For doctors treating patients with serious bacterial infections in hospitals, a big question looms: which antibiotic(s) should be given to a patient and for how long?  

If the treatment is too light or ineffective, the infection could actually grow stronger and spread; if the treatment is too strong, the patient’s recovery could be delayed and accompanied by harsh side effects. Doctors thus seek out just the right amount of antibiotics to kill the harmful bacteria while minimizing side effects and optimizing patient outcomes.  

That is where Professor Nusrat Shafiq comes in.  

About ten years ago, Nusrat was charged with improving antibiotic stewardship at the Postgraduate Institute of Medical Education and Research in Chandigarh, a public hospital in Northern India that receives millions of patients every month, and one of the premier health institutes in the country. At the time, the Global Action Plan on AMR had not yet been rolled out, and there was much lower general awareness of AMR than there is today. 

She started by taking a closer look at patients entering the intensive care unit. “Patients were coming or being referred with all kinds of antibiotic prescriptions,” said Nusrat.  

Soon Nusrat and her colleagues realized that overprescription and inappropriate prescription was a widespread problem caused by multiple factors. Various prescribing practices were being used within each department, and available diagnostic facilities were not being optimally utilized.  

With institutional support, Nusrat and her team began working on improving the rational use of antibiotics—so that the right patients would get the right antibiotics at the right time for the right duration. They believed that they could obtain as good or better patient outcomes, as well as generate savings for hospitals and patients and help to preserve the efficacy of antibiotic treatments. 

To begin, Nusrat and her colleagues zeroed in on surgical prophylaxis, the pre-surgery prescription of antibiotics to prevent infections. Supported by data that showed that patients could fare at least as well with a shorter antibiotic treatment prior to surgery, they went about engaging with surgeons who were accustomed to giving their patients a cocktail of antibiotics.  

Nusrat recalls one surgeon in particular who agreed to follow the single-shot protocol, but with a condition: “He said, ‘Okay, we can implement the protocol you recommend for my patients, but you have to follow them for six months and show me that the recommended treatment does not adversely affect their outcomes.’ We were able to show that. Subsequently we took this story from department to department, and our work kept on getting bigger.”  

Nusrat and her team learned along the way. They tapped into momentum that was being generated at the national level with the drafting of the National Action Plan on AMR. They witnessed improved cleanliness, hygiene and infection control in hospitals thanks to the Kayakalp initiative, which was launched by the Indian government in 2015. They also noticed increased reporting on AMR in the media, and they themselves started to speak on the radio about the threat of AMR and the importance of rational use of antibiotics.  

In this context, a new culture around antibiotic stewardship began to take shape. And now after 10 years of efforts, Nusrat’s team have seen noticeable improvements:   

• The culture of de-escalation has increased, so doctors who start patients on broad-spectrum antibiotics are more willing to move to limited-scope treatments once the pathogen has been identified 

• Double anaerobic cover—so two antibiotics that cover organisms that do not require oxygen for survival—have gone from basically universal use to use in 1-2% of cases 

• Certain last-resort antibiotics are being used later in the treatment process, rather than up front 

• A new approach to developing guidelines for infection management, including involving stakeholders and taking into consideration available resources, has been increasingly adopted by healthcare systems 

• Diagnostic facilities are being better utilized to optimize antibiotic use 

And the work continues. “The more success we have, the easier it is. The good stories travel across departments and beyond to other institutes and community healthcare settings,” says Nusrat.