Medicosnext
Dr. Anup Subedi is a leading Infectious Disease specialist in Nepal, known for his work in clinical medicine, antimicrobial stewardship, and evidence-based infectious disease management. His insights have been instrumental in shaping conversations around rational antibiotic use and addressing the growing threat of antimicrobial resistance in Nepal.
This interview was facilitated by Ms. Bidushika Dahal, a medical student at Kathmandu Medical College, whose curiosity and preparation helped guide the discussion toward issues most relevant to young clinicians and the healthcare community.
Antibiotic use has become a very common practice worldwide.
What are the conditions for antibiotic use?
Antibiotics are a form of antimicrobials which are used only when there is a bacterial infection in the body. The human body naturally contains billions of bacteria, known as normal flora, which are essential for our health. We don’t use antibiotics to eliminate these beneficial organisms. They are prescribed only when bacteria invade areas where they aren’t normally found or cause problems in their usual spaces, for instance, gut bacteria entering the urinary tract and causing infection, or bacteria from the upper respiratory tract leading to pneumonia.
How have antibiotic use patterns evolved in Nepal over the past decade?
When I was a medical student, there were limited classes of antibiotics available. In the last few decades, there have been a few newer classes of antibiotics and a greater diversity in antibiotics from those classes available that are able to treat different organisms. In terms of the pattern of use, we have been using antibiotics of a broader spectrum than before. Several decades ago, penicillin would treat almost any infection. Now there are just so many drug-resistant bacteria both in the community and in healthcare settings that we have to rely on far more expensive, potentially harmful, broader spectrum of antibiotics, and also relatively more antibiotics given through the intravenous route rather than those that could be given orally. That is the new reality.
What factors influence your choice of antibiotics when treating common infections? How often do you rely on culture and sensitivity reports?
Not all infections require culture and sensitivity testing. We begin with a thorough history and physical examination to determine whether there is an infection and if it is bacterial before prescribing antibiotics. Many common illnesses, like a combination of runny nose, sore throat, and fever, are viral infections and don’t need antibiotics or cultures. Diarrhea, too, can be viral or bacterial, most cases resolve on their own, and antibiotics are only needed if it is accompanied by high fever, blood in stool, or severe diarrhea leading to dehydration and shock.
In Nepal, since many hospital laboratories struggle to identify bacteria accurately, we often have to treat empirically based on local epidemiology, such as ongoing cholera outbreaks or food exposures. We perform cultures when needed, like in cases of typhoid or liver abscess, to identify the bacteria and choose the right antibiotic. Overall, whether to order culture and sensitivity testing depends on the situation, and many infections don’t require it at all.
Antimicrobial resistance is considered a global concern, a silent pandemic these days. Could you shed some light on the emergence of this issue and why it occurs?
Antimicrobial resistance occurs mainly because antibiotics are present in the environment. Bacteria have existed for billions of years and are found everywhere, including in our bodies, homes, workplaces, and on everything we touch. When antibiotics are used in humans and animals or released into the environment through hospital or pharmaceutical waste, they create what we call a selection pressure. This kills bacteria that are sensitive to the antibiotic, allowing resistant ones to survive and multiply.
Over time, these resistant bacteria can replace the normal flora in our bodies or spread through contaminated water, food, and animal products. Because bacteria are constantly mutating and dividing, some naturally develop the ability to withstand antibiotics. Inefficient infection control in healthcare settings and poor hygiene or food handling practices further contribute to the transmission of these resistant strains in both hospitals and the community.
What is the trend of resistance in different antimicrobial groups?
There is resistance in all groups of antimicrobials; antibacterials, antifungals, antivirals, and antiparasitic drugs. In viruses, resistance can occur with drugs like Oseltamivir for influenza or antiretroviral therapy for HIV, especially when patients do not take their medication regularly.
Fungal resistance is also a growing concern, particularly against Azole antifungals. One alarming example is Candida auris, a highly drug-resistant yeast found in hospitals worldwide, and recently reported in Nepal. Unfortunately, most hospitals in Nepal lack the facilities to test fungal or viral resistance, so the actual burden remains unknown.
Antibacterial resistance is widespread, with Nepal among the most affected countries in South Asia, showing resistance to all major antibiotics. Multidrug-resistant and extensively drug-resistant tuberculosis are also serious concerns, with multidrug-resistant affecting roughly 2.3% to 3.2% of TB cases in Nepal, and extensively drug resistant constituting 8% of MDR cases.
Parasitic resistance has emerged as well; for instance, Plasmodium falciparum malaria has developed resistance to chloroquine, which was once the standard treatment.
What are the most common infections where you are noticing increasing antimicrobial resistance?
The most common infections showing increased antimicrobial resistance are those in healthcare settings. While I’m not familiar with resistance in the veterinary arena, studies show its present and very significant, even in routine samples from chickens.
For humans, it’s common in hospital-acquired infections like ventilator-associated pneumonia, catheter-associated UTIs, and central line-associated bloodstream infections. We’re also increasingly seeing resistance in community-acquired infections such as pneumonia and UTIs, even in patients who haven’t recently taken antibiotics. This is also notable in typhoid cases and MRSA in boils and abscesses.
So, resistance is widespread, but especially prevalent in healthcare settings, particularly in patients with prolonged hospital stays or frequent hospital visits.
In your view, what are the key drivers of antimicrobial misuse in clinical settings in Nepal?
The primary drivers of antimicrobial misuse in Nepal stem from healthcare providers’ inadequate knowledge of appropriate antibiotic use and the widespread lack of important diagnostic tools, including microbiology laboratory tests and viral infection tests. This often leads to empirical, sometimes incorrect, antibiotic prescriptions.
Compounding this, our medical education doesn’t sufficiently emphasize evidence-based medicine or continuous learning, instead encouraging ‘syndromic’ treatment without detailed investigation.
Additionally, the absence of regularly updated susceptibility data from public health labs in the neighborhood or in the country leaves clinicians without vital guidance for treating common infections.
Also, the existing perverse incentive structure in healthcare, which rewards increased number of hospital visits, extended inpatient stays, and expensive interventions, inadvertently promotes the overuse of broad-spectrum intravenous antibiotics and prolonged hospitalizations, even when simpler, oral treatments might suffice.
How do you handle patient expectations when they demand antibiotics for viral or mild infections?
I think the key is to spend time and listen to your patient. You can’t convince someone your recommendation is right if you don’t first hear their concerns. There’s a saying: “A patient will care about how much you know only when they know how much you care.”
In practice, doctors often rush through consultations due to overcrowded hospitals and time pressure. When I see a patient, I try to listen, make small talk, and build a connection before discussing their illness. Once that rapport is established, it becomes much easier to explain why antibiotics aren’t needed, and patients are more likely to accept your advice despite their initial expectations.
What role do you think the over-the-counter availability of antibiotics plays in promoting resistance?
Over-the-counter availability of antibiotics significantly fuels resistance due to a widespread lack of awareness about the risks of misuse. While there might be rare instances in remote areas where non-physicians need to prescribe antibiotics, generally, it’s inappropriate.
People often self-medicate or rely on chemists or pharmacists, who frequently dispense broad-spectrum antibiotics without proper clinical training. Consequently, by the time these patients reach a hospital, they are often resistant to common treatments, forcing us to use potentially more toxic or expensive antibiotics, or those requiring inpatient stay. This escalates costs and patient morbidities, making over-the-counter access a major contributor to this critical problem.
How well do you think general practitioners and junior doctors understand rational antibiotic prescribing?
This is very anecdotal, since I do not have the data to definitively state the percentage of doctors who understand rational antibiotic prescribing. But I want to point out that even the national authorities had put out guidelines in the early 2010s saying that you need to give certain antibiotics for upper respiratory tract infections, which was inappropriate. Only in 2023, these guidelines were rightly amended.
Most of the older generation doctors are used to prescribing antibiotics empirically in a lot of situations, without considering the possibility of the infection having a viral etiology. Since a lot of young doctors learn from their mentors, there is a lot of unnecessary usage of antibiotics among medical officers and general practitioners.
Do you have any specific experience or a memory that you would like to share to make others understand the severity of antimicrobial resistance?
I see patients every day who lose their limbs or even their lives because of antibiotic resistance. It can happen to someone admitted to the ICU for a heart attack, or even to a patient who develops an infection from a catheter or central line after receiving inappropriate antibiotics.
Such drug-resistant infections often go unrecognized and are difficult to treat, keeping patients hospitalized for weeks instead of days and sometimes leading to sepsis or death.
The most severe and fatal cases are often among patients who require hemodialysis or constant oxygen support. These infections are frequently acquired in hospitals due to poor infection control, contaminated equipment, or a lack of proper antibiotic stewardship.
I see such cases all the time. I have even lost family members to antimicrobial resistance.
How do you personally keep yourself updated with changing resistance trends and antimicrobial use guidelines?
As an infectious disease doctor, I have access to a wide range of literature on antimicrobial resistance, and I make it a point to stay updated. It is impossible to read every journal article, so I subscribe to publications that summarize recent findings relevant to my field. I receive email digests and read full articles when something catches my interest.
I am also a member of international professional forums such as the Infectious Disease Society of America (IDSA) and the European Society for Clinical Microbiology and Infectious Diseases (ESCMID), where doctors discuss complex cases and share best practices. These organizations also release updated guidelines every few years, which help me stay informed and guide my clinical decisions.
How often are antimicrobial resistance patterns monitored or reported in your hospital? Does it have any policy for antibiotic prescription?
At Kirtipur Hospital, we follow specific guidelines on when to send cultures before starting antibiotics, particularly for cases presenting to the ER with possible sepsis. As an infectious diseases specialist, I routinely send cultures when necessary to help track resistance patterns within the hospital.
We also prepare an annual antibiogram, which compiles culture data from various departments and summarizes the resistance trends of different organisms, helping us monitor emerging resistance.
Additionally, the hospital has antibiotic use guidelines for managing sepsis and infections in burn patients, ensuring more rational and evidence-based prescribing practices.
How does Nepal’s AMR situation compare to other low and middle-income countries in South Asia?
There isn’t much research directly comparing AMR across South Asian countries, as resistance patterns vary widely even within a single country. For example, in rural areas like Rukum, antibiotics such as amoxicillin may still be effective for many infections, whereas in Kathmandu, resistance levels are much higher. Similarly, within India, states like Kerala have far lower resistance compared to others due to stronger antibiotic policies.
Overall, South Asia remains a hotspot for emerging antimicrobial resistance, with many new resistant mutations originating in the region and later detected abroad on travelers. Nepal, unfortunately, is likely on par with the most affected parts of South Asia in terms of AMR burden.
What are your thoughts on the current national policies and surveillance systems for AMR in Nepal? Are there any promising initiatives that you are aware of?
Nepal has some government-initiated reporting systems in place, where selected sentinel hospitals share antimicrobial resistance (AMR) data with the National Public Health Laboratory (NPHL). While this provides some insight, it is far from comprehensive.
Data collected from a few hospitals cannot reflect the true burden of AMR across the country, as samples are only taken when doctors request cultures. This limits the accuracy and representativeness of the findings.
There have been some promising steps, such as ICU-based registries in certain hospitals that document AMR-related infections, but these remain limited in scope.
Overall, Nepal needs to significantly strengthen its sample collection methods, data management systems, and coverage to build a more reliable national surveillance framework, including areas like fungal and non-tubercular mycobacterial resistance, where data are almost non-existent.
Are there any effective international practices on limiting AMR that Nepal can learn from?
Yes, there are several effective practices Nepal can learn from. Optimizing antibiotic use through stewardship programs is key, as these provide clear guidelines on when and how to prescribe antibiotics. Improving diagnostic facilities also helps reduce unnecessary use, while strong infection prevention and control practices in hospitals can limit the spread of resistant bacteria.
Kerala serves as a good example, having banned non-prescription antibiotics and introduced the ‘Smart Antibiotic Hospital Initiative,’ which enforces the WHO’s AWaRe classification to keep antibiotic use within limits. Such approaches could help reduce inappropriate antibiotic use and lower resistance in Nepal as well.
If you could implement one intervention immediately to change the current AMR scenario in Nepal, what would it be?
A very important step would be to reduce antibiotic use in animals. In Nepal, around two-thirds of the antibiotics usage is seen in livestock and agriculture. And most of these cases can be attributed to the over-the-counter purchase of these drugs without proper approval. That needs to be curtailed.
The other intervention would be to educate people and make them aware that upper respiratory tract infections do not require antibiotics, because that is where the vast majority of antibiotic use is observed among the public.
What message would you give to medical students and young medical professionals about their role in combating AMR?
AMR is one of the greatest public health challenges in the country, probably second only to air pollution. With very few new classes of antibiotics expected in the coming decades and resistance spreading rapidly, medical students and young healthcare professionals must understand the risks of inappropriate antibiotic use.
They must be rational and systematic in their approach, first assessing whether a condition is truly an infection, then determining if it is bacterial, and if bacterial, whether it requires antibiotics, and if so, ensuring the correct drug, dose, duration, and route of administration is prescribed.
Adhering to standard treatment guidelines issued by the Department of Health Services, Ministry of Health, or by international professional bodies such as the Infectious Diseases Society of America (IDSA), ESCMID, or the WHO, is essential to preserve antibiotic effectiveness for future generations.
