It was more of a shock than concern when I saw a young man last week during my ICU consultation for possible pneumonia. He was rescued from drowning in a river and was shifted to the ICU after a brief resuscitation, intubation and was on ventilator. On hospital day 1, tests were sent as he was running fever with a low BP and oxygen level. In most cases of near-drowning, the lung injury could be due to several causes and infection leading to pneumonia is one of them which worried the treating consultant.
Culture report of the sample taken from airway identified a bug named Klebsiellawhich is resistant to most of the antibiotics including the most potent ones, the ‘carbapenems’. Carbapenem was the backbone of treatment for most critically ill patients a decade ago. Carbapenem-resistant enterobactericeae, also known as ‘CRE’ and popularly called the ‘nightmare bacteria’, is one of the ‘super bugs’ considering its potential to develop and spread antibiotic/ antimicrobial resistance (AMR) worldwide. AMR suggests the bug has developed some mechanism to escape from action of the antibiotic. Infections caused by these bacteria are considered an urgent threat that needs to be tackled quickly.
Coming back to the young man on ventilator, why is his sample taken from his airway on the first day of hospital growing the ‘nightmare bacteria’, sensitive only to couple of antibiotics? Isn’t it scary? Such resistant bacteria are usually seen only in those who are admitted with repeated infections and have received multiple episodes of antibiotics. But this young man was never hospitalised prior to current hospital admission nor has he received recent antibiotics for infections. Did he acquire the ‘nightmare bacteria’ from the water he aspirated or was he having it all along?
This brings us to the scariest thought of how polluted and dangerous can our environment be. Ultimately this patient was lucky, his lung slowly cleared up, ably managed by ventilatory support and antibiotics to become an ‘antimicrobial resistance (AMR) survivor’! Several battles are fought daily and as days go by our AMR survivors are declining.
We are talking about those tiny microns which mutate to survive the antibiotic pressure and become resistant making our antibiotic armamentarium ineffective. Why does this happen? Widespread use of antibiotics all over the world over last decades is only one among many reasons and antibiotic abuse is only partly responsible for AMR. But using antibiotics wisely, what we call antibiotic or antimicrobial stewardship, is the way to preserve what is left with. Antibiotics cause a selective pressure by killing susceptible bacteria, allowing antibiotic resistant bacteria to survive and multiply. Over a period of time the small resistant population multiply to outgrow the normal gut bacteria as well as drug-sensitive bacteria and become dominant. The best comparison would be weeds waiting for the right condition to outgrow the plants in your garden. The consequence of multiplication of resistant bacteria could be fatal as they invade human blood and organs. Not often do we have the luxury of multiple antibiotic opti
ons to choose from or could get away with simple drugs like penicillin, pushing us all to the pre-antibiotic era where infections were the major killer disease of mankind.
Is small dose of antibiotics less harmful? Contrary to the belief, it is more damaging as it does not kill the bacteria and helps it develop antibiotic resistance a thousand times higher. The common examples of using low dose antibiotic are wrongly prescribed antibiotic dose, over the counter antibiotic use and inadequate antibiotic duration, but surprisingly, these form only a minority.
The second annual report of the World Organisation for Animal Health on the use of antimicrobial agents intended for use in animals suggests that huge proportion of antibiotics is used in meat production and aquaculture (fish and other marine animals) where low dose antibiotics are added to animal feed to make them grow faster. As the bacteria in the intestine of animals, poultry or aquatic forms are exposed to low levels of antibiotics over long periods, they mutate and develop antibiotic resistance and subsequently infect humans through various forms of animal food that are consumed. Also during a course of antibiotics, a high proportion of the antibiotic dose is excreted in the urine and can then spread into watercourses and soil. Thus our environment may contain low levels of antibiotics and resistant bugs.
Compounding this problem is poor hygiene, sanitation and crowding. Polluting our water sources with human excreta and dumping of poultry waste etc., help superbugs reach far and wide in no time. Not surprisingly it is now found that superbug has reached as far as the Arctic, 12,000 kms from India. After all we are one small world separated by seemingly pristine water bodies!!
The medical fraternity has its responsibility to use antibiotics rationally. Nothing more is urgent than to educate and train regarding correct use of antibiotics which will definitely save lives and curtail antibiotic resistance. But in reality, achieving this may be only 30 per cent of the job done. To reduce antibiotic abuse, major change needs to be brought in non-human use- which is animal, poultry and fisheries. Worldwide, 70 per cent, 60 per cent and 50 per cent of antibiotics are used in animals in US, Europe and China, respectively. We don’t have exact data from India but in here, too, animals are a big share-holder of antibiotics.
Moreover, as poultry litter is used in vegetable farming, these bacteria can also contaminate vegetables. In 2014, India was the country with the highest number of people practicing open defaecation with around 530 million people and imagine the impact on environmental pollution. This brings us to the reality that AMR is a complex public health problem. ‘One health’ is the concept linking human health to animal and environment, and if one is affected, others will be. If we can ensure what we eat is free from antibiotics, improve our hygiene index and use antibiotics wisely, we will have a few more years to hold on, until new discoveries happen to tackle the AMR.
Penicillin, the first commercialised antibiotic, was discovered in 1928 by Alexander Fleming. Within a century we have not only lost penicillin but many more that followed penicillin and we have nothing much in the pipeline. At least 2 million people are infected with antibiotic-resistant bacteria in U.S, and it accounts for 23,000 deaths a year. As per reports, death attributed to AMR now is around 7 lakhs which is a gross under estimation. The estimated deaths due to AMR in 2050 are 10 million, making it the highest and even crossing cancer deaths, to be a greater killer of mankind.
Let us hope that the Swachh Bharat Abhiyan campaign will improve the hygiene index by building toilets and cleaning up our rivers and waterbodies. The Chennai Declaration, a vision document prepared in 2012 by representatives of various stakeholders and eminent experts in India to tackle the challenge of anti-microbial resistance from an Indian perspective, had an unprecedented impact at national and international levels. The Central government under ICMR has rolled out a national programme for containment of AMR. The Kerala government initiative (KARSAP- Kerala Antimicrobial Resistance Strategic Action Plan) supported by WHO involves various stake-holders like health and family welfare, medical doctors, animal husbandry, fisheries, environment, pharmacy reiterating on ‘One Health’ approach is again a laudable effort.
If we look at all these campaigns and programmes, it is very evident that ultimately human actions and habits form the core. WHO and several other organisations are promoting responsible use of antibiotics in animals and limit their use for sickness in animals.
As a citizen, you have the right to ask questions and speak up your concerns regarding preventing infections, antibiotics prescribed to you, refrain from antibiotic use in animals for short term benefits, enquire for antibiotic free animal food (getting more popular in West), follow simple food safety tips, improve hygienic practices in household and outside to the extent you can.
Within the hospital, hand hygiene is a simple way to prevent spread of infections and patients have the right to gently remind anyone caring them to perform hand wash before touching them, be it even a social handshake!
(Dr A. Rajalakshmi is consultant, Infectious Disease and Infection Control, KIMS Hospital, Thiruvananthapuram.)
