Infection control and antimicrobial stewardship in hospitals

Definitions and why they matter in geriatrics. Infection prevention and control (IPC) is the set of measures that prevent transmission of pathogens within healthcare settings. Antimicrobial stewardship (AMS) is a coordinated programme to optimise the choice, dose, route and duration of antimicrobials so as to improve outcomes, reduce toxicity and cost, and limit resistance. Older inpatients are the highest-risk group because of atypical presentation (fever and leucocytosis may be absent), high device use, prolonged stay and heavy antibiotic exposure.

Core IPC measures. Hand hygiene (WHO 5 moments) is the single most effective intervention; standard precautions plus transmission-based precautions (contact, droplet, airborne); appropriate PPE; environmental cleaning and disinfection; safe injection and sharps practice; isolation or cohorting of MDRO carriers and C. difficile; biomedical waste management; and device care bundles for CAUTI, CLABSI, ventilator-associated pneumonia and surgical site infection.

Surveillance. Continuous surveillance of device-associated infection rates, construction of a hospital antibiogram to guide empirical therapy, outbreak detection, and MDRO screening. In India, the ICMR Antimicrobial Resistance Surveillance Network (AMRSN) and NCDC's HAI surveillance network provide national resistance data.

Core elements of an AMS programme (CDC / ICMR). Leadership commitment (budget and staff); accountability — a named physician lead; pharmacy expertise; action — formulary restriction and pre-authorisation, prospective audit and feedback, an antibiotic timeout at 48–72 hours, de-escalation on culture results, IV-to-oral switch and defined duration limits; tracking (DDD per 100 bed-days, days of therapy); reporting; and education.

Practical prescribing rules. Send cultures before the first antibiotic dose; choose empirical therapy from the local antibiogram, not from memory; apply the WHO AWaRe classification — Access preferred, Watch restricted, Reserve for last-line use; use the shortest effective duration; and adjust every dose for renal function, with therapeutic drug monitoring mandatory for aminoglycosides and vancomycin in older adults.

Geriatric-specific stewardship issues. Do not treat asymptomatic bacteriuria or colonisation; avoid fluoroquinolones where possible (delirium, tendon rupture, QT prolongation, aortic aneurysm, C. difficile — flagged in the Beers criteria); watch for antibiotic-related drug interactions (warfarin, statins, antiarrhythmics); recognise antibiotics as a leading precipitant of C. difficile infection and of delirium; and remember that vaccination (influenza, pneumococcal, COVID-19, herpes zoster) is itself a stewardship intervention because it prevents antibiotic-requiring illness.

India launched the National Action Plan on Antimicrobial Resistance 2.0 (NAP-AMR 2.0, 2025–2029) on 18 November 2025, during World AMR Awareness Week. Key changes from NAP-AMR 1.0 (2017–21): IPC programmes are now mandatory in all healthcare facilities; environmental surveillance of antibiotic residues in wastewater from hospitals, farms and pharmaceutical units is mandatory; the ICMR AMRSN is being expanded with genomic surveillance; and governance is elevated to a standalone pillar, with 20+ ministries required to submit time-bound, budgeted action plans. It follows the One Health approach and is aligned with the UNGA 2024 political declaration target of a 10% reduction in AMR-related deaths by 2030. If this appears as a 15-mark question, add: the burden of AMR (Lancet GRAM: 1.27 million deaths directly attributable globally in 2019; ~2.97 lakh AMR-attributable deaths in India); Indian resistance patterns (carbapenem-resistant Klebsiella and Acinetobacter, ESBL E. coli, Candida auris); a full CAUTI/CLABSI/VAP bundle; the Schedule H1 regulation of antibiotic sales; NABH accreditation requirements for hospital infection control committees; AMS outcome metrics and reported Indian results (reduction in ceftriaxone and piperacillin-tazobactam DDDs after AMSP introduction); and barriers to AMS in Indian secondary-care hospitals.