Improving antimicrobial stewardship and surveillance: the Chennai DeclarationBMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f591 (Published 28 January 2013) Cite this as: BMJ 2013;346:f591
- Susan Hopkins, consultant in infectious diseases and microbiology
In December 2012 Indian doctors from all medical specialties published the Chennai Declaration in the Indian Journal of Cancer.1 The declaration documents the outcomes of the successful roadmap meeting in August 2012, led by Abdul Ghafur. At this meeting, Indian medical societies, the World Health Organization, and European and US experts came together to develop recommendations for combating the spread of antimicrobial resistance in India and improving antimicrobial stewardship across the healthcare economy in India.
India has an estimated population of more than 1.2 billion people, with more than 20 000 hospitals and more than 750 000 doctors. A large repeated survey in New Delhi showed that, when prescribing antibiotics, private clinics and pharmacies more often prescribed cephalosporins, whereas public clinics more often prescribed penicillin.2 In addition, a recent study found that more than half of rural and urban pharmacists dispensed antibiotics without a doctor’s prescription to people who presented with clinical symptoms to pharmacies.3 However, the selling of unprescribed antibiotics is not a uniquely Indian problem; drugs can increasingly be bought on the internet without prescriptions.4
Over the past 10 years, widespread dissemination of resistant bacteria and a rising prevalence of antimicrobial resistance have been reported throughout India. The prevalence of extended spectrum β lactamase producers is reported to be 50-80%.5 6 7 The prevalence of metallo-β lactamases, which confer pan resistance to β lactams and which are associated with many other mutations that underpin resistance, is reported to be greater than 20% in isolates tested in many hospitals and over 50% at some sites.8 9 This translates to minimal or no antibiotic options to treat critically ill patients. The worldwide spread of carbapenem resistance, resulting in reported outbreaks particularly related to New Delhi metallo-β lactamase, was initially linked to travel to Asia. This has had an economic impact related to screening and the need for isolation of at risk patients and contacts.10 11 No longer a doomsday prediction, medical care without antibiotics is a highly likely scenario, particularly if urgent action on antibiotic stewardship is not taken, and especially in India.
India developed an antibiotic policy and framework in 2010.12 However, the Indian health minister, after feedback from stakeholders, rejected the recommendations, which included a global ban on over the counter sales of antibiotics and the prohibition of carbapenem use except in major hospitals. He argued that this restrictive strategy could have an overwhelmingly negative effect in rural areas, where access to specialist healthcare is difficult.
The new Chennai Declaration demonstrates excellent progress and leadership on behalf of Indian doctors, who have translated worldwide guidelines on antimicrobial stewardship into solutions that can be readily implemented in India.
They have developed four key objectives. Firstly, over the counter sale of antibiotics must be regulated. Recommended approaches vary from complete restriction of all such sales to an initial restricted list with the addition of other antimicrobials in a phased manner. Secondly, antibiotic usage within hospitals should be monitored. Controlling and monitoring the most important drugs, such as colistin (the current drug of last resort) and carbapenems, should be a priority, alongside monitoring and giving feedback on all high usage antibiotics. Thirdly, measures to develop microbiology laboratory facilities must be initiated. This would improve diagnostic ability across the country and improve the detection of antimicrobial resistance by introducing standardised methodologies and standards. Lastly, national antimicrobial resistance surveillance systems should be developed to facilitate understanding of the epidemiology and spread of resistant bacteria. These measures would improve antimicrobial prescribing and reduce the spread of antimicrobial resistance; they are to be recommended worldwide, not just in India.
Each objective outlines several alternative strategies, and a formal evaluation by experts and stakeholders across the public and private sector is recommended. This puts patient safety and care at the centre of the declaration. A widespread consultation process with potential collaboration and agreement of the “roadmap” will allow India to learn from strategies introduced in other countries, such as Brazil, and hopefully encourage engagement with the private sector. In addition, the Indian government’s aim of providing free healthcare to more than half of the population by 2017 may aid the introduction of these strategies. The government would do well to follow in the footsteps of Brazil, where certain drugs are now provided for free, nudging prescribers towards the use of narrow spectrum agents and away from critically important antibiotics, such as fluoroquinolones and carbapenems.
The Chennai Declaration clearly summarises the roles and responsibilities of key players across the health service; the absolute requirement for each hospital to have a functioning infection control committee; and the role of undergraduate and postgraduate medical education in ensuring that the doctors of the future are adequately trained. Education of pharmacists and the role of the drug industry in educating pharmacists, doctors, and the community should also be emphasised.
The declaration is thoughtful, collaborative, and far reaching. To control worldwide antimicrobial resistance, health communities worldwide should encourage the endorsement of these recommendations by the Indian Health Ministry and help the Indian medical community to achieve the roadmap goals over the next five years.
Cite this as: BMJ 2013;346:f591
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; externally peer reviewed.