Indian public sector health facilities, workers should lead the fight against AMR

Both are important links across sectors; they should unleash their full impact on the life of the common man for curtailment of AMR.

By Sagar Khadanga
Published: Saturday 21 November 2020
AIIMS, New Delhi. Photo: Vikas Choudhary

 Sagar Khadanga

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It has been more than three years since the National Action Plan for Anti-microbial Resistance (NAP-AMR) was rolled out across India, in line with the Global Action Plan for Anti-microbial Resistance (GAP-AMR).

Different states of the country have been at various stages of development of the State Action Plan for Anti-microbial Resistance. Till date, only three states (Kerala, Madhya Pradesh and Delhi) have come out with their state action plan.

There have been multiple ice-breaking sessions among Health Care Workers (HCW) across the country and the result is that Anti-microbial Resistance (AMR) is no more a buzz word to us.

Once given the most important priority, healthcare facilities and HCWs have played only a limited role in the containment of AMR. Hence, the concept of ‘One Health’ has emerged, emphasising the role of other sectors like animal health, food, agriculture and environment in addition to human health.

Moreover, the multimillion industries which run these sectors are the fulcrum of AMR containment. 

Public Sector Health Care Facilities (PSHCF) remain the most sought-after healthcare facilities for more than two-thirds of Indians. There has been a pyramid-shaped provision of primary, secondary and tertiary healthcare facilities, with the maximum number being of primary care facilities at the base.

Over the last decade or so, there has been a rapid progress in teaching tertiary care facilities. During the same time period, many apex institutes like the All India Institute of Medical Sciences (AIIMS) have come up across the country to balance the regional differences in healthcare delivery.

Each type of healthcare facility has different challenges and opportunities for the containment of AMR.

The scope of individual healthcare facilities is beyond the scope of this article. Anti-microbial stewardship practice (AMSP) has been a low-hanging target but is yet to be unleashed to fullest of its capability.

Stewardship literally means supervising or taking care. But in the context of AMR, AMSP has far more implications than initially thought. 

Diagnostic stewardship

This emphasises the quality of the microbiology laboratory and hence the local antibiogram. There are only handpicked PSHCFs with antibiograms of their own in India. Compare that with the West, where almost all hospitals have their own antibiogram.

An up-to-date antibiogram provides confidence to clinicians while choosing an antimicrobial empirically. In absence of an antibiogram, the practice of ‘hit hard’ and ‘hit fast’ will prevail and only increase AMR.

The use of freely available WHONET to generate local antibiograms and the practice of truncated reporting of drug susceptibility is the need of the hour.

Clinical stewardship

Clinicians have to be trained in common principles of antimicrobial use, especially common pharmacological properties. They have to practice different sets of principles for out-patients, in-patients and those with or without sepsis-defining illness.

There are 5 ‘Ds’ to practice: Right diagnosis, Right drug, right dose, right duration and right time to De-escalate (decrease or stop).

Regular Point Prevalence Study (PPS) of antibiotic usage, Days Of Therapy (DOT) and Defined Daily Doses (DDD) are a good way of surveillance. But in the absence of computerised platforms, this becomes hard to achieve.

Prospective feedback is an attractive yet herculean task. Formulary restriction of antimicrobials are still debated, considering the fact that most of the emergency cases are handled by relatively junior HCWs. 

Infection control stewardship

Infection Control Practice (ICP) is one of the most neglected yet most powerful link to break the cycle of AMR. It ranges from simple hand hygiene, surface cleaning, bio medical waste segregation to complex issues of operation theatre air change, positive and negative pressured cabins to biomedical waste management.

There have been recent improvements in overall ICP measures of most of the PSHCFs under the ambit of ‘Kayakalp’, a Government of India initiative across the country. The concept has been apt covered during the novel coronavirus disease (COVID-19) pandemic. 

Environment and sanitation stewardship 

PSHCFs have to be role models for protecting the nearby environment. Many cases of hospital-transmitted infections are often noticed. Though a matter a debate, the proposed and contested theory of the seepage of the Wuhan virus from a laboratory and the subsequent COVID-19 pandemic it caused is still fresh in our memory. 

Stewardship in training-teaching and research

A deep knowledge of AMR and its consequences has to be imparted to the budding HCWs graduating from tertiary PSHCFs, who will work with communities.

Investing in them will lead to rich rewards in the times to come and save many more dollars than changing their practices at a later date. Research ideas of microbes, AMR and AMSP need to be fostered and nurtured. 

Administrative & leadership stewardship

Overall, the PSHCFs most often than not, lack leadership identity in the field of AMR. This may be because of AMR being non-rewarding, non-profiting and results in it being hard to measure.

However, the time is apt for PSHCFs to portray themselves as role models to all stakeholders. Doctors are one of the most influential people in society.

They should utilise this influence to the fullest for highlighting AMR in each and every platform, from primary education to politicians. No wonder, the role of leadership has been the only difference between the strategic points of GAP-AMR and NAP-AMR. 


HCWs and PSHCFs are an important link across sectors as role models in the field of AMR. It is time that PSHCFs rise to the occasion and unleash their full impact on the life of the common man for curtailment of AMR. 

Sagar Khadanga is Assistant Professor, Department of Medicine, All India Institute of Medical Sciences Bhopal. Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth

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