Diagnostic Tests Must before prescribing Antibiotics to patients: NMC guidelines for doctors

New Delhi: In its recently released National Action Plan on Antimicrobial Resistance (NAP-AMR) Module for Prescribers 2024, the National Medical Commission (NMC) has advised doctors to treat patients with antibiotics in the presence of diagnostic reports and cases of severity. "The decision to treat with antibiotics should be made by the presence of severity and laboratory report of sputum and culture examination," the Commission stated in the module, adding that the empiric antibiotic therapy must be limited to seriously ill patients.

Medical Dialogues had earlier reported that NMC released the Module for Medical students, Doctors (Residents. Faculty, Medical officers etc.) and allied health professionals (Nurses, Pharmacist, Technicians and other allied health professionals) and administrators, while considering the emerging threats of Antimicrobial Resistance (AMR), which is now 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 and 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.

Releasing the module, which was prepared by NMC Ethics Board's member Dr. Vijaya Lakshmi Nag and other experts, NMC 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.

While discussing the clinical approach for prescribing Antimicrobials, the Commission stressed on the importance of accurate and thorough examination and a proper communication between the clinicians and the laboratory.

"The communication between the clinicians and laboratory is vital. The positive culture reports must be conveyed rapidly to prescribers so that the therapeutic interventions can be made in desired time frame. The decision of starting antibiotics should be governed by the antibiograms. This will not only be a cost-effective approach of treating infections but also reduce AMR," NMC mentioned in the module.

Apart from this, the module also specified in detail the factors affecting the decision to prescribe antimicrobials. 

As per the Module, the 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.

"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," the Commission added.

Further, the new guidelines also mentioned that recording cardinal symptoms of major systems like fever, cough, sputum, breathlessness, haemoptysis, chest pain may suggest an infective respiratory illness like pneumonia. It clarified that the decision to treat with antibiotics should be made by the presence of severity and laboratory report of sputum and culture examination.

"Jaundice and abdominal pain may be present in medical conditions like viral hepatitis, alcoholic hepatitis, leptospirosis, malaria, dengue etc. or in surgical conditions like choledocholithiasis or cholangitis. Prescribers should take a detailed history of any recent travel, drug abuse, blood transfusion, recent surgeries etc. to narrow down the differential diagnosis," it added.

NMC has also pointed out the importance of a Hospital antimicrobial policy, adding that such a 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," it added in the module.