Antimicrobial Resistance (AMR) in India – Explained Pointwise

A recent major study of hospitalised patients across India has found that infections caused by antibiotic-resistant bacteria are more likely to be fatal and more expensive to treat than infections caused by drug-susceptible strains. Conducted by the ICMR’s AMR Surveillance Network across 20 tertiary-care hospitals, the study analysed data from nearly 1.6 lakh patients.

What is Antimicrobial Resistance? What are the different kinds of Antimicrobial Resistance?

• Antimicrobial Resistance (AMR) is the resistance of microorganisms (bacteria, virus, parasites and fungi) to an antimicrobial agent (antibiotics, fungicides, antiviral agents and parasiticides), to which they were first sensitive.
• As a result of AMR, standard treatments become ineffective, and infections can persist, potentially spreading to others.
• WHO declared AMR one of the top 10 global public health threats.

Types of Antimicrobial Resistance:

What is the extent of AMR in India according to the National Centre for Disease Control (NCDC) Report on AMR?

1. Bacteria like E. coli, Klebsiella, Acinetobacter, Staphylococcus aureus, enterococcus have become resistant to even the latest generation of antibiotics.
   
2. Third-generation antimicrobial drugs like cephalosporins, imidazoles, amino-glycosides, ceftriaxone, metronidazole, amikacin and piperacillin, used to treat cold, fever, skin diseases and urinary tract infection have become ineffective.
   
3. E. coli showed over 80% resistance to ampicillin and more than 70% resistance to the third-generation cephalosporin cefotaxime.
4. MRSA (methicillin-resistant Staphylococcus aureus) prevalence stood at a national average of 47.8%, but reached as high as 65% in states such as Bihar, where weaker healthcare infrastructure compounds the problem.
5. Inappropriate use of antibiotics in human, animal and agricultural sectors has generated superbugs that are resistant to these antibiotic drugs, which spread due to inadequate sanitation and improper infection prevention in healthcare.

What are the reasons behind the growth of Antimicrobial Resistance in India?

1. Misuse of antimicrobial medicines: The use of antibiotic medicine in non-bacterial infections, use of over-the-counter antibiotics, self-medication and emergence of fixed drug compositions, have contributed to the increase in antimicrobial resistance in India. For e.g. Overuse of antimicrobial medicines during the Covid-19 outbreak.
2. Inadequate laboratory facilities: India lacks severely in the laboratory network and capacity to support Clinicians/Doctors with the bacterial culture test and suggesting an appropriate antibiotic.
3. Lack of trained healthcare personnel: There is lack of adequate training of healthcare personnel in antibiotic selection, escalation, and de-escalation.
4. Inadequacy of healthcare facilities: Overcrowded hospitals have left very little time for the doctors to examine patient’s medical history, conduct proper blood tests and then recommend proper antimicrobial treatment.
5. Inappropriate use of antimicrobials in agriculture and allied sectors: The overuse of antimicrobials in agriculture and allied sector have led to increase in AMR. For e.g. Use of Colistin as growth promotional agent in poultry farming has led to Colistin AMR in India.
6. Inadequate monitoring: India lacks proper monitoring system to control the antibiotic prescription and dispensing practice by health system. For e.g. Ineffective monitoring to stop the sale of over the counter antibiotics.
7. Self-Medication: Patients often take leftover antibiotics or stop their prescribed courses early when symptoms improve, leaving surviving, resistant bacteria to multiply.
8. Patient Non-Compliance: When patients don’t complete their full course of antibiotics, the infection isn’t fully cleared, and the surviving bacteria are more likely to develop resistance.
9. Crony capitalism: The pharmaceutical industry incentivises the sale of antibiotics by being hand in gloves with the healthcare personnel like doctors, pharmacists etc.
10. Contamination around pharmaceutical manufacturing sites: The untreated waste from the pharmaceutical industries releases large amounts of active antimicrobials into the environment.
11. Inadequate sanitation facilities: Poorly functioning sanitation systems like open defecation, poorly contained septic tanks have led to increase in AMR.
12. Improper infection prevention in healthcare institutions: AMR has also spread due to the lack of proper infection prevention mechanism in hospitals, clinics and laboratories. For e.g. Candida auris acquired by hospital patients.
13. No new antimicrobial developments: The exit of big pharma from antibiotic development and lack of investment from venture capitalists to support the commercial viability of antibacterial agents, has pushed AMR into a global health crisis.

What are the challenges posed by spread of Antimicrobial Resistance?

1. Threat to the healthcare system: The antimicrobials helped in significantly reducing the mortality rates in low and middle-income countries (LMICs) of Asia and Africa. The ineffectiveness would impair the modern health system by failing to prevent infections post a routine surgery or cancer treatment.
2. Loss of Human Lives: Drug-resistant infections can lead to severe complications and deaths, particularly among ICU patients, newborns, elderly people and immunocompromised patients. AMR is responsible for up to 7 lakh deaths a year (GRAM Project Report). For e.g. E.coli and MRSA (Methicillin Resistant Staphylococcus Aureus) are among the drug-resistant bacteria that lead to most deaths.
3. Economic Brunt: Prolonged illness and disability keep working-age adults out of the workforce. The World Bank estimates that by 2050, AMR could cause a 3.8% reduction in global GDP, pushing up to 28 million people into poverty, with developing nations hit the hardest. As per an estimate by the Global Research on Antimicrobial resistance (GRAM) project, AMR can lead to an economic brunt on the world economy to the tune of US $1 trillion by 2050.
4. Threat to Food Security: AMR in livestock, poultry and aquaculture can affect animal health and productivity and facilitate transmission of resistant organisms through the food chain, making AMR a major One Health challenge.
5. Inequality in Healthcare: Poorer populations are particularly vulnerable because they may face limited access to diagnostics, quality medicines and specialist care, while resistant infections impose higher treatment costs.
6. Looming possibility of next pandemic: There is a looming possibility that the next pandemic will be caused by a superbug. For e.g. Concerns about the spread of C. Auris superbug.

What steps have been taken to control AMR?

Domestic Steps and Actions:

Global Steps and Actions:

What measures should be adopted to effectively combat & reduce AMR?

AMR is a complex socio-economic and political challenge and not just a scientific issue to be solved by doctors and researchers alone.

1. Promote Antimicrobial Stewardship: Ensure antibiotics are prescribed only when necessary, using the right drug, dose and duration. Strengthen hospital antimicrobial-stewardship committees, prescription audits and standard treatment guidelines among healthcare professionals to prevent misuse and resistance.
2. Strengthen AMR Surveillance: Expand NARS-Net and antimicrobial-consumption surveillance across India and data from humans, animals, food and the environment under a One Health surveillance system. For e.g. NCDC’s surveillance of E. coli, Klebsiella and MRSA helps track resistance trends and guide treatment policies.
3. Regulate Antimicrobial Use in Animals & Agriculture: Restrict non-essential antimicrobial use in livestock, poultry and aquaculture. Strengthen veterinary prescription systems and surveillance of antimicrobial consumption in agriculture.
4. Improvement of Sanitation and Hygiene: The sanitation in hospitals and basic access to personal hygiene must be improved to reduce the spread of AMR. Improving Clean Water, Adequate Sanitation, and Hygiene infrastructure in low- and middle-income communities cuts off sewage-to-waterway transmission routes. 
5. Implementation of the Chennai Declaration on AMR: The new H1 rule which banned the use of only second and third-line antibiotic must be implemented at the earliest to prevent the over-the-counter sales of antibiotics.
6. Investment in Public Health infrastructure: The investment in public health infrastructure like network of laboratories, hospitals, recruitment of trained medical professionals must be enhanced at the earliest. For e.g. NCCD reports points out that states with good public health systems have lower AMR.
7. Improving governance and monitoring framework: Environmental governance, planning and regulatory frameworks must be enhanced to combat the menace of AMR. For e.g. Involve the Ministry of environment to stop the contamination of antimicrobials.
8. One Health Approach: Any actions on AMR must be guided by the ‘One Health Approach’- a holistic approach that links the health of humans with our shared environment. Create stronger coordination among MoHFW, NCDC, ICMR, ICAR, FSSAI, environmental authorities and veterinary institutions, with shared data and accountability.
9. Robust investment in R&D of new antibiotics: Develop new antibiotics, antifungals, vaccines, diagnostics and alternative therapies. Support genomic surveillance and research into AMR transmission pathways. 
10. Awareness Generation on AMR: Discourage self-medication and incomplete courses. Expand AMR awareness among doctors, pharmacists, farmers, veterinarians and the public. Peru’s efforts on patient education to reduce unnecessary antibiotic prescriptions must be used as a learning point.

Conclusion: The development of resistance to antimicrobials is a major public health problem all over the world. It makes even minor infections tough to treat, causing severe illnesses and deaths. Hence, a clarion call to end this menace must be taken at local, national and global levels that would eventually help in attainment of SDG 3 (ensuring good health and well-being for all).