Govt. Of India Guideline For Treatment of Muti-Drug Resistant Bacterial infections

In 2016 National Centre For Disease Control, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India came out with National Treatment Guidelines for Antimicrobial Use in Infectious Diseases.

Methicillin- Resistant S. aureus (MRSA) 

These organisms are considered resistant to all penicillins, cephalosporins and macrolides.

Though MRSAstrains may be reported as susceptible to Fluoroquinolones, aminogycogides, chloramphenicol and doxycycline in-vitro, these drugs are NOT to be used alone or as initial treatment for serious MRSA infections.

Rifampicin use should be avoided in diseases other than Mycobacterial diseases.

The drug of choice for treatment of infections due to MRSA is the glycopeptides i.e Vancomycin and Teicoplanin.

Linezolid can be used to treat skin and soft tissue infections caused by MRSA.

Mupirocin local application (intranasally bid x 5 days) for eradicating nasal carriage.

Daptomycin: Daptomycin is an intravenous antibiotic approved to be used for the treatment of complicated skin infections and Staphylococcus aureus bacteraemia. Daptomycin should NOT be used for treatment of pneumonia due to its inactivation by surfactant.

Vancomycin Resistant Enterococcus (VRE) 

The treatment for VRE should be based on infection severity and in-vitro susceptibility of the strain to other antibiotics.

Linezolid: Linezolid is the only drug specifically approved for the treatment of VRE-blood stream. Linezolid is effective orally.

Doxycycline: Not a first line therapy. For susceptible isolates, not for bacteremia or endocarditis. It should not be used as monotherapy.

Nitrofurantoin: For uncomplicated UTI

Fosfomycin: For urinary tract infections (cystitis) with isolates susceptible to fosfomycin.

Chloramphenicol: For chloramphenicol-susceptible isolates of E faecium and E. faecalis. Not a first-line therapy and it should not be used as monotherapy.

Gentamicin or streptomycin: To be used in combination with ampicillin for the treatment of enterococcal endocarditis caused by organisms susceptible in vitro to either agent; streptomycin is used when gentamicin cannot be used because of resistance.

Tigecycline: Tigecycline has in vitro activity against a broad spectrum of Gram-positive and -negative bacteria, anaerobes as well as multidrug-resistant pathogens such as MRSA and VRE. However, large scale clinical datar is currently unavailable.

Extended Spectrum Beta-Lactamases (ESBL) Producing Enterobacteriaceae.

ESBLs are plasmid mediated beta—lactamases that confer resistance to broad spectrum beta-lactum antibiotics including third and fourth generation cepahlosporlns, azetronam and extended spectrum penicillins. These plasmids often encode mutations which confere resistance to other broad spectrum agents including aminoglycosides, cortrimoxazole and fluoroquinolones, resulting in organism resistant to most broad spectrum antibiotics. The emergence of ESBL producing enterobacterlaceae is related to indiscriminate use of third generation cephalosporlns.

The carbapenems (Ertapenem, Meropenem and lmipenem) are currently considered the drug of choice for serious infections caused by these pathogens. Piperacillin -Tazobactam and Cefoperazone— Sulbactam may be considered options in mild infections and when ESBL producers are demonstrably susceptible in -vitro.

Carbapenem- Resistant Enterobacteriaceae (CRE)

Most carbapenemase producers are extremely drug resistant: being resistant to β-lactam antibiotics, aminogycosides, and β-lactam–βlactam inhibitor combinations.

Polymyxins, tigecycline & fosfomycin are the agents with most frequent in vitro activity, but all have limitations. Dosage will vary with the patient and infection site, but should be on the principle of ‘highest safe’ rather than ‘minimum potentially effective; durations should be as standard for the infection type.

Colistin – Case reports of successful use in a range of infections due to carbapenemase producers.

Tigecycline: Licensed for complicated skin and soft-tissue Infections and complicated intraabdominal infections. Low blood concentrations; off-label use should be cautious for blood stream infections, unsuitable in urinary infections as only 22% excreted in urine. Excess deaths in some trials, especially ventilator associated pneumonia (not a licensed indication).

Recommended measures to control spread of Multi-drug resistant organisms (MDRO)
Improved laboratory detection and reporting of MDRO.

Enhanced infection surveillance and control in ICUs.

Prevent spread by barrier precautions : Gowns and gloves.

Hand Washing.

Restricted use of 3rd generation cephalosporins.