Antibiotics are one of most revolutionary discoveries of modern science. Ever since their accidental discovery by Alexander Fleming (1928), antibiotics have completely transformed medicine. By virtue of their lethal and selective action against pathogenic microbes, they have contributed to the dramatic extension of human lifespan. But in recent years pathogens have advanced their defences to fight against antibiotics. Thus even our powerful arsenal of antibiotics weapons accumulated over decades seems to fall short in this war against pathogens. Superbugs or microorganism with antibiotic resistance has emerged as a new threat to humanity. The world is now transitioning into a “post-antibiotic era” where common infections and minor injuries will become deadly once again, due to increasing “Anti-Microbial Resistance” (AMR) of microbes. As a result, many lives are being lost due to deadly infections caused by continuously evolving strains which are beyond our capabilities to eradicate or to prevent their spreading.
What is a Superbug?
A superbug, also called multi resistant, is a bacterium that carries several resistance genes. These are resistant to multiple antibiotics and are able to survive even after exposure to one or more antibiotics.
What is AMR?
The WHO defines antimicrobial resistance as a microorganism’s resistance to an antimicrobial drug that was once able to treat an infection by that microorganism.
The main reasons for the antimicrobial resistance are as follows:
The natural resistance in certain types of bacteria.
The genetic mutation.
By one species acquiring resistance from another
What causes bacteria to mutate like that?
Like all other living organisms, bacteria can mutate and evolve as they multiply. So, over time, a select few will mutate in particular ways that make them resistant to antibiotics. And thus, when antibiotics are introduced, only the bacteria that can resist that treatment can survive to multiply further, proliferating the line of drug-resistant bugs.
Important points to remember:
- The resistance to antimicrobials is a natural biological phenomenon.
And it is the microbe which will become resistant to antibiotics and not the person (patient). A person cannot become resistant to antibiotics because the resistance is a property of the microbe, and not by a person or other organism infected by a microbe.
- Resistance can appear spontaneously because of random mutations, or by more commonly following the gradual build up over time, and because of misuse of antibiotics or antimicrobials.
- The resistance is generally slow to reverse or is irreversible. This urges that the interventions to stop the development of resistance should be implemented early before resistance becomes a problem.
What are the Factors responsible for increasing AMR?
The rising consumption of antibiotics is a major contributor. The microbes can develop drug resistance when people take incorrect doses of antibiotics. Resistant strains can then be contracted directly from animals, water, air or other people.
- Misuse of antibiotics in animal husbandry: They are given as growth promoters in animals and fishes. Irrational administration of antibiotics to livestock then gets passed off to humans through animal products such as meat. Food crops grown in water and fertilizers containing animal faeces and drug-resistant bacteria when consumed by humans leads to the introduction of resistant strains in humans
- Poor regulation of pharmacies, Cheap antibiotics, Self Medication: The lack of awareness among patients regarding the appropriate use of antibiotics has led to self-medication and non-adherence to the prescribed course of antibiotics, further intensifying the problem. Over the counter sale of drugs and improper consumption of antibiotics without prescription of a medical practitioner.
- Unhygienic conditions near drug manufacturing centres and active pharmaceutical ingredients.
- The weak public health system, creates poor infection control, aided by inadequate sanitary conditions give an ideal environment for the development of superbugs.
- Excessive Prescription of antibiotics for a variety of diarrhoeal and respiratory infections despite their limited curative potential has exacerbated the situation.
- Administration of broad-spectrum antibiotics as an empirical therapy to the outpatients is another factor that leads to the emergence of resistant strains.
Why does the world need to worry to about AMR and superbugs?
- Ever since the discovery of Penicillin countless antibiotics have been developed which have saved millions of lives. Although antibiotic resistance develops naturally with normal bacterial mutation, humans are speeding it up by using antibiotics improperly.
- AMR is increasingly responsible for killing, hampering the control of infectious diseases by rendering Lives saving drugs impotent. It increases the costs of health care due to lengthier treatments required in hospitals. AMR poses severe challenges to medical procedures like organ transplants, major surgeries, etc. which rely on effective antimicrobials for success. This jeopardizes health-care gains to the whole society. On a global level, it threatens the ground covered in Millenium Development Goals and endangers the achievements of Sustainable Development Goals.
- The World Health Organization (WHO) is afraid of a post-antibiotic world, where loads of bacteria are superbugs. Many experts fear that we’re one step away from deadly, untreatable infections since the mcr-1 E.coli is resistant to that last-resort antibiotic Colistin. Evidently many infections like tuberculosis, gonorrhoea, and pneumonia are becoming harder to treat with topical antibiotics. Moreover, anyone, of any age, in any country, can get an antibiotic-resistant infection – irrespective of their intake of antibiotics.
- According to a research, now, in the US, over 2 million infections are caused by bacteria resistant to at least first-line antibiotic treatments, (and 23,000 of them die of those infections) costing the US health system $20 billion each year.
Nearly 2 lakh people die every year from multi-drug and extremely drug-resistant TB.
Why is AMR a bigger concern for INDIA?
India is presently facing a dual challenge of overconsumption of antibiotics breeding drug-resistant bacteria while ensuring that the poor and vulnerable have easy access.
The lack of access or delayed access to effective antibiotics is causing more deaths in India than from drug-resistant bacteria.
What are the reasons for the recent increase in the use of antibiotics in India?
The reasons for the sharp increase in antibiotic use are as follows:
- The high disease burden.
- The easy and cheap availability of these medicines to the public.
- The uncontrolled sales of antibiotics.
- Poor public health infrastructure.
- Lack of awareness regarding the misuse of antibiotics.
India has one of the world’s highest infectious disease burdens and inappropriate and irrational use of antimicrobial agents against these diseases, leading to increasing in development of antimicrobial resistance.
The health sector in India suffers from gross inadequacy of public finance which will result in the conditions favourable for the development of drug resistance. The burden of poor sanitation and malnutrition exacerbates these conditions.
In India, around 5% of GDP is spent on health out of which public health sector contributes to 0.9% and rest is covered by the private health sector. Again around 80% share of private health sector contribution comes from out of pocket expenditure mostly for medicines.
On top of it, AMR can further increase out of the pocket expenditure and accelerate the incidence of poverty. The patient remains sick for a longer period thus requiring prolonged treatment usually with expensive and at times toxic drugs which results in increased morbidity and mortality. Thus the burden on the health system also increases.
Hospital-acquired infection (NOSOCOMIAL INFECTIONS) in vulnerable patients with resistant strains is another major threat in the Indian context. This can undermine the thrust toward achieving SDG.
Various laboratories in India reveal an increasing trend of development of resistance to commonly used antimicrobials in pathogens like Salmonella, Shigella, Vibrio cholerae, Staphylococcus aureus, Neisseria gonorrhoeae, N. meningitis, Klebsiella, Mycobacterium tuberculosis, HIV, Plasmodium and others.
In India, 60,000 newborns die each year of Antibiotic-Resistant Neonatal Infections. Around 70 percentage of diarrhoeal illness is caused by viral infections, against which antibiotics are ineffective. But for diarrhoea treatment antibiotics are used frequently. Nearly 500 million antibiotics courses are used each year to treat diarrhoea in India, Indonesia, Nigeria and Brazil. The Universal access to improved water and sanitation could reduce this by 60 per cent.
What has India done to tackle the problem of AMR?
- IIMAR (Indian Initiative for Management of Antibiotic Resistance): launched in March 2008, with WHO support, by a consortium of NGOs to promote prudent use of antimicrobials.
- INSAR (Indian Network for Surveillance of Antimicrobial Resistance):
a network of 20 laboratories in the private as well as public sector across the country to generate quality data on AMR
- The government is urging hospitals to get accredited with the National Accreditation Board for Hospitals and Health Care Providers which will result in practices relating to judicious use of antibiotics.
Amendments to drug and cosmetic rule to include no: of antibiotics in the H1 schedule in pursuance of national policy for containment of AMR (Redline campaign)
- The National Health Policy 2017 highlights the problem of antimicrobial resistance and calls for a rapid standardization of guidelines regarding antibiotic use, limiting the use of antibiotics as over-the-counter medications, banning or restricting the use of antibiotics as growth promoters in animal livestock, and pharmacovigilance including prescription audits inclusive of antibiotic usage – in the hospital and community.
Kerala is all set to become adopt a comprehensive policy to fight AMR. It has recently prepared a draft.
In line with the WHO’s GLOBAL ACTION PLAN ON AMR, India has formulated a NATIONAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE with following components :
- Improve awareness and understanding of AMR through effective communication, education and training.
- Strengthen knowledge and evidence through surveillance
- Reduce the incidence of infection through effective infection prevention and control
- Optimize the use of antimicrobial agents in health, animals and food
- Promote investments for AMR activities, research and innovations
- Strengthen India’s leadership on AMR
The NAP-AMR outlines the priorities and interventions planned to be implemented over 2017 –2021 to tackle the public health challenge of AMR in India
- The Union health ministry’s Anti-Microbial Resistance awareness campaign urges people not to use medicines marked with a red vertical line, including antibiotics, without a doctor’s prescription. These medicines are called the ‘Medicines with the Red Line’.
- To check the irrational use of antibiotics, the ‘red line’ will helps the users to differentiate them from other drugs.
- This campaign is aimed at discouraging unnecessary prescription and over-the-counter sale of antibiotics causing drug resistance for several critical diseases including TB, malaria, urinary tract infection and even HIV.
What are the other solutions available to combat the Antimicrobial Resistance?
- Educate patients and the general community on the appropriate use and dangers of misuse of antimicrobials.
- Educate all groups of prescribers and dispensers (including drug sellers) on the importance of appropriate antimicrobial use and containment of antimicrobial resistance.
- The Prescription Audit may minimize the overuse and misuse of drugs, helps to plan essential drug selection and to estimate the drug need of the community and help the health administrators, policy planners, manufacturers, distributors, health professionals and various consumer groups for their decision making.
- The regular review of health care procedures and documentation of auditing is also important in combating AMR
- Link professional registration requirements for prescribers and dispensers to requirements for training and continuing education.
- Control and monitor pharmaceutical company promotional activities within the hospital environment and ensure that such activities have an educational benefit.
- Establish infection control programs, based on current best practice, with the responsibility for effective management of antimicrobial resistance in hospitals and ensure that all hospitals have access to such a program.
- Improving the sanitation, proper vaccination and maintaining a good and healthy lifestyle can prevent the use of antibiotics to an extent.
It is estimated that the prevalence of Multi-Drug-Resistant Tuberculosis (MDR-TB) in India is 2-3%among the new pulmonary TB patients and around 15% for re-treatment pulmonary TB patients. There are numerous challenges that we need to overcome in order to cope up with the menace of antimicrobial resistance in superbugs. Some of them being: strengthening of surveillance data, the establishment of standard operating guidelines, improving antibiotic prescription practices and stopping self-medication and over the counter sale of antibiotics, addressing poor sanitation, endemic infections, malnutrition and limited public awareness & government commitment, lack of coordination & fragmentation of effort etc.
Way out lies in effectively overcoming the above-mentioned challenges to tide over the looming destructive consequences. We also need to focus on research related to public health aspects of AMR at community and hospital level. India will need a revamped healthcare system in place to provide optimum treatment to its population and manage the extensive risks posed by the superbugs. Nations all over the world need to come together and urgently address the indiscriminate use of antibiotics as superbugs are being transmitted across international borders. The research on the next generation of drugs is also required to be fast-tracked in the meantime.
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