Abstract
BACKGROUND:
Antimicrobial resistance has emerged as a global challenge to human health, primarily due to inappropriate use. The ICMR reports revealed that there is sustained rise of AMR in India.
OBJECTIVE:
The objective of this study was to evaluate the prescribing pattern of antimicrobials and rationality of empiric antimicrobial use in a tertiary care hospital.
METHOD:
A prospective observational study, approved by the Institutional Ethical Committee (IEC) was conducted for a period of one year from July 2023 to June 2024 among the admitted patients of the hospital. The prescribing pattern was assessed in accordance with AWaRe classification and prescribing indicators by the World Health Organization. Rational use of empiric therapy was assessed as per the ICMR 2022 guidelines.
RESULTS:
A total of 653 antimicrobials were prescribed to 289 patients and maximum antimicrobials were from Watch category (55.7%), followed by Access (40.4%), and Reserve category (2.3%). The respiratory tract infection was the most common indication to start empiric antimicrobial therapy. The empiric therapy was appropriate for 80.3% patients as per the ICMR guidelines. The observed deviations were the empiric use of amikacin for bone & joint infection, duplicate beta lactam therapy, 3rd generation cephalosporins for uncomplicated urinary tract infection, the use of Reserve antibiotic-linezolid, and the use of piperacillin/tazobactam for sepsis patients.
CONCLUSION:
There is a need to strengthen the antimicrobial stewardship program by adhering to the national guidelines in the hospital settings, to prevent antimicrobial misuse and resistance. The use of Assess category should be encouraged, Watch category should be used under proper monitoring and the use of Reserve antimicrobials as an empiric therapy should be avoided.
Keywords: Aware classification, antimicrobial resistance, empiric antimicrobial use, Indian Council of Medical Research guidelines
Introduction
Antimicrobial resistance (AMR) is one of the major global challenges to human health. The occurrence of AMR is leading to higher treatment expenditures, longer hospital duration, and increased incidences of mortality. There were an estimated 4.95 million deaths associated with bacterial AMR in 2019.[1] A recent global analysis estimates more than 39 million deaths from antibiotic-resistant infections over the next 25 years.[2]
It is well known that inappropriate use of antimicrobials is the primary cause of resistance. In India, the prevalence of AMR is on higher end due to huge burden of infectious diseases and irrational use of antimicrobials.[3] India has the second highest antimicrobial consumption worldwide, with a 47% increase between 2010 and 2020.[4]
The AMR-related concerns have already been raised by the World Health Organization (WHO). The WHO has clearly stated that if no appropriate measures are taken to combat the antimicrobial misuse, then there will be no possible cure of AMR tomorrow.[5] The AWaRe classification of antibiotics into three groups, namely Access, Watch, and Reserve, was developed by the WHO experts, as a tool to promote antibiotic stewardship and better clinical outcomes.[6] Access antimicrobials generally have lower resistance potential, narrow spectrum of activity, and good safety profile. They are often recommended as empiric first-or second-choice treatment options for common infections while Watch antimicrobials are broad-spectrum antimicrobials, generally recommended only as first-choice options for patients with more severe clinical presentations or for infections where the causative pathogens are more likely to be resistant to Access antimicrobials. Reserve antimicrobials are the last-choice antimicrobials used to treat multidrug-resistant infections.
The Indian Council of Medical Research (ICMR) launched its antimicrobial stewardship programme with an aim to achieve the rational use of antimicrobials and to prevent AMR.[7] The ICMR released its first edition on the guidelines for antimicrobial use in 2017 and the subsequent revised versions in 2019 and 2022.[8,9] The latest report published by the ICMR in 2024 highlights the antimicrobial misuse and sustained rise of AMR in India. According to this report, an increase in carbapenem resistance to Gram-negative pathogens has left the physicians with limited options to treat such patients and increase in resistance-related mortality. There is a significant increase in imipenem-resistant Pseudomonas aeruginosa from 26% to 43%, meropenem-resistant Pseudomonas aeruginosa from 31.3% to 38%, imipenem-resistant Klebsiella pneumonia from 41.5% to 74%, and meropenem-resistant Klebsiella pneumonia from 51.9% to 64.9% from 2017 to 2024. In addition, methicillin-resistant Staphylococcus aureus (MRSA) rates have also increased from 33% in 2017 to nearly 53% in 2024.[10]
Although the antimicrobial stewardship programme has been well established across countries, its effective implementation remains an ongoing challenge. Empirical antimicrobial misuse is especially rampant among the hospitalized patients. The studies assessing the empirical use of antimicrobials according to the ICMR guidelines are lacking in India. Therefore, the present study was designed to assess: (1) the empirical use of antimicrobials with reference to ICMR guidelines and (2) prescribing patterns of antimicrobials according to the WHO AWaRe, anatomical therapeutic chemical (ATC) classification, drug use indicators; and National List of Essential Medicines (NLEM) listing 2022.
Methods
The study was carried out only after being approved from the Research Project Advisory Committee and Institutional Ethical Committee (IEC) of Jamia Hamdard, New Delhi (Ref no: HIMSR/IEC/0095/2023).
A prospective observational study was conducted to evaluate the antimicrobial use among the admitted patients of a tertiary care teaching hospital located at North Delhi, India. The study was conducted for 1 year from July 2023 to June 2024. Patients of all age groups admitted either in intensive care unit (ICU), or under different specialities namely Medicine, Paediatrics, Surgery, Orthopedics, Gynecology, Plastic Surgery, Gastroenterology, and Urology, prescribed at least one antimicrobial agent, were enrolled in the study. A total of 289 patients were enrolled in the study. The sample size was determined at 95% confidence level, 80% of statistical power, and 75% of expected proportion of event of interest with 5% margin of error using the following formula:
n = required sample size for the desired study
Z = Standard normal variates for alpha = 1.96
α = Level of significance = 5%
d = Absolute precision (margin of error) = 5%
p = Proportion of event of interest for the study based on the previous studies = 75%
Using the above values, the sample size was determined as 289.
Inclusion/exclusion criteria
Inclusion
Patients of all age groups presented with sepsis or septic shock, community acquired pneumonia, skin and soft-tissue infections, urinary tract infection, gastrointestinal infection, bone infection, who were prescribed antimicrobials with or without culture positivity test were included in the study.
Exclusion
Readmission (within 30 days of discharge), human immunodeficiency virus infection, tubercular infection, hematological malignancies, transplantation, and patients who were not willing to give informed consent were excluded from the study.
The medical records of patients were reviewed for demographics, prescribed antimicrobials, and reason to start the empiric antimicrobial therapy. The information was recorded in the case record form as approved by the IEC.
The assessment was done using ICMR guidelines 2022, WHO AWaRe classification,[11] ATC classification system 2021, and selected drug use indicators by the WHO. Under ATC classification system, drugs are classified according to organ or system on which they act and their chemical, pharmacological, and therapeutic properties. ATC classification is recommended by the WHO and serves as a tool for drug utilization statistics and international comparisons.[12] The antimicrobials were also checked for their listing in NLEM of India, 2022.[13]
The selected indicators were used to assess the use of generic name while prescribing the antimicrobials, adherence to the hospital drug formulary, average number of antimicrobials prescribed, and mean duration of antimicrobials prescribed.
The data were collected and entered into spreadsheet for the analysis. The data were analysed using the SPSS V26 software and the results are presented as mean, standard deviation, and percentage. The findings were presented in accordance with the strengthening the reporting of observational studies in epidemiology guidelines.
Results
A total of 289 enrolled patients admitted under different clinical departments of the hospital were assessed for antimicrobial use during the study period. The mean age of patients enrolled in the study was 40.9 ± 21.8 years. The mean age of enrolled pediatric patients was 5.8 ± 5.2 years. Of 289 patients, 52.9% patients were female and 47.1% patients were male. The maximum number of patients were admitted in the medicine department (63.7%) followed by pediatrics (15.9%), surgery (12.5%), and orthopedics (4.8%). The respiratory tract infection (36%) was the most common reason for which empiric antimicrobial therapy was started to the patients, followed by intra-abdominal infection (24.9%) and pyrexia of unknown origin (16.6%). Among enrolled patients, 59.2% patients had no comorbidity and 40.8% patients had one or more comorbidities. The demographic and clinical characteristics of enrolled patients are presented in Table 1. Diabetes mellitus (32.6%) was the most common comorbidity followed by the hypertension (25%) and hypothyroidism (8.5%).
Table 1.
Patient demographics
| Parameters | Estimates |
|---|---|
| Total number of patients (n) | 289 |
| Mean age (years)±SD | 40.9±21.8 |
| Gender, n (%) | |
| Female | 153 (52.9) |
| Male | 136 (47.1) |
| Admission category, n (%) | |
| Medicine | 184 (63.7) |
| Pediatrics | 46 (15.9) |
| Surgery | 36 (12.5) |
| Orthopedics | 14 (4.8) |
| Gynecology | 4 (1.4) |
| Plastic surgery | 3 (1.0) |
| Gastroenterology | 1 (0.3) |
| Urology | 1 (0.3) |
| Reason to start empiric antimicrobial therapy, n (%) | |
| Respiratory tract infection | 104 (36.0) |
| Intra-abdominal infection | 72 (24.9) |
| Pyrexia of unknown origin | 48 (16.6) |
| Urinary tract infection | 30 (10.4) |
| Bone and joint infection | 14 (4.8) |
| Surgical prophylaxis | 11 (3.8) |
| Skin and soft tissue infection | 6 (2.1) |
| Sepsis | 2 (0.7) |
| CNS infection | 2 (0.7) |
| Comorbidities, n (%) | |
| 0 | 171 (59.2) |
| 1 | 44 (15.2) |
| 2 | 44 (15.2) |
| 3 | 21 (7.3) |
| 4 | 5 (1.7) |
| 5 | 4 (1.4) |
| ICU stay, n (%) | |
| No | 204 (70.6) |
| Yes | 85 (29.4) |
| Length of stay, n (%) | |
| Average length of treatment (days), mean±SD | 7.4±3.9 |
| Average ICU stay (days) of ICU patients, mean±SD | 4.5±3.3 |
| Types of antimicrobials therapy, n (%) | |
| Monotherapy | 98 (33.9) |
| Combination therapy | 191 (66.1) |
| Outcome, n (%) | |
| Discharged | 283 (97.9) |
| Expired | 6 (2.1) |
SD=Standard deviation, CNS=Central nervous system, ICU=Intensive care unit
There were 29.4% patients who experienced ICU stay during the course of treatment based on the clinical conditions. The overall average length of the patient’s stay was 7.4 ± 3.9 days and average length of ICU stay of ICU patients was 4.5 ± 3.3 days. Of 289 patients, combination antimicrobials therapy was prescribed to 66.1% patients and monotherapy to 33.9% patients. A total of 97.9% patients were discharged successfully posttreatment and 2.1% patients expired during the treatment due to the clinical conditions.
Prescribing and hospital indicators
A total of 653 antimicrobials were prescribed from different antimicrobial classes. Of 653 prescribed antimicrobials, 479 (73.4%) antimicrobials were prescribed as an empiric therapy. A total of 160 (24.5%) antimicrobials were prescribed with generic name. The average number of antimicrobials prescribed per patient was 2.3 ± 1.4 [Table 2]. The average length of antimicrobial treatment was 6.4 ± 3.9 days. However, duration of antimicrobial treatment was mainly based on the indication, severity of infection, and recommendations of standard treatment guidelines.
Table 2.
Prescribing and hospital indicators
| Value | |
|---|---|
| Prescribing indicators | |
| Number of antimicrobials prescribed with generic name, n (%) | 160 (24.5) |
| Antimicrobials prescribed as per hospital drug formulary, n (%) | 653 (100) |
| Average number of antimicrobials prescribed per patient, mean±SD | 2.3±1.4 |
| Hospital indicators | |
| Availability of a set of key antimicrobials in the hospital pharmacy, n (%) | 37 (100) |
| Average number of days that a set of key antimicrobials were out of stock, n (%) | 0 |
| Existence of standard treatment guidelines for antimicrobial use | Yes |
| Existence of an approved hospital drug formulary | Yes |
| Other | |
| Average length of antimicrobial treatment, mean±SD | 6.4±3.9 |
| Percentage of antimicrobials prescribed with injectable route (%) | 80.6 |
SD=Standard deviation
The standard treatment guidelines for antimicrobial use and hospital drug formulary were available in hospital during the study period. All the key antimicrobials were present in the hospital pharmacy and no stock out was observed. All antimicrobials were prescribed as per hospital drug formulary. Overall, 80.6% injectable antimicrobials were prescribed to the patients.
Table 3 shows the prescribed antimicrobials as per the WHO AWaRe classification. Among 653 antimicrobials prescribed, 40.4% antimicrobials were from the Access category, 55.7% from Watch category, 2.3 from Reserve category, and 1.5% from unclassified fixed dose combinations.
Table 3.
WHO Access, Watch, and Reserve classification
| WHO AWaRe category | Number of prescribed antimicrobials (n=653) | Injectable route (n=526) |
|---|---|---|
| Access, n (%) | 264 (40.4) | 227 (86) |
| Watch, n (%) | 364 (55.7) | 290 (79.7) |
| Reserve, n (%) | 15 (2.3) | 6 (40) |
| Unclassified fixed dose combinations n (%) | 10 (1.5) | 3 (30) |
WHO=World Health Organization, AWaRe=Access, Watch, and Reserve
Most commonly prescribed antimicrobial was ceftriaxone (17.9%) from Watch category followed by amoxicillin/clavulanic acid (12.9%) from Access category and piperacillin/tazobactam (10.0%) from the Watch category [Table 4]. A total of 37 different antimicrobials were prescribed 653 times among enrolled patients and 22 (59.5%) antimicrobials were listed in NLEM of India, 2022.
Table 4.
Distribution of commonly prescribed antimicrobials as per the Access, Watch, and Reserve classification
| ATC code | Antimicrobial name | Pharmacological class | n (%) | Listed in NLEM 2022 |
|---|---|---|---|---|
|
| ||||
| Access (n=264) | ||||
| J01CR02 | Amoxicillin/Clavulanic acid | Beta-lactam/beta-lactamase-inhibitor | 84 (12.9) | Yes |
| J01GB06 | Amikacin | Aminoglycosides | 63 (9.6) | Yes |
| J01XD01 | IV Metronidazole | Imidazoles | 59 (9.0) | Yes |
| J01FF01 | Clindamycin | Lincosamides | 26 (4.0) | Yes |
| P01AB01 | Oral Metronidazole | Imidazoles | 11 (1.7) | Yes |
| J01AA02 | Doxycycline | Tetracyclines | 9 (1.4) | Yes |
| J01EE01 | Sulfamethoxazole/trimethoprim | Sulfonamide/folic acid inhibitor | 4 (0.6) | Yes |
| J01CA01 | Ampicillin | Penicillins | 3 (0.5) | Yes |
| P01AB02 | Oral Tinidazole | Imidazoles | 2 (0.3) | No |
| J01GB03 | Gentamicin | Aminoglycosides | 2 (0.3) | Yes |
| J01CR01 | Ampicillin/Sulbactam | Beta-lactam/beta-lactamase-inhibitor | 1 (0.2) | No |
|
| ||||
| Watch (n=364) | ||||
|
| ||||
| J01DD04 | Ceftriaxone | Third-generation-cephalosporins | 117 (17.9) | Yes |
| J01CR05 | Piperacillin/Tazobactam | Beta-lactam/beta-lactamase-inhibitor_anti-pseudomonal | 65 (10.0) | Yes |
| J01DC02 | Cefuroxime | Second-generation-cephalosporins | 35 (5.4) | Yes |
| J01FA10 | Azithromycin | Macrolides | 35 (5.4) | Yes |
| J01FA09 | Clarithromycin | Macrolides | 33 (5.1) | Yes |
| J01DH02 | Meropenem | Carbapenems | 31 (4.7) | Yes |
| J01XA01 | IV Vancomycin | Glycopeptides | 13 (2.0) | Yes |
| J01MA02 | Ciprofloxacin | Fluoroquinolones | 9 (1.4) | Yes |
| J01DD01 | Cefotaxime | Third-generation-cephalosporins | 7 (1.1) | Yes |
| J01XA02 | Teicoplanin | Glycopeptides | 5 (0.8) | No |
| J01MA01 | Ofloxacin | Fluoroquinolones | 4 (0.6) | No |
| J01MA12 | Levofloxacin | Fluoroquinolones | 2 (0.3) | Yes |
| J01DD12 | Cefoperazone | Third-generation-cephalosporins | 2 (0.3) | No |
| J01DD08 | Cefixime | Third-generation-cephalosporins | 2 (0.3) | Yes |
| J01MA14 | Moxifloxacin | Fluoroquinolones | 2 (0.3) | Yes |
| J01DE01 | Cefepime | Fourth-generation-cephalosporins | 1 (0.2) | No |
| J01DH03 | Ertapenem | Carbapenems | 1 (0.2) | No |
|
| ||||
| Reserve (n=15) | ||||
|
| ||||
| J01XX08 | Linezolid | Oxazolidinones | 7 (1.1) | Yes |
| J01DI03 | Faropenem | Penems | 6 (0.9) | No |
| J01DF01 | Aztreonam | Monobactams | 1 (0.2) | No |
| J01XB01 | IV Colistin | Polymyxins | 1 (0.2) | No |
|
| ||||
| Other (Unclassified fixed dose combination antimicrobials) (n=10) | ||||
|
| ||||
| NA | Ceftriaxone/Disodium Ededate/Sulbactam | NA | 2 (0.3) | No |
| NA | Ofloxacin/Ornidazole | NA | 1 (0.2) | No |
| NA | Ciprofloxacin/Tinidazole | NA | 1 (0.2) | No |
| NA | Cefixime/Clavulanic acid | NA | 1 (0.2) | No |
| NA | Cefoperazone/Sulbactam | NA | 5 (0.8) | No |
NLEM=National List of Essential Medicines
The empirical use of antimicrobials and its assessment as per the ICMR guidelines are shown in Table 5. Among 289 patients, 232 (80.3%) patients received the rational therapy. Appropriate empiric therapy was prescribed among 91.3% patients for respiratory tract infections, 86.1% patients for intra-abdominal infection, 95.8% patients for pyrexia of unknown origin, 46.7% patients for urinary tract infection, 7.1% patients for bone and joint infection, 90.9% patients for surgical prophylaxis, 33.3% patients each for skin and soft tissue infection, and sepsis, while 100% patients for CNS infection received appropriate therapy.
Table 5.
Empiric antimicrobial use and its assessment as per the Indian Council of Medical Research guidelines
| Indication to start empiric antimicrobial therapy | Number of patients (n) | Rationality as per ICMR 2022 Guidelines n (%) |
|---|---|---|
| Respiratory tract infection | 104 | 95 (91.3) |
| Intra-abdominal infection | 72 | 62 (86.1) |
| Pyrexia of unknown origin | 48 | 46 (95.8) |
| Urinary tract infection | 30 | 14 (46.7) |
| Bone and joint infection | 14 | 1 (7.1) |
| Surgical prophylaxis | 11 | 10 (90.9) |
| Skin and soft-tissue infection | 6 | 2 (33.3) |
| Sepsis | 3 | 1 (33.3) |
| CNS infection | 1 | 1 (100) |
| Total Patients | 289 | 232 |
|
| ||
| Inappropriate antimicrobial therapy | ||
|
| ||
| Common inappropriate empiric antimicrobial therapy | Number of cases | Details of deviation from ICMR guidelines |
|
| ||
| Amikacin for bone and joint infection | 10 | The prophylactic and empiric use of amikacin is not recommended |
| Duplicate beta lactam therapy | 7 | Respiratory tract infection: 4 patients Pyrexia of unknown origin: 1 patient urinary tract infection: 1 patient intra-abdominal infection: 1 patient |
| 3rdgeneration cephalosporin for uncomplicated urinary tract infection | 13 | Ceftriaxone: 12 patients and Cefoperazone/sulbactam: 1 patient |
| Piperacillin/tazobactam use for sepsis patients | 2 | Piperacillin/tazobactam should be avoided in septic shock till bacteraemia with cephalosporin-resistant organisms is excluded, as mortality increases |
| Linezolid (Reserved antibiotic) prescribed as an empiric therapy | 2 | Bone and joint infection: 1 patient Respiratory tract infection: 1 patient |
ICMR=Indian Council of Medical Research
Of 104 patients infected with respiratory tract infection, 19 patients were diagnosed with pneumonia. Among these patients, 17 patients received appropriate treatment as per the guidelines. The major concerns were the empiric use of amikacin for bone and joint infection among 10 patients, duplicate beta-lactam therapy among 7 patients, use of 3rd generation cephalosporins for uncomplicated urinary tract infection among 13 patients, use of piperacillin/tazobactam for 2 sepsis patients, and empiric use of reserved antibiotic linezolid among two patients.
Discussion
AMR is a major cause of mortality in the world today. The Global Burden of Disease, AMR Collaborators estimated 4.71 million associated deaths and 1.14 million deaths attributable to AMR in 2021. The group forecasts a global estimate of 8.22 million deaths associated with and 1.91 million deaths attributable to AMR in 2050.[2]
One of the major causes of AMR is irrational/overuse of antimicrobials. Inappropriate use of antimicrobials exerts a significant impact on patient safety and clinical outcomes. This study was conducted with an aim to identify the empirical antimicrobial use according to the ICMR guidelines and prescribing pattern of antimicrobials in the hospital setting according to the WHO AWaRe classification of antibiotics into Access, Watch, and Reserve categories.
Among 653 prescribed antimicrobials, a maximum of 55.7% antimicrobials were prescribed from Watch category followed by 40.4% from Access category, and 2.3% from “Reserve” category. In addition, there were 1.5% unclassified fixed dose combination antimicrobials which are not listed in the WHO classification. According to the study conducted by Peddireddy et al., 57.7% antimicrobials were prescribed from watch category, 42.3% from access category, and 0% from reserve category highlighting the maximum use from “Watch” category.[14] Almost similar results were identified in one of the European studies by Hodoșan et al., which highlighted 59.7% use from “Watch” category, 37.1% from “Access,” and 0.82% from “Reserve” category.[15] To promote the responsible use of antimicrobials and to slow the spread of AMR, WHO targets that 60% of antimicrobials should be from Access category at country level.[11] Hence, improvement is required at a global level and use of “Access” category antimicrobials should be encouraged.
The most commonly prescribed antimicrobial in our study was ceftriaxone (17.9%) from the Watch category followed by amoxicillin/clavulanic acid (12.9%) from the Access category and piperacillin/tazobactam (10.0%) from the Watch category. A point prevalence survey in India by Bhattacharjee et al. highlighted the maximum use of third generation cephalosporins.[16] A European survey by Plachouras et al. showed the maximum use of amoxicillin/beta lactamase inhibitor followed by piperacillin/beta lactamase inhibitor and ceftriaxone in acute care hospitals.[17] As per the global survey conducted by the Pauwels et al., review of data set of hospitalised patients in 664 hospitals throughout 69 countries revealed the overall maximum use of antimicrobials from Watch category globally.[18] As per this study, ceftriaxone was the most commonly prescribed antimicrobial globally and the excessive use of 3rd generation cephalosporin has been identified as the possible cause of Extended Spectrum Beta Lactamase (ESBL) producing bacteria.
Empirical antimicrobial therapy remains an essential component of initial management of infectious diseases. In our study, 80.3% patients received rational empiric antimicrobial therapy as per the ICMR recommendations. However, we found many deviations from the guidelines.
Empirical use of amikacin for bone and joint infections was identified among 10 patients. According to the recommendations, empirical therapy of aminoglycosides such as amikacin is not recommended due to their limited penetration into bone tissue and the risk of nephrotoxicity and ototoxicity.
Another important variation contributing to the nonadherence was the administration of duplicate beta-lactam therapy among seven patients. Of seven patients, four patients of lower respiratory tract infection received the simultaneous administration of meropenem with piperacillin/tazobactam, meropenem with ceftriaxone, and ceftriaxone with amoxicillin/clavulanic acid. Penicillins, cephalosporins, and carbapenems, all belong to the beta-lactam antimicrobials and their concurrent administration should be avoided. Other three irrational duplicate combinations were the concomitant use of cefuroxime and meropenem for pyrexia, double ceftriaxone of different brands for urinary tract infection and ceftriaxone along with piperacillin/tazobactam for intra-abdominal infection. A review by Geurra et al.[19] indicated that increasing side effects, antibiotic antagonism, and the impact on gut microbiota contribute to physician’s hesitancy on choosing dual beta-lactam therapy.
Empirical use of 3rd generation cephalosporins is not recommended for uncomplicated urinary tract infection according to the guidelines. However, 13 patients in our study were prescribed ceftriaxone and cefoperazone/sulbactam as the inappropriate therapy for this indication. Due to high resistance rates among common uropathogens and the risk of promoting ESBL production, the empirical use is not recommended.
We identified two patients of sepsis being prescribed with the piperacillin/tazobactam. According to the guidelines the use of piperacillin/tazobactam should be avoided in septic shock till bacteraemia with cephalosporin-resistant organisms is excluded, as mortality increases according to the Merino trial investigators.[20]
Linezolid was empirically prescribed to two patients of bone and joint infection and respiratory tract infection. Linezolid is a reserve antibiotic intended for culture-proven infections caused by resistant Gram-positive organisms, such as MRSA or vancomycin-resistant Enterococcus.
Conclusion
The study indicated that there is a requirement of strong adherence to the ICMR guidelines on antimicrobial use. The use of Watch category of antimicrobials should be done under proper monitoring and the use of Reserve antimicrobials as an empiric therapy should be avoided to prevent the antimicrobial misuse and resistance. Healthcare accreditation bodies like National Accreditation Board for Hospitals and Healthcare Providers (NABH) also mandates the implementation of an Antimicrobial Stewardship Programme as a part of its accreditation standards for hospitals. Strengthening the compliance monitoring with measurable indicators aligning to the NABH standards and national antimicrobial guidelines may create the sustainable system to promote the patient safety and to combat the AMR.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We would like to express our gratitude to Prof (Dr.) B.M Singh Lamba and Prof (Dr.) Vindu Amitabh for the constant guidance and support throughout the research work. We are thankful to all the staff members of HAHC hospital and enrolled patients for supporting us during the study.
Funding Statement
Nil.
References
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