रा�ीय आयु�व��ान आयोग

National Medical Commission

National Action Plan

on Antimicrobial Resistance
(NAP-AMR)
Module for Prescribers

2024

Publication Division, National Medical Commission

Pocket-14, Sector-8, Dwarka Phase-1, New Delhi-110077, INDIA
National Action Plan on Antimicrobial Resistance (NAP-AMR)
Module for Prescribers

रा ीय आयु व ान आयोग
National Medical Commission

-Editor-
Dr. Vijaya Lakshmi Nag
Officer in-charge, National Action Plan (NAP-AMR) NMC,
Member (Whole-Time),
Ethics and Medical Registration Board,
National Medical Commission.

Professor and HOD, Department of Microbiology

Ex – Dean Research,
All India Institute of Medical Sciences, Jodhpur.
 AMR Module for Prescribers

Contributors

Sr.
Expert’s Name
No.

1. Dr. Sonal Saxena, Director Professor & HOD

Department of Microbiology, Maulana Azad Medical College, New Delhi
Email ID - sonalsaxena3@gmail.com

2. Dr. Raja Ray, Professor & HOD

Department of Microbiology, Institute of Post Graduate Medical Education & Research,
Kolkata, West Bengal
Email ID - rjrm1175@gmail.com

3. Dr. Vimala Venkatesh, Professor

Department of Microbiology, King George’s Medical University, Lucknow, UP
Email ID - vimalavenkatesh@gmail.com

4. Dr. R. Jeyalalitha, Professor

Department of Pharmacology, Government Medical College, The Nilgiris, Tamil Nadu
Email ID - jeya0909@gmail.com

5. Dr. Syed Sajad Hussain, Professor

Department of Pharmacology, Government Medical College, Srinagar, Jammu & Kashmir
Email ID - sajadsafvi@gmail.coms

6. Dr. M.V.S. Subbalaxmi, Professor

Department of General Medicine, Niazam’s Institute of Medical Sciences, Hyderabad,
Telangana
Email ID - ubbalaxmimvs@gmail.com

7. Dr. Veenasree S. N., Professor

Department of Pharmacology, Government Medical College, Ernakulam, Kerala
Email ID - veenabiju73@yahoo.com

8. Dr. Purva Mathur, Professor

Department of Laboratory Medicine, JPNA Trauma Centre, AIIMS, New Delhi
Email ID - purvamathur@yahoo.co.in

9. Dr. V. Dillirani, Professor & HOD

Department of Microbiology, Government Stanley Medical College, Chennai, Tamil
Nadu
Email ID - v.dilliraniveda@gmail.com
 AMR Module for Prescribers

10. Dr. P. Gnanaguru, Professor & HOD

Department of Microbiology, K.A.P. Viswanathan Government Medical College, Trichy,
Tamil Nadu
Email ID - r2v1g1@gmail.com

11. Dr. Bhaskar Thakuria, Professor & HOD

Department of Microbiology, All India Institute of Medical Sciences, Patna, Bihar
Email ID - drbhaskart@aiimspatna.org

12. Dr. Ramesh Aggarwal, Professor

Department of Medicine, Lady Harding Medical College, New Delhi
Email ID - rameshhlmc@gmail.com

13. Dr. Gulnaz Bashir, Professor & HOD

Department of Microbiology, Sher-I-Kashmir Institute of Medical Sciences Srinagar,
Jammu & Kashmir
Email ID - gulnaz.bashir@skims.ac.in

14. Dr. Debadatta Dhar Chanda,

Professor & Head,
Department of Microbiology
Silchar Medical College & Hospital, Silchar
Email ID - drdebadattadhar@rediffmail.com

15. Dr. Yashik Bansal, Assistant Professor

Department of Microbiology, ESI Medical College Hospital, Alwar, Rajasthan
Email ID - dr.yashikbansal@gmail.com

16. Dr. Vibhor Tak, Additional Professor

Department of Microbiology, AIIMS, Jodhpur
Email ID - takv@aiimsjodhpur.edu.in

17. Dr. Manisha S. Mane, Professor & HOD

Department of Microbiology, ESIC Medical College & Hospital, Sanathnagar,
Hyderabad, Telangana
Email ID - drmanishamane@gmail.com


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AMR Module for Prescribers

Acknowledgement
We acknowledge, with gratitude, the inspiration and patronage of Dr Suresh Chandra Sharma, the
then Chairman, NMC for assigning this task and providing leadership guidance and encouragement
at every step.
We are thankful to Padma Shri Prof. B N Gangadhar, Officiating Chairman, NMC for providing
guidance, strength and support in fulfilling this task.
We are grateful to our esteemed Presidents and Members of all four boards for their constant
encouragement and continued input which has been very useful for formulating the module. We
thank Dr Vijay Oza, President of PGMEB, for attending the meetings and providing on-the-spot
inputs and suggestions for taking forward the program to all institutions in the country. We are also
greatly appreciative of the contribution from Dr Aruna V. Vanikar, President of UGMEB, for her
encouragement, valuable comments and suggestions.
We sincerely appreciate and acknowledge Dr Atul Goel, DGHS & Director, NCDC; Dr Lata
Kapoor, Additional Director, NCDC, New Delhi for their valuable suggestions, cooperation and
help to jointly host the two-day physical meeting of NAP-AMR in NMC.
We also acknowledge the inputs for the module from Dr Kamini Walia, Senior Scientist, ICMR,
New Delhi.
We were fortunate to have a panel of esteemed Experts who, with the help of their vast knowledge,
experience and skill had devoted their time and energy to giving the present shape to the module.
We are grateful to them.
We sincerely appreciate and acknowledge the experts* who attended various meetings held in
support of this module and provided their valuable comments and suggestions in preparing this
document.

I would like to extend my great appreciation to the Media section of NMC for their unwavering
support in creating and printing this module.

Last but not least, we thank all our staff who worked behind the screen relentlessly to enable the
document to see the light of the day.

Lastly, we thank the almighty for His blessings.

 AMR Module for Prescribers

Special thanks to*

1. Dr. Ramesh Babu Myneni, Professor & HOD

Department of Microbiology, Alluri Sitaram Raju Academy of Medical Sciences, Eluru,
Andhra Pradesh

2. Dr. Suresh Malla, Professor & HOD

Department of Pharmacology, Maharajah Institute of Medical Sciences
Vizianagaram, Andhra Pradesh

3. Dr. Gurusharan H. Dumra, Professor & HOD

Department of Pharmacology, Ahmedabad Municipal Corp. Medical Education Trust
Medical College, Ahmedabad, Gujarat

4. Dr. Manish Purohit, Associate Professor

Department of Microbiology, MGM Medical College, Indore, Madhya Pradesh

5. Dr. Neelam Attar, Associate Professor

Department of Microbiology, Bharati Vidyapeeth (DU) Medical College & Hospital,
Sangli, Maharashtra

6. Dr. Nirmal Sahu, Associate Professor

Department of General Medicine, Saheed Laxman Nayak Medical College & Hospital,
Koraput, Odisha

7. Dr. Rupinder Kaur Bakshi, Associate Professor In-charge

Department of Microbiology, Government Medical College, Patiala, Punjab

8. Dr. Manisha S. Mane, Professor & HOD

Department of Microbiology, ESIC Medical College & Hospital, Sanathnagar, Hyderabad,
Telangana

9. Dr Sumit Rai
Professor & Head,
Department of Microbiology, AIIMS, Manglagiri, Andhra Pradesh

10. Dr. Pooja Rao,

Associate Professor,
Department of Microbiology
Kasturba Medical College, Mangalore

11. Dr Sushil Kumar Sahu

Associate Professor,
Department of Microbiology
R N T Medical College, Udaipur
 AMR Module for Prescribers

12. Dr. Dhruv Chaudhary

Sr. Professor & HoD,
Department of Pulmonary & Critical Care Medicine, Pt. B D Sharma Postgraduate Institute
of Medical Sciences, Rohtak , Haryana

13. Dr.T. Jeetankumar

Professor,
Department of Medicine Regional Institute of Medical Sciences, Imphal, Manipur

14. Dr. Nirmal Sahu

Associate Professor,
Department of General
Medicine Saheed Laxman Nayak Medical
College & Hospital, Koraput, Odisha

15. Dr. Suresh Malla

Associate Professor
Department of Pharmacology
Maharajah Institute of Medical
Sciences, Vizianagaram, Andhra Pradesh

16. Dr. Shubhdeep Kaur, Associate Professor

Department of Microbiology, Maharishi Markendeshwar College of Medical Sciences &
Research, Ambala, Haryana

17. Dr. Kamini Walia,

Scientist F,
Department of Epidemiology and Communicable Diseases, ICMR,
Ansari Nagar, New Delhi

18. Dr. R. Sajith Kumar,

Professor Medical Education & Infectious Diseases,
Government Medical College, Kottayam, Kerala.

19. Dr. Anuj Sharma,

Public Health Professional, WHO India Staff Member,
Who Country Office for India, Nirman Bhawan, New Delhi.


 रा ीय आयुिव ान आयोग
National Medical Commission

National Action Plan

on Antimicrobial Resistance
(NAP-AMR)
Module for Prescribers

- 2024 -
AMR Module for Prescribers


Table of Contents

Title Page No. PPT Page no.

List of Abbreviations (ii) -
1. Background and Objectives 1 59
2. Clinical Approach for Prescribing Antimicrobials 4 68
3. Microbiological Diagnostic Stewardship 10 84
4. Interpretation of Antimicrobial Sensitivity Results 17 96
5. Antimicrobial Resistance-Principle and Implications 22 110
6. Antimicrobial Policy 27 118
7. Antimicrobial Stewardship 28 121
8. Infection Control 34 131
9. Toolkit for Prescribers 53 -
10. Presentations 58 -
References 153 -

(i)
 AMR Module for Prescribers


List of Abbreviations

3GCEB : Third Generation Cephalosporin Resistant Enterobacterales

AMR : Antimicrobial Resistance
AMSP : Antimicrobial Stewardship Program
AST : Antimicrobial Susceptibility Test
AUC : Area Under the Curve
BMQ : Breakpoint to MIC Quotient
CDC : Centre for Disease Control & Prevention
CLSI : Clinical and Laboratory Standards Institute
CRAB : Carbapenem Resistant Acinetobacter baumannii
DDD : Defined Daily Doses
DOT : Days of Therapy
ESBL : Extended Spectrum Beta Lactamase
EUCAST : European Committee on Antimicrobial Susceptibility Testing
GAP-AMR : Global Action Plan on Antimicrobial Resistance
HBV : Hepatitis B Virus
HCV : Hepatitis C Virus
HIV : Human Immunodeficiency Virus
HLGR : High Level Gentamicin Resistance
I : Intermediate
ICMR : Indian Council of Medical Research
ICU : Intensive Care Unit
IV : Intravenous
MIC : Minimum Inhibitory Concentration
MoHFW : Ministry of Health & Family Welfare
MDRO : Multi Drug Resistant Organism
MDR TB : Multidrug Resistant Tuberculosis
MRSA : Methicillin Resistant Staphylococcus aureus
NACO : National AIDS Control Organization
NAP AMR : National Action Plan on Antimicrobial Resistance
NCDC : National Centre for Disease Control
OSHA : Occupational Safety and Health Act
PEP : Post Exposure Prophylaxis
PCR : Polymerase Chain Reaction
PK : Pharmacokinetics
PD : Pharmacodynamics
R : Resistant
SARS : Severe Acute Respiratory Syndrome
SDD : Susceptibility Dose Dependent
S : Susceptible
VRE : Vancomycin Resistant Enterococci
WHO : World Health Organization

(ii)
AMR Module for Prescribers

Overview of AMR 1
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.
AMR is a complex problem that 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.
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.

Background and Objectives

In 2015, understanding the gravity of the problem of antimicrobial resistance (AMR),

the World Health Assembly (WHA) has 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 World Health Organization (WHO) has outlined five core objectives for NAP-AMR that
countries should strive towards:
1. Improve awareness and understanding: This involves educating the public, healthcare
professionals, and policymakers about AMR through effective communication, education,
and training programs.

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 AMR Module for Prescribers

2. Strengthen knowledge and evidence base: This objective focuses on improving surveillance
of AMR trends, conducting research on resistant pathogens, and identifying best practices
for infection prevention and control.
3. Reduce the incidence of infection: Strategies here target preventing infections in the first
place, including promoting hygiene and sanitation practices, and ensuring access to clean
water.
4. Optimize use of antimicrobial medicines: This objective aims to ensure antimicrobials are
used appropriately in both human and animal health. This involves developing national
guidelines for antibiotic use, promoting antimicrobial stewardship programs, and tackling
the misuse of antibiotics in agriculture.
5. Develop economic case for investment: This objective highlights the need for sustainable
investment in research and development of new diagnostics, vaccines, and antibiotics to
combat AMR. It also emphasizes the economic burden of AMR and the return on
investment for proactive measures.
Later in May 2017, the WHO resolution urged member states to align National Action
Plans on AMR (NAP-AMR) with GAP-AMR. In India the Core Working Group as notified by
MoHFW had developed “National Action Plan on AMR” involving consultation with various
stakeholders Ministries/ Departments at the national level. The strategic objectives of NAP-
AMR are aligned with the GAP-AMR based on national needs & priorities.

The NAP-AMR sets out six strategic priorities (Fig 1) and under each strategic priority,
specific objectives of key focus areas with elaborate interventions, activities and key outputs
along with responsible agencies and expected timelines, have been stated.

1. Improve awareness 3. Reduce the incidence

and understanding of 2. Strengthen knowledge of infection through
AMR through effective and evidence through effective infection
communication, surveillance prevention and control
education and training

4. Optimize the use of 5. Promote investments

6. Strengthen India’s
antimicrobial agents in for AMR activities,
leadership on AMR
health, animals and food research and innovations

Fig 1: Six strategic priorities in national action plan for antimicrobial resistance in India

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Objectives under National Medical Commission:

NMC is responsible in following specific objectives under priority 1 and 4 for human health
 Strategic priority 1- 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,

This is to be achieved by-

 Reviewing and revising curricula of undergraduate medical professionals-Undergraduate
module.
 Reviewing and developing training modules for in-service medical professionals –
Prescribers’ module.
 Reviewing and developing training modules for allied health professionals- Non
prescribers’ module.

 Strategic priority 4- 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

This is to be achieved by-

 Developing structured (and mandatory) training programmes on optimal antimicrobial use
 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.
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



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 AMR Module for Prescribers


Clinical Approach for Prescribing Antimicrobials

Learning Objectives
2
At the end of the session, a prescriber should be able to:
• identify common presentations of infective syndromes
• know the importance of taking thorough history, clinical examination and selection of
appropriate investigations for diagnosis of infective disease.

2.1 Introduction
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.

2.2. One way of clinical assessment is to follow a “Syndromic Approach”. (Fig 2) A patient
suspected of infective disorder may be classified into following syndromes:
 Acute febrile illness with Rash:
An acute febrile illness with a rash can have various causes, ranging from infectious to non-
infectious etiologies. Some common conditions that present with fever and rash include:
1. Viral Infections:
 Dengue Fever: A mosquito-borne viral infection characterized by sudden onset of high-
grade fever, headache, backache, joint pain, muscle pain and rash.
 Chickenpox (Varicella): Fever, malaise and a rash that starts as red spots and progresses
to vesicles.
 Measles: Characterized by a high fever, cough, running nose, red eyes (conjunctivitis)
and a rash that starts as erythematous macule behind the ear, on the neck and hairline
and spreads to the trunk and the extremities by the 2nd day.
 Rubella (German measles): Presents with a low-grade fever, enlarged lymph nodes and
a rash that starts on the face and spreads to the trunk and extremities.
2. Bacterial Infections:
 Scarlet Fever: Caused by streptococcal bacteria, it presents with fever, sore throat, and
a characteristic sandpaper-like rash.
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 Rocky Mountain Spotted Fever: Caused by rickettsial infection and transmitted by ticks,
it presents with fever, headache, and a rash that starts on the wrists, ankles, and spreads
centrally.
 Meningococcemia: Infection with Neisseria meningitidis can cause fever, headache, and
a petechial rash.
3. Other Infections:
 Lyme Disease: Caused by Borrelia burgdorferi transmitted by ticks, it presents with
fever, headache, and a characteristic bull's eye rash (erythema migrans).
 Rickettsial Diseases: Various infections such as Typhus and Q fever can present with
fever and rash.
4. Non-Infectious Causes:
 Drug Reactions: Some medications can cause febrile illnesses with rashes, such as
Stevens-Johnson syndrome or Drug Reaction with Eosinophilia and Systemic
Symptoms (DRESS).
 Autoimmune Diseases: Conditions like lupus erythematosus or Kawasaki disease may
present with fever and rash.
 Toxic Shock Syndrome: Associated with certain bacterial infections or tampon use, it
presents with fever, rash, and other systemic symptoms.

 Acute febrile illness with Jaundice:

1. Viral Hepatitis: Viral infections, particularly Hepatitis A, B, C and E viruses, can cause
acute febrile illness with jaundice. Symptoms may include fever, fatigue, abdominal pain,
nausea, vomiting, dark urine, and yellowing of the skin and eyes (jaundice).
2. Malaria: Severe cases of malaria, caused by Plasmodium parasites and transmitted by
mosquitoes. If the case turns into a complicated malaria, the patient may present with
jaundice because of the haemolysis.
3. Leptospirosis: This bacterial infection, typically acquired through exposure to
contaminated water or soil, can cause fever, muscle aches, headache, and jaundice.
4. Typhoid Fever: Caused by Salmonella Typhi bacteria, typhoid fever can present with high
fever, abdominal pain, splenomegaly, headache, and jaundice in severe cases.
5. Acute Biliary Tract Infections: Cholangitis and cholecystitis can lead to fever, abdominal
pain, and jaundice. Every patient of jaundice does not require antimicrobials. Their blood
sample should be sent to laboratory for identifying type of hepatotropic virus and
symptomatic management should be initiated. Conditions like leptospirosis and acute
biliary tract infections are emergencies which require empirical antibiotics as per
guidelines.

 Acute febrile illness with Neurological involvement:

Some possible causes of acute febrile illness with neurological involvement are:

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1. Meningitis: Inflammation of the protective membranes covering the brain and spinal
cord (meninges) can be caused by bacterial, viral, parasitic or fungal infections.
Symptoms include fever, severe headache, neck stiffness, altered mental status, and
photophobia.
2. Encephalitis: Inflammation of the brain, often caused by rickettsial infections like scrub
typhus and viral infections such as Herpes Simplex virus, Japanese Encephalitis virus,
West Nile virus. Symptoms may include fever, headache, confusion, seizures, and focal
neurological deficits.
3. Cerebral Malaria: A severe form of malaria caused by Plasmodium parasites, which can
lead to neurological symptoms such as altered consciousness, seizures, and coma, in
addition to fever and other systemic manifestations.
4. Acute Flaccid Paralysis: Certain viral infections, such as poliovirus or enteroviruses,
can cause acute flaccid paralysis, characterized by sudden weakness or loss of muscle
tone. Fever may or may not be present, depending on the specific virus.
5. Guillain-Barré Syndrome (GBS): An autoimmune disorder where the immune system
attacks the peripheral nerves, leading to muscle weakness and sometimes paralysis. GBS
can be triggered by viral or bacterial infections, and fever may accompany the
neurological symptoms.
Bacterial meningitis is a life threatening condition. CSF examination should be done if
there are no contraindications, and the sample should be sent to laboratory for analysis.
Empirical antibiotics are initiated and later modified as per available results from
laboratory. Cerebral malaria requires rapid identification of malarial parasite in the blood
and initiation of antimalarials.
 Acute febrile illness with Respiratory syndrome:
Most of the respiratory illnesses do not require antimicrobials. Viral infections are self-
limited and treated symptomatically. However, if patient of respiratory symptoms
presents with expectoration and signs of septicaemia, pneumonia should be suspected.
Sputum sample should be sent to laboratory and empirical antibiotic may be initiated.
Some of the causes of acute febrile illness with respiratory involvement are:
1. Influenza (Flu): A viral infection caused by influenza viruses, which can lead to fever,
cough, sore throat, nasal congestion, body aches, and fatigue. In severe cases, pneumonia
may develop.
2. Pneumonia: Inflammation of the alveoli in one or both lungs, typically caused by
bacterial, viral, or fungal infections. Symptoms include fever, cough, shortness of breath,
chest pain, and sputum production.
3. Acute Respiratory Infections (ARIs): Various viral infections, such as respiratory
syncytial virus (RSV), adenovirus, or parainfluenza virus, can cause ARIs with fever,
cough, and difficulty in breathing.
4. COVID-19: The disease caused by the novel coronavirus (SARS-CoV-2) can present
with fever, cough, shortness of breath, fatigue, muscle aches, and loss of taste or smell.
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In severe cases, it can lead to pneumonia and acute respiratory distress syndrome
(ARDS).
5. Tuberculosis (TB): An infectious disease caused by Mycobacterium tuberculosis
bacteria, which primarily affects the lungs. Symptoms may include fever, cough
(haemoptysis sometimes), chest pain, weight loss, and fatigue.
 Acute febrile illness with abdominal involvement: Gastroenteritis, acute appendicitis,
cholecystitis, diverticulitis, acute viral hepatitis and liver abscess are the conditions
involved.
 Acute febrile illness with Renal involvement:
1. Urinary tract infections: Patient present with symptoms like increased frequency of
micturition, burning micturition and fever. Morning mid-stream sample as discussed later
in the module should be collected and sent to laboratory for microscopic and culture
examination. Antimicrobials may be initiated empirically in situations like pregnancy,
diabetes etc and can then be modified as per available reports.
Pyelonephritis: This is a bacterial infection of the kidneys, often causing fever, flank pain,
and urinary symptoms. Antibiotics have to be started in suspected cases after sending
complete urine examination and urine culture. If there is a suspicion of pyelonephritis
blood cultures also need to be sent.
2. Scrub typhus can rarely present as fever, pneumonia, hepatitis and acute renal failure.
3. Glomerulonephritis: This refers to inflammation of the glomeruli, can be caused by
infections, autoimmune diseases, or other systemic conditions.
4. Haemolytic Uremic Syndrome (HUS): This is a rare but serious condition characterized
by the destruction of red blood cells, acute kidney injury, and low platelet count. It is
often caused by certain strains of bacteria, such as E. coli, and can occur following
gastrointestinal infections or urinary tract infections.
5. Systemic Lupus Erythematosus (SLE): This is an autoimmune disease that can affect
multiple organs, including the kidneys and can lead to acute kidney failure, nephrotic
syndrome and chronic renal failure (CRF).
 Acute febrile illness with cardiovascular involvement:
Myocarditis, infective endocarditis, pericarditis, Kawasaki disease, viral haemorrhagic
fevers such as dengue fever, yellow fever, Ebola fever present with cardiovascular
involvement including vascular leakage, haemorrhage and shock.

2.3 Accurate history and thorough clinical examination

 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.

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 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
 Urinary tract infections (UTI) and skin infections like foot ulcers develop in diabetic
patients. The collection of mid-stream urine samples in suspected UTI cases should be
done. Prescribers may refer to the proper collection technique of urine samples in male
and females as described later in this module.
 Recording cardinal symptoms of major systems like fever, cough, sputum, breathlessness,
haemoptysis, chest pain may suggest an infective respiratory illness like pneumonia. 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.
 History of unconsciousness, headache, and altered behaviour should raise the suspicion
of meningitis or meningoencephalitis and if accompanied by signs of meningeal irritation,
CSF should be done. As CSF is a precious sample, prescribers should be aware of
collection technique and transportation of this sample to the laboratory.
 Sometimes a patient of valvular heart disease may present with fever raising the suspicion
of infective endocarditis. Blood culture is the diagnostic test of choice for identifying the
causative organism in such cases. Therefore, proper technique of blood culture sampling
and proper communication with the microbiology laboratory is the key to successful
diagnosis and management in such cases.
 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.

2.4 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.

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Step 3: Choose the appropriate antibiotic based on clinical evaluation and most likely
pathogen keeping antibiogram in mind.

Fig 2: Syndromic approach to Acute Febrile Illness

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
Microbiological Diagnostic Stewardship
3
Learning Objectives

On completion of this chapter, the prescriber should be able to:

• define diagnostic stewardship
• understand the difference between infection and colonization
• describe the sample collection techniques, precautions, transport and rejection criteria
of common samples.

3.1 Introduction
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.”

3.2 Correct sample for correct report

 The microbiology laboratories must be effectively utilized by the clinicians to assist them
to prescribe appropriate antimicrobials.
 The 4 T of diagnostic stewardship:
1. choosing the right Test from
2. the right Type of sample, collected at
3. the right Time, in order to
4. guide Treatment decisions.
 Appropriate selection of samples, their proper collection and transport helps to improve
the diagnostic performance of a microbiology laboratory.
 The turn-around time for laboratory investigations must be known to all clinicians.
 The ability to distinguish between viral and bacterial infection is also useful, since
patients with viral infections may be able to be managed without antimicrobials.
 Many pathogenic microorganisms may be found as part of the normal commensal flora.
Isolation of these organisms may not necessarily indicate infection. Likewise, many body
sites have a normal commensal flora and samples sent to the laboratory in the absence of
signs or symptoms of infection may be difficult to interpret. Therefore, the clinician must
understand the limitations of testing and result interpretation and be able to put these into
clinical context rather than simply take a result at face value.

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 A common mistake is to send a sample for a wide range of diagnostic tests when the
likelihood that the patient has the conditions concerned is low. This often means that a
positive test result is more likely to be a false-positive result than a genuine result. So, the
patient may be given an incorrect diagnosis and be treated for something that they do not
have. Equally important, they are not treated for whatever it is that they do have.
 A blood culture can easily be contaminated with skin organisms at the time that the
sample is being taken. Patients with contaminated blood cultures are often commenced
on unnecessary antimicrobial therapy while the issue is being investigated. They may also
have other investigations to investigate an infection that they haven’t got.

3.3 General precautions while collecting samples

 The sample for bacterial culture must be collected prior to antimicrobial therapy
whenever possible.
 Appropriate specimen from suspected site of infection must be collected in correct
container according to case definition.
 The sample must be collected by trained staff after precise instructions to the patient.
 It must be transported within 1-2 hours after collection, in the correct package.
 Blood and CSF should never be refrigerated, can be kept at room temperature (37ºC) at
the collection site and transported at room temperature.
 All samples must be accompanied by a request form with complete clinical, demographic
and epidemiological information.

3.4 Colonization and infection

 Most organisms which colonize are harmless commensals and should not be treated.
 An organism isolated from a sample taken from a normally sterile site like the CSF, blood,
pleural fluid etc. is likely to be a true invader and the causative pathogen.
 An organism isolated from a non-sterile specimen like sputum or a wound swab may be
a colonizer.
 If the organism is persistently isolated despite ‘effective’ systemically administered
therapy, careful clinical decision must be taken keeping in mind the organism may be a
multidrug resistant pathogen or simply a colonizer.

3.5 Sample collection techniques

1. Blood
 Preferably collect paired blood sample for culture from two different sites (e.g. right and
left antecubital fossa) to differentiate between probable pathogens and possible
contaminants and to increase the rate of isolation. The dilution ratio should be 1 ml of
blood to 10 ml of culture media.
 Wear gloves, thoroughly disinfect the venepuncture site.

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 Cleanse an area about 50 mm in diameter with 70% ethanol and allow to air-dry.
 Apply 2% tincture of iodine or chlorhexidine/ alcohol-based disinfectant in a circular
action, swab the area beginning at the point where the needle will enter the vein.
 Allow the disinfectant to dry on the skin for at least 1 minute.
 Wipe the top of the bottle cap using an ethanol swab and allow to dry before injecting the
sample aseptically into the bottle.
 Inoculated blood culture bottles should be transported to the laboratory immediately or
held at room temperature until they reach the laboratory.

2. CSF
 Sequentially collect CSF into a minimum of three sterile calibrated tubes.
Lumbar puncture
 Disinfect the puncture site with antiseptic solution and alcohol in a manner identical to
phlebotomy skin preparation for blood culture to prevent specimen contamination and
introduction of infection.
 Insert a needle with stylet at the L3-L4, L4-L5, or L5-S1 interspace. When the
subarachnoid space is reached, remove the stylet; spinal fluid will appear in the needle
hub.
 Measure the hydrostatic pressure with a manometer.
 Sequentially collect the CSF into three calibrated sterile tubes labelled.
 Physicians should be instructed to sequentially collect 0.5-2.0 ml of CSF into three sterile
calibrated tubes (in each tube) if only routine chemistry (total protein and glucose),
bacteriology (culture & sensitivity), and haematology (cell count) are required.

3. Sterile body fluids

 Normally sterile body fluids such as pleural, pericardial, peritoneal, synovial, etc. should
be collected with needle and syringe using sterile technique.
 The aspirated fluid (1-5ml) should be transferred into aerobic and anaerobic blood culture
bottles preferably, retaining some (0.5 ml) in syringe for Gram stain and direct plating.
 If culture bottles are not available at site the aspirated fluid should be transferred to a
sterile screw-capped tube or a paediatric isolator tube.
 The sample should not be submitted in syringe with needle attached. The syringe should
be cap secured to prevent leakage.
 Swab specimens are inferior and should NEVER be used if fluid specimens can be
obtained.

4. Urine
 Preferably, early morning first midstream urine (2-5ml) to be collected in sterile, wide
mouth, leak proof container.

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 In catheterized patients, clamp the catheter, clean the catheter wall vigorously with 70%
ethanol and aspirate 5 to 10 ml of urine via a sterile needle and syringe above the clamp.
Never collect urine sample from the urine collection bag or by disconnecting the catheter
from the tube of the urine collection bag.
 In non-catheterized patients, the following instructions should be given:
 Female: Wash the hands, cleanse the area around the urethral opening with soap and
water, and collect the midstream urine in a sterile container with the labia held apart.
 Male: Wash the hands, retract the foreskin, cleanse the glans with soap and water, collect
midstream urine in the sterile container.
 Urine samples must be sent to the laboratory as soon as possible (preferably
immediately). In case of delay of more than 1 hour, the sample must be refrigerated.

5. Sputum
 Use a clean/sterile, wide mouth leak-proof container, and collect the sample preferably
during early morning after rinsing mouth with water but before brushing, fluid or food
intake.
 Patient is instructed to cough deeply after taking a deep breath.
 Specimen must be sputum, and not saliva.
 Samples must be sent to the laboratory as soon as possible preferably within (2 hours of
collection). In case of delay, the sample should be refrigerated (except in case if
Streptococcus pneumoniae and/or Haemophilus influenzae infection is suspected).
 In case of external soiling of the sample container with sample, a phenol-containing
disinfectant should be used to wipe the outside of the container.

6. Endotracheal aspirate (ETA)

 Endotracheal aspiration is done with a sterile technique using a 22-inch, 12F suction
catheter.
 The catheter is introduced through the endotracheal tube for at least 30 cm. Gentle
aspiration is then performed without instilling saline solution.
 The first aspirate is discarded, the second aspirate is collected after tracheal instillation
of 5 ml saline in a mucus collection tube.
 If very little secretion is produced by the patient, chest vibration or percussion for 10 min
is used to increase the retrieved volume (> 1 mL).
 Send the specimen to the laboratory as soon as possible.

7. Bronchoalveolar lavage (BAL)

In this procedure 100-300 ml volume of saline is infused to a lung segment through the
bronchoscope to obtain cells and protein of the pulmonary interstitium and alveolar
spaces and a portion of it to be sent to the laboratory as soon as possible.

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8. Throat/nasopharyngeal swabs
 The procedure is explained to the patient, including that they may gag briefly.
 After wearing appropriate PPE the patient should be positioned such that the light source
illuminates the posterior oropharynx.
 The patient is asked to open the mouth and relax the tongue by saying "aaaah” and the
tongue is pressed down using a tongue depressor.
 Both tonsils and the posterior pharynx are swabbed.
 The swab is then placed in the culture medium, or a suitable transport medium, or sterile
test tube.
 For collection of nasopharyngeal swabs, the patient must be seated comfortably with the
back of their head against the headrest. The swab is inserted in the nose horizontally,
along an imaginary line between the nostril and the ear.
 The swab should be placed in viral transport medium (VTM) if viral diagnostics is
required.

9. Stool
 Freshly voided sample should be collected in a clean/sterile wide mouth leak-proof
container.
 If the above is not possible, then the patient can be advised to transfer stool from a clean
bedpan / nappy pad which is not mixed with urine, disinfectant etc. including mucus or
blood part.
 If the patient (infant/small children) is passing loose stool then sterile plastic catheter
(disposable) no. 26 is to be used. Transport to the laboratory within 2 hrs of collection.
 Collect at least 5 ml of sample in case of liquid stool, approximately 1 g (walnut-sized)
sample in case of semi-formed or formed stool.
 In case of delay, contact to microbiologist for preferable transport media.

10. Pus/ tissue biopsy aspirate

 In case of open wounds, debride to clear overlying debris with scalpel and swabs or
sponges, and thoroughly rinse with sterile saline prior to collection of samples.
 Collect biopsy or curette sample from base or advancing margin of the lesion. The
specimen must never be sent in formalin for culture.
 In case of closed wounds, disinfect the area as for collection of blood sample before
aspiration.
 Pus from an abscess is best collected at the time the abscess is incised and drained, or
after it has ruptured naturally.
 Collect the sample (at least 1 ml) by using a syringe and needle and put in a sterile
container or blood collection tube without anticoagulant (e.g., vacutainer or similar type).

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 A portion of the samples should also be placed in a sterile tube containing anaerobic
medium like Robertson’s cooked meat media (RCM) if an anaerobic culture is required.
 Collect swabs only when tissue or aspirate cannot be obtained as swab is not an
appropriate/ preferred sample for culture.
 Send the specimen to the laboratory as soon as possible.

11. Genital swabs

 For vaginal swabs the excess mucus is cleaned with cleaning swab and discarded.
 The swab is inserted into the cervical canal and rotated for 15-30 seconds.
 The swab should be immediately broken off and placed into the transport tube.
 For endocervical swabs, the sample should be collected with help of speculum.
Table 1 summarizes the sample collection techniques described above.

3.6 Sample rejection criteria

 Samples collected in incorrect containers or in broken, poorly sealed and leaking
containers.
 Unlabelled specimens or mismatch between sample requisition form and container.
 Unacceptable delay between specimen collection and arrival at laboratory.
 Sample stored incorrectly before or during transport.
 Inadequate quantity of specimen.
 24 hours urine collection.
 Foley’s catheter tips and endotracheal tube tips.
 Urine from the bag of a catheterized patient.

3.7 Follow up cultures

 Whether treatment has been successful or not is best judged by clinical criteria, but it is
useful to know whether the infecting organism has been eliminated.
 Repeated cultures are, therefore, sometimes indicated.
3.8 Rapid tests
 These tests rapidly confirm the presence of a bacterial pathogen or help to rule out a
bacterial infection and hence used for selection of appropriate therapy.
 PCR identification of respiratory viruses in children with lower respiratory tract
infection help to exclude viral infection.
 Inflammatory markers such as Procalcitonin, C-Reactive Protein etc. guide prescribers
to institute rational therapy especially in sepsis cases. They can be useful to differentiate
between a bacterial and a viral infection and therefore is a potential guide to initiate
antimicrobial therapy.

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Table 1: Summary of sample collection and transport

Sample Collection Transport Remarks
Blood 1ml blood per 10ml Immediately or at room
media for conventional temperature
culture; and as per
instruction in case of
automated culture
CSF 0.5-2 ml in sterile Immediately or at room Never refrigerate
container temperature
Sterile body 1-5 ml sterile container Immediately or refrigerate if Do not transport in
fluids (Pleural, delay up to 2 hours capped syringe
Pericardial,
peritoneal etc.)

Urine 2-5ml Immediately or refrigerate if Give proper

delay of more than 1 hour instructions for
Sputum Sample coughed up Immediately or at room collection and
into container temperature transport to patient
Throat/ two swabs (culture and Immediately before drying, in Wear appropriate
oropharyngeal microscopy) VTM for viral diagnostics PPE
swabs
Stool 1g (formed stool) to Immediately or at
room Sample to be sent
5ml (liquid stool) temperature to the laboratory
within 15minutes
for trophozoites
Pus/ Tissue Sterile wide mouth Immediately or refrigerate if Do not add
biopsy/ aspirates container delay up to 4 hours formalin or saline
Genital swabs Dacron or rayon swabs Immediately Add to VTM if
viral diagnostics is
required.

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Interpretation of Antimicrobial Sensitivity Results

Learning Objectives
4
On completion of this chapter, the prescriber should be able to:
• understand the importance of quality assured antimicrobial susceptibility testing (AST)
• interpret the antimicrobial susceptibility testing report
• interpret the surrogate and cascade reporting.

4.1 Introduction
 The microbiology laboratory must be accessible for 24 hours.
 The communication between the clinicians and laboratory is vital.
 The reports must be conveyed promptly to the prescribers so that the therapeutic
interventions can be made in desired time frame.
 The results of 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.

4.2 Antimicrobial Susceptibility Testing

 Antimicrobial susceptibility testing is done by manual and automated methods.
 Automated methods are available commercially that provide extrapolated Minimum
Inhibitory Concentration (MIC) results within 12-18 hours.
 Worldwide there are two popular guidelines to ensure quality testing in AST: Clinical
and Laboratory Standards Institute (CLSI, formerly NCCLS) and European Committee
on Antimicrobial Susceptibility Testing (EUCAST).
 The choice of antimicrobials for AST must be made as per guidelines and in
consultation with clinicians keeping the hospital formulary in mind.

4.3 Interpretation of AST result

 Interpretive criteria of susceptibility are based on standard dosing in a patient with
normal renal function tests and in absence of co-morbidities. The results of AST are
reported as:
i. Susceptible: The bacteria are inhibited by the usually achievable concentrations of
antimicrobial agent when the dosage recommended to treat the site of infection is
used.
ii. Intermediate: The bacteria for which the response rates to usually attainable blood
and tissue levels of antimicrobial agent are lower compared to susceptible isolates. It
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is a buffer zone between the susceptible and resistant categories. It also indicates that
the clinical response will be achieved in cases where antimicrobials are concentrated
at the site of infection such as urine.
iii. Resistant: The bacteria which are not inhibited by the usually achievable
concentrations of the agent with normal dosage regimens and that the clinical efficacy
of the agent against the isolate may not be sufficient.
iv. Susceptible-dose dependent (SDD): The susceptibility of the bacteria depends on
the dosage regimen that is used in the patient.
v. Non-susceptible (NS): Only a susceptible breakpoint is designated because of the
absence or rare occurrence of resistant strains. Also, it does not necessarily mean that
the isolate has a resistance mechanism.
 Indicator/Surrogate drugs: An indicator drug is used to detect the presence of the
mechanism that gives resistance not only to the indicator, but also to related agents
(Table 2).

Table 2: Indicator/surrogate/equivalent antimicrobials used in AST reports

Bacteria Antimicrobial Inference (if indicator found resistant)
tested
Staphylococcus spp. Cefoxitin as Cefoxitin resistant is MRSA: Resistant to all beta-
surrogate for lactam agents except ceftobiprole and ceftaroline
predicting
MRSA
Ciprofloxacin Acquisition of at least one target mutation that leads
or ofloxacin 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 Determines loss of synergism of

(high level) aminoglycosides with beta-lactam agents and
glycopeptides irrespective of MIC value

Enterobacterales Ciprofloxacin Resistant to all fluoroquinolones

Ceftriaxone or 3rd generation cephalosporin
cefotaxime
Enterobacterales, Colistin or Any one agent can be used
P.aeruginosa, polymyxin b
Acinetobacter
baumannii complex
Klebsiella spp./ E. coli Ceftazidime Resistant to all cephalosporin except cephamycins
(cefoxitin, cefotetan)

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Gram-negative Cefazolin Predicts results for all oral cephalosporins such as

isolates from cefaclor, cefdinir, cefpodoxime, cefprozil,
uncomplicated UTIs cefuroxime, cephalexin, and loracarbef
 Equivalent Agents: Results from one antimicrobial can be used to predict results for
the other antimicrobials. For example, sensitivity to erythromycin can be used to predict
sensitivity to clarithromycin or azithromycin.

4.4 Selective Testing: AST for particular drug- microbe combinations are not performed
due to the following reasons (Table 3):

Table 3: Reasons for selective testing and reporting

Reasons Examples
Bacteria suspected of being If one of the two blood cultures reveals
contaminants or normal flora. 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 Ceftriaxone AST is not performed for
predicted based on the organism Pseudomonas aeruginosa because P.
identification alone (i.e., no resistance aeruginosa is intrinsically resistant to
yet identified or intrinsic resistance*). ceftriaxone.
Group A streptococci is not tested
against penicillin as resistance has not
been reported.
A particular drug-microbe CLSI or FDA breakpoints for
combination may not have tigecycline in case of Acinetobacter
interpretative breakpoints baumannii are not available
A particular drug-microbe Daptomycin AST results are not
combination may be inappropriate for reported on isolates from a respiratory
a given site of infection. source as it is inhibited by surfactant.

A drug may be inappropriate for a AST results for certain drug classes
particular patient population. such as fluoroquinolones or
tetracyclines may not be reported for
children.

4.5 Cascade reporting (CR): In this, AST results of secondary (e.g., broader-spectrum,
costlier) agents may only be reported if an organism is resistant to primary agents within
a particular drug class. This helps to guide clinicians toward using narrower-spectrum
agents. Restricted antimicrobials/second-line antimicrobials should be reported only in
cases of resistance to first-line/unrestricted antimicrobials.
Example: Carbapenem AST results are not reported for Escherichia coli if the isolate
is susceptible to ceftriaxone.

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4.6 Interpretation of MIC results

 MIC is the lowest concentration of antimicrobial agent that prevents the in- vitro growth
of bacteria.
 The absolute value of the MICs reported on susceptibility testing must not be evaluated
vertically between the different drugs tested. For example, if there is an antimicrobial
A with a MIC of 0.5 mg/L and the breakpoint 2 mg/L, and an antimicrobial B with a
MIC of 2 mg/L but breakpoint of 16 mg/L, the drug with a MIC more favourable is the
antimicrobial B. The ratio of clinical breakpoint MIC to MIC of organism is named
breakpoint to MIC quotient (BMQ). Higher the BMQ, better the clinical response.

4.7 Organism specific AST results

 Enterococci
 Cephalosporins, clindamycin, and trimethoprim-sulfamethoxazole may appear active
in- vitro but are not effective clinically and should not be reported as susceptible or
prescribed even when reported as susceptible.
 Combination therapy with ampicillin, penicillin, or vancomycin (for susceptible
strains) plus an aminoglycoside is usually indicated for serious enterococcal infections.
This synergy is lost in presence of penicillin resistance or high-level resistance to
gentamicin (HLGR).
 Staphylococci
 Penicillin-susceptible staphylococci are also susceptible to other β-lactam agents with
established clinical efficacy for staphylococcal infections.
 Methicillin (oxacillin)-resistant staphylococci are resistant to all currently available β-
lactam antimicrobial agents, with the exception of ceftaroline.
 Inducible clindamycin resistance if present then antimicrobial therapy with clindamycin
may fail clinically.
 Salmonella and Shigella species
 Aminoglycosides, first- and second-generation cephalosporins and cephamycins may
appear active in- vitro but are not effective clinically and should not be reported as
susceptible or prescribed even when reported as susceptible.
 For extraintestinal isolates of Salmonella spp., a third-generation cephalosporin should
additionally be tested and reported, and if requested, chloramphenicol and azithromycin
may be tested and reported.
 Susceptibility testing is indicated for typhoidal Salmonella (S. enterica ser. Typhi and
Salmonella enterica ser. Paratyphi (A–C) isolated from extraintestinal and intestinal
sources.
 Routine susceptibility testing is not indicated for non-typhoidal Salmonella spp.
isolated from intestinal sources. However, susceptibility testing is indicated for all
Shigella isolates.

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 Only ampicillin, a fluoroquinolone, and trimethoprim-sulfamethoxazole should be

reported routinely in case of stool isolates of Salmonella and Shigella spp.
 For CSF isolates, the following must not be prescribed/ reported:
 Only orally administered antimicrobials
 First- and second-generation cephalosporins and cephamycins
 Doripenem, ertapenem, and imipenem
 Clindamycin
 Macrolides
 Tetracyclines
 Fluoroquinolones

4.8 Sample specific AST results

AST results are provided only if clinical assessment suggests infection in the following
situations:
 Urine: The urine of patients with indwelling catheters frequently becomes colonised.
Unless the patient becomes systemically unwell, treatment is not indicated.
 Sputum: Antimicrobial therapy may be indicated if clinical or radiological evidence of
lower respiratory tract infection is present. Otherwise, this probably represents upper
airway colonisation, for which antimicrobial therapy is not required.
 Pus Swab: Antimicrobial therapy may be indicated in case of cellulitis or deep-seated
infection only.

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Antimicrobial Resistance: Principle and Implications

Learning Objectives
5
On completion of this chapter, the prescriber should be able to:
• define and explain the differences between antimicrobials and antibiotics
• outline the drivers for resistance
• outline the global epidemiology of key antimicrobial resistant pathogens and
antimicrobial consumption
• explain the clinical and economic impact of drug resistant infections and health care
acquired infections.

5.1 Introduction
 ‘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).
 Antibiotic refer to compounds that are produced by microorganisms and act against
bacteria.
 Antimicrobials are unique, and pose special challenges due to following:
 Limited shelf life: The efficacy of antimicrobials wanes over time.
 Multispecialty usage: They are used for prophylaxis and treatment of various
conditions in a variety of situations.
 Inappropriate use: May harm other people who are even not exposed to the
antimicrobial.
 Limited drug development: Past three decades have not seen significant development
and licensing of antimicrobials.
 Change in natural bacterial flora: Overuse of antimicrobials tend to select bacteria with
resistance to proliferate in environment and body.

5.2 Overview of Antimicrobial resistance

 Antimicrobial resistance (AMR) occurs when microorganisms such as bacteria,
viruses, fungi, and parasites develop changes and fail to respond to antimicrobials.
 This makes standard treatments ineffective, prolonging infections that can increase the
risk of spread to others. The resistant microbes are able to grow/multiply in the
presence of drug that would normally kill them or limit their growth.
 AMR is a now recognized as a grave public health problem. As per estimations, AMR
will be responsible for the death of 10 million people by 2050 and will cost as much
as US$ 100 trillion.

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 Multiple agencies including WHO agree that spread of AMR is an urgent issue that
requires a global, coordinated action plan to address. A report in lancet estimates that
the magnitude of bacterial AMR is almost equivalent to major diseases such as HIV
and malaria, and potentially much larger.

5.3 Mechanism of action of antimicrobials

Antimicrobials act on bacteria in multiple ways. They can kill the cell (bactericidal) or
retard its multiplication (bacteriostatic) (Table 4). They can act by
 Inhibition of cell wall or cell membrane synthesis in microbes.
 Disruption of essential processes such as protein synthesis of microbes.
 Disruption of nucleic acid synthesis in microbes.

Table 4: Bacteriostatic and bactericidal antimicrobials

Bactericidal Bacteriostatic

Beta lactams, Macrolides,

glycopeptides, clindamycin,
cyclic lipopeptides, tigecyclines,
aminoglycosides, tetracyclines,
fluoroquinolones linezolid

5.4 Mechanism of antimicrobial resistance

Bacteria may develop resistance to an antimicrobial by several mechanisms and resist
getting killed or inhibited by the antimicrobial. Some bacteria inherently do not respond
to certain drugs (intrinsic resistance) while others may stop responding to a drug to
which it is originally sensitive (acquired resistance). Some of the common intrinsic
resistance in common bacteria is given in Table 5:

Table 5: Intrinsic resistance in some commonly isolated bacteria

Bacteria Drug
Gram positive bacteria Aztreonam
All Gram negative bacteria Glycopeptides, Lipopeptides
Klebsiella species Ampicillin, Amoxicillin-clavulanate, Ticarcillin,
Cefazolin
Citrobacter species Ampicillin, 1st & 2nd generation Cephalosporins,
Cephamycins
Proteus species Colistin, Cefazolin, Tetracycline, Nitrofurantoin
Pseudomonas aeruginosa Ampicillin, Amoxicillin, Amoxicillin-clavulanate,
Trimethoprim-suphamethoxazole, Sulfonamides,

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1st and 2nd generation Cephalosporins, Cefotaxime,

Ceftriaxone, Ertapenem, Chloramphenicol,
Tetracycline
Acinetobacter species Ampicillin, Amoxicillin-clavulanate, Aztreonam,
Chloramphenicol, Fosfomycin, Ertapenem,
Enterococcus Aminoglycosides, Cephalosporins, Clindamycin,
many β-lactams, Aztreonam, Polymyxin B/colistin,
and Nalidixic acid

Acquired resistance: Bacteria may stop responding to a drug to which it is originally sensitive)
by in any of the following actions:
 Production of enzymes that destroy the antibacterial drug (e.g., beta-lactamases in
penicillin and cephalosporins)
 Expression of efflux systems that prevent the drug from reaching its intracellular target
(e.g., efflux pump mechanism [fluoroquinolone resistance])
 Reduction of permeability of drug through mutation of porin proteins (as seen with
aminoglycosides)
 Modification of the drug’s target site (e.g., penicillin-binding protein)
 Production of an alternative metabolic pathway that evades the action of the drug (e.g.,
folate metabolism)

5.5 Drivers of Antimicrobial Resistance

In the latter half of the 21st century, bacteria have developed resistance against every
class of antimicrobial drug. The development of AMR is multifactorial. The risk factors
most commonly found to be associated with development of antimicrobial resistance
are:
1. Excessive and irrational prescriptions of antimicrobials in community and hospitals
2. Increase in invasive procedures, transplants surgeries and immunosuppressive
therapy.
3. Increase use of prosthetic devices amenable to super-infection and resistant
bacteria.
4. Lack of effective preventive infection control measures such as hand hygiene,
isolation procedures of patients with multi drug resistant organisms.
5. Lack of effective antimicrobial stewardship programs restricting antimicrobial
usage in community and hospitals.
6. Use of antimicrobial in agriculture sector, animal husbandries and fisheries.
7. Improper disposal of antimicrobials and antimicrobial residues which leads to
finding their way in community and entering food chain through food, animals and
water.

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5.6 Key Antimicrobial Resistant Pathogens:

The World Health Organization (WHO) has identified a list of priority pathogens that
pose a critical threat to human health due to their resistance to antimicrobials. These
pathogens as per the recent 2024 list include:

 Carbapenem resistant Enterobacterales (CRE) These include Klebsiella spp. and

Escherichia coli that are resistant to carbapenems and are placed atop in the critical list
of priority pathogens.
 Third generation cephalosporin-resistant Enterobacterales (3GCREB) - Gram-
negative bacteria resistant to third-generation cephalosporins, a broad class of
antibiotics used to treat many different types of infections.
 Carbapenem resistant Acinetobacter baumannii (CRAB) The emergence of CRAB
poses a formidable challenge due to limited treatment options particularly in ICU
settings.
 Methicillin-resistant Staphylococcus aureus (MRSA) – S, aureus resistant to many
common antibiotics, making it difficult to treat skin infections, pneumonia, and
bloodstream infections.
 Vancomycin-resistant Enterococcus (VRE) - one of the last-resort antibiotics used to
treat serious infections.
 Fluoroquinolone-resistant bacteria - This includes strains of E. coli, Salmonella and
Campylobacter that are resistant to fluoroquinolones, commonly used to treat urinary
tract infections, diarrhea, and respiratory infections

5.7 Global Epidemiology of AMR:

AMR is a global problem, but its impact varies from country to country. Low- and
middle-income countries are often disproportionately affected due to factors like limited
access to clean water and sanitation, overcrowding, and poor infection control practices
in healthcare settings. The breakdown of the global epidemiology of AMR is as follows:
 High burden: Low- and middle-income countries in Southeast Asia, Africa, and Latin
America.
 Emerging burden: Eastern Europe and Central Asia.
 Established burden: High-income countries in Europe and North America.

5.8 Antimicrobial Consumption: The overuse and misuse of antimicrobials are major
drivers of AMR. This includes:
 Using antibiotics for viral infections, which are ineffective.
 Taking antibiotics for an incomplete course of treatment.
 Using antibiotics for non-medical purposes, such as promoting growth in livestock.

5.9 Impact of AMR: The consequences of AMR include:

 Increased morbidity and mortality from infections.
 Longer hospital stays and higher healthcare costs.
 Limited treatment options for common infections.
 The emergence of untreatable "superbugs."

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For Combating AMR a multi-pronged approach has been included in NAP-AMR that includes-
 Surveillance: Monitoring AMR trends to identify emerging threats.
 Stewardship: Promoting the responsible use of antimicrobials in humans and animals.
 Infection prevention and control: Implementing measures to prevent infections in
healthcare settings.
 Research and development: Developing new antibiotics, diagnostics, and vaccines.

5.10 Clinical Impact: both drug resistant infections (DRIs) and hospital acquired infections
(HAIs) pose significant challenges for patient care. The clinical impact are-
 Drug resistant infections
 Increased mortality: DRIs are associated with higher death rates, because effective
treatment options become limited, and alternative drugs may have lower efficacy or
more severe side effects.
 Treatment delays: due to delay in diagnosis worsen the course of the infection.
 Limited treatment options: for DRIs, effective antibiotics may be scarce or
unavailable or having serious side effects.
 Increased length of hospital stay
 Hospital acquired infections
 Increased mortality compared to community-acquired infections due to
compromised immune status of the patient making them more susceptible to severe
complications.
 Antibiotic resistance: the frequent use of antibiotics in hospitals selects for resistant
strains, making it harder to treat future infections.
 Increased complications like pneumonia, sepsis, and organ failure.
 Psychological impact in form of anxiety, stress, and depression in patients,
impacting their overall well-being.

5.11 Economic impact: combined effect of DRIs and HAIs are-

 Increased costs: due to longer hospital stays, the use of more costly antibiotics, and
the need for additional treatments for complications.
 Reduced productivity: due to longer recovery times, leading to lost workdays and
decreased productivity.
 Strain on healthcare systems: due to increased demand for resources to treat DRIs
and HAIs limited resources available for other patients.
 Global economic impact: The World Bank estimates that AMR alone could push an
additional 10 million people into poverty by 2030.

5.12 To mitigate impact of AMR

To reduce the clinical and economic burden of DRIs and HAIs, several strategies are crucial:
 Antimicrobial stewardship
 Infection prevention and control
 Surveillance
 Research and development of new antibiotics, diagnostics, and vaccines to combat
DRIs and HAIs.

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Antimicrobial Policy
6
Learning Objectives

On completion of this chapter, the prescriber should be able to:

• describe the attributes and features of antimicrobial policy
• understand the key elements of developing hospital antimicrobial policy
• assist in developing antimicrobial policy.

6.1 Introduction
 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.
 The hospital antimicrobial policy should be based upon the following factors:
 prevalent local antibiogram
 spectrum of antimicrobial activity
 pharmacokinetics/ pharmacodynamics of antimicrobials
 adverse effects and potential to select resistance of antimicrobials
 cost of the therapy
 special needs of individual patient groups like immunosuppressed, pregnant women, etc.
6.2 Development of antimicrobial policy
Key elements of developing hospital antimicrobial policy are given in Fig 3.
Develop propylactic
Adapt National/state Recommend
and empirical
Multidisciplinary guidelines to suit antimicrobials based
guidelines including
group to make, need of hospital and on efficacy against
for intravenous to
review and adapt review hospital AST prevalant pathogens
oral switch, special
policy surveillance with dose, duration
groups, surgical
data/antibiogram and route
prophylaxis

Review policy by Revise as per yearly

Monitor and review
experts other than antibiogram and
antibiotics policy
developing group feedback.

Fig 3: Key elements of developing hospital antimicrobial policy

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Antimicrobial Stewardship in Humans

Learning Objectives

On completion of this chapter, the prescriber should be able to:

• define antimicrobial stewardship
• outline the goals, strategies and interventions of antimicrobial stewardship
• describe the core and supplemental interventions
• outline the pharmacokinetics and pharmacodynamics approach to antimicrobial
prescription
• describe and interpret antibiogram
• understand the utility of antibiogram in formulating empirical therapy.

7.1 Introduction
 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”.
7.2 Goals of Antimicrobial stewardship
The goals can be briefly described as:
 Ensure the best clinical outcome, for treatment or prevention of infection
 Minimize unintended consequences of antimicrobial use such as adverse drug reactions,
emergence of clones of antimicrobial resistance
 Minimize healthcare costs without compromising quality of care
 Accurate diagnostics and diagnostic pathways

Antimicrobial stewardship program (AMSP) have a direct responsibility to ensure prudent

antimicrobial prescribing. It focuses on “4Ds” of prescribing antimicrobials (Fig 4).

Right drug
Right dose
Right duration
De-escalation
at right time

Fig 4: 4Ds of prescribing antimicrobials

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7.3 AMSP interventions

Interventions can be introduced in phased manner or in whole hospital depending upon
the facilities and motivation. Broadly the interventions that can be introduced are given
below (Table 6).

Table 6: Core and supplemental interventions in antimicrobial stewardship

Core interventions Supplemental interventions
Prospective audit Dose optimization and combination therapies
Antimicrobial timeouts Streamlining or de-escalation of therapy
Antimicrobial consumption analysis Parenteral to oral conversion
Formulary restriction Laboratory surveillance and feedback
Guidelines and clinical pathways Information, education and communication

Core Interventions

Prospective audit
Regular bedside review of the patients to be done to analyse the prescriptions related to
antimicrobial prescribing. After reviewing, feedback should be provided to the prescriber
advising change if required on the optimal antimicrobial therapy.

Antimicrobial “Time outs”

Antimicrobials are often started empirically in hospitalized patients while diagnostic
information is being obtained. All prescribers should review antimicrobials prescription
after 48 hours to assess all 4Ds of antimicrobial stewardship.

Antimicrobial consumption analysis

Quantitative analysis of antimicrobial consumption: It should be collected from pharmacy
purchase stores which will give proxy data of overall consumption of antimicrobials by
the population (antimicrobial consumption surveillance).
 Qualitative analysis of appropriateness of prescription: Information regarding which
patients are being given what antibiotics, their indications, dose and duration is collected
using point prevalence surveys. It gives antimicrobial use surveillance.

Formulary Restriction
 Antimicrobials included on the hospital formulary should be divided into three groups:
1. Unrestricted: may be prescribed by any clinician
2. Consultant only: may only be prescribed by a consultant
3. Restricted: may only be prescribed following prior discussion with, and approval by,
the antimicrobial stewardship team

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 This list should be reviewed periodically preferably every year on the basis of
antimicrobial usage data and rates of antimicrobial resistance.

Guidelines and clinical pathways

 Every hospital must develop antimicrobial prescription guidelines based on principles
of rational antimicrobial prescription.
 In absence of local guidelines, National Antimicrobial prescription guidelines may be
adopted.
Supplemental Interventions

Dose optimization and combination therapies

 Antimicrobial must be given at the optimal dose, frequency and duration, based on
individual patient characteristics such as age, weight, renal function, likely causative
organism, site of infection, and pharmacokinetic and pharmacodynamic characteristics
of the antimicrobial agent(s).
 A few combinations are considered synergistic, such as:
 Aminoglycoside and beta–lactam antimicrobial.
 Beta –lactam antimicrobial and beta–lactamase inhibitor.
 Beta –lactam antimicrobial and glycopeptide (vancomycin/teicoplanin)
 Sulphamethoxazole and Trimethoprim
Antimicrobial drug therapy cannot be considered in isolation, it may be ineffective
in cases where pus is not drained, septic shock is not treated and hypoxia/ anaemia
are not corrected.

Streamlining or de-escalation of therapy

All empiric antimicrobial therapy should be reviewed on a daily basis by the clinician
responsible for the patient’s care. Special attention must be paid to factors such as:
• Antimicrobial combinations with overlapping spectrum of activity. For example: Drugs
like meropenem, clindamycin and piperacillin tazobactam provide cover against
anaerobic bacteria and hence additional anaerobic antimicrobial such as metronidazole
should not be given.
• Prolonged use of broad spectrum antimicrobials
• Unauthorised use of restricted agents
• Antimicrobial use not in accordance with hospital antimicrobial policy.
• Clear criteria for prescribing intravenous antimicrobials.

Parenteral to oral conversion

 Always review intravenous prescription after 48 hours (at least) and switch to oral if
possible.
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 Early switch from intravenous (IV) agents to the equivalent oral preparation offers
several benefits:
 Decreased total cost of therapy,
 Decreased potential for line associated infections,
 Potential for decreased length of stay and patient preference,
 Increased patient comfort and mobility,
 Savings in nursing time spent preparing and administering intravenous doses.

Laboratory surveillance and feedback

The Microbiology laboratory must share antimicrobial susceptibility data as an
antibiogram with the prescribers. Also, feedback on follow up cultures must be
promptly provided to allow timely review of antimicrobial prescriptions.

Utility of antibiograms
 Empiric antimicrobial therapy is started to provide initial control of a presumed
infection of unknown cause. Hence, local cumulative antibiograms are required to
select appropriate empiric antimicrobials for patients with common infections.
 It also provides a broad overview of local antimicrobial resistance over time (e.g. the
proportion of S. aureus isolates that are methicillin-resistant).
 Can provide an overview of the emergence of antimicrobial resistance in particular
settings over time.
 It can assist in managing infections due to multidrug-resistant organisms.

Information, Education and Communication (IEC)

 Prescriber IEC: Educational aids to guide prescribers at the point of prescribing such
as clinical algorithms for the diagnosis of infection, or methods to standardise
documentation of treatment decisions must be displayed at important locations in
hospitals by the hospital administration in consultation with the AMSP committee.
 Patient IEC: Patients, their families and general public should be educated through
awareness program, regarding appropriate use of antimicrobials such as:
 When antimicrobials are not needed, like in cases of upper respiratory tract infections
which are mostly of viral etiology and do not require antimicrobials.
 Inappropriate use may cause antimicrobial associated diarrhoea, allergic reaction,
colonization with drug resistant bacteria, and autoimmune diseases, likely through
disturbing the microbiome etc.
 They should be made aware of the importance of adherence to antimicrobial
treatment.

7.4 Pharmacokinetic (PK) and pharmacodynamic (PD) approach to optimize

antimicrobial prescription: right antimicrobial selection for an infection PK and PD both
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to be considered (PK -how the drug behaves in the body and PD (how it interacts with the
target pathogen)-

 Matching the antibiotic to the site of infection: like tissue penetration ensures the
antibiotic reaches the target location in sufficient concentrations.
 Dosage Optimization: the appropriate dose and dosing frequency to maintain effective
antibiotic levels throughout the treatment course.
 Patient-Specific Adjustments: Factors like age, weight, kidney function, and liver
function can affect PK parameters. PK/PD allows for adjustments to ensure optimal
drug exposure for each patient.

7.5 Interpretation of antibiogram results: should be interpreted in conjunction with other

factors like-
 the patient's clinical condition,
 local resistance patterns, and
 potential for adverse effects.

7.6 Principles of rational prescription

The general principles guiding antimicrobial prescription must be followed for all patients.
Some of these principles are given below:
 Do NOT use antimicrobials
 To treat colonization or contamination unless there is clear indication such as
immunosuppression or post splenectomy.
 As general prophylaxis or “Feel good” factor.
 To treat infections which have high suspicion of viral causes such as influenza
 Use antimicrobials only
 In cases of high degree of suspicion of infection.
 After a treatable infection has been recognized
 For prevention of infection where evidence has demonstrated that the potential
benefits outweigh the risks.
 Empirical therapy must be based on local/national prescribing guidelines.
 Use targeted therapy instead of broad-spectrum antimicrobials unless there is a clear
clinical reason (for example, mixed infections or life-threatening sepsis).
 Review broad spectrum antimicrobials as early as possible and promptly switch to
narrow spectrum agents when sensitivity results become available.
 Choose antimicrobials as determined by the sensitivity of identified causative organism.
 The indication for which the patient is being prescribed the antimicrobials should be
documented in the drug chart and case notes by the prescriber.
 Always have a stop/review date on antimicrobial order form/ patient chart. No
antimicrobial should be written for indefinite time.
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 Pre-surgical prophylaxis guidelines must be followed.

7.7 Strategic approach for development and intervention of AMSP

The strategic approach must be as per the availability of resources in the local settings:
 Committee preparation: An AMS committee is required to provide leadership and
overall coordination of the AMS programme. Committee must include Administrative
leader, Clinicians from each clinical department, Clinical pharmacist, Microbiologist,
Nursing officer etc. as per standard guidelines.
 Prescribers’ education: The policy-makers and health care administrators to provide
opportunities for physicians to address information gaps through clinical education and
continuing professional development.
 Development of Institution-specific guidelines and interventions: Institution-
specific guidelines or algorithms can be adapted from national or international
evidence-based guidelines to reflect local epidemiology, access to diagnostic testing
and drug availability.

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Infection Control

Learning Objectives

On completion of this chapter, the prescriber should be able to:

• define and describe the elements of standard precautions
• define and describe transmission-based precautions.
• define biomedical waste management
• describe various segregation methods and their disposal as per BMW rules.
• define device associated infections
• define and describe preventive care bundles for device associated infections

Introduction
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.
Three things are necessary for an infection to occur:
 Source: Places where infectious agents live (e.g., sinks, surfaces, human skin, water,
food)
 Susceptible Person with a way for microbes to enter the body
 Transmission: how the microbes are moved to the susceptible person

Interactions are more common in hospital environment and provide microorganisms an

opportunity to cause infection in susceptible host. Healthcare-associated infections (HAIs/
HCAIs) are influenced by the interaction between host, pathogen and environmental
factors. This chain of transmission is favoured by health care workers.
In order to prevent HAIs, this chain of transmission needs to be broken by appropriate
infection control Practices
Infection control prevents or stops the spread of infections in healthcare settings. There
are two tiers of recommended precautions to prevent the spread of infections in healthcare
settings: Standard precautions and transmission-based precautions.

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8.1 Standard Precautions

Standard precautions (previously known as universal precautions) are the minimum
infection prevention practices that apply to all patient care, regardless of the suspected or
confirmed infection status of the patient, in any setting where healthcare is delivered.
Standard precautions consider every person (patient or staff) as potentially infectious and
susceptible to infection. It aims to prevent transmission of infections from:
 Patient to healthcare worker
 Healthcare worker to patient
 Patient to patient (cross-transmission)
 Hospital environment to patient
 Hospital waste to community (spread)
The basis of standard precautions is that it presumes all specimens are potentially
infectious. Standard precautions apply to blood, semen, vaginal secretions, synovial fluid,
cerebrospinal fluid, pleural fluid, peritoneal fluid, pericardial fluid and amniotic fluid.
They do not apply to feces, nasal secretions, sputum, sweat, tears, urine, vomitus and
saliva. Given below in Table 7 are the elements of standard precautions:

Table 7: Elements of standard precautions

i. Hand hygiene vi. Patient care equipment/ devices
ii. Personal protection equipment/ management
PPE (gown, mask, face protection, vii. Environmental control
gloves, goggles etc.) viii. Respiratory hygiene/cough
iii. Safe injection practices etiquettes
iv. Sharp management ix. Proper disposal of biomedical
v. Spill management waste
(Source:www.cdc.gov/HAI/settings/outpatient/outpatient-care-gl-standared-
precautions.html, Version 2.3 - September 2016)
i) Hand hygiene
 Hand hygiene is the single most important strategy in preventing HAIs. Clean hands
prevent infections and this applies in any setting, at home, at school or at work.
 In healthcare settings, handwashing is the simple and most effective way to prevent
potentially fatal infections spreading from patient to patient and from patient to healthcare
worker and vice versa. However, this is often overlooked by most healthcare personnel.
 Hence, it is essential to emphasise its importance and educate the personnel about the
correct technique of handwashing.
 Key points where hand hygiene should be performed are known as the five moments of
hand hygiene as given below:

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 Before touching a patient, even if gloves are to be worn,

 Before coming out of the patient’s care area after touching the patient or the patient’s
immediate environment,
 After contact with blood, body fluids or excretions or wound dressings,
 Prior to performing any aseptic task (e.g., placing an intravenous line or preparing an
injection),
 If hands are likely to move from a contaminated body site to a clean body site during
patient care; and after removal of gloves
The 5 moments of hand hygiene are given in Fig 5

Fig 5: The WHO 5 moments of hand hygiene

(Source: https://openwho.org/courses/IPC-HH-en)

 Good hand hygiene practices, which include the use of alcohol-based hand rubs and
washing with soap and water, are critical to reducing the risk of spreading infections in
ambulatory care settings.
 The process takes around 40–60 seconds in its entirety. Steps of hand washing are given
in Fig 6.
 Hands must be fully dried, as moisture can breed microorganisms. A cloth towel should
not be used as the organisms can remain and be transmitted. If possible, paper towel
should be used to turn off the tap and dry hands. Unwashed hands of a nurse or any
healthcare worker are loaded with bacteria.

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(Source:https://www.who.int/teams/integrated-health-services/infection-prevention-
control/hand-hygiene/training-tools)
Fig 6 : Steps of handwashing

If soap and water are not available, then alcohol- based hand sanitiser (hand rub) can to
use to clean hands. They significantly reduce the number of organisms on skin and are
fast- acting. However, if hands are visibly dirty, then washing with soap and water is
the only method that should be used. Using a hand rub generally reduces the time to
around 15–20 seconds (Fig 7). However, for surgical scrub (prior to performing
surgery), the process takes five minutes. When using an alcohol-based hand sanitiser:
Apply product to the palm of one hand, rub hands together and then rub the product
over all surfaces of hands and fingers until hands are dry.

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(Source: Guideline on Hand Hygiene in Health Care in the Context of Filovirus Disease
Outbreak Response, WHO, 2014)
Fig 7 : Steps of hand rub
ii) Personal protective equipment (PPE)
As per OSHA (Occupational Safety and Health Act) PPE is defined as “Specialized
clothing or equipment worn by an employee for protection against infectious
materials”. It refers to wearable equipment intended to improve healthcare workers
safety from exposure to or contact with infectious agents. It includes gloves, lab coats,
gowns, goggles, and masks.
The purpose of PPE is to prevent blood and body fluids from reaching the worker’s
skin or mucous membranes. A full PPE is required while providing care to patients who
have highly infectious diseases like COVID-19, Ebola and Nipah virus infections,
which require isolation and barrier nursing in containment areas of the hospital.
The group of items used in PPE can be used separately or in combination, acting as a
barrier to prevent contact between health workers and a patient/object/environment.
Recommendations on use of PPE is based on the expert opinions regarding disease
transmissions, known portals of entry, perception of risk and severity of transmission.
All PPE should be made of standard impervious material.
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Components of PPE
 Gowns and aprons: Gown is meant to cover the body from the neck to the knees and
the arms down to the wrists with an opening and closing mechanism, usually at the
back. These protect health care worker’s clothes/scrubs from getting contaminated
while performing procedures that might create spatters of blood or body fluids.
The gowns can be disposable or non-disposable. Apron is made of waterproof material
and is worn over gown as barrier. The same gown should not be worn for the care of
more than one patient.
 Safety eyewear such as glasses, wraparounds, goggles: The purpose of safety
eyewear is to prevent aerosols, spatters and droplets from coming in contact with
conjunctival mucus membrane. Personal glasses are not a substitute for goggles. The
safety eyewear should fit snuggly over and around eyes. To wear, the goggles must be
positioned over eyes and secured to the head using the ear pieces or headband.
 Face protectors and face shields: These should cover forehead, extend below chin and
wrap around side of face. To wear face shield, position it over face and secure on brow
with headband. It should be then adjusted to fit comfortably covers the entire face and
wearer does not require additional eye protection or a mask to guard against droplet-
transmissible agents. Mouth, nose and eye protection should be in place during
procedures likely to generate splashes or sprays of blood or other body fluids.
 Masks: Just like conjunctiva, mucous membranes of the nose and mouth are portals of
entry for infectious agents. So, it is essential to protect them. The barriers can be in the
form of mask or respirators. Masks are made up of impervious material and can be
pleated or preformed. Efficiency of masks reduces with moisture and should be changed
frequently. Masks can be surgical or N-95 NIOSH or CDC certified.
 Boots, jumpsuits, overall and hoods: These do not provide any added protection but
only prevent soiling of clothes or street shoes.
 Gloves: These are intended to prevent contact of hands with contaminated sources such
as the skin of patients colonized or infected with multidrug resistant microorganisms.
A surgical mask should be worn when placing a catheter or injecting material into the
spinal canal or subdural space. There are two methods of wearing sterile gloves:
 Closed gloving: In this method the hands are covered by the gown sleeves. The hands
remain inside the cuff and the gloves are worn one hand after another.
 Open gloving: The gloves are worn by touching the inner surface of the gloves for one
hand followed by outer sterile surface for the other hand.
The gloves should be placed on top of the cuff of the gown while using long-sleeve
gowns. With reference to gloves, the following precautions are recommended:
 Gloves should be worn when there is a possibility of contact with blood, body fluids,
mucous membranes, non-intact skin or contaminated equipment.
 Gloves should always be changed between patients or if they develop breaks or tears.
 Gloves should not be washed for the purpose of reuse.
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 Under no circumstance should glove use replace hand hygiene.

 Hand hygiene should be performed immediately after removing the gloves.

Donning of PPE
Before donning PPE make sure that hair is tied and all jewellery is removed. The worker
must ensure that the PPE is of correct size before breaking open the seal.
The PPE must be worn in the following order as shown in Fig 8.

Fig 8: Donning of PPE (source: https://www.cdc.gov>hai>pdfs>ppe-sequences)

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Doffing of PPE
PPE should be removed in an order that minimizes the potential for cross contamination.
PPE should be doffed in the following order as shown in Fig 9.

Fig 9: Doffing of PPE (source: https://www.cdc.gov>hai>pdfs>ppe-sequences)

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iii) Safe injection practices

Safe injection practices prevent transmission of infectious diseases between patients
and between patients and healthcare workers (HCW) during the preparation and
administration of parenteral medicines. The following are recommended:
 Aseptic techniques should be used when preparing and administering medicines.
 Access diaphragms of medicine vials should be cleaned with 70% alcohol before
inserting a device into the vial.
 Medicine should never be administered from the same syringe to multiple patients.
 A used syringe should not be used to draw medicine from a vial or solution.
 Fluid infusion or administration sets (e.g., intravenous tubing) should not be used for
more than one patient.
Multi-dose vials should be dedicated to a single patient whenever possible.
iv) Sharp management
 Sharps like needle and syringes have to be rendered unusable and disinfected
immediately on use at source before disposal.
 Containers should be available at point of use or generation point.
 Sharps or needles should not to be purposely bent or broken by hand. The needle is put
inside disposal container with the sharp end first. Never push or force in with the hand.
Have a clear view of the container opening and the inside of the container during
disposal.
 Used needles should not be re-capped on any account. One hand scoop technique can
be done if needed.
 If needle and syringe need to be transported from one area to another, then a rigid walled
container must be used.
 The sharps container must be removed when half filled. The lids must be securely
closed.
Sharp Injury management: In the event of a needlestick injury/ splash of blood or body
fluid into the eye, the area should be washed with running tap water or with an eye wash
and, the following protocol needs to be followed immediately to prevent transmission of
HBV, HCV and HIV.
 The event needs to be reported to the infection control nurse and medical officer
incharge/infection control officer. The source patient’s status should be verified. (If the
status is not known, and with consent of the patient, the person may be tested for HIV,
hepatitis B and hepatitis C).
 If the patient is known to be HIV-positive or if the status is unknown, post-exposure
prophylaxis (PEP) is initiated (according to NACO, CDC and WHO guidelines).
 Hepatitis B—if the healthcare worker is vaccinated, no treatment is required, but if not
vaccinated, HBIg and HB vaccine are initiated as per guidelines.
 Hepatitis C—no treatment is currently recommended.

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v) Spill Management
 Body fluid spills can be spills that are visibly contaminated with blood and those which
are not. Both types of spills require same treatment.
 Exposure to blood and other body fluids poses a risk of infection to health care persons
and patients. Spillages of blood must be dealt with immediately.
 Any splashes of blood or body fluids on the skin must be washed off immediately with
soap and water.
Procedure for Spill Management
 Spillage of less than 30 ml is treated as small and more than 30 ml as large spill.
 Infection control nurse must be informed in case of large spill after immediate action
has been taken by the concerned department.
 Staff must be trained in proper procedure to manage spills.
 Spill management protocols must also be displayed at prominent locations (sample
given in Fig 10) in the hospital especially at point of use as a ready reference for the
staff for management of spills.

Fig 10: Steps in spill management

Spill kit: A spill kit must be readily available with all departments especially where
risk of spill is more, like laboratory, sample collection room, wards etc. Spill kit must
have the following contents (Table 8):
Table 8: Contents of a spill kit
 Gloves-2 pairs  Waste disposal bag
 Apron  Cleaning equipment – bucket, mop,
 Mask cloth, soap etc.
 Shoe covers  Freshly prepared 1% sodium
hypochlorite solution
 Absorbent material like
newspaper or blotting paper  Forceps, tongs or scooper

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vi) Patient Care Equipment/ Devices management

 Medical equipment may be reusable or meant for single use. Reusable medical
equipment (e.g., endoscopes) come with instructions for their cleaning and
disinfection or sterilisation, as appropriate. Single-use devices are labelled by the
manufacturer for one-time use and come with reprocessing instructions.
 Reusable medical equipment (e.g., blood glucose meters and other point-of-care
devices, surgical instruments, endoscopes) is cleaned and reprocessed appropriately
before being used on another patient.
 Soiled patient care equipment: Wear gloves if visibly contaminated and practice
routine hand hygiene. Follow procedures for routine care, cleaning and disinfection
of environment surface, especially frequently touched surfaces in patient care
areas.
vii) Environmental Cleaning
 Cleaning refers to the removal of visible soil and organic contamination from a
device or environmental surface with appropriate chemical agents. This process
removes large number of microorganisms from surfaces and must always be
performed before disinfection.
 Handling soiled or contaminated linen: Gloves should be used at all times. The linen
must be inspected for any needles, or syringes etc. while stripping. Linen should
not to be placed on floor but in a yellow doubled plastic bag sealed by a knot.
 Terminal disinfection is the method of thorough cleaning of the patient bed,
surroundings, and the patient utilities after the discharge of the patient. Do not admit
another patient in the same room for at least 12 hours.
viii) Respiratory Hygiene/Cough Etiquette
 This refers to the standard precautions to be taken by any individual with signs of
illness including cough, congestion, rhinorrhoea or increased production of
respiratory secretions. Such individuals need to be promptly identified to prevent
transmission of respiratory infections.
The elements of Respiratory Hygiene/Cough Etiquette include:
 Education of staff, patients, and visitors in a Health Care Facility (HCF).
 Posted signs (in languages understood by the population served), with instructions
to patients and accompanying family members/ friends beginning at the point of
initial encounter in a HCF (e.g., triage, reception and waiting areas in emergency
departments, outpatient clinics and physician offices).
 Source control measures (covering the mouth/nose with a tissue while coughing
with prompt disposal of used tissues or using surgical masks on the coughing
person as appropriate).
 Hand hygiene after contact with respiratory secretions.

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 Spatial separation (ideally >3 feet), of persons with respiratory infections in

common waiting areas when possible.
 Health Care Practitioner (HCPs) are advised to observe Droplet Precautions and
perform hand hygiene when caring for such patients.
 HCPs who have a respiratory infection are advised to avoid direct patient contact,
especially with high- risk patients. At least a mask should be worn while providing
patient care.
 Provide tissues and no-touch receptacles (e.g., foot-pedal operated lid or open,
plastic-lined waste basket) for disposal of tissues.

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8.2 Transmission based Precautions

Introduction
CDC recommends two tiers of precautions to prevent transmission of infectious agents. The
standard precautions as mentioned earlier apply to all irrespective of their disease status while
transmission- based precautions are to be followed in case the patient is known case or is
suspected to be infected or colonized with infectious agents.
 As these patients carry a high risk of transmitting the pathogen to the healthcare worker
and adjacent patients, further measures are needed in addition to standard precautions to
prevent transmission of infection. Usually, these patients must be isolated and the
appropriate transmission-based precautions must be used. Following transmission-based
precautions are followed in addition to standard precautions (Table 9):
 Airborne precautions
 Droplet precautions
 Contact precautions

 Airborne precautions: These are to be followed for droplet nuclei <5μm, e.g.,
tuberculosis, chicken pox, measles and influenza. This requires:
 Isolation of patients in individual room with adequate ventilation: This includes, where
possible, negative pressure; door closed; at least twelve air exchanges per hour; exhaust to
outside placed away from intake ducts
 Staff wearing high-efficiency masks in room

 Droplet precautions: These are to be followed for droplet nuclei >5 µm, e.g.,
meningococcal meningitis, diphtheria, respiratory syncytial virus. The following
procedures are required:
 Individual room for the patient, if available
 Surgical mask for healthcare workers
 Restricted circulation for the patient; patient wears a surgical mask if leaving the room
 Teach the patient to follow respiratory hygiene/cough etiquette.

 Contact precautions: Direct contact occurs when performing patient- care activities that
require touching the patient’s skin. Indirect contact occurs when touching potentially
contaminated environmental surfaces or equipment in the patients’ environment
Individual room for the patient if available; grouping patients if possible
 Staff wear gloves on entering the room; a gown for patient contact or contact with
contaminated surfaces or material
 Wash hands before and after contact with the patient, and on leaving the room

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 Restrict patient movement outside the room

 Appropriate environmental and equipment cleaning, disinfection, and sterilisation

Contact Precautions are to be followed for patients infected with organisms capable of
transmission through either direct or indirect contact, e.g., patients with enteric infections and
diarrhoea which cannot be controlled or skin lesions which cannot be contained, and
multidrug- resistant organisms [MDRO].

Table 9: Elements of specific precautions

Specific Source Isolation of Restriction of Appropriate Disposable Prioritize
precautions Control: patient movement of PPE to be used or cleaning or
patient to patients dedicated disinfection
wear mask patient of patient
equipment rooms
Contact No No Limit movement Gloves and Yes Daily and no
Precautions outside room. gown room and
Follow contact material
precautions if should be
transfer is allowed to be
needed covering used by
colonized areas another
of the patient’s patient prior
body. to cleaning.
Droplet MUST wear In single room Yes Gloves, apron Yes -do-
Precautions mask. possibly. and mask

Airborne Fit-tested In airborne Yes Full PPE with Yes -do-

Precautions NIOSH- infection fit-tested NIOS
approved N95 isolation room approved N95 or
or higher level with negative higher level
respirator for pressure. If not respirator for
healthcare possible then healthcare
personnel. mask patient personnel.
and place in a
private room
with the door
closed

Isolation of Patients
 All patients admitted with contagious infections must be isolated. Patients infected
with MRSA and multi drug- resistant organisms, which are resistant to three or more
classes of antibiotics, need to be isolated and treated by barrier nursing.
 The nursing care is individualised so that the infection does not spread to other patients
via the nurse.
 All personal protective equipment is dedicated to single use.
 For the isolated patients, transmission-based precautions must be followed in addition
to the standard precautions.

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Table 10 shows patients who should be isolated into separate rooms or wards are those
with:

Table 10: Patients with clinical presentations/ diseases that require isolation
 Undiagnosed rashes and fevers  Influenza
 Chickenpox  Patients known to be colonised with
 Measles MRSA, VRE, and other multi-drug
 Severe acute respiratory syndrome resistant organisms
(SARS)  Multidrug-resistant tuberculosis
(MDR-TB)
Protective isolation or reverse barrier nursing) is practised when the patient requires
protection. Reverse barrier nursing works by protecting vulnerable patients, such as
those with impaired immune systems (immune- compromised), against infection by
medical staff.
Multidrug Resistant Organisms
 The increased occurrence of antimicrobial-resistant microorganisms (methicillin-
resistant S. aureus [MRSA], extended spectrum beta-lactamase [ESBL] or
vancomycin-resistant enterococci [VRE]) is a major medical concern.
 The spread of multi resistant strains of S. aureus and VRE is usually by transient
carriage on the hands of healthcare workers.
 The following precautions are required for the prevention of spread of MDRO:
 Minimise ward transfers of staff and patients
 Ensure early detection of cases, especially if admitted from another hospital; screening
of high-risk patients may be considered
 Isolate infected or colonised patients in a single room, isolation unit or cohorting in a
larger ward
 Re-enforce handwashing with antiseptic by staff after contact with infected or
colonised patients
 Use of personnel protective equipment (PPE)
 Proper waste segregation and disposal system

Consider treating MRSA nasal carriers with mupirocin.

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8.3. Proper Disposal of Biomedical Waste

Introduction
Biomedical or hospital waste refers to any waste generated while providing health care,
performing research and undertaking investigations or related procedures on human beings or
animals in hospitals, clinics, laboratories or similar establishments (Management and
Handling Rules: Government of India, 2016). The objectives of biomedical waste
management are to prevent harm resulting from waste, minimise its volume, retrieve reusable
materials and ensure safe and economical disposal.
Reduction in volume of waste can be achieved by proper planning and using reusable items
wherever safely possible.
Segregation refers to the separation of waste at the point of generation into the various types
with respect to their category and mode. Segregated waste must be put into different coloured
containers, as prescribed in the rules, for appropriate treatment. These guidelines were
modified in 2018. The colour coding is shown in Table 11.
Storage refers to the measures taken to ensure that biomedical waste is kept safely at the point
of generation before being sent to the biomedical waste treatment facility.
Treatment of waste means all the procedures and processes intended to reduce the bulk of
the waste and make it non-infectious and harmless.

Table 11: Colour-coded bags for biomedical waste segregation

Colour of the
Type of waste Waste treatment
bag
Yellow a) Human anatomical waste Incineration or plasma pyrolysis or
b) Animal anatomical waste deep burial
c) Soiled waste
d) Expired or discarded Returned to the manufacturer or
medicines 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, Non-chlorinated chemical disinfection
mattresses, beddings followed by incineration or plasma
contaminated with blood or pyrolysis
body fluids
h) Microbiology, Pre-treat to sterilise with non-
biotechnology and other chlorinated chemicals on-site as per
clinical laboratory waste NACO or WHO guidelines and
thereafter send for incineration
Red Contaminated waste Autoclaving or microwaving/
(recyclable) like plastic bag, hydroclaving followed by shredding
bottles, pipes or containers or mutilation
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Colour of the
Type of waste Waste treatment
bag
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, Waste sharps including Autoclaving or dry-heat sterilisation;
translucent metals: Needles, syringes followed by shredding or mutilation or
with fixed needles, needles encapsulation in metal container or
from needle tip cutter or cement concrete sent for final disposal
burner, scalpels, blades to iron foundries (having consent to
operate from the state pollution
control committees) or sanitary
landfill or designated concrete waste
sharp pit
Blue cardboard Glassware: Broken or Disinfection (by soaking the washed
box with blue discarded and contaminated glass waste after cleaning with
label or blue glass including medicine detergent and sodium hypochlorite
leak- and vials and ampoules except treatment) or through autoclaving or
puncture-proof those contaminated with microwaving or hydroclaving, then
container cytotoxic wastes; metallic sent for recycling
body implants

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8.4 Preventive Bundles for Device Associated Infections

Introduction
 Device associated infections: These healthcare–associated infections are infections that
can be associated with the devices used in medical procedures, such as catheters or
ventilators.
 Care bundles: These are a set of interventions that when applied together result in better
prevention of device associated infections than individual elements implemented alone.
 Some recommended preventive bundles are as below. The hospitals may modify these
bundles according to their availability of resources and other logistics.

I) Central line insertion and care bundle

 Hand hygiene
 Maximal barrier precautions upon insertion/manipulation
 PI/ alcohol/ chlorhexidine skin antisepsis
 Optimal catheter site selection, with avoidance of the femoral vein for central venous
access in adult patients
 Daily review of line necessity with prompt removal of unnecessary lines
II) Preventive bundle for urinary catheter insertion/care
 Catheterize only if absolutely necessary
 Reduce the duration of catheterization
 Closed drainage
 Intermittent catheterization
 External collection devices
 Ensure dependent drainage
 Use of systemic antimicrobials: Only if patient is symptomatic and culture suggests UTI
 Compared with latex catheters, silastic catheter has a decreased incidence of urethritis and
possibly urethral strictures. However, because of its lower cost and similar long term
outcomes, latex is preferably used for long term catheterization.
 Remove catheters as early as possible
III) Recommended preventive bundle for Ventilator Associated Pneumonia (VAP)
 Avoid unnecessary antibiotics
 Avoid unnecessary stress ulcer prophylaxis
 Sucralfate for stress ulcer prophylaxis
 Oral intubation
 Selective digestive decontamination
 Short-course parenteral antibiotics
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 Appropriate hand disinfection

 Appropriate staffing
 Avoid tracheal intubation
 Shorten duration of mechanical ventilation
 Semi recumbent positioning
 Avoid gastric overdistention
 Subglottic suctioning
 Avoid ventilator circuit changes/manipulation
 Drain ventilator circuit condensate
 Prevent accidental extubation

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Prescribers’ toolkit for combating

AMR

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Prescribers’ toolkit for combating AMR

9
Table 12: The competencies, learning objectives and the assessment methods

S. No. and Learning objectives Domain Target Teaching Assessment

Competency audience learning method
addressed methods
(TLM)

1. Background 1.1 Understand the present K Prescribers Theory Written: MCQ,

and objectives burden of AMR session- 30 min SAQ

1.2 Understand the concept

of this national program

1.3 Assist in implementing

this program

2.Clinical 2.1 Identify common K Prescribers Exploratory Written: MCQ

approach for presentations of infective and interactive -Case based
prescribing syndromes theory session discussion
antimicrobials with case Clinical problem
2.2 Describe and studies- 60 min solving
understand the importance
of taking thorough history,
clinical examination and
selection of appropriate
investigations for diagnosis
of infective disease soft
tissue infections etc).

3.Microbiolog 3.1 Define diagnostic K, A, S Prescribers Exploratory Written: SAQ,

-ical stewardship and interactive MCQ
diagnostic theory session
stewardship 3.2 Understand the with
difference between demonstration
infection and colonization of collection
containers,
3.3 Describe the sample videos for
collection techniques, collection- 60
precautions, transport and min
rejection criteria of
common samples.

4. 4.1 Understand the K, S Prescribers Exploratory Written: SAQ,

Interpretation importance of quality and interactive MCQ,
of assured antimicrobial theory session Case discussion,
antimicrobial susceptibility testing (AST) with samples of AST problem
sensitivity AST reports- solving
results 4.2 Interpret the 60 min
antimicrobial susceptibility
testing report.

4.3 Interpret the surrogate

and cascade reporting.

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5. 5.1 Define and explain the K Prescribers Exploratory Written: SAQ,

Antimicrobial differences between and interactive MCQ
resistance: antimicrobials and theory session-
Principle and antibiotics 40min
implications
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

6. 6.1 Describe the attributes K Prescribers Exploratory Written: SAQ,

Antimicrobial and features of and interactive MCQ
policy antimicrobial policy theory session
with examples
6.2 Describe the key from in house
elements of developing antibiotic
hospital antimicrobial policy- 30 min
policy

6.3 Assist in developing

antimicrobial policy

7. 7.1 Define antimicrobial K, S Prescribers Exploratory Written: SAQ,

Antimicrobial stewardship and interactive MCQ, Case
stewardship in theory session based problem
humans 7.2 Outline the goals, with examples
strategies and interventions of in house
of antimicrobial antibiograms
stewardship and their
interpretation-
7.3 Describe the core and 60 min
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

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8. Infection 8.1 Define standard K Prescribers Exploratory Written: SAQ,

control precautions and interactive MCQ
theory session-
8.1.1 Describe the elements 15 + 15 + 15 +
of standard precautions 15 min = 60
min
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

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.

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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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Powerpoint Presentations on
NAP-AMR
Module for Prescribers
(The presentations are based on modules, prescribers can modify
according to their need)

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