NMC Releases National Action Plan on Antimicrobial Resistance Module for Prescribers 2024, details
New Delhi: Considering the emerging threats of Antimicrobial resistance (AMR), which is now one of the top global public health threats facing humanity, the National Medical Commission (NMC) has now released the National Action Plan on Antimicrobial Resistance (NAP-AMR) Module for Prescribers 2024.
This module was prepared by the Officer-in-charge, Dr. Vijya Lakshmi Nag, who is a member of the Ethics and Medical Registration Board (EMRB) of NMC.
Apart from Dr Nag, the other experts who contributed preparing the module include Dr. Sonal Saxena, Dr. Raja Ray, Dr. Vimala Venkatesh, Dr. R. Jayalalitha, Dr. Syed Sajad Hussain, Dr. M.V.S Subbalaxmi, Dr. Veenasree S.N., Dr. Purva Mathur, Dr. V Dillirani, Dr. P. Gnanaguru, Dr. Bhaskar Thakuria, Dr Ramesh Agarwal, Dr. Gulnaz Bashir, Dt. Debadatta Dhar Chandra. Dr. Yashik Bnasal, Dr. Vibhor Tak, and Dr. Manisha S. Mane.
In this module, the Apex Medical Commission has discussed the objectives of NMC in this regard, clinical approach for prescribing Antimicrobials, Microbiological Diagnostic stewardship, interpretation of antimicrobial resistance- Principle and implications, antimicrobial policy, antimicrobial stewardship, infection control, Toolkit for prescribers and presentations.
Antimicrobial resistance (AMR) is one of the top global public health threats facing humanity. It is estimated that bacterial AMR was directly responsible for 1.27 million global deaths in 2019 and 4,95 million deaths were associated with drug-resistant infections. AMR puts many of the gains of modern medicine at risk.
It threatens the effective prevention and treatment of infections caused by resistant microbes, resulting in prolonged illness and a greater risk of death. Treatment failures also lead to longer periods of infectivity and the prohibitive high cost of second-line drugs may result in failure to treat these diseases in many individuals.
What is Antimicrobial Resistance (AMR)?
Explaining the issue of AMR, the NMC module stated, "Antimicrobial Resistance (AMR) occurs when microorganisms change over time and become resistant to drugs, making common infections harder, increasing the risk of disease spread, severe illness and death. This is a significant threat as it undermines the effectiveness of antibiotics and antimicrobials, which are crucial for surgeries, chemotherapy and managing chronic infections. The emergence of multi-drug resistant organisms (MDROs) further complicates the issue, as these "superbugs" are resistant to many different antimicrobials, making infections very difficult to treat."
Terming AMR to be a "complex problem", the module mentioned that this issue requires a united multisectoral approach that considers factors like antibiotic overuse in humans and animals, hygiene practices, and development of new drugs. "It is an ongoing threat to modern medicine throughout the world with a negative effect on patient treatment outcome. Pathogens are developing mechanisms of resistance, making it difficult to treat common infectious diseases like pneumonia, tuberculosis and foodborne diseases," stated the module.
"Antibiotic prescribing is determined by various factors, including the socio-cultural and socio-economic factors of each country and the beliefs of patients and professionals regarding antibiotic use. The shortage of appropriate diagnostic tools, the insufficient regulatory policies of country can further cause an increase in over-the-counter antibiotics. Medical professionals have to be prepared appropriately in order to face the challenges of antimicrobial use in everyday clinical practice," it added.
Global Action Plan on AMR (GAP-AMR):
Understanding the gravity of the problem of antimicrobial resistance (AMR), the World Health Assembly (WHA) in 2015 adopted the Global Action Plan on AMR (GAP-AMR) in collaboration with the World Health Organization (WHO), Food & Agricultural Organization (FAO) & World Organization for Animal Health (WOAH).
The different issues discussed in the National Action Plan on Antimicrobial Resistance (NAP-AMR) Module for Prescribers are as follows:
Objectives of National Medical Commission (NMC):
Laying down the objectives of the NMC in respect of the Antimicrobial Resistance, the module mentioned that NMC aims to improve awareness and understanding of AMR through effective education and training.
The intervention activities mentioned for achieving the objectives are- Improve knowledge and capacity of key stakeholders regarding AMR and related topics- by strengthening and consolidating AMR and related topics as core components of professional education and training
Target audience:
Medical students, Doctors (Residents. Faculty, Medical officers etc.) and allied health professionals (Nurses, Pharmacist, Technicians and other allied health professionals) and the administrators.
NMC plans to achieve this objective by reviewing and revising curricula of undergraduate medical professionals, reviewing and developing training modules for in-service medical professionals, reviewing and developing training modules for allied health professionals.
The other objective of the Apex Medical Commission is to optimise the use of antimicrobial agents in human health. The intervention activities mentioned for achieving the objective are- Improve knowledge and skills of prescribers, dispensers & medical trainees
To optimise the use of antimicrobial agents in human health, NMC plans to develop structured and mandatory training programmes on optimal antimicrobial use. The Commission also plans to collaborate with regulatory bodies to mandate periodic training to optimise antibiotic use through pre-service and in-service trainings.
"The aim of the Prescribers module is to facilitate institutions and professionals in developing an understanding of AMR and its importance in clinical practice and medical education. This training module will assist in imparting required knowledge and skill of the prescribers and will assist in rational prescription of antimicrobials and implementation of antimicrobial stewardship in teaching hospitals," NMC mentioned.
Two other modules are in process of development-
The training module and toolkit for undergraduate students
The training module and toolkit for Non-prescribers i.e. for allied health professionals
Clinical Approach for Prescribing Antimicrobials
NMC mentioned in the module that the use of antimicrobials has grown manifold in the recent years. Easy access of antimicrobials and the haste to start them in any suspected infective aetiology is primarily responsible of their misuse, and in turn lead to increased anti-microbial resistance (AMR). Infective disorders can be bacterial, viral, fungal or parasitic. Identification of the clinical problem and making a differential diagnosis at the bed side will help in deciding of whether to start or not to start any antimicrobial.
The history should assess the risk of infection based on the symptoms and signs and the common patterns of presentation of different diseases such as upper respiratory tract infections (URTI), lower respiratory tract infection (LRTI), urinary tract infection (UTI), meningitis, diarrhoea, skin and soft tissue infections etc.
The Commission stated that one way of clinical assessment it to follow a "syndromic Approach". As per NMC, a patient suspected of infective disorder may be classified into syndromes like- Acute febrile illness with Rash, Acute febrile illness with jaundice, Acute febrile illness with Neurological involvement, Acute febrile illness with Respiratory syndrome, Acute febrile illness with Renal involvement.
Accurate history and thorough clinical examination
NMC opined in the module that the clinician should always take a detailed history of presenting infection, history of any surgical, medical disorders, co-morbidities like diabetes as these may predispose an individual to infections. History of previous hospital admission, recurrent infections in the past, surgical intervention or any organ transplant should be taken. Previous use of antibiotics in such situations may predispose for AMR in current illness.
A detailed physical examination is an important part of the evaluation of a patient with fever to arrive at a diagnosis. Finding an eschar on general physical examination pinpoints the diagnosis of scrub typhus. Finding a murmur on examination of cardiovascular system examination can point towards an infective endocarditis, it stated.
Prescription of antimicrobials should be based on the following steps:
Step 1: Making a clinical diagnosis based on accurate history taking and thorough clinical examination helps in selecting the right test for the right patient. A clinical diagnosis also helps in predicting most likely organism causing a clinical syndrome. The sample must be collected before the start of antimicrobials.
Step 2: The empiric antibiotic therapy must be limited to seriously ill patients. This choice should be based upon institutional/local antibiograms.
Step 3: Choose the appropriate antibiotic based on clinical evaluation and most likely pathogen keeping antibiogram in mind.
Microbiological Diagnostic Stewardship
Diagnostic stewardship refers to "co-ordinated guidance and interventions to improve appropriate use of microbiological diagnostics to guide therapeutic decisions. It should promote appropriate, timely diagnostic testing, including specimen collection, and pathogen identification and accurate, timely reporting of results to guide patient treatment."
Insisting on the importance of correct sample for correct report, NMC mentioned in. themodule that the microbiology laboratories must be effectively utilized by the clinicians to assist them to prescribe appropriate antimicrobials.
The Commission also discussed issues like general precautions while collecting samples, colonization and infection, sample collection techniques, sample rejection criteria, follow-up cultures, and rapid tests.
Summary of sample collection and transport
Sample | Collection | Transport | Remarks |
Blood | 1ml blood per 10ml media for conventional culture; and as per instruction in case of automated culture | Immediately or at room temperature | |
CSF | 0.5-2 ml in sterile container | Immediately or at room temperature | Never refrigerate |
Sterile body fluids (Pleural, Pericardial, peritoneal etc.) | 1-5 ml sterile container | Immediately or refrigerate if delay up to 2 hours | Do not transport in capped syringe |
Urine | 2-5ml | Immediately or refrigerate if delay of more than 1 hour | Give proper instructions for collection and transport to patient |
Sputum | Sample coughed up into container | Immediately or at room temperature | Give proper instructions for collection and transport to patient |
Throat/ oropharyngeal swabs | two swabs (culture and microscopy) | Immediately before drying, in VTM for viral diagnostics | Wear appropriate PPE |
Stool | 1g (formed stool) to 5ml (liquid stool) | Immediately or at room temperature | Sample to be sent to the laboratory within 15minutes for trophozoites |
Pus/ Tissue biopsy/ aspirates | Sterile wide mouth container | Immediately or refrigerate if delay up to 4 hours | Do not add formalin or saline |
Genital swabs | Dacron or rayon swabs | Immediately | Add to VTM if viral diagnostics is required. |
Interpretation of Antimicrobial Sensitivity Results:
NMC mentioned in the module that the results of the AST are used to- choose the most appropriate empirical antimicrobial agent, establish antimicrobial prescription policies at institutional/state/national level, predict upcoming resistance, assess the efficacy of newly developed antimicrobial agents.
While discussing the matter, NMC addressed issues including Antimicrobial Susceptibility Testing, Interpretation of AST result, selective testing, cascade reporting, interpretation of MIC results, organism-specific AST results, sample specific AST results.
Table : Indicator/surrogate/equivalent antimicrobials used in AST reports
| Bacteria | Antimicrobial tested | Inference (if indicator found resistant) |
| Staphylococcus spp. | Cefoxitin as surrogate for predicting MRSA | Cefoxitin resistant is MRSA: Resistant to all betalactam agents except ceftobiprole and ceftaroline |
| Ciprofloxacin or ofloxacin | Acquisition of at least one target mutation that leads to resistance to all fluoroquinolones. This may lead to development of resistance during therapy with other quinolones | |
| Erythromycin | Can be used to predict the activity of azithromycin or clarithromycin also | |
| Enterococcus spp. | Ampicillin | Can be used to predict the activity of amoxicillin, amoxicillin-clavulanate, ampicillin-sulbactam, and piperacillin-tazobactam among non–β-lactamase producing enterococci. |
| Enterococcus spp. | Gentamicin (high level) | Determines loss of synergism of aminoglycosides with beta-lactam agents and glycopeptides irrespective of MIC value |
| Enterobacterales | Ciprofloxacin | Resistant to all fluoroquinolones |
| Ceftriaxone or cefotaxime | 3 rd generation cephalosporin | |
| Enterobacterales, P.aeruginosa, Acinetobacter baumannii complex | Colistin or polymyxin b | Any one agent can be used |
| Klebsiella spp./ E. coli | Ceftazidime | Resistant to all cephalosporin except cephamycins (cefoxitin, cefotetan) |
| Gram-negative isolates from uncomplicated UTIs | Cefazolin | Predicts results for all oral cephalosporins such as cefaclor, cefdinir, cefpodoxime, cefprozil, cefuroxime, cephalexin, and loracarbef |
Table : Reasons for selective testing and reporting
Reasons | Examples |
Bacteria suspected of being contaminants or normal flora. | If one of the two blood cultures reveals the growth of Staphylococcus epidermidis, AST is not reported in ordinary circumstances as the isolate is usually a suspected contaminant/ commensal flora. |
Susceptibility or resistance can be predicted based on the organism identification alone (i.e., no resistance yet identified or intrinsic resistance*). | Ceftriaxone AST is not performed for Pseudomonas aeruginosa because P. aeruginosa is intrinsically resistant to ceftriaxone. Group A streptococci is not tested against penicillin as resistance has not been reported. |
A particular drug-microbe combination may not have interpretative breakpoints | CLSI or FDA breakpoints for tigecycline in case of Acinetobacter baumannii are not available |
A particular drug-microbe combination may be inappropriate for a given site of infection | Daptomycin AST results are not reported on isolates from a respiratory source as it is inhibited by surfactant. |
A drug may be inappropriate for a particular patient population. | AST results for certain drug classes such as fluoroquinolones or tetracyclines may not be reported for children. |
Antimicrobial Resistance: Principle and Implications:
'Antimicrobials' is a broad term that is used for all agents that act against different types of microorganisms namely bacteria (antibacterial), viruses (antiviral), fungi (antifungal) and parasites (antiparasitic).
While discussing this point, NMC referred to issues like overview of Antimicrobial resistance, Mechanism of action of antimicrobials, mechanism of antimicrobial resistance, Drivers of Antimicrobial Resistance, key Antimicrobial Resistant Pathogens, Global Epidemiology of AMR, Impact of AMR and the consequences of AMR, clinical impact, economic impact etc.
Antimicrobial Policy:
Hospital antimicrobial policy helps to minimize the morbidity and mortality due to antimicrobial-resistant infection; and helps to preserve the effectiveness of antimicrobial agents in the treatment and prevention of communicable diseases. The policy must define prophylaxis, empirical and definitive therapy and must incorporate specific recommendations for the treatment of different high-risk/special groups such as immunocompromised hosts; hospital-associated infections and community-associated infections, NMC mentioned in the module.
Antimicrobial Stewardship in Humans:
NMC mentioned that the Antimicrobial stewardship has been defined as "coordinated interventions designed to improve and measure the appropriate use of antimicrobial agents by promoting the selection of the optimal antimicrobial drug regimen including dosing, duration of therapy, and route of administration".
The commission discussed issues like goals of Antimicrobial stewardship, AMSP interventions, Pharmacokinetic (PK) and pharmacodynamic (PD) approach to optimize antimicrobial prescription, Interpretation of antibiogram results, Principles of rational prescription, Strategic approach for development and intervention of AMSP.
Infection Control:
Microbes are a part of everyday life and are found in our environment (air, soil, water), and in/ on our bodies. Many microbes live in and on our bodies without causing harm but a small portion of them are known to cause infection. Many microbes live without causing harm but a small portion of them is known to cause infection. For any infection to occur,a sequence of events occur that transmit an infectious microorganism to a susceptible host, NMC mentioned.
The Commission discussed about standard precautions, transmission-based precautions, proper disposal of biomedical waste, preventive bundles for device-associated infections, etc.
Table : Elements of specific precautions
Specific precautions | Source Control: patient to wear mask | Isolation of patient | Restriction of movement of patients | Appropriate PPE to be used | Disposable or dedicated patient equipment | Prioritize cleaning or disinfection of patient rooms |
Contact Precautions | No | No | Limit movement outside room. Follow contact precautions if transfer is needed covering colonized areas of the patient’s body | Gloves and gown | Yes | Daily and no room and material should be allowed to be used by another patient prior to cleaning. |
Droplet Precautions | MUST wear mask. | In single room possibly | Yes | Gloves, apron and mask | Yes | -do |
Airborne Precautions | Fit-tested NIOSHapproved N95 or higher level respirator for healthcare personnel. | In airborne infection isolation room with negative pressure. If not possible then mask patient and place in a private room with the door closed | Yes | Full PPE with fit-tested NIOS approved N95 or higher level respirator for healthcare personnel. | Yes | -do |
Table : Patients with clinical presentations/ diseases that require isolation
Undiagnosed rashes and fevers Chickenpox Measles Severe acute respiratory syndrome (SARS) | Influenza Patients known to be colonised with MRSA, VRE, and other multi-drug resistant organisms Multidrug-resistant tuberculosis (MDR-TB) |
Table 11: Colour-coded bags for biomedical waste segregation
| Colour of the bag | bag Type of waste | Waste treatment |
| Yellow | a) Human anatomical waste b) Animal anatomical waste c) Soiled waste | Incineration or plasma pyrolysis or deep burial |
| d) Expired or discarded medicines | Returned to the manufacturer or supplier for incineration at temperature >1,200°C | |
| e) Chemical waste | Incineration, plasma pyrolysis, deep burial or encapsulation | |
| f) Chemical liquid waste | Pre-treatment and then disposal | |
| g) Discarded linen, mattresses, beddings contaminated with blood or body fluids | Non-chlorinated chemical disinfection followed by incineration or plasma pyrolysis | |
| h) Microbiology, biotechnology and other clinical laboratory waste | Pre-treat to sterilise with nonchlorinated chemicals on-site as per NACO or WHO guidelines and thereafter send for incineration | |
| Red | Contaminated waste (recyclable) like plastic bag, bottles, pipes or containers | Autoclaving or microwaving/ hydroclaving followed by shredding or mutilation Treated waste to be sent to registered or autoclaved recyclers or for energy recovery of plastics to diesel or fuel oil or for road-making |
| White, translucent | Waste sharps including metals: Needles, syringes with fixed needles, needles from needle tip cutter or burner, scalpels, blades | Autoclaving or dry-heat sterilisation; followed by shredding or mutilation or encapsulation in metal container or cement concrete sent for final disposal to iron foundries (having consent to operate from the state pollution control committees) or sanitary landfill or designated concrete waste sharp pit |
| Blue cardboard box with blue label or blue leak- and puncture-proof container | Glassware: Broken or discarded and contaminated glass including medicine vials and ampoules except those contaminated with cytotoxic wastes; metallic body implants | Disinfection (by soaking the washed glass waste after cleaning with detergent and sodium hypochlorite treatment) or through autoclaving or microwaving or hydroclaving, then sent for recycling |
Prescribers’ toolkit for combating AMR
Table : The competencies, learning objectives and the assessment methods
| S. No. and Competency addressed | Learning objectives | Domain | Target audience | Teaching learning methods (TLM) | Assessment method |
| 1. Background and objectives | 1.1 Understand the present burden of AMR 1.2 Understand the concept of this national program 1.3 Assist in implementing this program | K | Prescribers | Theory session- 30 min | Written: MCQ, SAQ |
| 2.Clinical approach for prescribing antimicrobials | 2.1 Identify common presentations of infective syndromes 2.2 Describe and understand the importance of taking thorough history, clinical examination and selection of appropriate investigations for diagnosis of infective disease soft tissue infections etc) | K | Prescribers | Exploratory and interactive theory session with case studies- 60 min | Written: MCQ -Case based discussion Clinical problem solving |
| 3.Microbiolog -ical diagnostic stewardship | 3.1 Define diagnostic stewardship 3.2 Understand the difference between infection and colonization 3.3 Describe the sample collection techniques, precautions, transport and rejection criteria of common samples. | K.A.S | Prescribers | Exploratory and interactive theory session with demonstration of collection containers, videos for collection- 60 min | Written: SAQ, MCQ |
| 4. Interpretation of antimicrobial sensitivity results | 4.1 Understand the importance of quality assured antimicrobial susceptibility testing (AST) 4.2 Interpret the antimicrobial susceptibility testing report. 4.3 Interpret the surrogate and cascade reporting. | K, S | Prescribers | Exploratory and interactive theory session with samples of AST reports60 min | Written: SAQ, MCQ, Case discussion, AST problem solving |
| 5. Antimicrobial resistance: Principle and implications | 5.1 Define and explain the differences between antimicrobials and antibiotics 5.2 Outline the drivers for resistance 5.3 Outline the global epidemiology of key antimicrobial resistant pathogens and antimicrobial consumption 5.4 Explain the clinical and economic impact of drug resistant infections and health care acquired infections | K | Prescribers | Exploratory and interactive theory session40min | Written: SAQ, MCQ |
| 6. Antimicrobial policy | 6.1 Describe the attributes and features of antimicrobial policy 6.2 Describe the key elements of developing hospital antimicrobial policy 6.3 Assist in developing antimicrobial policy | K | Prescribers | Exploratory and interactive theory session with examples from in house antibiotic policy- 30 min | Written: SAQ, MCQ |
| 7. Antimicrobial stewardship in humans | 7.1 Define antimicrobial stewardship 7.2 Outline the goals, strategies and interventions of antimicrobial stewardship 7.3 Describe the core and supplemental interventions 7.4 Outline the pharmacokinetics and pharmacodynamics approach to antimicrobial prescription 7.5 Describe and interpret antibiogram 7.6 Understand the utility of antibiogram in formulating empirical therapy | K, S | Prescribers | Exploratory and interactive theory session with examples of in house antibiograms and their interpretation60 min | Written: SAQ, MCQ, Case based problem |
| 8. Infection control | 8.1 Define standard precautions 8.1.1 Describe the elements of standard precautions 8.1.2 Describe moments and steps of hand hygiene 8.2 Define and describe transmission-based precautions 8.3 Define and describe various segregation methods of biomedical waste and their disposal as per BMW rules. 8.4 Define device associated infections 8.4.1 Define preventive care bundles for device associated infections 8.4.2 Describe care bundles for different types of device associated infections | K | Prescribers | Exploratory and interactive theory session15 + 15 + 15 + 15 min = 60 min | Written: SAQ, MCQ |
Case scenario 1
A 55 year old man presented with fever for 5 days, cough and sputum. He was a known diabetic and was hospitalised last year for similar complaints. On examination: conscious, drowsy, pulse: 110/ minute, BP: 100/60 mm Hg, RR: 26/ minute, Temp: 100 degree F. Chest examination: Crepitations right infrascapular region.
Q1: Describe the presenting complaints?
Q2: Discuss the Co- morbidities?
Q3: Discuss the relevant past history of any illness and treatment history and its importance?
Q4: Discuss the differential diagnosis?
Q5: Demonstrate the examination of this patient.
Q6: Discuss based on your examination, the site of care and type of care for this patient.
Case scenario 2
A 45-yr old patient, diagnosed case of chronic kidney disease (on maintenance hemodialysis) presents with high grade fever for two weeks. He complaints of swelling over cheek with blood discharge from nose. The doctor requests for fungal infection screen
a. Discuss the differential diagnosis of infection in this case
b. Plan the investigations and management in the case for infections in immunocompromised.
Case scenario 3
1. A two-year old girl presents with fever for five days with cough and fast breathing for two days. At examination she is lethargic, has weak thready pulses with tachycardia (suggestive of shock).
a. Demonstrate clinical skills to assess for sepsis and shock in this patient
b. Identify and prescribe the first-hour bundle of care in sepsis in this child and monitoring care
c. Plan rational investigations in this case
2. A 4 year old toddler with runny nose, sore throat since two days. On examination she has inflammed tonsils with white patch over it.
a. Discuss the differential diagnosis of infection in this case (keeping both viral & bacterial etiology)
b. Plan the investigations & management in this case.
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