In 1956, Ernest Jawetz, the author of Review of Medical Microbiology, said, “The physician is under great pressure to prescribe the newest, best, broadest antibiotic preparation without worrying too much about specific etiologic diagnosis or proper indication of the drug.” That was true in 1956 and is even more so in 2016. This problem has led to one of the biggest health crisis — antibiotic resistance. It is a global health emergency and the situation is worse in developing countries such as India. If not tackled immediately, it will leave doctors with no ammunition to fight infections as most of the bacteria are developing increased resistance to antibiotics.
When Alexender Fleming discovered penicillin in 1928, it seemed then that all forms of infection could be defeated. While collecting his Nobel Prize, in 1945, he had a warning — inappropriate use of penicillin would lead to resistant bacteria. Antibiotics help us perform complex surgeries, treat cancer patients and manage sick patients in intensive care. They are, basically, drugs that kill or inhibit growth of micro-organisms.
‘Antibiotic resistance’ is somewhat an arbitrary designation which implies that an anti-microbial drug will no longer inhibit bacterial growth at clinically-achievable concentrations. Antibiotics were first used in the 1940s and, since then, bacteria have been developing mechanisms to escape their effects. Over the decades, scientists developed new new antibiotics to overcome bacterial resistance.
Since the 1990s, development of new antibiotics has fallen sharply while bacterial resistance has continued to increase. Multi-drug resistant genes are now prevalent in common pathogens such as Escherichia coli, Klebsiella pneumoniae and Staphylococcus aureus. Antibiotic resistance is responsible for countless human deaths and hundreds of crores of rupees in healthcare expenses.
How big is the problem?
Bacteria resistant to antibiotics is prevalent in both community and hospital settings. In May this year, a report on anti-microbial resistance estimated that the 7 lakh annual deaths attributable to infections by drug-resistant pathogens will increase to 1 crore by 2050, if urgent remedial measures are not initiated. The extra healthcare costs and productivity losses could run into a trillion dollars. The risk for nosocomial infection (disease originating within hospital settings) can be two to 20 times higher for patients in developing countries compared to developed countries.
Read: ‘Cases were filed for not using antibiotics’
Antibiotic consumption — A global trend
A study from Princeton University, Global Trends in Antibiotics Consumption, 2000-2010, found that worldwide antibiotics use had risen by 36 per cent. The five BRICS nations — Brazil, Russia, India, China and South Africa — responsible for more than three-quarters of that surge. India was the world’s largest consumer of antibiotics for human health at 12.9 x 109 units (10.7 units per person).
Challenges in India
India has the highest burden of bacterial diseases in the world with nearly 4.1 lakh deaths annually only due to pneumonia. It also has the maximum number of neo-natal deaths because of sepsis. Many of these deaths could have been prevented using timely and appropriate antibiotics. At same time, antibiotics are prescribed for cold and uncomplicated diarrhoea, when it is not needed. Antibiotics use has been to so rampant here that sometimes, there is a question, “does fever mean antibiotic deficiency?”.
Which is why even though antibiotic resistance is a global phenomenon, India seems to be its epicentre. While fever can be due to infectious or non-infectious causes, there is increasing pressure on physicians and patients to use antibiotics for the everyday cold and cough. The antibiotics do not have any effect on its virus. Registered medical practitioners and paramedics in villages, who do not have any idea about diagnosis and side effects of medicines, use antibiotics such as Meropenam and Vancomycin, leading to emergence of resistant strains. Antibiotics are prescribed, changed and added without doing any cultures.
As a result, we do not have data about the organisms prevalent across communities and hospitals and hospital-acquired infection with resistant organisms is showing concerning trends. Additionally, poor public health indicators, rising incomes and the availability of inexpensive antibiotics over the counter are converging to create ideal conditions for a large-scale dissemination of resistance genes in India The classical example is the spread of New Delhi metallobeta-lactamase-1 (NDM-1) — a transmissible genetic element with resistance against known beta-lactam antibiotics across countries. Within a year, 70 countries reported this organism in patients. Many had no history of travel to India. There are also worrying reports of the emergence of plasmid-mediated resistance gene (mcr-1) to Colistin — a last resort antibiotics. If there is a spread of these organisms, doctors will then have run out antibiotics to treat such infections.
Antibiotics in Animals
Anti-microbials are also aggressively used in livestock, aquaculture and plant production. Growing antibiotic use in animal husbandry is resulting in a greater selection of pathogens and is being driven by an increased demand for meat and poultry. The exposure of antibiotics in a sub-optimal dose leads to emergence of resistant strains in animals and environment. Environmental bacteria, being quantitatively the most prevalent organisms, serve as the source for anti-microbial resistant genes that over time, affect humans. Along with humans, globalisation led to increase movement of livestock too. Due to better travel infrastructure, there was a rapid spread and mixing of anti-microbial resistant genes.
Read: Food is feeding antimicrobial resistance
Possible way out
A combined desire and effort from patients, physicians, hospitals, pharmaceutical companies and agriculturists along with regulation from governments will only lead to an appreciable change in cutting anti-microbial resistance. To prevent over-the-counter sales of important antibiotics, the Central Drugs Standard Control Organisation had implemented Schedule H1 in India starting March 1, 2014. But a bigger problem is that of regulating sales of substandard and illegitimate anti-microbials. Which is why — at the ground level — we need to establish an effective surveillance platform to get data about anti-microbial use and resistance in the country.
Recommendations to reduce antibiotics resistance
Drug regulatory bodies:
They must safeguard against antibiotics being sold OTC and phase out the use of anti-microbial growth promoters in livestock. Irrational antibiotics combination drugs must be banned. Certain antibiotics should be available in hospital pharmacies only.
Outpatients:
Doctors and patients must be told that antibiotics are not needed for common cold and uncomplicated diarrhea. People should be prevented from buying antibiotics over the counter without a prescription.
Hospitals: Strict infection
control practices can reduce nosocomial infections, or those originating in hospitals. Hospitals must also establish antibiotic stewardship programmes to regulate irrational antibiotics use.
For patients:
A ‘behavioral shift’ is needed among physicians and patients. There should be campaigns to educate the public and physicians about the dangers of uncontrolled antibiotic use.
The writer is Director and Head of Dept Rainbow Children’s Hospital, Hyderabad
