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AMS in India

Dr Sanjeev Singh talks about AMS in India.
Good evening, sir. Thank you so much for giving us your time. Good evening, Vrinda. So this interview is basically to discuss about your experiences in trying to implement an antibiotic stewardship programme in this setting. So first of all, could you briefly describe your role in this institute and what is it that you do here? Thank you, Vrinda. This is a university teaching hospital, which has a 1,350 bed, which has a medical college, dental, nursing, pharmacy and allied health sciences courses. I am a chief of medical services here, and I work with all the clinical departments to put a strategic plan together and then an operational plan.
I basically am responsible for all profit and losses and a business plan for each department, and day-to-day coordination with respect to operation theatre scheduling, with respect to bed management, with respect to various accreditation and legal formalities. So institution basically is now declared as an institute of eminence, and there is a vision for a research institute to write grants, to publish, to be international– to have international collaborations, and to do something which is innovative and which either has a product or a process patent.
So our basic role is to coordinate with all the schools within the university, primarily between the school of medicine, school of dentistry, pharmacy, nano biotechnology, engineering, and getting an idea together which could possibly bloom it up into either a startup or a good research project. Other than that, I have a huge interest in quality, and I look at the accreditation programmes nationally and internationally. Our institute was the first to be accredited by NABH as a medical college. Then we are also accredited by labs and as an academic institution by university grants commission. The other chief role is building other outreach centres within the university.
And right now, we are building another hospital at Faridabad and at Amravati, which is, again, twice the size of this present hospital. Antibiotic stewardship and infection prevention is a work of passion. And I initiated this work somewhere in 2005, where we met a few champions and then they encouraged me to follow up my– follow up work and do PhD. And that is where I got interested, and that is where I would like to have a vision for this institute, to do something which is evidence -based, which is remarkable, which is good, and which could promote this as a centre of excellence and also create more institutions which have good antibiotic stewardship and infection prevention activity, which others can also learn.
So you seem to have a very busy schedule day-to-day. And you were mentioning that antibiotic stewardship was out of passion that you went into that field. So could you tell me what actually triggered you to implement this programme in this hospital? When we were working on putting an antibiogram, an antibiotic policy together, each year we would possibly get a similar antibiogram, and we would get similar high risk patients since we are a tertiary reference centre. And they were all coming pumped up with antibiotics from the community or from the referral hospitals, and then we would struggle with these patients in our critical care unit.
And we would force our critical care physicians to adhere to certain policy and procedures, and we realised that we are hardly making an impact. It was almost a similar antibiotic policy, it was a similar antibiograms, it was a similar kind of high risk patients who are being referred, and then there is hardly a change, which we were doing. At that point of time, I realised that there is something which is bigger which we’d need to establish, where a better and a bigger team should come to coordinate the activity. And we reached out to a few clinicians who were champions and who had an inclination to practise good practices.
We got all of them together, we put a good infection prevention team and we put a good stewardship team. We also realised that it is also not making a impact, because there is a lot of data which needs to be collected, and there was hardly any data which was coming in, so it was more of an emotional statement and we were running helter skelter. Few clinicians were called for few cases. At that point of time, we realised that there is a course which has been run within our institute, which is a pharm D course, and there are a lot of clinical pharmacists who were extremely well trained, but they were also a very uncoordinated group.
We reached out to the principal and we asked them that can they all be posted by the clinical departments so that they round with the clinicians and then they make an adequate difference. So that also took a lot of time, because the acceptance of the clinicians to clinical pharmacist was not there. We almost took one to two years to get this bridge– being bridged together for good practice. We also reached out to the nursing college, nursing students, to participate in infection prevention and then into stewardship, at least raise a trigger wherever the loading dose are not appropriate, where the dosings were not appropriate.
And then I think getting all the team together of clinical pharmacists, nursing, and other clinical people, both surgical and physician, really helped to get the antibiotic stewardship team and the process in place. So in this process of implementing the stewardship programme in the hospital, could you brief us about the key challenges that you faced and how you were able to overcome those? So one of the key challenges was the leadership’s involvement, because there needs to be a resource which needs to be put in for appropriate collection of data, for appropriate follow up, and that is where we had done a bit of exercise with infection prevention, where we had done a cost benefit, cost effective, and cost utility analysis.
And we knew that this would be an exercise, which would be worth taking. And we presented the infection prevention bit that needs to copy that for the antibiotics stewardship bit, and the leadership got very excited and said that this is the way to go. The other challenge was the participation of all the clinical team. And it was very, very difficult, because there was no ID physician. I think that was the biggest challenge for us. And every internist believed that they knew how to practise antibiotics, how to write antibiotics and do an adequate follow up both in OP and IP.
Anything wherever a notice would come to them, they would feel extremely insecure and they would not take it in a right rhythm. And that is where I think our team also started breaking in between, because there were various activities which were quoted which was not communicated well and which was not done well. Other than that, I think another challenge was our hospital information system. So until and unless we get the data right on time to understand which are the restricted antibiotics and what is the consumption pattern, and then where are these patients where we need to go and look for clinical history was again a biggest challenge.
So we have worked on it, and I think we have now a decent data, which is available. So from your answer, I understand that the programme has really been very successful in this hospital. So you’re also trying to bring this success– taking this success to other institutions, and you’re also working with the government in spreading the antibiotic stewardship programme throughout the state. So could you share your experiences in this regard? Working with the government was always mixed with lots of feelings, good as well as something which was difficult.
We realised when we were working with our antibiotic policy, within our intensive care unit, we were not making much of progress, because the patients were always coming to a tertiary care centre who were always given antibiotics, two or three hospitalisation, and they were not in good shape. There is where I realised that just doing it in our institution is not going to help. I reached out to the government mentioning that there is a huge problem and all hospitals, public and private, need to reach out or adhere to some good practices. It wasn’t liked by the government, initially, because they said that they don’t think there is a problem. And that is where they asked me to conduct a survey
to understand: is there a problem? We conducted a survey with close to 500 physicians across 14 districts of Kerala. We also reached out to microbiology labs, interviewing the microbiologist and the technician. We also interviewed the pharmacist. And we came up with a document, a white paper, which shows that our prescription practices were abysmally poor, both in private and public hospitals. And to our surprise, maximum antibiotics were being used by dental, orthopaedics, ENT, and dermatology. And we were on having an assumption that it would be the surgical branch or maybe an internal medicine or pulmonary medicine branch, and that wasn’t the case. That was an eye opener.
Majority of the labs– the report were given by a microbiology technician who had no clue how to read the report. And over the counter prescription were rampant, and there was no follow up done by the pharmacist at all. This is the report what we submitted to the government, and they realised that there is a need to work towards putting a policy together. They also wanted to reach out to all the private institutions, because in India, health care is offered 70% to 72% by private institutions. And there is where I think we should be made a phenomenal progress, where we worked with 18 societies which could be associations of physicians of India, associations of surgeons, the gynaec, the ENT, orthopaedics, dental.
All 18 societies came together. It took a lot of time to get everybody together in a platform. All of them also were asking for data, is there data to work upon, and there was none. So we said that if this is a scenario, can we have a disease based antibiotic policy, what would be a first choice and what would be a second choice? There also to our surprise, many of the physicians were writing banned antibiotic drugs. And parallelly, we started work with the government, both the state as well as centre and ICMR, that there are few combinations, which are non-scientific and it should be banned.
Coming together led to a development of clinical guidelines, and our state was the only state which had a clinical guidelines developed for almost all speciality which was disease- based and which was also released by the health minister and the health secretary. Sustaining all this activity was the biggest challenge, and to always keep communicating to all the stakeholders, giving appropriate feedback. And to say that there are few successes and there are few impacts was again a big challenge, because there wasn’t a big forum. There is an infection prevention committee and there is an antibiotic stewardship committee, but out of 840 physicians, they are only represented by 30, 35 people in that committee.
So communicating everybody and getting everybody’s participation was also a huge challenge. But I think the team was excellent. They were young, they were honest, they were ready to invest, and they engaged with whatever came through their way.
And I am extremely grateful to the team: the responses they have shown and the kind of impact which they have created that we were able to withhold the activity together. And these challenges were limited, and the success was much more visible.

Dr Sanjeev Singh is interviewed by Dr Vrinda Nampoothiri, a research pharmacist. Dr Sanjeev Singh is the Medical Superintendent at Amrita Institute of Medical Sciences, Kochi, India.

Dr Singh tells us how antimicrobial stewardship was always a passion of his, so when he realised there was a serious problem he put together a multidisciplinary AMS team.

He shares the important stages he went through:

  • Reaching out to senior hospital leadership and AMS champions

  • Looking into existing and available expertise

  • Encouraging multidisciplinary accountability and responsibility

He also stresses how all of this took a lot of time.

Dr Singh talks about some of the key challenges he faced such as getting leadership involved, encouraging clinicians to change their practice and adjusting their hospital information system.

He also mentions some of the steps he took to help make AMS a more widespread practice. Dr Singh talks about how he helped start a survey that went out to laboratories, clinicians and many others. The results of this survey helped prove to the government that there was a serious problem and enabled him to go on to discuss a disease based antibiotic policy with all 18 medical societies in the area.

In the comments below please let us know:

  • Are there factors which are similar to AMS in your area?
  • Are there factors which differ to AMS in your area?
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