Fighting Antimicrobial Resistance with Evidence.

Prof. Dr. Bharat Mani Pokhrel Ph.D., with a Fulbright Post Doc. Fellowship on ‘Antibiograms and Antibiotic Use’ is an asset for Nepal. He has retired after a long career as Professor of Microbiology at Tribhuvan University Teaching Hospital, Institute of Medicine. He is currently working as Consultant Microbiologist at Upendra Devkota Memorial National Institute of Neurological and Allied Sciences UDM-NINAS, Neuro Hospital Bansbari. He is instrumental in ensuring the due diligence of the hospital’s microbiological and antimicrobial practices.

Dr. Pokhrel, you have been working on antibiograms in Nepal for many years. Could you share how you first got involved in this field and what motivated you to focus on it?

First of all, I would like to thank you for giving me this opportunity to share my experience and opinions. While working at Tribhuvan University Teaching Hospital (TUTH), I used to regularly isolate Escherichia coli, Klebsiella, Pseudomonas, Acinetobacter, and Staphylococcus aureus from clinical specimens from the patients, and also determine their antibiogram. If I remember correctly, in mid-1985, I encountered multi-drug resistant Staphylococcus aureus which was also resistant to Methicillin (MRSA). This is a pyogenic bacterium that is responsible for infections in multiple organ systems through its toxins and enzymes and is largely associated with hospital-acquired infections. Since then, I was motivated to study drug-resistant pathogens.

For readers who may not be familiar, what exactly is an antibiogram? How is it created, and why is it important for hospitals and doctors?

An antibiogram is a report showing which antibiotics work best against bacteria found in a hospital or community. It is made by testing the bacteria from patients’ samples in the laboratory and summarizing the results, showing how well different antibiotics work against the isolated bacteria. It is created by compiling all the bacteria from patients’ samples (like urine, blood, or wound swabs) and testing which antibiotics work best against them. The results from many patients over a period of time are collected and summarized into a chart, which is called the antibiogram. It is important because it helps doctors choose the right antibiotic quickly and accurately. It also prevents the overuse of ineffective antibiotics, thereby reducing antibiotic resistance. Hospitals can track local resistance patterns and improve infection control. In short, an antibiogram is a vital tool that guides doctors to choose the right antibiotic, improves patient care, and protects both patients and the community from resistant infections.

Types of antibiogram:

1. Hospital antibiogram:

• Periodic summary of antibiogram data used to guide empirical therapy. It provides general susceptibility patterns in percentages.
• Indicates changing patterns of microorganisms and their antimicrobial trends; therefore, it is useful for formulating antibiotic policies.

2. Patient-specific antibiogram:

• Used for treatment of a defined disease in a patient.
• The test organism is swabbed on a culture plate (Petri dish), and discs coated with antibiotics are placed for testing.
• The plate is incubated for 18–24 hours at 37°C.
• This method, also called the Kirby-Bauer disc diffusion method, is commonly used in Nepal.
• The zone of inhibition around each antibiotic disc is measured to interpret sensitivity or resistance of the antibiotic against the tested organism.
• The procedure follows the standards described by the Clinical Laboratory Standard Institute (CLSI).
• Findings are crucial for selecting the right antibiotic from a battery of antibiotics tested.
• It helps in evidence-based antibiotic selection for successful treatment when given at the recommended dose and duration.

Despite their importance, many hospitals and clinicians in Nepal still do not routinely use antibiograms. Why do you think that is, and what needs to change?

Clinicians must be encouraged to prescribe antibiotics based on evidence—the results of culture and sensitivity tests. I would advise the government to plan for adding microbiology facilities in every healthcare facility with a laboratory to enable evidence-based medical practice. The public must also be made aware to request culture and sensitivity results before using antibiotics. Antibiotics must not be used randomly.

Beyond hospitals, the misuse of antibiotics in the community, such as self-medication or over-the-counter purchases, is a major concern. What role do the public play in fueling resistance, and how can we raise awareness?

Antibiotic resistance is a global problem, but the situation in Nepal is even more alarming. The community must be made aware of the risks of misuse—both underuse and overuse of antibiotics. People need to understand the grave consequences of improper antibiotic use. The government should take the lead in formulating policies that ensure antibiotics are sold only with a prescription from a registered medical practitioner.

From your perspective, what steps should Nepal take in the next 5–10 years to strengthen antibiotic stewardship and fight resistance?

Following steps should be adopted to strengthen antibiotics stewardship and fight antibiotic resistance:

To strengthen hospital antibiotic stewardship programme

Core elements include:

1. Leadership commitment: Full institutional support.
2. Accountability: A designated individual responsible for program outcomes.
3. Drug expertise: Pharmacist involvement to optimise antibiotic use.
4. Action: Implementation of recommendations and interventions.
5. Tracking: Monitoring resistant pathogens and antibiotic use.
6. Reporting: Communicating resistance patterns to healthcare workers.
7. Education: Teaching mechanisms of antibiotic resistance and promoting optimal prescribing.

To fight against drug-resistant pathogens:

1. Establish a high-standard research centre dedicated to combating drug-resistant pathogens in Nepal.
2. Strengthen Infection Prevention and Control (IPC) programmes.
3. Survey drug-resistant pathogens in the environment.
4. Promote coordination and cooperation among scientists, pharmaceutical companies, media, health workers, veterinarians, and all stakeholders.
5. Conduct surveillance of drug-resistant pathogens in humans and animals.
6. Monitor drug quality and detect substandard antibiotics.
7. Promote the rational use of antibiotics in humans and animals.
8. Formulate antibiotic policies—dispensing rules, standard guidelines for use, prescription control, and limits on antibiotic use in animal husbandry and poultry.
9. Strengthen prevention and control through vaccination and invest in the development of new vaccines.
10. Encourage pharmaceutical companies to develop new antimicrobial drugs.
11. Collaborate with resource-rich countries to partner in combating drug-resistant pathogens.

Can you share your approach for the prevention and control of drug-resistant pathogens here at UDM-NINAS?

The hospital has formed three committees dedicated to this purpose. These bodies actively work to prevent and control drug-resistant pathogens:

1. Infection Prevention and Control Committee
2. Healthcare-Associated Infection Control Committee
3. Antibiotic Stewardship Programme Committee

Major activities include:

• Regular exposure of culture plates in the ward, ICU, OT, and Emergency twice a month to assess the burden of microorganisms.
• Active surveillance whenever a new infection occurs.
• Checking the efficacy of disinfectants and antiseptics before use.
• Regular updates every 6 months on microorganisms isolated from clinical samples and their antibiogram, presented by the Microbiology Laboratory. Antibiotic policies are updated accordingly.
• Use of WHO guidelines for infection prevention and control.
• Implementation of an Antibiotic Stewardship Programme to prevent and control drug-resistant pathogens.
• Strong coordination and cooperation among staff members.
• Rational use of antibiotics.
• Manuals for sterilization and disinfection have been prepared and monitored.

Steps to interrupt transmission of microorganisms:

• Sterilization and disinfection of medical equipment and devices.
• Proper maintenance of instruments.
• Microbial monitoring of mechanical ventilators, breathing circuits, humidifiers, nebulizers, etc.
• Use of colour-coded containers for segregation of laboratory and hospital waste.
• Proper disposal of hospital waste.
• A strong IT department for communication support.
• Harmonious coordination between clinicians and the microbiology department.

As a result, infection rates are none or rare at the Neuro Hospital, UDM-NINAS.

Finally, what is your message to medical practitioners, policymakers, and the general public when it comes to the proper use of antibiotics?

For medical practitioners:
Practice evidence-based medicine with judicious and rational use of antibiotics. Prioritize the Access group antibiotics over the Watch and Reserve groups. The WHO developed the AWaRe classification for an important reason—if antibiotics are misused without discretion, they will fail when we need them the most.

For pharmacists:
Stop selling antibiotics without a prescription from a registered medical practitioner.

For policymakers:
Establish a national commission dedicated to the prevention of drug-resistant pathogens in Nepal.

For the general public:
a) Use antibiotics only as per the prescription of a registered medical practitioner.
b) Avoid self-medication, especially with anti-infective agents (antibiotics, antifungals).

In the end, I would like to emphasize that hand washing is the most practical and effective procedure for preventing cross-contamination (person-to-person). It may be the single most important step for preventing infection.