Antibiotic resistance from misuse and overuse has become a global concern with emerging multi-drug resistance bacteria, setting the stage for significant challenges in providing appropriate treatment for life-threatening illnesses. In 2009, a bacteria with novel mechanism for drug resistance was traced back to India, and named the New Delhi Metallo-protease (NDM). Dr. Amita Gupta, Deputy Director of Johns Hopkins Center for Clinical Global Health Education, has partnered with researchers at BJ Medical College and DY Patil Medical College in Pune, India, in a prospective study of the use of antimicrobials and resistance pattern in adults and children in India. With a target sample size of 1000, researchers are conducting active surveillance of adults and children admitted with acute febrile illness at participating hospitals through blood, urine, sputum, and CSF cultures, as well as perirectal swabs at the time of admission and at 7 days. The main objectives are to describe antimicrobial resistance patterns, as well as to assess clinical outcomes and risk factors for drug resistant organism infection. My aim in participating in this research is to assist with data collection and interpretation, conduct relevant literature review, and gain exposure to the intricacies of conducting global health research. Under the supervision of dr. Vidya Mave, I hope to additionally gain clinical exposure to management of febrile illness in India, as well as and understanding of the impact of HIV, TB, and malaria in this setting. This elective will help me gain further experience in international health, community-based research, and infectious disease – all of which are important for my career goals.
Host Institution: Dy Patil Medical College, Pune, India
Rotation: Bacterial Antimicrobial Resistance Patterns in Pune, India
Global Health Fellowship Reflections
I received a Paul S. Lietman Global Health Travel Fellowship to spend two weeks in Pune, India, assisting with a research project studying acute febrile illness and antimicrobial resistance in two hospitals – BJ Medical College/Sassoon Hospital (government) and DY Patil Hospital (private). In addition to learning about and helping with the research, I observed in clinical settings on the wards and in clinic.
Data collection for this study began at Sassoon Hospital in July 2013. Having now enrolled 1000 patients, the study is expanding to DY Patil Hospital. During my limited time in Pune, I assisted the DY Patil staff in identifying barriers to data collection, which largely revolve around busy residents and hospital staff not having the time to assist with enrollment—barriers that would likely be the same in any clinical setting.
Initial data analysis shows high empiric antibiotic use, with 3rd generation cephalosporins being the most commonly used. For adults, antimalarial drugs are the next most common antimicrobial. However, among the nearly 500 adult patients enrolled, only about 20% had a diagnosis confirmed by culture or rapid test (including malaria) that would require antimicrobial therapy. While it is understandable that antimicrobials are started empirically on febrile hospitalized patients and in the busy outpatient setting, initial data from this study and others on febrile illness in India suggest that the majority of patients will not ultimately require antimicrobial treatment. This type of research is important in order to guide interventions and policy to reduce inappropriate antibiotic use and limit the development of antimicrobial resistance.
The most striking clinical observation is the sheer volume of patients. In the US, we often remark at how many patients we have to see in a limited time, but physicians in India are even more overwhelmed. India has 0.7 physicians per 1000 people, compared to the US which as 2.5. Each outpatient encounter takes about 2-3 minutes, and patients are seen together in a room with several other patients at the same time. Physicians have to become astute diagnosticians, able to appropriately treat patients with a limited history and physical. In this setting, it becomes understandable how the norm has been to prescribe antibiotics initially, with a plan for further workup if therapy fails. The availability and use of rapid diagnostics would be one step toward changing the culture of antibiotic use in this busy clinical setting.
Infection control procedures are also different in the hospitals I visited compared to the US, and the most obvious difference is the limited capacity for tuberculosis isolation and control. In the US, anyone with suspected TB is placed in a negative-pressure isolation room and all staff interacting with them wears a well-fitted N95 mask. While visiting Pune, I saw many patients with active TB who were mixed amongst all the other patients, and health workers wear no protective gear. Given the high rate of TB and the expense of the N95 masks, it is understandable how this is the case (though at the same time the hospital had many modern amenities including a cardiac MRI). One important step in controlling TB in India would be protecting patients and health workers while in the hospital.
Personal Career Reflections
I have had exposure to global health and research in the past, but in the last several years of medical school and residency, I have focused largely on health issues in the US. This experience, though short and somewhat superficial, reignited my interest in global health research and programs. I had the opportunity to attend a conference on tuberculosis during my trip, and the presentations on the severity of disease in India and the need for more research reinforced for me the reasons that I went into public health and medicine. I left my trip feeling more confident in my career path, which I now feel should include a fellowship in infectious disease.