Are oral antibiotics still effective in Bihar?

Oral Antibiotics Remain Effective in Bihar, India

Oral antibiotics remain effective in Bihar, India, but should be prescribed judiciously following evidence-based guidelines to prevent antimicrobial resistance. 1

Current Status of Antibiotic Effectiveness

• Oral antibiotics continue to be effective therapeutic agents in Bihar, but their effectiveness is threatened by inappropriate prescribing practices and emerging resistance 1, 2
• In rural India, including Bihar, antibiotics are frequently overprescribed, with studies showing that up to 74% of prescriptions from informal healthcare providers include antibiotics, often unnecessarily 2
• Broad-spectrum antibiotics are most commonly prescribed (95% of antibiotic prescriptions), with fluoroquinolones (31%), extended-spectrum penicillins (27%), and third-generation cephalosporins (20%) being the most frequently used classes 2

Evidence-Based Antibiotic Prescribing Guidelines

Upper Respiratory Tract Infections (URTIs)

• Antibiotics should not be prescribed for non-specific URTIs as these are predominantly viral in nature 1
• For acute bacterial rhinosinusitis, antibiotics should only be prescribed if symptoms persist for at least 10 days beyond the onset of upper respiratory symptoms or worsen within 10 days after an initial improvement 1
• For sinusitis requiring antibiotics, recommended options include amoxicillin-clavulanate, cefuroxime-axetil, or cefpodoxime-proxetil for 7-10 days 1
• Fluoroquinolones should be reserved for situations where major complications are likely or when first-line therapy fails 1

Acute Otitis Media (AOM)

• For children under 2 years of age with AOM, antibiotic therapy is recommended 1
• For children over 2 years of age, antibiotics can be withheld unless there are marked symptoms (high fever, intense earache) 1
• When treating AOM, amoxicillin is the first-line choice for suspected pneumococcal infection, while cefixime, cefpodoxime-proxetil, amoxicillin-clavulanate, or cefuroxime-axetil are indicated when H. influenzae infection is suspected 1
• Treatment duration should be 8-10 days for children under 2 years and 5 days for older children 1

Tympanostomy Tube Otorrhea

• For children with tympanostomy tube otorrhea, topical antibiotic eardrops should be prescribed rather than oral antibiotics 1
• Topical antibiotics provide better coverage against common pathogens including Pseudomonas aeruginosa and MRSA while avoiding systemic side effects 1

Improving Antibiotic Prescribing Practices in Bihar

• A multifaceted intervention implemented in primary care settings in Kolkata, India (which could be applicable to Bihar) reduced inappropriate antibiotic prescribing for URTIs from 62.6% to 7.2% 3
• Key components of successful interventions include:
  • Regular audit and feedback on prescribing practices 3
  • Interactive training sessions for healthcare providers 3
  • Development and implementation of local antibiotic guidelines 3
  • One-to-one case-based discussions with prescribers 3

Challenges in Bihar's Healthcare System

• Limited access to licensed physicians (only 0.70 licensed physicians per 1000 people in India) leads to heavy reliance on pharmacies as primary healthcare providers 4
• 75% of pharmacy employees in rural areas may be unlicensed practitioners with limited understanding of antibiotics and antibiotic resistance 4
• Economic factors often lead to dispensing shortened antibiotic courses (1-2 days), which patients rarely complete, contributing to resistance development 4
• Seasonal variations affect antibiotic prescribing patterns, with higher rates during monsoon season (76%) 2

Recommendations for Appropriate Antibiotic Use

• Implement short-term, intensive training programs on appropriate antibiotic prescribing for both formal and informal healthcare providers 4
• Develop context-specific guidelines that account for local resistance patterns and healthcare access challenges 1
• Establish antimicrobial stewardship programs in healthcare facilities to monitor and improve antibiotic prescribing 5
• Focus on reducing unnecessary antibiotic prescriptions for conditions that are predominantly viral, such as non-specific URTIs 1, 3
• When antibiotics are indicated, ensure complete courses are prescribed, dispensed, and taken by patients 4, 2

Pitfalls to Avoid

• Avoid prescribing antibiotics for viral infections or non-specific symptoms 1
• Do not dispense shortened courses of antibiotics due to economic constraints, as this promotes resistance development 4
• Avoid routine use of broad-spectrum antibiotics when narrow-spectrum options would be effective 2
• Do not modify antibiotic regimens based solely on persistent fever in clinically stable patients 1