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Insights into Editorial: The global toll of bacterial resistance to drugs

 

Introduction:

Hundreds of thousands of deaths occur today due to previously treatable infections such as lower respiratory and bloodstream infections because the bacteria that cause them have become resistant to treatment.

A comprehensive estimate of the global impact of antimicrobial resistance (AMR), covering 204 countries and territories and published in The Lancet, has found that 1.27 million people died in 2019 as a direct result of AMR, which is now a leading cause of death worldwide, higher than HIV/AIDS or malaria.

 

About Antimicrobial Resistance:

  1. Recently, the United Nations (UN) has begun considering the threat of antimicrobial resistance (AMR) to be at par with diseases like ebola, HIV.
  2. The term antibiotic resistance is a subset of antimicrobial resistance or AMR which is the ability of a microbe to resist the effects of medication.
  3. Antimicrobial resistant-microbes occur naturally and are found in people, animals, food, and the environment (in water, soil and air).
  4. They can spread between people and animals, including from food of animal origin, and from person to person.
  5. Inadequately treated sewage waste containing resistant bacteria which mixes in the environment also magnify the burden of AMR.
  6. Poor infection control, inadequate sanitary conditions and inappropriate food handling encourage the spread of AMR.
  7. AMR is facilitated by the inappropriate use of medicines, for example, using antibiotics for viral infections such as the flu.
  8. In 2015, WHO launched the Global Antimicrobial Surveillance System (GLASS) to work closely with WHO collaborating centres and existing antimicrobial resistance surveillance networks.
  9. As members of GLASS, countries are encouraged to implement the surveillance standards and indicators gradually based on their national priorities and available resources.

 

Overview of Antimicrobial Resistance in India:

  1. India is among the nations with the highest burden of bacterial infections.
  2. An estimated 4,10,000 children aged five or less die from pneumonia in India annually; with pneumonia accounting for almost 25 % of all child deaths.
  3. The crude mortality from infectious diseases in India today is 417 per 1,00,000 persons.
  4. The Food Safety and Standards Authority of India (FSSAI) banned the use of antibiotics and several pharmacologically active substances in fisheries.
  5. There is no regulation in the poultry industry where many of the commercially available pre-mixed feeds come with added antibiotics.

 

Causes Behind Acquired Antimicrobial Resistance:

  1. Overuse, misuse, and improper use (e.g., taking antibiotics to treat viral diseases!) of antimicrobials.
  2. Greater access to over-the-counter antibiotic drugs in developing countries.
  3. Using broad-spectrum antibiotics over narrow-spectrum antibiotics (targeting specific microbes only).
  4. Dumping of inadequately treated effluents from the pharmaceutical industry.
  5. Antibiotic use in livestock feed at low doses for growth promotion is industrialized countries.
  6. Poor sanitation and hygiene that forces the extended use of antimicrobials.

 

The analysis: Global Research on Antimicrobial Resistance (GRAM) report:

  1. The Global Research on Antimicrobial Resistance (GRAM) report used statistical modelling to estimate deaths linked to 23 pathogens and 88 pathogen-drug combinations.
  2. Apart from 7 lakh deaths caused directly by AMR (these would not have occurred had the infections been drug-susceptible), another 49.5 lakh deaths were associated with AMR (a drug-resistant infection was implicated, but resistance itself may or may not have been the direct cause of death).
  3. HIV/AIDS and malaria were estimated to have caused 8.6 lakh and 6.4 lakh deaths respectively in 2019.
  4. Of the 23 pathogens studied, drug resistance in six (E coli, S aureus, K pneumoniae, S pneumoniae, A baumannii, and P aeruginosa) led directly to 9.29 lakh deaths and was associated with 3.57 million.
  5. One pathogen-drug combination – methicillin-resistant S aureus, or MRSA – directly caused more than 1 lakh deaths.
  6. Resistance to two classes of antibiotics often considered the first line of defence against severe infections – fluoroquinolones and beta-lactam antibiotics – accounted for more than 70% of deaths caused by AMR.

 

Antibiotics in Covid:

  1. There is a lot of improper use of antibiotics happening in Covid too. A study reported by ICMR (Indian Council of Medical Research) from 10 hospitals showed that when Covid patients acquire drug-resistant infections in hospitals, the mortality is almost 50-60%.
  2. However, data is difficult to collect because of absence of hospital information systems in most hospitals.
  3. The real impact of drug-resistant infections in patients can be determined when the laboratory reports are connected with the clinical outcome.
  4. Until changes in ICMR guidelines earlier this week, azithromycin was routinely prescribed for all Covid patients even though there is no evidence that this is helpful.
  5. The absolute lack of regard for the life-saving value of antibiotics may come back to haunt us when we need these drugs for bacterial infections.

 

Why data matter?

  1. This is the first time we have evidence-based numbers as to what could be the toll of drug resistance in terms of morbidity and mortality.
  2. We have tried to come up with what could be the burden of these infections in the country.
  3. However, deaths are not recorded due to drug-resistant infections but reported mainly as symptoms or the disease with which the patient got admitted.
  4. It (drug resistance) has yet to be linked with clinical outcomes. That has been one of the key reasons why we have not got the policymakers’ attention to do something substantial to address the problem.

 

Conclusion:

A multi-stakeholder approach, involving private industry, philanthropic groups and citizen activists is needed. Private pharmaceutical industries must take it upon themselves to distribute drugs in a responsible manner.

Philanthropic charities must fund the development of new antibiotics, while citizen activists must drive awareness.

These stakeholders must appreciate that the only way to postpone resistance is through improved hygiene and vaccinations.

Increasing public awareness and understanding is therefore the most crucial pillar towards tackling antimicrobial resistance. AMR is an increasingly serious threat to the global public health that requires action across all government sectors and societies.