The Path of Least Resistance 
The BBC radio recently broadcasted A 30 min long radio program on the ABR problem, with reflections of Dr David Livermore of HPA, Professor Otto Cars of ReAct, and Chief Medical Officer of UK Dame Sally Davies. The Audio of the radio program is available here.

Why Subir Ghosh left a  pharmaceutical company ??

Subir Ghosh spent the first three years of his professional career in sales and marketing of a pharmaceutical company. Then he left it and opted for other carriers……….WHY ???????

Subir Ghosh stumbled upon http://save-antibiotics.blogspot.com/ liked it and expressed his wish to join IIMAR.

When I realized that Subir Ghosh had worked with a pharmaceutical company once and because of his experience at the company, is deeply concerned about antibiotic use or really to say ANTIBIOTIC MISUSE, I requested him to contribute something for us.  He suggested a piece from his site http://www.write2kill.in. We have edited it suitably to make it fit here.

We will welcome any other similar contributions.

While Subir tells us a story from his life, the same trend exists all over the world. And corrective measures are required all over the world, then and then only there is some salvation. Let us hope the stakeholders in this area become awake and do something remedial.

Over to SUBIR………

…………….When I was in XXXX pharmaceutical company  in 1988, the compnay had just reintroduced its phenoxymethyl penicillin. A wonderful drug to start with. But the company would simply not meet the demand, because at that time it had already launched norfloxacin, and was on the verge of launching ciprofloxacin. And for other things there was always cephalexin (at that time).

Shortly after I landed in Agartala towards the end of 1988, some seemingly philosophical questions confronted me. ..…This was, after all, my first job and I intended to retain it. Come hell or high water. The issue of a philosophical dilemma was posed because I was a simpleton, and hadn’t still lost my innocence. There was reason for me to be upset over the question of what was right, and what wasn’t.

It was still early in one’s life to throw away ideals to the winds. So I started off as ethically as I would. Within weeks it dawned on me that I was living in a fool’s paradise. I was in Tripura as a medical representative, to sell drugs for a leading pharmaceutical company. Here you couldn’t meet your sales targets if you behaved like a gentleman. For, everyone else around wasn’t. A gentleman, I mean. From the doctors to the retailers, from the stockists to the company warlords. It didn’t matter how you sold your medicines, as long as you did.

After the first month (when I failed to meet my target), I decided to hard-sell. From the doctors to the retailers. I tried every trick in the trade. …… I didn’t give a damn, and neither did the doctors. My targets were the young docs there, of my age; they took to me well. I started doing relatively well for myself. My company’s products did well too. For me it was a job, it was a question of livelihood. Till one fine day……

That fine day was an early morning when the 1988-89 winter days were in their last throes. Morning OPD hours would always be chaotic. If I was there, the young docs knew it was fun hour.

Till I threw a poser at the boss of the lot. “You sure my products figure in your prescriptions”, I smiled with a glint. The friendliness may have been there in my smile, but not in the eyes. This particular boss and all his understudies were in my pocket. I had befriended them, then bought off their allegiance with my unending samples and overflowing gifts. And so this animal, proceeded to prove his loyalty. The patient he was examining was a young and pregnant tribal girl. Young, very young to be a mother. Still in her teens, I still am sure. The doctor scribbled the prescription and showed it off shamelessly. To yours truly. It took me a moment to realise what he was asking this girl to ingest over the next few days. It was norfloxacin, 2 tabs TID, for five days.

If you are not in the business of drugs, then you wouldn’t know what it meant. So, let me explain to you as briefly as I can.

That was the time when antibiotics were becoming drugs of the past, antibacterials were in. The first to hit the market big time was this antibacterial called norfloxacin. It was potent, and it was expensive. During those days my company sold it at Rs 8 per tab. Of course, over time prices dropped drastically as the demand skyrocketed. But then, coming back to the drug itself. This was reckoned to be a powerful drug for many reasons, one of them being the fact that its half-life was on the higher side. In other words, it would remain in the bloodstream longer. For this very reason you did not require too much of it, and not certainly so frequently as you had to swallow the earlier-day antibiotics. If the girl to whom this was prescribed followed the regimen, at the end of the course she would have little other than norfloxacin flowing in her blood. No, she wouldn’t have died. But this was something that, to me, was simply not done.

I looked at the girl again. She seemed resigned to fate. She stood there without uttering a word. All the monosyllabic speaking was done by the gnarled old man. Her father he was, obviously; one who too seemed resigned to fate. They were tribals. …. The girl’s pachra and risha (skirt and blouse, to us) were wearing out. A look at the two and you would know they did not live off more than Rs 10 a day. I looked at the girl, into her eyes. She was staring at the prescription, a semblance of hope in her eyes. Her gaze sapped something inside me.

No, this is just not done. The prescription is an overkill for a urinary tract infection (UTI), dangerous in fact. I was furious with the physician. The banter went to hell, and I made the man rewrite the prescription, making him drop my product and opt instead for a much mild antibiotic. The doc didn’t like it a wee bit; this after all I had made him do in front of his juniors. The bonhomie between me and the doctors ended then and there.

On my part, I made up my mind that whatever happens or doesn’t, I am not going to make a career out of selling medicines. Then on, I hated the pharmaceutical industry. It was ruthless, it was powerful. Without scruples. And it did the dirty job through callous medical representatives.

I did work as an MR for a short while again because I needed a job. But I couldn’t do as well as I had earlier. You can’t sell medicines if you play it straight. The pharmaceutical industry was rich and influential. The MBBS folks did not know so much about drugs as the B Pharms did. There was nothing called a level-playing field. And MRs would do anything to meet targets. You coaxed or armtwisted pharmacists. You cajoled or bought off doctors. …. the pharmaceutical industry was on a roll. If there were losers in this coldblooded game, it were the patients. The people. The people have no idea how much of gunieapigs they are being reduced to. Pharma companies actually control our lives more than you would believe ……... Reality is scarier.

On behalf of and with encouragement from IIMAR, Mohini Adke, Assistant Professor, KTHM college, Nashik, Maharashtra, India, has started the cause - STOP- Antibiotic Resistance on `facebook`. Please join the cause here http://www.causes.com/causes/search?q=stop+antibiotic+resistance 

Response to the article

Anti-microbial resistance – Who is responsible? Lab or clinician? 

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. 

`Regulations to prevent Antibiotics Resistance & Promotion of Rational use of antibiotics`- Suggestions to Planning commission Constituted working Group

Dear all

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 antibio.resistance@gmail.com.  

Dr.A.J.Tamhankar