Target Population:

Targeting two key stakeholders-

1. Healthcare professionals in Primary Healthcare Centres (PHCs) and
Community Healthcare Centres (CHCs); Doctors and medical students in
Tertiary Healthcare Centres (THCs).
2. Patients and their family seeking treatment in these resource restricted
government aided set ups.

Proposed Solution:
Currently there is a lack of focus on the two major contributors of any health
programme and their relationship: Healthcare Providers and Patients.

FOR DOCTORS
Physician education on AMR has to be the driving force in implementing and
maintaining good antibiotic practices.
Parallel to the principles laid in the Treat Antibiotics Responsibly Guidance,
Education and Tools (TARGET) toolkit developed by the RCGP, a protocol can be
formulated that is realistic in our Hospital set up.19, 20, 21
A. Regulatory body
The Hospital Infection Control Committee (HICC) will be responsible for the
execution of the antibiotic policy within a THC (which further acts as the
reference point for SCs, PHCs and CHCs). HICC will be the body responsible
for infection prevention, its monitoring, surveillance, reporting and physician
education and feedback.17, 22

B. Workshops and Presentations19, 25, 26

 Demonstrating AMR patterns in India and within the hospital and the role of
effective prescription pattern.
 Emphasise on recommended treatment choices for prevalent infections.
 Areas of intervention and how they can effectively reduce AMR burden.
 Platform for physicians to offer potential solutions as well as problems with
execution.
 Education on infection prevention and control practices.

C. Nationalised Guidelines
Medical education falters in the practical application of the spectrum of
antibiotics. A concise referral manual in the form of a Hospital Essential
Medicine List including case conditions and action plans (in accordance with
national guidelines) is necessary.23, 27

D. Audits
To assess baseline antibiotic and post intervention prescription patterns through
clinician self-assessment.20
Through this a loop of understanding, feedback and change can be enforced.
Evidence has shown that physician feedback on prescription conduct can result
in significant behavioural changes.24, 28

FOR PATIENTS
The role of patient education and reinforcement towards antibiotics has not been
given significance in spite of documented evidence stating its efficacy in reducing
resistance
Keeping this in mind we propose the introduction of an innovative simple tool
for patient antibiotic use documentation in the form of a Card.
All text on The Card would be in the local language, understood by the patient.
This Card would include on one side the identifying details of the patient (such as
name, year of birth, sex, patient id, place of residence), prescribed antibiotic details
(generic drug name, dose), culture sensitivity reports (including specimen id).
The front of The Card would be for the patient’s reference. It would include important
information regarding antibiotic use, conservative management for illnesses such as
URTI, diarrhoea and viral fevers along with means of preventing infections and signs
requiring a physician’s visit.31
The Card would be kept by the patient along with other medical documents and
carried whenever visiting a healthcare centre; drug information would be filled by the
doctor when antibiotics are prescribed.

Implementation Plan:
A. ENGAGEMENT
HICC is the most capable authority within a large medical set up for ensuring
antibiotic stewardship policy and The Card use enforcement. 22

B. ASSESSMENT & EVALUATION

Antibiotic use and resistance parameters for comparison and evaluation that can be
measured within a hospital set up or derived from existing data include-
1. Antibiotic Resistance
 Through the associated Microbiology department associated.
 Done for various strains through susceptibility testing against relevant
antibiotics for appropriate break points.32, 33

2. Antibiotic consumption
 Measured across the pharmacy operating within the health centre.
 Antibiotic use assessed through Defined Daily Doses through a summation of
the antibiotics sold within a time period. IPD measured through patient
records and OPD through pharmacy sale records, stock and dispensing
logs.34, 35

3. Appropriateness of Antibiotic Use

 By comparing physician prescription patterns against standard hospital
guidelines and categorising the corresponding data based on appropriate
decisions or inappropriate indication, choice, application or divergence from
guidelines.
 Can be done as a prevalence survey which has been useful in identifying
incorrect antibiotic use and its determining factors and is more feasible to
conduct.37, 38

4. Infections
 Measured from patient records and microbiological reports.
 Compared against national and international statistics.
5. Knowledge, Attitude and Practices
Behavioural patterns play a major role in unnecessary antibiotic prescription
and use. Intervention for each stakeholder involves targeting gaps in
comprehension and therefore a clear understanding is required. This requires
baseline and post intervention KAP surveys to be used for future analysis
targeted towards Physicians, Students and most importantly Patients. 31, 39, 40, 41,
42, 43

C. PLANNING
Goal:
Increased awareness on the severity of antimicrobial resistance and
implementation of practices to curb it on an individual, community and
national level by patients, medical students and healthcare providers.

Objectives:
 Short term
1. Ensure the HICC is structured;
2. Frame/alter the hospital essential drugs and treatment protocols to be in line
with National Guidelines and local resistance patterns.
3. Establish baseline statistics of the indicators within the hospital.
4. Consult pharmacologists/microbiologists who are certified under an
antimicrobial stewardship program.44
5. Create and conduct an interactive workshop for clinicians within the hospital
using TARGET resources and a pre and post event assessment.
6. Establish an Infection Control Protocol (ICP) within the hospital and
disseminate accessible information (including correct method and 5 points of
hand washing) throughout centres.22
7. Distribute The Card to physicians after ensuring clear understanding of its
function and establishing the method of instructing patients (through
simulations, printed guidelines, lectures).
8. Regular emphasis should be placed on its salient points and instructions to
the patient (required to be carried at all times within hospital, carry with
identification, present at pharmacist when purchasing any drug, always ask
the pharmacist if he is giving you an antibiotic, never purchase an antibiotic
without prescription, follow preventive and conservative protocols).
9. Independent Pharmacists within an area should be informed about The Card.
It is to be stressed on that they should not tamper with it and that it has no
relevance to their practice.
10. Ensure compliance to monthly frequency of HICC meetings.
11. Reiteration of The Card use and importance, hearing out any grievances and
suggestions and areas of possible alteration should be examined
12. Microbiologists/Pharmacologists should be notified when 2nd and 3rd line
drugs are given for any condition.
13. Periodic Evaluation of indicators should be done
14. At the end of 1 year, final evaluation of indicators and a project report is
formulated.
  Intermediate
1. Utilizing data and reports obtained from pilot hospital, scale up to other THCs
and sub-divisions.
2. Done by demonstrating the programme efficacy to the District Health Officer
(DHO), to begin coordination with other Hospitals including associated PHCs
and CHCs through a DICC (District Infection Control Committee). The DICC
will work through the supervising heads of their respective HICC (or in the
absence of one, the IDO or Senior Microbiologist/Pharmacologist) to
implement the programme as at the Pilot Centre.
3. Coordination and communication among the district microbiologists regarding
existing and emerging resistance patterns.
4. In teaching hospitals, a medical student/s should be mobilised to act as
Student Anti-Microbial Control Representatives. They would function under
the Senior Microbiologist to encourage compliance to the programme, attend
HICC meetings and maintain minutes and assist in data collection and
compilation of clinical indicators.
5. Developing digital clinical modules for practitioners and students which are
suited to the clinical scenario.20, 21

 Long term
After 3 years when considerable inter-district coordination is implemented,
State Director of Health, State Ministry of Health and Family Welfare are
encouraged to undertake the programme on a State-wide level. Currently
Maharashtra, State of India does not have an implemented antibiotic policy 33.

Risks, Limitations, and Challenges:

For the patient, The Card is the most acceptable solution. Though every new
component has a risk of poor patient compliance, this can be minimized by
mandating it as a necessary document for the existing National Healthcare
Schemes. (Aadhar and Ration cards)
It is simultaneously important to emphasise to Centres about digitisation and
centralisation of the information regarding previous diagnoses and prescriptions
through a standard patient id.
Antibiotic c/s surveillance is often underused as it takes 3 day to complete, during
which first line antibiotics can be tried clinically and shifted to an alternative 5, 7, 46. As a
result, physicians and patients are more inclined towards a clinical trial and error
method when faced with an infection not responding to antibiotics.
This can only be mitigated by emphasis on protocol and ensuring a shift of treatment
plan based on c/s findings.

Budget and Sustainability:

The chief advantage of this programme is that it is economical, feasible and requires
negligible funding in the pilot stage. It is a prime example of using locally
available appropriate technology.
Practitioner education is organised within the hospital and conducted by their trained
staff. Resources, information and assessment for the same can be availed from
existing open resources20, 21.
The Card can be printed and distributed at a local level.
The main expenditure required in the programme is the active participation and
momentum of the involved stakeholders.
It can be implemented in phases throughout districts and gradually stepped up for
national coverage. It would galvanize the District and State to finance the requisite
funding for the public awareness programme.

Expected Impact:
BENEFITS OF THE CARD-
1. It is taken for granted that some degree of infection prevention methods and
good hygiene practices have been communicated to a patient visiting a
healthcare set up in the past; this is often not the case.
With such information printed and available in a concise and easily accessible
manner, doctors have a scripted guideline to be communicated to the patient,
which makes for more likely reiteration and especially for an illiterate person
could be their only source of this information 31, 47.
2. The term antibiotics is emphasised and a differentiation from the rest of the
prescription is made. Though unregulated AM OTC sale is a pressing
concern, as documented in the past restricting sale will do more harm at our
level16, 48, 49. Hence we aim to mobilise patients (along with practitioners) to
recognise the value and harm associated with antibiotics.
3. Certain salient points such as completing the course and not reusing or
sharing pills are stated, which are commonly missed.
4. Options for conservative management and indications for when to visit a
doctor would be beneficial for patients and doctors at both an individual level
and in the large scheme of community resistance.
5. It gives doctors an awareness of prior antibiotic use and resistance if found in
another set up so that those drugs could be bypassed. Additionally non
responsiveness to a previous drug regime with no corresponding c/s testing
done could still point to AMR. With lack of computerised data this could
potentially be the only source of prior treatment when visiting a new
practitioner.
6. This could prevent unnecessary treatment with broader spectrum drugs in
Patients visiting a THC who are assumed to have been administered first line
antimicrobials at PHCs and CHCs.
7. It would make establishing case history easier as the patient has a condensed
account of his past significant infectious illnesses.
Additionally, when antibiotics are prescribed it is beneficial for the practitioner
to put importance while communicating with the patient to correlate the
patient’s current symptoms specifically their severity, as rationale for antibiotic
use.
Overall, The Card is an important method for initiating the discussion and
establishing emphasis on antibiotic use.
It does not have any burden of responsibility on the patient or practitioner which
would hamper its application or long term compliance.
It’s the most acceptable solution in a resource and time restricted
surrounding.