(Ab)using Antibiotics


With hospitals finding no time to sterilise the operation theatres, the ICU in all the main hospitals is a source of infection, which sometimes turns serious. In the given situation, doctors find the use of antibiotics as the only viable option and that is creating a mass crisis, reports Saima Bhat

Struggling to breathe in harsh winters, 55-year-old Zarina Begum was admitted to SKIMS late January 2017.  A Chronic Obstructive Pulmonary Disease (COPD) patient, Zarina showed no sign of improvement after spending two days in the emergency observation ward. As her condition deteriorated, doctors suggested the patient be shifted to intensive care unit (ICU) for ventilator support.

One of her four sons, serving SKIMS, decided against the suggestion. He started helping her manually, instead. The health graph did not show an improvement. Her sons had an argument. It was three versus one. The three brothers argued outside the emergency ward with their doctor brother.

Finally, Dr Rafiq, Zarina’s son, revealed his fears: There is a “particular infection” in ICU that can worsen her condition. “They rarely get a chance to fumigate the room or sterilise the machines,” he reasoned.

But witnessing her deteriorating condition, the doctor succumbed to the pressure and she was finally put on a ventilator. A day later, she lost her battle and died of pneumonia on January 30.

Dr Rafiq’s concerns are shared by many of his colleagues. Since the ICU at SKIMS, especially after being shifted to a smaller space, always remains overburdened, managers rarely get a chance to sterilise the machines.

Presently SKIMS has 10 operative rooms and three emergency operative rooms operational. Another coming up operative section will add five more operation theatres.

Besides, there are six intensive care units with 16 beds in Surgical ICU, 4 in neurosurgery ICU, 4 in CVTS ICU, 4 in paediatrics ICU, 27 in neonatology ICU and 8 in medical ICU.

But Dr Amin Tabish, the medical superintendent, who heads the infection control department, disagrees. “We have the latest technology of fogging, which is a latest international technique for clearing the infections in the theatres and ICU’s. It needs just one or two hours to work. Other than that we have tubing that is for single use,” Tabish insisted.

But, he says there are some infections in the hospital that vary from place to place. “It is not the same in the whole hospital. We have three common strains of bacteria in the hospital: E coli, Klebsiella, Pseudomonas and Acinetobacter.” But he was reluctant to provide the details about how many patients were admitted to the different ICUs of the hospital and how many died of the hospital infections.

Hospital insiders say they know what kind of infections are in the hospital so they “put the patients directly on the required antibiotics, no matter how sick is the patient but all the three bacteria’s are mostly resistant to high doses of antibiotics.”

“Patients who are admitted here are mostly critical but we are also adding to it. See we don’t have a separate critical care ward for H1N1 influenza patients, no doubt they are incubated but we don’t have an isolation ward for them. We have to keep them in the same ward. And then we have hospital-acquired infections, which are present in all hospitals, and mostly the critical patients admitted in the ICU complaint of developing ‘pneumonia’,” One informed insider said.

After continuous bleeding from his rectum, Muhammad Akbar Mir was admitted to SKIMS hospital for a severe form of Crohn’s Disease, a chronic inflammatory bowel disease that affects the lining of the digestive tract. After 12 hours, his family flew him to a Delhi hospital.

Within a week Mir’s condition started improving. Suddenly, however, he started showing symptoms of pneumonia. Despite being shifted on a ventilator, he died.

The situation is somewhat similar in SHMS hospital where the medical superintendent, Dr Saleem Tak, says they have weekly fumigation of the theatres and ICU’s. It has six operation theatres with three different ICU’s. Ward 17 has 8 ventilators, 4 in medical ICU, post anaesthesia care and 4 ventilators in medical ICU.

The hospital, Tak says is inspected daily by a team from GMC’s microbiology department. “Every day they take a swab from anywhere in the hospital and then we work as per their suggestions. But mostly we do fumigation of theatres on Saturday evening, which continues till Monday morning (more than 24 hours),” Tak said.

Tak accepts that every hospital has a few infections that are present in theatres and ICU’s like Pseudomonas. Locally they call it hospital-acquired infections. “This is a teaching institute so our drug policy depends on what is written in the books. We change with the upgraded books,” he added.

“All our machines and ICU linens are sterilised by CCD’s and every Saturday we do fumigation of theatres for 24 hours,” Tak said. “For the hospital wards, we keep on using disinfectants. And linens are sent for washing with antiseptic, hot press and other chemicals.”

Generally post-operation, patients are put on antibiotics to tackle the hospital-acquired infections across Kashmir, a practice doing away in most of the world.

In Kashmir, the directorate of health services says almost 95 percent peripheral residents trust government hospitals. “We don’t do just gallbladder or appendicitis surgeries but we have done around 10,000 laparoscopic surgeries including the surgery of pancreas, hip replacement, knee replacements, neuro and liver surgery,” a senior official at the Directorate said. “We have the best results.”

This, he said, is despite the inadequate manpower, and the questionably low ratio of doctors to patients. World Health Organisation (WHO) wants a doctor for 1000 patients but in J&K the ratio is 1: 1658. “When it comes to super speciality, the ratio dips down three times,” the officer said.

Insiders in the fraternity said hospitals lack staff. “We have more workload but a less human resource. Even GMC is deficient in 40 percent faculty,” he said.

The infections, are mostly Surgical site infections (SSIs), which are considered to be the second most common cause of hospital-acquired (Nosocomial) infections, says Dr Feroz, a state level microbiologist with DHSK. These complications of surgical procedures cause considerable morbidity and, when these occur deep at the site of the procedure it can lead to mortality as high as 77 percent.

The source of SSIs may be endogenous (normal flora of the patient’s skin, mucous membranes, or hollow viscera) or exogenous, which includes surgical personnel (especially members of the surgical team), the operating room environment (including air), and tools, instruments, and materials brought to the sterile field during an operation. Maintaining a sterile environment in operation theatre can only control the major part of exogenous infections. Dr Feroz started working with DHSK in 2013, and he claims his department has reached at least 70 percent in the peripheral hospitals.

“Initially the results were very bad but now the situation has improved a lot,” Dr Manzoor Kadri, state surveillance officer with DHSK, said. “We go for tests forthrightly and we have very minimal wound infections now.”
But sub-district hospitals are yet to be added to the microbiology inspection list so nobody can say if these hospitals are safe or not, says an insider.

To prevent the wound infections among patients in postoperative care, the use of antibiotics has a judicious rule. “Mostly one shot of antibiotics should be given to the patients going for surgery. But we have to put them on extra dose just because our hospitals are overcrowded.”

Experts believe if patient-nurse ratio would have been normal then the risk of cross infections would also decrease. “Presently the ratio is disproportionate: 1:50.”

In ‘clean up’ surgeries like the removal of the breast, only one dose of antibiotics is needed, he said. In case of the intestine or appendix removal, there are chances of getting contamination, so those patients need antibiotics dose after surgery as well.

Unlike Kashmir, antibiotics use is least because hospitals go for theatre sterilisation frequently. “Most importantly the patient: doctor: nurses are in a ratio where the patient comes in contact with lesser infections,” he says.

A DH Baramulla doctor said their hospital has three theatres: one for gynaecology running 24×7, the general theatre where at least seven surgeries are done on routine per day and the third where ENT and Orthro surgeries are done. The hospital administration has built up a new theatre block which will add at least 10 more theatres to the hospital.

“The hospital has sterilisation issues: out of 112 surgeries six developed wound infections,” the doctor said. “Fumigation is done sometimes on weekends because we don’t have too many theatres to shift our patients to.

And if sterilisation is breached, we add to the antibiotic intake.”

Antibiotics are so commonly used that it is now part of self-medication.

The yearly sales of pharma companies in Kashmir are around Rs 600 crore and 40 percent of it includes antibiotics and Proton Pump Inhibitors (PPI), the medicines prescribed for stomach, says Mushtaq Ahmad Pokhta, the general secretary of Pharma associations in Kashmir that has around 1000 distributors. “The crisis is that every pharma company is selling everything in Kashmir.

In 2012, Pokhta says his team met the then Chief Minister and requested him that no drug should get into Kashmir without proper sample checking. But nothing has happened so far for the plan.

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