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Simulated patient study sheds new light on antibiotic use in India

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Shobha Shukla, CNS (Citizen News Service)

(CNS): Overuse and/or misuse of antibiotics has led to antimicrobial resistant superbugs pose a global health emergency. This threat is particularly great in India, that has the highest burden of TB in the world and is also the world's largest consumer of antibiotics. In a first of its kind study, led by Dr Srinath Satyanarayana of McGill University, and published in The Lancet Infectious Diseases, researchers used standardized patients (also called 'simulated or mystery patients') to understand how pharmacies in 3 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 study aimed to assess the drug dispensing practices of pharmacies for standardised patients with presumed and confirmed TB in India.

The study results show that pharmacies frequently dispensed antibiotics to simulated patients who presented with typical/classical TB symptoms, and rarely referred them to doctors (which can delay the diagnosis of TB). However, the good news is that none of the pharmacies dispensed first-line TB drugs. Also, the use of 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 laboratory test confirming TB.

Novel use of standardized patients

Researchers used two trained standardized patient cases - one with a patient presenting with 2-3 weeks of pulmonary TB symptoms and a second with a patient with microbiologically confirmed pulmonary TB. Between April 1, 2014, and Nov 29, 2015, these 'trained patients' then presented each case once to sampled 622 pharmacies in 3 Indian cities (Delhi 54 pharmacies, Mumbai 308 pharmacies, and Patna 260 pharmacies), completing 1200 interactions with pharmacists. None of these standardised patients presented with drug prescriptions. They collected all the pills that were dispensed to them by the pharmacists. After each pharmacy visit, standardised patients were debriefed with a structured questionnaire within 1 hour of the visit.

Standardised patients trained as Case 1 presented with 2--3 weeks of cough and fever and directly sought drugs from a pharmacy. Differential diagnosis for this case included upper respiratory tract infection, pneumonia, asthma and acute or chronic bronchitis. Antibiotic use might be warranted for some of these conditions, although not without a prescription from a doctor.

Standardised patients trained as Case 2 presented with 1 month of cough and fever and a recent sputum smear positive TB test report from a government dispensary. In this case, TB was confirmed, although the patients, who posed as uninformed patients, made it clear that they did not fully understand what their report said.


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