The right prescription for AMR

When repeatedly exposed to drugs, disease-causing bacteria and fungi undergo mutational changes making them not susceptible to routinely used antibiotics

The WHO has identified anti-microbial resistance (AMR) to be one of the top 10 global threats. The Lancet journal estimates over a million died in 2019 from AMR. The emergence of superbugs is pushing us back to the early 50s and 60s when people died due to lack of antibiotics, observes Dr S P Kalantri, director and professor of Medicine at MGIMS and Medical Superintendent of Kasturba Hospital, Wardha, who has followed the development of bacterial resistance over decades.
In the Jaipur Declaration by health ministers of the WHO South-East Asian region, in 2011, India along with other member countries committed to take stringent measures against AMR. India had the National Policy for Containment of AMR in 2011 and the first NAP (National Actional Plan) in 2017 which incorporated the contributors of the AMR in the environment directly and indirectly.

OTC antibiotics

Though it was a promising beginning, its major recommendations have not been fully implemented in any of the Indian states yet. The focus is to prevent the sale of over-the-counter antibiotics, including higher-end antibiotics which continue to be available freely without a prescription.
To address these and many associated issues, various medical societies of India came together in Chennai in 2012 and brought out a “Chennai Declaration,” a road map to tackle antibiotic resistance in India. Dr Abdul Ghafur, a senior consultant in infectious diseases, views this issue as a socio-political and economic problem requiring remedial actions from each of the contributors. While the generation of resistance of bacteria is related to excessive use of antibiotics, the spread of the same is related to socio-economic factors in a country like India where sanitation issues still predominate.

Antibiotic resistance

Dr Ghafur has witnessed the resistance of Klebsiella bacteria to antibiotics increase from two percent in 2008 to close to fifty percent now and another bacteria E Coli also developing resistance faster. Sensing 70 percent of the irrational antibiotic use is being driven by the farming, poultry, and livestock industries, Ghafur was one such strong proponent for a ban on growth promotional use of the antibiotic Colistin. Most of this antibiotic was being imported from China, which banned it in 2016. India finally banned the import of Colistin in 2019.
The genomic surveillance studies pursued by Dr Ghafur had shown half of the poultry, vegetables, and fresh fish studied and the stool samples of 14 percent of healthy volunteers had Colistin-resistant bacteria, which is again derived from the food source.

Dengue, leptospirosis, and scrub typhus cases increase during the monsoon season. Doctors use the third generation of cephalosporins to treat empirically all such fever cases Dr Kalantri has observed over the years. A typical Indian patient would have received two to three different antibiotics within the first week. During the Covid-19 pandemic, Azithromycin antibiotic usage had become a norm with no evidence that it was useful.
Irrational antibiotic prescribing by doctors stems from a lack of understanding about the drugs, partly influenced by their peers who are prescribing the antibiotics freely and being influenced by the pharmaceutical industries, feels Dr Kalantri.
Introducing AMR-related education early during medical training, good mentorship during post-graduation, and driving a cultural change among junior doctors for rational antibiotic use is the need of the hour, believes Dr Kalantri.
Mandating all the hospitals to have local antibiotic guidelines, regular monitoring of resistance patterns, and reporting and disallowing other non-allopathic practitioners from prescribing antibiotics should be implemented to address antibiotic abuse, opines Dr Priya Deshpande, Associate Professor of Community Medicine, Miraj.
Strict implementation of infection prevention guidelines and antibiotic stewardship policies if diligently implemented in hospitals can have good control of infection spread, something Dr Ghafur and his team have successfully developed with more than a decade of effort in their setup.

Regulating wastewater discharge from pharmaceutical plants, hospitals and monitoring antimicrobial residues while providing legislative support to punish the offenders, and full implementation of the Swachh Bharat Mission to improve sanitation will go a long way in addressing this source of AMR contribution.
As microbiology labs and microbiologists play a crucial role in the management of infections, innovations in point-of-care rapid diagnostics that can quickly diagnose the infection would be especially useful in the Indian setting.

Newer antibiotics are not coming to the market as anticipated. Discovering new antibiotics active against infections caused by the pathogens deemed by the WHO as a critical and high priority for new treatments is scientifically challenging. The R&D ecosystem has also been fragmented by the withdrawal of most large pharma from this area. Instead of ‘end-to-end’ research and development, there are multiple actors filling distinct roles. A scarcity of new antibiotics is also the result of the lack of profit to be made from antibiotics, which has led to under-investment in R&D, challenges in clinical trials and supply chains, and regulatory hurdles, observes Prof Laura JV Piddock, Scientific Director of the Global Antibiotic R&D Partnership (GARDP) based in Geneva. GARDP is collaborating with ICMR to conduct studies in a few public and private tertiary hospitals. These studies will generate clinically relevant data that could be used to tackle highly resistant pathogens. Prof Piddock is hopeful that G20 leadership will provide the impetus for multiple sectors of the government to tackle this complex problem.

(The author is a consultant haemato-oncologist with a special interest in stem cell transplantation at Royal Wolverhampton NHS Trust, UK. He can be reached at [e-mail])