Clearer guidelines for antibiotics in the offing

Government doctors will get a clearer and more structured guide to prescribing antibiotics under the third edition of the National Antibiotic Guideline (NAG 2019) as part of efforts to curtail antimicrobial resistance in this country.

The Health Ministry is currently in the final phase of reviewing NAG 2014 (second edition of NAG) and is expected to publish NAG 2019 in the first quarter of this year.

NAG, the first edition of which was introduced in 2008, outlines principles of antibiotic therapy and rational antibiotic prescribing.

One of the core areas of focus of NAG 2019 will be on the prescription of antibiotics with regard to empirical treatment (treatment given without knowledge of the cause or nature of a patient’s disorder or based on the doctor’s observations and experience).

The Health Ministry’s national advisor for infectious diseases Datuk Dr Christopher Lee (pic) says NAG 2019 will provide government doctors and pharmacists clearer guidelines on empirical treatment.

“For example, when a patient shows signs of a bacterial infection, the doctor, based on the NAG, can prescribe an ordinary antibiotic first before sending the patient’s (blood or urine) sample to the lab for a bacteria culture test. A stronger antibiotic drug like carbapenem should only be prescribed based on the culture test result and if the patient shows no improvement,” he says.

(Bacteria culture tests are used to help diagnose certain types of infection and it usually takes about two or three days to get the results of a culture test from the laboratory.)

Dr Lee says based on a study of NAG 2014, it was found that there were many cases of government doctors prescribing strong or high-end antibiotics such as carbapenem to their patients even before getting the results of the bacteria culture test.

This practice has led to increasing resistance to high-end antibiotic drugs among Malaysians.

Dr Lee, who is also a senior consultant (infectious diseases) and heads the Medical Department at Hospital Sungai Buloh, says doctors should first prescribe a low-end antibiotic for any bacterial infection but can give the patient a stronger one later if the patient’s condition shows no sign of improvement and the result of the bacteria culture test warrants it. 

NAG 2019 also focuses on giving clearer guidelines to government medical officers to control infections in hospitals, as well as cutting down the use of carbapenem as a strategy to aggressively counter the growing resistance to the antibiotic drug.

It (carbapenem) will only be prescribed as an antibiotic of last resort and on a case by case basis,” he said, adding that NAG 2019 would restrain doctors from using strong antibiotic drugs in an arbitrary manner.

While NAG acted as a professional guide for the public healthcare sector, the private healthcare sector is also encouraged to develop its own guidelines on antibiotic usage but they have to be based on the Health Ministry’s existing antibiotic guideline.

Carbapenems are a group of antibiotics that are usually prescribed for the treatment of serious bacterial infections. However, due to the overuse of these antibiotics, some germs or bacteria from the Enterobacteriaceae family, dubbed as superbugs, have developed high levels of resistance to carbapenems.

According to Dr Lee, there has been an increase in cases involving carbapenem-resistant Enterobacteriaceae (CRE) in Malaysia. In 2013, the Health Ministry recorded 15 such cases but in 2017, the number of CRE cases had grown to 150.

Recently, Deputy Health Minister Dr Lee Boon Chye said superbugs are the cause for 700,000 deaths a year worldwide. He was citing statistics from the Review on Antimicrobial Resistance which was commissioned by the United Kingdom government in July 2014.

Speaking at a World Antibiotic Awareness Week 2019 national-level event at a private medical centre in Subang Jaya, he said the number of such deaths globally could rise to 10 million by 2050 if no serious action is taken by all governments at the international level.

He urged healthcare practitioners to be more cautious when prescribing antibiotic drugs in order to check the increasing number of cases involving antibiotic resistance.

“Not all diseases need to be treated with antibiotics… 95 percent of patients with illnesses not classified as dangerous and caused by viruses can be treated with normal drugs. So, doctors and pharmacists need to control the use of antibiotics and only prescribe it if it is appropriate to do so,” he said. –MUHAMMAD BASIR ROSLAN