New guidelines were launched in India’s capital Delhi to
help healthcare personnel rightly diagnose and treat people
in a timely manner. Failure to do so is fuelling
antimicrobial resistance (AMR). Early and accurate diagnosis
and treatment (without any delay), with medicines that work
on a person, along with standard infection control and
disease prevention efforts, remain a cornerstone for public
health. And yet this is a distant dream for many in
need.
Underlining the human impact of late and/or
incorrect diagnosis, and misuse or irrational use of
medicines on human beings, Dr Sangeeta Sharma (who led the
guideline development process) said: “How can we ignore
the substantial impact of poor quality of care on premature
mortality rates – 60% of untimely deaths result from
treatable conditions that are not addressed correctly.” Dr
Sangeeta Sharma is a senior Professor at the Institute of
Human Behaviour and Allied Sciences (IHBAS), and President
(Honorary) of the Delhi Society for Promotion of Rational
Use of Drugs (DSPRUD).
She emphasised the importance
of the new guidelines “as a reliable tool to improve
healthcare quality and patient safety; providing clear,
evidence-based guidelines tailored to the Indian context and
helping clinicians avoid irrational or inappropriate
prescribing practices.”
Why are these guidelines
important?
These guidelines are an important tool to
help the healthcare workers at all levels to use the right
diagnostic test and offer right treatment in a timely manner
– and help combat antimicrobial resistance (AMR).
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Let
us understand how misuse or overuse of medicines result in
antimicrobial resistance (or drug resistance) and is now
ranked amongst the top-ten global health
threats.
“Antimicrobial Resistance (AMR) is a
problem driven by misuse and overuse of antimicrobial
medicines, including antibiotics and antivirals, and results
in critical medicines losing effectiveness to treat
infections,” said Thomas Joseph, Head, AMR Awareness,
Advocacy and Campaigns, World Health Organization
(WHO).
“AMR inflicts significant mortality,
morbidity and economic loss in low- and middle-income
countries, including India. Several countries in Asia and
Africa have observed a worrying trend of increasing drug
resistance, while progress towards AMR containment efforts
remain scattered and fragmented,” said Dr Kamini Walia who
is the Convener and Co-Chairperson of Scientific Committee
of Global AMR Media Alliance (GAMA) and a senior AMR
scientist at the Indian Council of Medical Research
(ICMR).
Agrees Thomas: “AMR is associated with 5
million deaths a year. Besides this, there is the huge
burden of morbidity and healthcare expenditure that can
affect severely household welfare. The World Bank estimates
that Global GDP could fall by US$ 1 to US$ 3.4 trillion
annually after 2030 due to AMR,” he added. The World Bank
estimates that an additional 24 million people would be
forced into extreme poverty by 2030 if no action is taken on
AMR today.
7th Edition of the Standard Treatment
Guidelines
The 7th Edition of the “Standard Treatment
Guidelines: A Comprehensive Resource for Informed Clinical
Decision-Making”, was developed by Delhi Society for
Promotion of Rational Use of Drugs (DSPRUD) and launched at
Lady Hardinge Medical College in Delhi, India. The guideline
launch took place at the 7th Diagnostic Stewardship
Programme to combat AMR.
These guidelines encompass
over 350 priority diseases across 11 medical
super-specialties, providing medical experts with invaluable
insights into clinical manifestations, therapeutic advances,
patient management, and patient education.
Dr Atul
Kotwal, Executive Director, National Health Systems Resource
Centre (NHSRC is a technical support institute with National
Health Mission of Government of India) said that NHSRC and
DSPRUD are partners in disseminating and implementing
Standard Treatment Guidelines effectively in clinical
practice.
Over the past two years, these joint
initiatives (guidelines and diagnostic stewardship
programmes) have engaged over 10,000 healthcare
professionals from across India, demonstrating the demand
for continuous professional development and adherence to
standardized treatment protocols.
Absence of
diagnosis and AMR
In the absence of a diagnosis,
there is overuse of antibiotics (or other antimicrobials
such as antivirals, antifungals, or antiparasitics), said Dr
Ranga Reddy Burri, President, Infection Control Academy in
India. “Diagnostic uncertainty is influenced by factors
such as challenges in diagnosing infections, fear of missing
a diagnosis, limited access to rapid diagnostic tests,
reliance on clinical judgment, and patient
expectations.”
Inter-relatedness of diagnostic
stewardship and adherence to standard treatment guidelines
is paramount in ensuring effective patient care, said Dr
Sarita Beri, Director, Lady Hardinge Medical College. By
promoting accurate diagnosis, informed treatment decisions,
and responsible antimicrobial use, these initiatives aim to
enhance patient safety and combat the spread of
AMR.
Dr Sangeeta Sharma said that these standard
treatment guidelines have been formulated to:
– Assist
clinicians in making informed and effective patient
management decisions as they serve as a guiding light across
various levels of healthcare- from primary health care to
tertiary care health centres
– Ensure their
reliability and relevance in today’s dynamic healthcare
environment, as they are meticulously crafted through the
collaboration and contribution of a multitude of experts and
reviewers
– Offer reader-friendly, up-to-date, and
evidence-based expert information at the point of
care
– Include pharmacological and non-pharmacological
management strategies tailored to different healthcare
settings, along with clear goals of treatment, criteria for
assessing response to therapy, step-up and step-down
approaches, referral criteria, and guidelines for
follow-up.
Advancing AMR stewardship when multiple
medical disciplines are practiced in India is a challenge.
Dr Sangeeta Sharma added that “There is a significant
variation in clinical practice, where different
practitioners may adopt diverse approaches to treating
similar conditions, leading to inconsistencies in patient
care at times. This variation often stems from a reliance on
past practices rather than evidence-based guidelines,
resulting in treatments that may not reflect the latest
research or best practices.”
Furthermore, the rising
demand for healthcare services has put a strain on
resources, necessitating more efficient and standardised
approaches to treatment in order to effectively meet patient
needs.
Diagnostic delays = Catastrophic costs and
Access versus Excess paradox
When we fail to diagnose
a disease timely and accurately, we add to diagnostic
delays, fuel the spread of disease (either in the affected
person in case of a non-communicable disease or in the
community as well if it is an infectious one) – and this
results in avoidable human suffering, as well as an
onslaught of catastrophic cost – all of this is so
avoidable.
Dr Sharma shared that “Access versus
Excess paradox highlights the issue where, despite broad
availability of medications, there can be either a lack of
access to necessary drugs or an excess leading to
inappropriate use. The abundance of different types of
pills, coupled with free over-the-counter availability,
further contributes to misuse and potential
harm.”
In addition, there are issues with labelling,
packaging, and nomenclature of medicines that create
confusion and increase the risk of medication
errors.
Additionally, factors such as illegible
handwriting in prescriptions, incomplete knowledge of drug
names, and the similarity in clinical use of different
medications exacerbate the risk of errors.
“Standard
Treatment Guidelines significantly enhance the value of
health systems by promoting consistency, cost-effectiveness,
and quality in patient care. They provide a framework for
uniform care delivery, ensuring that patients receive
evidence-based treatments irrespective of the healthcare
provider or location,” said Dr Sharma.
What’s new
in the 7th edition of the guidelines?
Dr Sharma
worked with a team of medical experts from across
super-specialities in the country to revise the latest
guidelines. Dr Kamal Kishore Chopra, who is the former
Director of the prestigious New Delhi TB Centre and part of
the leadership of TB Association of India was also a part of
the experts’ group that shaped the 7th edition of the
guidelines. Dr Kuldeep Singh Sachdeva, who is the former
head of Indian government’s TB and HIV programmes (earlier
served as Deputy Director General at the Ministry of Health
and Family Welfare, Government of India) and former
Southeast Asia Director of International Union Against
Tuberculosis and Lung Disease (The Union) was also part of
the experts’ group that worked on the guidelines. Dr
Rajendra Prasad, Dr BC Roy National Awardee and former
Director of Vallabhbhai Patel Chest Institute in Delhi and
former Head of Respiratory Medicine, King George’s Medical
University (KGMU) was also part of the guideline development
panel of experts.
Dr Sangeeta Sharma said: “The 7th
edition of the standard treatment guidelines introduces
several key updates and new features to ensure comprehensive
and up-to-date medical guidance. All sections have been
thoroughly revised and updated with the latest
recommendations, including new algorithms and evidence-based
practices for critical areas such as hypertension, sepsis,
burns, trauma, bleeding disorders like haemophilia, chronic
obstructive pulmonary disease (COPD), tuberculosis,
HIV/AIDS, and dental conditions.”
“New sections
have been added, focusing on palliative care, with a special
emphasis on opioid use, and psychiatric emergencies,
including management of patients with suicide risk, delirium
tremens (severe form of alcohol withdrawal), acute
agitation, extra-pyramidal syndrome, neuroleptic malignant
syndrome, lithium toxicity, and valproate toxicity,” added
Dr Sharma.
Updates also extend to surgical conditions
such as urolithiasis (formation of urinary stones) and
benign prostatic hyperplasia (enlarged prostate
gland).
“These guidelines offer a detailed,
practical approach to diagnosing and managing a wide range
of conditions. For example, the hypertension section
emphasizes a comprehensive diagnosis process, outlining
common mistakes while measuring the blood pressure (BP) and
the need for multiple readings to avoid misdiagnosis. It
also provides a step-by-step approach to managing
hypertension, diabetes, and infections, highlighting the
importance of lifestyle modifications and evidence-based
treatment protocols.”
Another notable feature is its
detailed guidance on handling snake bites and dog bites,
including crucial do’s and don’ts to prevent complications
and ensure effective initial treatment.
For trauma
management, the book offers clear instructions on first aid
measures, ensuring timely and effective response to
injuries.
This edition also includes comprehensive
coverage of common pitfalls and precautions, ensuring that
healthcare professionals can provide accurate and effective
care in various clinical scenarios.
7th meeting on
diagnostic stewardship
Diagnostic stewardship
involves ordering the right tests for the right patient at
the right time and interpreting the results to provide the
right antibiotic in the right dose, said Dr Sangeeta Sharma,
key organiser of the 7th Diagnostic Stewardship
meet.
“The aim of this meeting is to foster a
culture of responsible antimicrobial use by equipping
healthcare professionals with the knowledge and skills
needed to order the right tests, interpret results
accurately, and select the appropriate antimicrobial for
treatment” said Dr Renu Gupta, faculty at IHBAS and
Secretary of DSPRUD.
‘Just in case’
medicine
Diagnostic uncertainties have emerged as a
crucial factor to fuel the inappropriate use of
antimicrobials. Doctors sometimes prescribe antimicrobials
as a precautionary measure, known as “just in case”
medicine, due to an inability to establish a confirmed
diagnosis. This is often due to suboptimal availability of
laboratory support or the misinterpretation of laboratory
reports.
For example, microscopy test underperforms in
diagnosing TB. That is why WHO has called upon the countries
to completely replace microscopy with WHO-recommended
molecular tests. We have to do so to stop missing TB cases
among those who take a TB test. More importantly, we have to
take the lab to the people by deploying point-of-care and
point-of-need, laboratory independent and battery-operated,
decentralised TB screening and diagnostic tools- like
ultraportable x-rays and WHO recommended Truenat (World’s
only point-of-care and decentralised molecular test for TB).
Truenat is also being used on solar power in several
countries such as Democratic Republic of the Congo and
Nigeria. We have to find all TB, treat all TB and prevent
all transmission of TB in a people-centred, rights-based and
gender transformative manner.
But we are not doing as
good as we can with existing tools. As per the latest WHO
Global TB Report (2023), we could diagnose less than HALF of
people with drug-resistant TB: out of 410,000, globally we
could just diagnose only 170,000 in 2022. Imagine the
diagnostic delays and catastrophic costs, as well as human
suffering, for 170,000 people with drug-resistant TB, and
for the remaining people who were not even diagnosed or
linked to therapy – and risk of further spread of
infection and untimely death. All this could have been
averted if we had diagnosed each one of them accurately and
early, and linked them to effective treatment, care and
support. Hugely missed opportunity it is, as we believe at
CNS and Global Call to Find All TB.
A Call to
Action
Addressing AMR is a shared responsibility.
Health authorities, healthcare providers, and the public
must work together to promote the responsible use of
antimicrobials. Enhancing microbiological laboratory
infrastructure, training healthcare professionals in
diagnostic stewardship, and raising awareness about AMR are
critical steps towards this goal.
A ray of hope lies
in Dr Sangeeta Sharma’s led initiative to train healthcare
workers to combat AMR. To date, her course has trained over
1,000 doctors and engaged 1,600 nurses and laboratory
technicians in diagnostic stewardship.
Judicious use
of medicines, along side other meausres, will go a long way
in controlling antimicrobial resistance and protecting human
lives!
Bobby Ramakant – CNS (Citizen News
Service)
(Bobby Ramakant is part of editorial team of
CNS (Citizen News Service) and a Board member of Global
Antimicrobial Resistance Media Alliance (GAMA) and Asia
Pacific Media Alliance for Health and Development (APCAT
Media). Follow him on Twitter
@BobbyRamakant)
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