture must not be subjected to direct sensitivity. This may be a useful option for neonatal septicemia or urinary tract infections.
The important issue is that Gram-negative bacilli form other samples like endotracheal tube, catheter tips etc. are unnecessarily sent to the laboratory for culture and sensitivity. The ‘laboratories report and clinicians treat’ the contamination.
The patient is saved if a direct sensitivity is done and report given as GNB sensitive to –xxx antibiotics.
For therapy before identification and sensitivity report empirical antibiotics are there.
Unfortunately our clinicians feel that we have only pipracillin (taxzobactam), Imipenem, meropenem as the empirical antibiotics. No one wants to follow the policy established at the center.
A commercial and non-scientific term; ‘Higher Antibiotic’ is successfully established in the medical world by the people who have vested interest in the sale of antibiotics.
Another strategy is to phone up and suggest a drug for Gram neg sepsis to the clinician. It will also prevent misuse of high-end antibiotics.
Clinicians are very happy to get a quick result from Microbiology and are incredulous when you phone the first time. They ask “But don’t you need 48 hrs to say that?”
Most clinicians consider it below dignity to take an opinion from a microbiologist or a pharmacologist. They however, are ready to catch a suggestion from a medical representative who is a BSc or even BA.
What we need to implement is not just a judicious policy but a wise and sane attitude. Microbiologists feel that clinicians are callous and clinicians feel that microbiologists are not practical.
Friday, July 15, 2011
Response by - Dr. R. D. Kulkarni
Professor & Head, Dept. of Microbiology, SDM College of Medical Sciences & Hospital, Dharwad - 580009 (Karnataka)
Most of the ideas employed in the usage of antibiotics are borrowed especially from America. We have certainly a very good pool of experienced thinkers. Let us not inflate the facts to scary levels. MRSA may be a frightening term in US but in India a lot of hospitals have reported isolations rates above 50%. However, there are hardly any reports of deaths because of MRSA in uncomplicated infections in this country. The same is the case for ESBL and AmpC producers.
Let us not be obsessed with the fear psychosis of intractable drug resistance. The only organism which is really posing a problem is acinetobacter especially in the neonatology units.
Let us understand the problem. Assess it on the basis of facts as we see them around us without being prejudiced by American viewpoint. A lot of effort is really essential for MDR and XDR tuberculosis which is addressed less emphatically compared to the other pathogens.
Monday, July 11, 2011
`Regulations to prevent Antibiotics Resistance & Promotion of Rational use of antibiotics`- Suggestions to Planning commission Constituted working Group
Is there anything you would like to see included in `Regulations to prevent Antibiotics Resistance & Promotion of Rational use of antibiotics`. Dr Mira shiva is a member of the Planning commission Constituted working Group on `Regulations on Drugs & Food`. She will make an endeavor to include these suggestions in the final document. Pl send your suggestions to firstname.lastname@example.org.
Saturday, July 9, 2011
Let us all Join together------
Several associations scattered all over India are working for spreading the knowledge about the problem of `Antimicrobial Resistance` (AMR) and making efforts to reduce the menace. IIMAR encourages all such efforts and wishes that we should all be together in solving the problem of AMR.
Towards this, we will make available space here for all these organizations to introduce themselves to others, so that several joint efforts can be launched.
Let us know today about the `Academy of Clinical Microbiologists` www.clinicalmicrobio.org .
A group of Microbiologists in Trivandrum , mainly working in the Govt. Medical College have formed `Academy of Clinical Microbiologists` to promote clinical microbiology which is totally neglected by microbiologists and generally discouraged by clinicians. The Group now has over 200 members all over India and a Triennial conference is held regularly, next one being due in October 2011, tentatively on 15th and 16th.
Dr. kavita Raja, Professor of Microbiology, SreeChitra Tirunal Instt. of Medical Sciences and Technology, Trivandrum, Kerala, informed about it. I requested her to also write about her ideas.
From my personal discussions with many I have generally found that many MBBS,MD clinicians do not have much interaction with the lab microbiologists and recommend the antibiotics from experience or then sometimes there are ego problems. Dr. Kavita Raja gives her opinion about this and many other things. We thank Dr Kavita for coming forward to give a write up. She suggests a a three-tier set-up in the labs with a doctor in charge of issuing reports that have a suggestion for treatment, a Medical microbiologist with PhD in charge of different sections in the lab and graduate technicians to carry out all the procedures.
Anti-microbial resistance – Who is responsible? Lab or clinician?
Dr. KAVITA RAJA
India has a large pool of scientists, doctors and technicians working in Microbiology. Now they are either duplicating each other’s work or competing to get a higher status in the lab/Hospital. This has resulted in a total divide between the clinician with his patient and the lab with different categories of workers. The patient does not benefit from the millions invested in highly advanced tests. Test reports from Microbiology often reach after treatment has been decided or after discharge /death of the patient. The antibiotic sensitivity done in labs so meticulously, ends up in the wastebasket. A full course of empirical therapy that seeks to cover all bacteria, fungi and even sometimes viruses, not to mention protozoa leads to a rising resistance by all the microbes mentioned.
My strong feeling is that we Microbiologists, especially those with MBBS, MD hold joint responsibility for this sorry state of affairs. Most Microbiologists are safely ensconced in their labs with no inkling of what is going on in the wards. A lot of importance is given to making an impeccable report that cannot be proved wrong by anybody. Gram-negative bacilli in two samples of blood is a dire emergency. Generally the report is given only after a thorough identification (this may be important in case of Stenotrophomonas maltophilia-very rare). The patient is saved if a direct sensitivity is done and report given as GNB sensitive to –xxx antibiotics. Another strategy is to phone up and suggest a drug for Gram neg sepsis to the clinician. It will also prevent misuse of high-end antibiotics. Clinicians are very happy to get a quick result from Microbiology and are incredulous when you phone the first time. They ask “But don’t you need 48 hrs to say that?”
The present policy is that Microbiologists with MD and MSc PhD are clubbed together as “Microbiologist” and most doctors even do not know that there is a doctor in the lab. I have NO bias against the scientists in Microbiology, but my idea is that they have to be given an independent existence in a lab. They should deal with the quality control and general day-to-day management of the lab, while the doctor Microbiologist should form a link between the lab and the clinician - this is the CLINICAL MICROBIOLOGIST.
The Clinical Microbiologist should be an expert in use of antibiotics and Doctors with MD should be encouraged to undergo training under a practising clinical microbiologist for a year. The Clinical Microbiologist should conduct Ward rounds and help in prescribing antibiotics to culture positive cases. When he/she becomes confident and the clinicians start relying on her, even empirical antibiotic prescribing can be taken up.
This will control wanton use of antibiotics in hospitals, better quality in the lab due to the services of a PhD and cheaper, effective infection control. I am actually practising this in my hospital, which is a superspecialty one and those who follow my advice find that their patients, if infected have sensitive organisms only!!!!
I feel that all doctors working in Microbiology should join and work to promote clinical microbiology, which may be the answer to this AMR problem.
Why cant we in India also have a three-tier set-up in the labs with a doctor in charge of issuing reports with a suggestion for treatment, a Medical microbiologist with PhD in charge of different sections in the lab and graduate technicians to carry out all the procedures. The manpower is there, but totally disorganized. The whole system has to be revamped with the Govt. insisting that every lab in a referral hospital should have all three categories and that one cannot be substituted for the other. Each category should then be allotted different designations, like-
Consultant/ Professor – Doctor
Scientist/Senior scientific officer – PhD with MScMicrobiology/MScMLT
Technician/Senior Technologist – BScMLT/MscMLT
Technical assistant –DMLT
In the above hierarchy, technicians will also have much scope for further studies and promotion prospects commensurate with level of education. Scientists can be graded as A,B,C,D,E etc. on seniority or merit basis ,as is done in other Departments.
Another advantage here is that different doctors can be put in charge of different sections and they can hone their skills in each area. They are not bothered with the day-to-day management of the lab, like seeing if the coagulase test is being done with fresh plasma or whether the technician is counting the colonies in the Urine culture. They can concentrate on conveying the relevant information on treatment to the clinician and also follow-up on the patients
The scientists in their respective sections can ensure quality control and also engage themselves in developing new tests or improving the existing tests. They are not bothered by doctors asking for this or that result. They can take up training programmes, PhD guideships etc without compromising on the quality of reporting in the lab.
Technicians and Technical assistants will find that when they are two categories, they complement each other’s work.
A well-organised set-up like this only, can even think of tackling the AMR menace. The authorities will do well to understand the important role played by each category and support their activities in a proper manner, without clubbing all as “Lab people”. Without such a lab no amount of discussions, guidelines or propaganda about resistance will help in eradication MDR organisms. This problem is a highly technical one unlike the AIDS epidemic, which is a social one, so it has to be tackled by technical and scientific means.