Multi drug-resistant tuberculosis and strains of total drug resistant tuberculosis, Klebsiella pneumoniae , Escherichia coli, methicillin-resistant Staphylococcus aureus (MRSA) are serious threats to public health. Plasmodium falciparum (parasite responsible for most virulent form of malaria) is rapidly developing resistance to all known classes of anti¬malarial drugs. Human immunodeficiency virus (HIV) - responsible for causing AIDS- is increasingly becoming resistant to first-line antiviral drugs. Antibiotic resistance exists for each class of antibiotics, as is the case with antivirals, antiparasitic and antifungal drugs.
Phenomenon of antimicrobial resistance has severe medical and financial costs for the entire world. It is estimated that super bug- the emerging micro organism which does not respond to any currently available antibiotics- could cost a loss of $100 trillion (more than whole of global economy put together) to the global economy by 2050. Even today, 700000 people die of resistant infections every year and the number is estimated to rise to 10 million individuals per year.
The situation is more precarious in developing counties like ours. As per a study 'State of World Antibiotics 2015' conducted by the ‘Centre for Disease Dynamics, Economics and Policy, New Delhi’, India is counted as the leading consumer of antimicrobial drugs. Another study has shown that India has the highest rate of antibiotic resistance, with resistance to some medicines touching almost 50 per cent. Also, a surveillance measure instituted last year by ICMR in six apex institutes of the country including AIIMS, PGIMER among others, found resistance to carbapenem (the strongest class of antibiotic) up to 50 to 60 per cent and in the case of acenotobacter (a hospital bug seen in ICU patients), the resistance was up to 70 to 80 per cent.
One of the main reasons of this astonishing magnitude of antimicrobial resistance is our misplaced priority on healthcare than on the public health system. In developed nations, focus is usually upon the improvement in sanitation facilities, provison of clean drinking water and proper sewerage facilities; antibiotics are used as a last resort. In India, on the other hand, antibiotics are the mainstay of tackling the routine stomach and respiratory infections; sanitation, water supply and environmental protection are given a second shrift.
Others contributory factors to the phenomenon are: high disease burden of infectious diseases due to rampant malnutrition- a condition in which we fair poorly even than sub Saharan countries- with consequent low immunity to microbial infections; sorry state of waste disposal facilities which results in mixing of antibiotic compounds with the water resources; drug companies manufacturing drugs containing sub standard dosages; failure of medical education to impart precise diagnostic capabilities to medical practitioners thus explaining their heavy reliance upon antibiotics for the cure of any disease; and convenience and laziness undergirded by ignorance of the individuals with the result that they don’t follow up the recommendations of the doctors and also take antibiotics on their own without consulting any medical practitioner. Increased usage of antibiotics in poultry and meat have also contributed to this phenomenon; in fact, it is amongst the most prominent contributors, as the demand for non vegetarian food surges in the name of diversity of food items and lifestyle demands.
Poor training and lack of motivation is the reason that many medical personnels are appalingly poor at making the accurate diagnosis and treatment plan of a disease. Consequently, they find the solution of each and every disease in antibiotics. Instances of inappropriate use include- starting antibiotics before results of tests come back, administering patients the broad-spectrum antibiotics when it is not clear which bacteria is causing the infection, or continuing antibiotics even when tests results come back negative. The fact was laid bare in a study conducted in 2014 in Bihar by Duke University and published in Journal of American Medical Association (JAMA). The researchers found that health care providers in rural Bihar universally resorted to using antibiotics for managing diarrhoea, whereas the first line of treatment recommneded by WHO is using ORS along with zinc supplementation. Antibiotics are not required at all in routine cases of diarrhoea; only poor knowledge can cause the prescription of antibiotics in routine cases. There is little reason to believe that this practice prevails in rural area of Bihar only. Even in the reputed tertiary hospitals of the country powerful and antibiotics of the last resort like Carbapeme are given for no apparent reasons.
Antimicrobials are not required in each case of infection, and many diseases are self limiting, caused as they are by viruses. Role of antibiotics in viral infections is absent at best. However, the insistence, by many patients, upon the doctors to prescribe strong medicines so that their disease wither away as soon as possible, and the failure to finish up the course at the first sign of improvement has meant that resistance in the microorganisms has always been on an upward trajectory. Easy availability of antibiotics with minimum restrictions has meant that each individual can get any antibiotic of his desire and contribute to the antibiotic resistance story.
Meat consumption in Indian diets, a shift which has often been extolled as the diversification and shift towards more nutrition, as more and more animal proteins are come to be included in diets, has increaesed 14 times as compared to the late 1980s! According to the Food and Agricultral Organization (FAO), since 1991, the year of economic reforms, there has been eight fold incresease in the consumption of eggs and 5 fold incresase in the consumption of the alcoholic beverages. Poultry and meat industries are notorious for using antibiotics broth (containing antibiotics many times advocated for human consumption) for the rapid growth of the spring chickens. These compounds then enter the human body and alter the resistance mechanism of the microorganisms.
More of demand side Management
The situation can be tackled by considering it in a holistic manner and formulating the responses targeting demand and supply sides. Of late, there has been reinvigoration of international efforts to find out new antimicrobial compounds as international momentum to fight against antimicrobial resistance continues to build. This was more evident in recent ‘World Economic Forum’ declaration at Davos where over 80 companies signed a declaration on antibiotic resistance. However, poor or developing countries like ours should not see much hope there as development of new antimicrobials is a slow and tardy procedure involving time period of decades, and the initial cost would be prohibitively high for an average resident of these countries.
So it becomes prudent to manage the demand side well. In an independent ‘Review on antibiotic resistance’ Jim O’Neill, scholar who also coined the acronym BRICS, highlights the power of simple measures to prevent infections and to slow the rise of drug-resistant superbugs. The report highlights three areas where decisive action has the potential to ‘shift the demand curve’ for antibiotics and other antimicrobials. Improved access to clean water and sanitation, greater focus on infection prevention and control in healthcare settings, and diligent surveillance of emergence of resistance are the three proposals he proffered in his review instituted last year by the Government of Britain.
It is estimated that improved water and sanitation can reduce the voulme of antibiotics by at least 60 per cent. Provisioning clean drinking water and proper sanitation facilities with scientific waste disposal system put in place will effectively reduce the incidence rate of diarrhea, the culprit responsible for increased antibiotic usage and contributor to malnutrition. Simple hand washing campaign and universal immunization program will limit the spread of microbial infection in first place. Civil society and NGOs have a much larger role to play in mobilizing masses towards the success of these campaigns.
Quality training and targeting attitudinal change in medical personnel would effectively reduce the antimicrobial consumption. Unless a strict code of practice forbids overuse and systems are put in place to monitor the behavior of medical personnel, they have the every incentive to treat the patient in front of them by any means, and not to worry about the theoretical patient a decade henceforth, who may suffer from the consequences of overuse of antibiotics. Also, development of rapid and portable diagnostics should be encouraged so that easy and early diagnosis is possible, and only suitable antimicrobials are used. Regulatory measure need to be put in place to ensure that counterfeit or substandard drugs -containing less than the proper dose of active ingredients, for example- are not given to patients.
Mainstay of the strategy to fight against antibiotic resistance should be Sensitization and nudging. Laypersons need to understand and grasp the gravity of the situation so they don’t indulge in self medication and complete the full course of antibiotics prescribed to them. Food campaigns to spread awareness about the adverse effects of excessive consumption of processed food and meat should be organized so that the people take a concious decision of their food habits and not always get lured by misguiding advertising campaigns of brands, or go by the biased perception towards traditional Indian diet being deficient in nutrients.
About the Authors: Dr. Varun Dhamija is Consultant Endodontist and Dr. Ruchi Juneja, is Ex Senior Resident, PGIMER, Chandigarh