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PERSPECTIVE
Year : 2021 | Volume
: 153
| Issue : 4 | Page : 416-420
Infectious disease blocks in district hospitals to augment India's resolve to contain antimicrobial resistance
Kamini Walia, Raman R Gangakhedkar
Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi 110 029, India
Correspondence Address:
Kamini Walia
Division of Epidemiology & Communicable Diseases, Indian Council of Medical Research, New Delhi 110 029
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijmr.IJMR_4031_20
India's commitment to containment of antimicrobial resistance 
The Government of India has conveyed its commitment to address AMR through a series of steps taken in the recent past, including releasing the National Action Plan (NAP) to tackle AMR in 2017[6]. The NAP mentions strengthening surveillance, reducing incidence of infections through effective infection prevention and control (IPC) and optimizing the use of antimicrobials through AMS programmes as the priority areas. Surveillance, to capture the trends and pattern of AMR across the country, has been strengthened through the establishment of two surveillance networks, i.e., the ICMR AMR surveillance network, operational in 30 hospitals, and the one supported by the National Centre for Disease Control (NCDC) in 20 hospitals[7]. Since both the networks collect data from the tertiary care hospitals, there are concerns around the generalizability of data. Paucity of good microbiology laboratories in secondary level hospitals makes it challenging to collect AMR data from lower levels of healthcare. The ICMR and All India Institute of Medical Sciences (AIIMS), New Delhi, have also initiated surveillance systems for capturing hospital-acquired infections and strengthen capacities for IPC in intensive care units of tertiary care hospitals, with technical and financial support from the Centers for Disease Control and Prevention (CDC), USA[8]. All the hospitals which are part of the ICMR network are being supported to introduce the AMS programmes[9]. All these initiatives promise a broad intent to launch a consolidated response on containment of AMR in the country. However, due to the lack of human resources and infrastructure available to implement these interventions in secondary-level hospitals, all these initiatives remain limited to the tertiary care hospitals only.
Spotlight on district hospitals (DHs) The DH is an essential component of the district health system and provides a link between the sub-DHs, community health centres, primary health centres below, and the tertiary care hospitals above. India has more than 700 DHs, out of which almost 200 hospitals also have more than 300 beds[10]. At a secondary level of healthcare, DHs are expected to provide curative, preventive and promotive healthcare services to the people in the district. Although the DHs are expected to provide specialized care, but this often fails due to understaffing at various levels and lack of availability of specialists. Cognizant of this gap, the NITI Aayog has proposed a mechanism to connect DHs to private medical college district facilities to bring specialized care facilities to the grassroots levels[11]. The absence of ID infrastructure in DHs has made it difficult to translate the AMR-related activities initiated at the tertiary care level, by ICMR and NCDC, to the secondary level.
The Government of India has launched a series of initiatives in the past few years to strengthen the infrastructure and resources available at secondary level hospitals. Swachata (cleanliness) programme was launched in 2015, to strengthen infection control practices in all public health facilities[12]. Under the National Health Mission, all DHs are being encouraged to go for accreditation by the prevalent accredited bodies and having an antibiotic policy is a requirement for the National Accreditation Board for Hospitals[10]. In yet another positive development for DHs, the Government of India has committed to introducing ID hospital blocks in all DHs and setting up public health laboratories in every block (not just in district), to address the paucity of laboratory network in rural areas. This was announced by the Finance Minister on May 17, 2020 as part of Emergency COVID-19 Response to enhance investment in public health[13]. India has signed a four-year agreement with World Bank for $1 billion loan with a commitment to use the funds for strengthening health systems to support prevention and preparedness, strengthening the One Health platform, community engagement, monitoring and evaluation and contingent emergency response[13].All these initiatives convey the Government of India's recognition of DHs and the pivotal role that these hospitals can play in prevention and control of IDs. The country has paid heavy price for not investing in secondary healthcare systems during COVID-19 pandemic and bringing the spotlight to DHs will trigger the much-awaited transformation of healthcare system at the secondary level. By virtue of its positioning in the healthcare system, DHs equipped with a dedicated and functional ID block can not only share the burden of tertiary care centres in the management of IDs but also can become the focal point for providing support to CHC and PHC for the management of IDs which are the first point of contact for the majority of patients.
To be effective, the ID blocks would need to be supported by trained manpower such as ID physicians, microbiologists, infection control nurses, clinical pharmacists and well-equipped diagnostic laboratories. ID physicians would be central to creation of the ID blocks. An earlier study has documented direct correlation between quantities of antimicrobials consumed and levels of drug resistance[14]. An ID specialist can rationalize antimicrobial prescriptions and lead to significant improvement in appropriateness of antibiotic prescriptions[15] by implementing series of interventions listed in [Box 1]. Since diagnostic stewardship is an integral part of AMS, a well-equipped functional microbiology laboratory is crucial to establishment of ID block. Having well-equipped microbiology infrastructure at DHs will therefore, be an excellent opportunity to introduce AMR surveillance and improve practices of infection control, diagnostic and AMS, within the DHs without worrying about their sustainability [Box 2]. The National Essential Diagnostics List (NEDL) also recommends the culture facility (manual /automated) for all clinical specimens to be available at DH level in India[16]. All this will collectively result in improved diagnosis, reducing the number of hospital-acquired infections and increase in the appropriateness of antimicrobial prescriptions, thus positively influencing cost of treatment and AMR rates. Strengthening culture facility and antimicrobial susceptibility testing in district-level hospitals will enable capturing community AMR trends and patterns, which is currently lacking, thus creating an opportunity for local leadership and ownership of the State-level response for containment of AMR.
Road ahead The approach to interrupt AMR transmission is now moving away from conventional institution-based efforts to coordinated prevention approaches to prevent AMR transmission such as improving evidence, reducing infections in hospitals through a structured infection control and rationalizing antimicrobial prescriptions through an AMS programme. Many States in India have developed State Action Plans on AMR, whose implementation depends on the availability of necessary resources and infrastructure within the State. The initiative to introduce ID blocks in DHs is therefore timely and will provide momentum to the State-level AMR containment activities. Equipped with local evidence of antimicrobial usage and AMR levels, DHs can work with regulators in enforcing antibiotic policies in States and with the help of local stakeholders such as civil societies, non-government organizations (NGOs) and local medical associations to ensure free flow of information and communication, thus enhancing the impact of coordinated prevention approaches. The ICMR AMR network, having previous experience of initiating these activities in tertiary care setup, can provide necessary leadership through its network of hospitals, in creating a cadre of Master trainers at State level who can further provide necessary hand-holding to the States through the designated State-level expert groups. There will, however, be many challenges in implementing this plan [Box 3]. The first and the most important challenge is the absence of ID physician posts in DHs and the dearth of trained ID physicians in the country, which has been previously highlighted in India as well as other low- and middle-income countries[17],[18]. To improve the availability of trained ID physicians, the country should look at creating more ID fellowship opportunities which can be offered online, with compulsory practical training for a short period. This will help create a pool of ID physicians quickly who can be employed at DHs. Till that happens, interested clinicians from other specialities could lead the ID and AMR activities after undergoing necessary training on IPC and AMS as mentioned above. An ID physician cannot function without a support of clinical microbiologist. As per the revised guideline for DHs issued in 2012[10], the post of microbiologist is desirable and not essential. There is no mention of infection control nurses (ICN) and clinical pharmacists at DH, which are crucial to IPC and AMS programmes implementation, respectively. The infection control nurses would be crucial to contain the hospital-acquired infections, which are currently managed by excessive antimicrobial use leading to development of highly drug-resistant pathogens. This is especially challenging as there is no government body which is responsible for IPC. Till the time a national body for IPC is established, the requirement of ICN should be mandatory for Swachata programme and also integral part of the ID blocks in hospitals that have intensive care units (ICUs). All these gaps would need to be plugged and necessary funding be allocated as the nationwide plan for implementation of creating ID blocks is drawn.
Conclusion As India moves towards universal health coverage (UHC), proper attention needs to be given to some key considerations around AMR. By proposing to establish ID blocks in all hospitals, the Government of India has recognized the need to strengthen the way IDs are handled at secondary-level hospitals. Having specialized ID blocks at DHs will provide much-needed push to the management of IDs and will have a direct impact on the containment of AMR, in terms of capturing data and implementation of interventions to interrupt AMR. This along with other initiatives of the Government of India, focussing on laboratory workforce development and quality system improvement will be a significant step towards expanding the reach and penetration of ongoing national initiatives addressing AMR to the next level of healthcare.
Conflicts of Interest: None.
References 
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