Ensure enforcement of rules to combat antimicrobial resistance

Rakesh Kochhar

Ex-President, Indian Society of Gastroenterology

THE Union Government recently advised doctors in medical colleges to mention the exact indication of the use of antibiotics in their prescription. It also instructed chemists and pharmacists not to dispense antibiotics without a doctor’s prescription. These directives were issued keeping in mind the rising incidence of antimicrobial resistance (AMR) in the country. In its 2014 report, the World Health Organisation (WHO) brought out the extraordinary rates of AMR in India, which is now the AMR capital of the world.

A survey conducted by the National Centre for Disease Control (NCDC) at 20 hospitals between November 2021 and April 2022 produced worrisome data. Of the over 9,600 patients surveyed, 72 per cent received at least one antibiotic, while a quarter of them received two or more. Significantly, 55 per cent of the patients were given antibiotics for preventing infection and not to treat any disease. The data sums up the prevalent practice across the country. Cough, cold, sore throat and acute diarrhoea are mostly self-limiting, and are often caused by viral infections that do not need antibiotics.

A study by Harvard University and UNICEF had gathered data from 70,000 patients who had turned up at clinics during the Kumbh Mela at Allahabad (Prayagraj) and Nashik in 2013 and 2015, respectively. About one-third of the patients walking into the clinics were prescribed antibiotics. At Prayagraj, nearly 70 per cent of the patients with respiratory symptoms received antibiotics.

AMR is one of the top global public health concerns. The WHO says that antibiotic resistance — the development of strains of microorganisms that do not respond to conventional antibiotics — can pose a ‘global threat’ to public health. Such resistant infections led to at least three lakh deaths in India and 1.27 million deaths worldwide in 2019. By 2050, the toll is expected to rise to 50 million. With the world becoming a ‘global village’ due to ease of travel, resistant organisms and infections can travel across continents at a very rapid pace, as was shown by the spread of Covid-19.

The WHO has classified antibiotics into three categories (AWaRe): access, watch and reserve, with the latter two being advocated only when specifically indicated. The ‘access’ group is for highly targeted compounds that are unlikely to cause antimicrobial resistance and are the first line antibiotics to be prescribed. The NCDC survey showed that 60 per cent of the antibiotics prescribed in India belonged to the ‘watch’ or ‘reserve’ groups. Giving higher antibiotics is counter-productive as it leads to antibiotic resistance that can spread in the community, and the subsequent infections can become difficult to treat.

Antibiotics fall under Schedule H/H1 of the Drugs and Cosmetics Rules, 1945, and can be sold only on prescription written by registered medical practitioners. However, the implementation of rules is lax in India, and chemists often dispense antibiotics on their own.

The WHO had formulated a ‘global action plan’ in 2015, and India followed suit in 2017 with an antimicrobial surveillance programme, an antibiotic stewardship programme and surveillance for drug resistance. A review of the plan, however, showed shortcomings in its implementation. While the WHO recommends the concurrence of infectious disease specialists when using higher antibiotics, India is woefully short of such trained personnel.

The ramifications of AMR go much beyond the simple misuse of antibiotics in humans. Antibiotics are often given to livestock for different reasons. It is, therefore, not surprising that bacterial cultures from milk, poultry and fish often show the growth of drug-resistant organisms. Similarly, resistant organisms are reported from various water sources, where they enter through pharmaceutical waste, hospital effluents, sewage and domestic waste. Open defecation is also a contributing factor, as the antibiotics excreted in urine and stool contaminate groundwater. Thus, faeces-contaminated water consumed by humans and livestock perpetuates the spread of resistant microorganisms.

Though antibiotic stewardship has shown a decrease in the use of antibiotics in hospitals where it was conducted, the situation in smaller hospitals and rural areas is worse. There is a lack of trained personnel and quality laboratories. Quacks and semi-trained healthcare workers are the first line of interface, and non-allopathic doctors also prescribe antibiotics. While only simple or ‘access’ antibiotics might be getting prescribed in rural areas, there is an indiscrete use of higher and often multiple antibiotics in cities.

The implications of AMR can be far-reaching — prolonged hospitalisation, an increase in cost and fatal hospital-acquired infections. Some years ago, a drug-resistant bacterium (Klebsiella spp), labelled the ‘Delhi superbug’, had a mutation that provided it resistance to most antibiotics. Antibiotics not only kill disease-causing microorganisms but also the beneficial ones in our intestines that form the microbiome. Alterations in the microbiome cause damage to the protective lining of the gut and are now incriminated in diseases like autoimmune diseases, inflammatory bowel diseases, neurological and degenerative diseases.

The ‘One Health’ concept, which encompasses the interdependence of human, animal and environmental parameters, should be used for the containment of AMR. There is also a need to have surveillance of AMR in different patient populations, along with changing patterns of drug resistance. Water supply, hospital and industrial waste should be tested periodically.

There is a need to educate the public through campaigns in the media. More importantly, doctors in clinics and smaller hospitals need to be updated. The Indian Council of Medical Research should prepare guidelines on indications and choices of antibiotics for different diseases and disseminate them widely. The wide network of the Indian Medical Association should be used for antimicrobial stewardship. Over-the-counter sale of antibiotics cannot be prevented by mere advisories to pharmacists. The government’s advice to clearly state the indication of antibiotics in the prescription is a step in the right direction but difficult to enforce.

To combat the emergence of AMR in catastrophic proportions, we need urgent measures in the form of public awareness campaigns, training of healthcare professionals, microbiological surveillance, fresh guidelines and strict implementation of rules.

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