Insights into Issues: Antimicrobial resistance
Antibiotic resistance arises when bacteria evolve mechanisms to withstand the drugs which are used to fight infection. It is one of the most important public health issues currently. Antimicrobial resistance happens when microorganisms (such as bacteria, fungi, viruses, and parasites) change when they are exposed to antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and anthelmintics). Microorganisms that develop antimicrobial resistance are sometimes referred to as “superbugs”. As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others.
Why is antimicrobial resistance a global concern?
- New resistance mechanisms are emerging and spreading globally, threatening our ability to treat common infectious diseases, resulting in prolonged illness, disability, and death.
- Without effective antimicrobials for prevention and treatment of infections, medical procedures such as organ transplantation, cancer chemotherapy, diabetes management and major surgery (for example, caesarean sections or hip replacements) become very high risk.
- Antimicrobial resistance increases the cost of health care with lengthier stays in hospitals and more intensive care required
- Antimicrobial resistance is putting the gains of the Millennium Development Goals at risk and endangers achievement of the Sustainable Development Goals
- For developing countries like India the emergence of resistance is likely to cause a huge economic burden on account of negative externalities like health
The World Alliance against Antibiotic Resistance (WAAAR) — a conglomerate of 600 individuals from 50 countries and 96 professional groups — is concerned by the increasing incidence of antibiotic resistance.
Reasons for Antibiotic Resistance:
- Caused by indiscriminate use, wrong dosage, not completing the treatment, poor hygiene, poor regulation, wrong incentives for doctors to prescribe them
- Unchecked use of antibiotics in humans, agriculture and livestock. In animal husbandry,these medicines are used not only to treat diseases but also to enhance the body mass of animals to increase their food yield. Last year a report in Delhi found unusual levels of antibiotic in poultry. This has important repercussions on human health
- The scale-up in antibiotic use in India has been enabled by rapid economic growth and rising incomes, which have not translated into improvements in water, sanitation, and public health. Antibiotics continue to be prescribed or sold for diarrheal diseases and upper respiratory infections for which they have limited value
- Health system factors are also at fault. Doctors routinely receive compensation from pharmaceutical companies and pharmacists in exchange for antibiotic prescriptions. Infection control in hospitals is poorly monitored and could be improved
- The problem of resistance is exacerbated by a wide range of fixed-dose combinations in the market, often without scientific or medical merit or evaluation. A recent study reported 48 fixed dose combinations and 22 loose antimicrobials for tuberculosis. Loose antimicrobials come without packaging and do not mention the name of the drug, its manufacturer, the date of manufacture, or the date of expiry. There is poor clinician awareness of the rationality and dosing of fixed-dose combinations
- Environmental antibiotic pollution encourages the transfer of resistance genes to. In particular, waste water treatment plants serving antibiotic manufacturing facilities have been implicated in the transfer of resistance genes into humans and pose a serious threat to antibiotic effectiveness given the size of India’s pharmaceutical sector
Why in news?
- Antibiotic resistance on the rise due to rise of superbugs. Earlier lancet had reported the rise of New Delhi Metallo-beta-lactamase-1 which was an enzyme that rendered bacteria resistant to a broad spectrum of antibiotics. A strain of the NDM1 had crossed the shores and spread resistance in the U.K. as well. Now another report in Lancet has stated the rise of Klebsiella, Acinetobacter, Ecoli in India
- It led to death cases in even minor diseases like sepsis and pneumonia. 26% of babies with sepsis died as Multi Drug Resistance made the ailment untreatable
- A March 2016 paper on ‘Antibiotic Resistance in India: Drivers and Opportunities for Action’ in PLOS Medicine makes a convincing case for action against resistance: “Antibiotic resistance is a global public health threat, but nowhere is it as stark as in India. The crude infectious disease mortality rate in India today is 416.75 per 100,000 persons…twice the rate in the U.S. (200) when antibiotics were introduced.”
Steps taken to deal with the menace:
- Over-the-counter access to antibiotics is a problem, but regulations to restrict access have to be balanced against the need to maintain access for the significant proportion of the population that lacks access to doctors. Indeed, lack of access to effective and affordable antibiotics still kills more children in India than does drug resistance. However, to prevent over-the-counter (OTC) sales of important antibiotics, the Central Drugs Standard Control Organization (CDSCO) implemented Schedule H1 that takes an important first step in that direction by introducing a stringent rule that prohibits medical stores from selling 24 key antibiotics without a doctor’s prescription
- Further the ICMR has set upNational Anti-Microbial Surveillance Network for understanding of underlying mechanisms of resistance
- National Cell for Monitoring Anti Microbial resistance:Govt has also decided to start a Rs 30 Crore Surveillance Plan in tertiary care centres across the country
- National Policy for Containment of Antimicrobial Resistance(2011), to address theproblem of multi-drug resistance due to widespread and indiscriminate use of antimicrobial / antibiotic drugs in the country. The salient features of the policy are as follows:
- Toreview the current situation regarding manufacture, use and misuse
- To initiate studies documenting prescriptions patterns & establish a monitoring system for the same.
- To recommend the design for creation of a National Surveillance System for Antibiotic Resistance
- To enforce and enhance regulatory provisions for use of antibiotics in human & veterinary and industrial use.
- To recommend specific intervention measures— such as rational use of antibiotics and antibiotic policies in hospitals
- Diagnostic Methods pertaining to antimicrobial Resistance Monitoring
Steps needed further:
- Much more needs to be done, including getting doctors to prescribe antibiotics only when essential. Behaviour change is needed among physicians and patients. India has achieved remarkable reductions in smoking in buildings and workplaces through regulation and behavior change communication. Similar campaigns could work to educate the public and physicians about the dangers of uncontrolled antibiotic use, as has been the case in high-income countries
- Changes in rules under which physicians can accept compensation are already in place under the rules of the Medical Council of India, and should be extended to cover prescriptions for antibiotic sales
- Hospitals must pay attention to proper infection control.
- Awareness drive around rationalisation of antimicrobial drug usage and acceleration of R&D activities for novel and more effective drugs.
- Incorporating principles of antimicrobial stewardship and appropriate use into undergraduate and postgraduate medical education can be implemented and is under consideration by the Government of India. A more difficult problem is that of regulating the sales of substandard and illegitimate antimicrobials, the extent of which is poorly quantified
- There are no regulations governing the discharge of antimicrobial waste into the environment, and these are needed.
- Currently, India does not have regulatory provisions for the use of antimicrobials in cattle, chickens, and pigs raised for domestic consumption. Recent studies in various regions of India have discovered antimicrobial residues in food animal products (such as chicken meat and milk), indicating that antibiotic use in food animal production is widespread. There are no standards for tolerance of antibiotic residues in poultry, although such standards do exist for seafood—including shrimps, prawns, or any other variety of fish and fishery products—under the Food Safety and Standards Regulations of 2011. Effective limits on antimicrobial growth promoters in India could have knock-on effects on neighbors such as Bangladesh, Nepal, and Sri Lanka that are likely to be guided and influenced by regulatory action in India, given the interconnectedness of the region’s pharmaceutical commerce
WHO Report states that “ the world is headed for a post- antibiotic era in which common infections and minor injuries, which have been treatable for decades, can once again kill,”. Resistance has negative externalities for the whole society. Due to reckless use, they are not only losing their effectiveness but becoming resistant. It was only about 70 years ago that penicillin was discovered. Today the resistance in microbes is developing at a much faster rate than the rate at which new drugs are developed. Much needs to be done, not only by governments but also by the private sector, which manages a big proportion of health care, as well as the veterinary sector