Inappropriate and overuse of antibiotics in fight against tuberculosis in India

Simulated patient study sheds new light on antibiotic use in India

As a result of the overuse or misuse of antibiotics, antimicrobial resistant superbugs represent an extraordinary threat to global health. This threat is particularly great in India, the world’s largest consumer of antibiotics and the country facing the highest burden of tuberculosis (TB) in the world.

Dr. Madhukar Pai

Dr. Madhukar Pai

In a study published in The Lancet Infectious Diseases, researchers at McGill University’s Faculty of Medicine, the Research Institute of the McGill University Health Centre, The World Bank’s Development Research Group, and other partners, used standardized patients (also called ‘simulated or mystery patients’) to understand how pharmacies in three Indian cities treated patients presenting with TB symptoms or diagnoses and to determine whether these pharmacies were contributing to the inappropriate use of antibiotics.

The researchers showed that pharmacies frequently dispensed antibiotics to simulated patients who presented with typical TB symptoms. However, none of the pharmacies dispensed first-line anti-tuberculosis drugs. The use of all antibiotics and steroids (which can be harmful to individuals who actually have TB), as well as the total number of medicines given, decreased sharply when the pharmacy staff decided to refer the patient to a doctor, which was far more commonly done when the patient presented with a lab test confirming TB, thus making the diagnosis apparent to the pharmacist.

“In India, many people believed that pharmacists were generating drug-resistant tuberculosis by dispensing anti-TB medications without prescriptions,” says Dr. Madhukar Pai, Canada Research Chair in Epidemiology & Global Health at McGill University and the paper’s joint senior author. “Our study clearly showed that not a single pharmacy gave away first line anti-TB drugs (isoniazid, rifampicin, ethambutol, pyrazinamide and streptomycin) without prescriptions. However, pharmacists gave away other antibiotics and rarely referred patients with typical TB symptoms, and that means they are contributing to delays in TB diagnosis. This can increase transmission of the infection in the community. So, there is great potential to harness pharmacists to identify those who need TB testing in India.”

Novel use of standardized patients

The researchers used two standardized patient cases, one with a patient presenting with two to three weeks of pulmonary TB symptoms and a second with a patient with microbiologically confirmed pulmonary TB. These trained patients then visited 622 pharmacies in three Indian cities (Delhi, Mumbai, and Patna), completing 1200 interactions with pharmacists. After each interaction, the patients remembered what was said to them, and collected all the pills that were dispensed to them by the pharmacists. Only 13% of simulated patients with TB symptoms were correctly managed, in sharp contrast to the 62% of patients presenting with known TB who were correctly managed. “Only a minority of urban Indian pharmacies correctly managed patients with presumed tuberculosis,” explains Dr. Srinath Satyanarayana, first author of the study, and a doctoral candidate in epidemiology at McGill University, “but most correctly managed a case of confirmed tuberculosis.”

“These findings can inform interventions to engage pharmacies in tuberculosis control and initiatives to improve antimicrobial stewardship,” notes Dr. Jishnu Das, a Lead Economist at the World Bank, and joint senior author of the study.

“This innovative study, which Grand Challenges Canada is proud to support, shows the critical importance of engaging pharmacists for reducing misuse of antibiotics, and for fighting TB. Antimicrobial resistance and tuberculosis are two global villains that require a concerted response,” says Dr. Peter Singer, CEO of Grand Challenges Canada, one of the funders of the study.

This study was supported by Grand Challenges Canada, funded by the Government of Canada, the Bill & Melinda Gates Foundation, The World Bank’s Knowledge for Change Program.

Study collaborators

McGill International TB Centre, World Bank, Harvard Medical School, Access Health International, Johns Hopkins University, and Institute for Socio-Economic Research on Development and Democracy, India.

About the study

Satyanarayana S et al. Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study. Lancet Infectious Diseases 2016. Published Online August 24, 2016.

About the RI-MUHC

The Research Institute of the McGill University Health Centre (RI-MUHC) is a world-renowned biomedical and healthcare research centre. The Institute, which is affiliated with the Faculty of Medicine of McGill University, is the research arm of the McGill University Health Centre (MUHC) – an academic health centre located in Montreal, Canada, that has a mandate to focus on complex care within its community. The RI-MUHC supports over 460 researchers and close to 1,300 research trainees devoted to a broad spectrum of fundamental, clinical and health outcomes research at the Glen and the Montreal General Hospital sites of the MUHC. Its research facilities offer a dynamic multidisciplinary environment that fosters collaboration and leverages discovery aimed at improving the health of individual patients across their lifespan. The RI-MUHC is supported in part by the Fonds de recherche du Québec – Santé (FRQS). rimuhc.ca

Contact

Valérie Harvey
Public Affairs & Strategic planning
McGill University Health Centre
514 934-1934 ext. 71381