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Friday, July 15, 2011

Response to the article

Response by - Dr. R. D. Kulkarni
Professor & Head, Dept. of Microbiology, SDM College of Medical Sciences & Hospital, Dharwad - 580009 (Karnataka)

 Statements in the Article                                                   Response                                                            
1
My strong feeling is that we Microbiologists, especially those with MBBS, MD hold joint responsibility for this sorry state of affairs.

Yes agreed.
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.

2
Most Microbiologists are safely ensconced in their labs with no inkling of what is going on in the wards.

Yes, agreed.
3
A lot of importance is given to making an impeccable report that cannot be proved wrong by anybody.

Not true.

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.

4
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.


5
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.

6
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. 

7
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.

NB –
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.