7 PM | Antimicrobial Resistance in India- An Analysis | 18 January, 2019

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What is antimicrobial resistance?

• Antimicrobial resistance is resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it. Among AMR, antibacterial resistance (ABR) is of prime concern.
• Microorganisms that develop antimicrobial resistance are called “superbugs”

Antimicrobial Resistance in India- Statistics

• According to Scoping Report on Antimicrobial Resistance in India, in 2014, India was the highest consumer of antibiotics, followed by China and the United States.
• India has some of the highest antibiotic resistance rates among bacteria that commonly cause infections in the community and healthcare facilities.
• Resistance to carbapenem class of antibiotics (one of the last-resort antibiotics) is the highest

Factors contributing to Antimicrobial Resistance in India:

1. High consumption of broad-spectrum antibiotics: High consumption of broad-spectrum antibiotics instead of narrow spectrum antibiotics due to changing prescription practices is a major contributing factor for AMR in India.
2. Improper use of Antibiotic fixed-dose combinations (FDCs):Indiscriminate use of antibiotic FDCs even without the knowledge of a proven advantage over single compounds, has led to the emergence of bacterial strains resistant to multiple antibiotics
3. Inappropriate use of antibiotics by public: Self-medication, access to antibiotics without prescription, use of pharmacies and informal healthcare providers as sources of healthcare, and lack of knowledge are major concerns
4. Inappropriate antibiotic prescribing: Many factors contribute to inappropriate prescribing by doctors such as perceived patient demand, fear of losing patients economic incentives from pharmaceutical companies.
5. Cultural Factors:cultural activities such as mass bathing in rivers (such as Ganga) as part of religious mass gathering occasions give arise to concerns over potential acquisition and spread of antibiotic-resistant bacteria
6. Antibiotics in food animals: There is rampant use of antibiotics as growth promoters in food animals and poultry industry in India. Antibiotic-resistant bacteria can be transmitted between humans and animals through food and environment.
7. Environmental Sanitation: Poor sanitation conditions in India plays a significant role in the spread of antibiotic-resistant bacteria and other microbes.
8. Pharmaceutical Industry Pollution:The effluents from the pharmaceutical industries contain a substantial amount of antibiotics, leading to contamination of rivers and lakes in India
9. Poor Infection control practices in healthcare settings:Poor infection control practices (egg. Hand washing practice) in most of the healthcare system has contributed to increasing AMR.
10. Water Contamination: Ineffective industrial effluent and sewage management has led to widespread contamination of water bodies with antibiotic residues. Subsequently recontaminating humans and animals through drinking water and food

Concerns:

1. Loss of first-line antibiotics:Due to growing resistance of pathogens to antimicrobial drugs first-line antibiotics are becoming redundant making a broad range of common infections much more difficult to treat.
2. Resistance to last resort antibiotics:Resistance to last resort antibiotics such as carbapenem class of antibiotics is on a rise.
3. Increased Cost and time of treatment: Resistant infections cost more to treat and can prolong healthcare use
4. Economic Impact: Studies estimate that if AMR continues to increase it would lead to reduction of 2% to 3.5% in GDP and amount to a loss of 100 trillion$ by 2050
5. Mortality:Number of researches in United Kingdom estimated that by 2050, as many as 10 million people globally could die annually from AMR complications.
6. Impact on Life threatening diseases:Resistance is an emerging concern for treatment of HIV infection, TB etc.

India’s Approach towards tackling AMR

1. National Policy for containment of Antimicrobial Resistance, 2011: It aimed at enforcement and enhancement of regulatory provisions for use of antibiotics for humans and for veterinary use.
2. Chennai Declaration, 2012: It aimed to initiate efforts to formulate a national policy to control the rising trend of AMR, and to take all possible measures to implement a strategy to combat AMR
3. National Programme for Containment of AMR (2012-17): It seeks to:

• Establish a laboratory based surveillance system to generate quality data on antimicrobial resistance
• Generate awareness among healthcare providers and in the community regarding rational use of antibiotics.
• Strengthen infection control guidelines and practices and promote rational use of antibiotics.

4. Red Line Campaign, 2016:It calls for prescription-only antibiotics to be marked with a red line, to discourage the over-the-counter sale and irrational use of antibiotics.
5. National Action Plan on Antimicrobial Resistance- Delhi Declaration , 2017: focuses on six strategic priority areas:

• Awareness and understanding through education, communication and training,
• Strengthening knowledge and evidence through surveillance,
• Infection prevention and control,
• Optimised antimicrobial use in health, animals and food,
• AMR-related research and innovation
• Strengthened leadership and commitment at international, national and sub-national levels.

6. Others:

• The Drugs and Cosmetic Rule, 1945 were amended in 2013 to incorporate a new Schedule H1 under which include 3^rd and 4^th generation antibiotics for having strict control over the sale of these drugs
• In 2017, FSSAI released certain guidelines limiting the antibiotics in food products
• The Department of Animal Husbandry, Dairying and Fisheries issued Advisories in 2014 to all States and Union Territories regarding judicious use of antibiotics to prevent AMR.

7. State-level:Kerala is India’s first state to release a comprehensive action plan to contain Antimicrobial resistance.

Challenges with tackling AMR:

1. Inadequate access to allopathic care for most people in India force them to go to untrained doctors in the private sector or quacks where there is maximum abuse of antibiotics
2. India has no public database of mortality caused by AMR and the surveillance system is in its nascent stage.
3. New antibiotics are not being introduced in the market as most pharmaceutical companies do not consider antibiotics as a good source of revenue generation and hence there is little R&D
4. CPCBs effluent standards for pharmaceutical industry waste do not include antibiotic residues, and thus they are not monitored in the pharmaceutical industry effluents
5. There is lack of proper training plan and material for appropriate use of antibiotics to impart training to professionals and workers in health and veterinary sectors.

Way Forward:

1. Awareness:The first step to combat AMR is to improve awareness and understanding of AMR through effective communication, education and training
2. Diagnostic stewardship: Reducing unnecessary prescribing of antibiotics, and ensuring appropriate prescribing through appropriate use of microbiological diagnostic
3. Strict Regulation: It is important to strengthen and expand regulatory mechanisms for production, sale and use of antibiotics in both human and animal health sectors.
4. Surveillance: It is important to have robust surveillance mechanisms in the health and veterinary sectors to generate reliable epidemiological information, baseline data, trends on antimicrobial resistance, and impact on the economy and health.
5. R&D: Increased R&D focussing on development and use of new diagnostics, new antibiotics and alternatives to antibiotics.

Glossary 

Source: https://www.livemint.com/Industry/0gKNQmAXGioNu1wS1ad9UN/Hooked-to-the-pill-Indias-antibiotics-overkill.html