Antibiotic use and resistance : patterns, perceptions, policy and the price to pay

Abstract: Background: Antibiotic resistance is a major health challenge especially in low and middle income countries such as India. Inappropriate antibiotic use is one important factor contributing to resistance. Strategies to improve use would help contain resistance. In order to develop strategies that are feasible and appropriate, knowledge is needed about patterns and perceptions of antibiotic use, the consequences of resistance and impact of policy guidelines. Current knowledge and evidence is limited in India. Aim: To improve knowledge on the patterns and perceptions of antibiotic use in the community, the consequences of resistance in individual patients, and the impact of policy guidelines on hospital antibiotic use, so as to identify potential interventional targets, generate key messages and subsequently develop appropriate strategies towards improving use and containing resistance. The specific objectives were: 1. To determine patterns of antibiotic use through a surveillance system in the community and challenges faced while developing the system. (I) 2. To ascertain the perceptions of stakeholders in antibiotic use and resistance and highlight the challenges to changing practice. (II) 3. To assess the impact of antibiotic resistance on cost burden and health consequences in patients with suspected sepsis. (III) 4. To determine patterns of inpatient antibiotic use over a decade and evaluate the impact of policy guidelines and modes of dissemination on antibiotic use. (IV) Methods: The first two studies (Paper I & II) for this thesis were done in urban and rural areas of Vellore district, south India and the two other studies (Paper III & IV) at Christian Medical College, Vellore (CMC), a not for profit, university teaching hospital with 2140 beds. Surveillance of antibiotic use patterns (prescriptions and dispensations) in thirty community healthcare facilities for 2 years was conducted with a repeated cross-sectional design (I). A qualitative study with eight focus group discussions among doctors, pharmacists and public explored perceptions about resistance, antibiotic use practices, factors driving use, and strategies for appropriate use (II). A one year observational study on inpatients with a preliminary diagnosis of suspected sepsis and a positive blood culture report analysed costs and health consequences in two groups, ‘resistant’ and ‘susceptible’ based on susceptibility of causative bacteria to the empiric antibiotic given (III). A time series segmented regression analysis of antibiotic use across a decade revealed the patterns of use over time segments and the impact of differing modes of policy guideline development and implementation (IV). Findings: Surveillance in community healthcare facilities (I) revealed that among 52,788 patients, 40.9% were prescribed or dispensed antibiotics (antibiotic encounters). There were significant differences among facilities types and areas. Fluoroquinolones and penicillins were widely used, co-trimoxazole more in rural hospitals and cephalosporins in urban private hospitals. 41.1% of antibiotics were for respiratory infections. Focus group discussions (II) revealed that the p resistance is a major health challenge especially in low and middle income countries such as India. Inappropriate antibiotic use is one important factor contributing to resistance. Strategies to improve use would help contain resistance. In order to develop strategies that are feasible and appropriate, knowledge is needed about patterns and perceptions of antibiotic use, the consequences of resistance and impact of policy guidelines. Current knowledge and evidence is limited in India. ?patterns and perceptions of antibiotic use in the ?community, the consequences of resistance in individual patients, and the impact of policy ?guidelines on hospital antibiotic use, ?qualitative study with eight focus group discussions among doctors, pharmacists ?and public explored perceptions about resistance, antibiotic use practices, factors driving use, ?and strategies for appropriate use (II). A ?ublic had limited awareness of infection, antibiotics and resistance and ?wanted quick relief through antibiotics. Doctors prescribed antibiotics for perceived patient ?expectations and quick recovery. Business concerns promoted antibiotic sales by pharmacists. ?Improving public awareness, provider communication, diagnostic support, and strict ?220 patients admitted into the hospital with suspected sepsis (III), the median difference between ‘resistant’ and ‘susceptible’ groups in overall costs, antibiotic costs and pharmacy costs was Rs. 41,993 (p = 0.001), 8,315 (p < 0.001) and 21,492 (p < 0.001) respectively. Length of stay, intensive care admissions, complications and mortality were significantly higher in ‘resistant’ group by 3 days (p = 0.027), 23% (p < 0.001), 19% (p = 0.006) and 10% (p = 0.011). The overall antibiotic use in the hospital (IV), expressed in DDD per 100 bed days, increased monthly during Segments 1 (0.95), 2 (0.21) and 3 (0.31), stabilized in Segment 4 (0.05) and declined in Segment 5 (-0.37). Pairwise segmented regression adjusted for seasonality showed a drop in antibiotic use of 0.401 (SE=0.089; p < 0.001) for Segment 5 (guidelines booklet and online intranet guidelines) compared to Segment 4 (guidelines booklet alone). Conclusion: The level of antibiotic use is significant in the community, especially for respiratory infections and fluoroquinolone use. Patterns of antibiotic use varied among healthcare facilities and stakeholders. Knowledge and understanding of resistance was limited. Patient demand and competitive pressures were some of the main challenges expressed in changing practice. Antibiotic resistance had significant impact on cost and health consequences in patients. Containment of rising inpatient antibiotic use was possible with guideline dissemination through intranet computer network.