Introduction

Introduction

Antimicrobial resistance (AMR) is a major global health threat overshadowing the potential gains made since the discovery of antimicrobials. The Global Burden Disease study on AMR revealed that 4.71 million deaths were associated with bacterial AMR including 1.14 million deaths attributable to bacterial AMR. All age groups of people in all regions are affected, with low- and middle-income countries most affected, making it a major socio-economic problem. The emergence of various multi-drug-resistant organisms (MDROs), commonly referred to as "superbugs" are further complicating the problem, making common infections much more difficult to treat. AMR also poses risk to safety of routine medical procedures, cancer treatments and surgeries which in absence of effective antibiotics may lead to increased treatment expenses, prolonged hospital stays and even increased mortality.

It is well known that AMR is primarily driven by misuse and overuse of antimicrobials. Also, the research and development for newer antimicrobials is slow, which generates an urgent need to tackle the issue of AMR with a multidisciplinary approach. The most important component of this approach is prevention of infections, both in the community and hospital settings through improved WASH and IPC practices, direct measures being universal access to quality and affordable diagnostics and appropriate treatment of infections based on appropriate laboratory investigations and inputs from qualified antimicrobial stewardship team where relevant e.g. while prescribing reserve group of antimicrobials or when managing patients with high risk of infections. Moreover, monitoring trends of AMR based on data from well-equipped and well utilized laboratories helps in understanding local trends of antimicrobial susceptibility, which guides the practitioners in selecting appropriate empirical antimicrobial therapy for management of patients with severe infections.

In 2015, World Health Assembly in its Sixty-eighth resolution (WHA68.7), adopted the global action plan on AMR. The resolution urged all the Member States to develop and implement national action plans on antimicrobial resistance, as per their local needs while adopting the resolution to endorse a global action plan on antimicrobial resistance (GAP AMR).

India developed its National action plan on AMR (NAP AMR) in alignment with the GAP AMR with involvement of various sectors and launched it in April 2017. India has updated its NAP AMR (2025–2029) which lays out the National Strategy for AMR Containment involving six strategic objectives. One of the strategic objectives is to strengthen laboratory capacity to enable appropriate use of antimicrobials and generate quality surveillance data. The fourth strategic objective focused on optimizing use of antimicrobials includes review of the National Treatment guidelines for common infectious diseases in humans as one of the activities to be carried out by NCDC.

The National Treatment Guidelines for Antimicrobial Use in Infectious Diseases was released in 2016 by National Centre for Disease Control. Indian Council of Medical Research in 2017 published Treatment Guidelines for Antimicrobial Use in Common Syndromes and 2^nd edition of the same was released in 2019.

Based on the trends of antimicrobial resistance in commonly isolated pathogens being tracked under NAS-NET coordinated by NCDC and AMRSN coordinated by ICMR and inputs from clinical experts from across the country, this updated version of the guidelines has been developed. These guidelines are expected to help in establishing consistency across the country for the empiric treatment of commonly identified infectious disease syndromes and ensure timely management of such patients. 123

This 'National Treatment Guidelines for Antimicrobial use in Common Infectious Disease Syndromes' (Version 2.0) aims to guide the empiric use of antimicrobials where the severity of infections mandate initiation of antimicrobials before culture and antimicrobial sensitivity results are available.

These guidelines list the recommended empiric treatments for common infectious disease syndromes while results of cultures of clinical samples are awaited. These recommendations are based on scientific evidence, literature review and are consistent with the already existing international guidelines and formulated with in-depth discussions with a large group of recognised national experts. The syndromes covered in this document include the commonly encountered syndromes in clinical practice, infections of specific body sites, and infections seen in certain special settings. Annexed at the end of these guidelines are common etiological agents causing the infections which are linked in appropriate sections.

Instructions to use these guidelines

These are general guidelines and primarily cater to places which do not have their local hospital/institute antibiotic policy. It is encouraged to develop/formulate institutional antibiotic policy. These guidelines can serve as a broad framework on which such policy can be based upon.

Before initiating the empiric therapy given in these guidelines appropriate clinical samples must be sent to the laboratory so that once the laboratory results are available, pathogen based targeted therapy must be initiated.

These guidelines are for prescriptions of antibiotic empirically (i.e. after making a clinical diagnosis), and must be modified based on culture and antimicrobial susceptibility testing (AST) results.

Antibiotic recommendations given here are based on clinical syndrome, likely pathogens causing that infection and antibiotic-resistance pattern in our country. Local antibiograms may be used to modify these recommendations.

All possible clinical conditions which require empirical use of antibiotics are covered in these guidelines, readers are advised to read the comments section also to get additional information for that particular clinical condition.

Basics of antibiotic prescriptions

Step 1: Making a clinical diagnosis is often not given enough importance and instead multiple lab tests are prescribed to establish the diagnosis. However, a clinical diagnosis made based on detailed history and existing signs and symptoms often helps to predict presumptive diagnosis along with suspected causative agents which would tailor the use of correct antibiotic rather than blindly relying on non-specific indicators like CRP, procalcitonin etc. Even results of more specific tests like WBC counts, culture & antimicrobial sensitivity tests or radiology must be correlated clinically before initiating or modifying therapy. Our thought process here should be:

How likely is it that the patient has an infection?

What are the possible non-infectious causes that the current clinical condition mimics?

Have we sent appropriate clinical samples for culture and AST to confirm the final diagnosis?

Step 2: Consider the possible etiology of the clinical syndrome

Elucidate possible sources of infection.

Identify possible microbial pathogens.

Review the local resistance pattern based on institutional antibiograms.

Step 3: Limiting empiric antibiotic therapy to seriously ill patients: Generally, empiric antibiotic therapy is ONLY recommended for a select group of patients, some of which are described below (after sending appropriate clinical samples for culture and AST)

Febrile neutropenia

Severe sepsis and septic shock

Community acquired pneumonia

Ventilator associated pneumonia

Necrotizing fasciitis

Meningitis

It is important to start smart and then based on culture and AST result evaluate if empiric therapy is justified or needs to be de-escalated and then make a plan with regard to the duration of therapy.

Step 4: Selection of the appropriate antibiotic

Based on the spectrum of the antibiotic taking into account possible resistant patterns

Use the correct dose, route and duration

Ensure chosen antibiotic has adequate tissue penetration at the site of infection

Optimize PK-PD parameters according to co-morbidities

Give β-lactams in extended infusion (3 hrs). Particularly in sick patients: For example: Meropenem 1g IV 8^th hourly (over 3 hrs), (provided that the particular brand used has stability as per manufacturer's instruction for extended infusion).

Note

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References