Antibiotic resistance- Need for action

“The time may come when penicillin can be bought by anyone in the shops. There is the danger that the ignorant man may easily under-dose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.” – Alexander Fleming at his 1945 Nobel Prize lecture

New Delhi, November 15, 2018:

India is among the world’s largest consumers of antimicrobial agents. This is a cause of extreme concern as we have reached a stage where there is wide spread resistance amongst most microbes to antibiotics. The concerns started creeping in the year 2009, when a 59-year-old Swede of Indian origin developed a multidrug resistant infection after visiting hospitals in Ludhiana and Delhi. Being a diabetic male, the patient developed bedsores- abscesses on buttocks and urinary tract infection. He underwent surgery for the same in Delhi and returned to Sweden. It was thought initially that bed-sores, abscesses could be part of his susceptibility of infection. The concern was that no antibiotic appeared to work on this patient including the strongest class known to the medical world. The urine analysis also showed a Klebsiella pneumoniae- again nothing unusual about the organism, but concern was that it was resistant to most antibiotics. Further analysis, showed that it carried a gene later named as   NDM-1 (New Delhi Metallo-beta-lactamase-1), after the city where the patient was thought to have picked up the bug, made the bacteria resistant to almost all antibiotics. This didn’t just make treatment difficult but also enabled the bacteria to move quickly from one bacterium to another, rapidly spreading the infection’s resistance. Since, then there are several case reports and studies which have shown that antibiotic resistance is real and urgent action is required.

In Indian, several factors such as high disease burden, unregulated sales of antibiotics with no proven efficacy, use of antibiotics in the animal livestock and agriculture industries, misuse or overuse of antibiotics by the health care industry have further enhanced the crisis. Antibiotics are agents that target infections caused by bacteria. They are ineffective in viral fevers like common cold, cough or flu.

Issues such as poor sanitation and malnutrition has further aggravated the disease burden in India. In the recent years, India has witnessed an increasing trend of development of resistance to commonly used antimicrobials in pathogens like Salmonella, Shigella, Vibrio cholerae, Staphylococcus aureus, Neisseria gonorrhoeae, N. meningitidis, Klebsiella, Mycobacterium tuberculosis, Human immunodeficiency virus, Plasmodium and others.

Antibiotics in animal husbandry and agriculture:

 Food production has always been an important issue for mankind, and the current food industry is relying on antibiotics to secure the supply of food and income to farmers.  However, this method to improve yield and production has caused serious health hazard. The amount of antibiotic use in agriculture has not been globally estimated as the use is unregulated. Most of the agriculture use is in animal production and to a lesser extent in plant production. In the United States, the estimate of antibiotic use in animal husbandry is as high as 70% and may not be significantly different across the globe.

Antibiotics in animal farming:

1] Treatment of Infection: Animals do succumb to infections just like humans. If the infection is caused by bacteria, they will require treatment with antibiotics.

2] Prevention: In many cases, antibiotics are used to prevent infection rather than treatment. This leads to increased antibiotic usage and resistance in animals.

3] Growth Promotion: Some early studies showed that by routinely giving animals sub-therapeutic doses of antibiotics, the animals grew faster, thus increasing the yield from animal production. Unfortunately, warnings of antibiotic resistance were ignored.

Why is this important?

The antibiotics used in animals are either the same or similar to the antibiotics used in human medicine. As antibiotic use selects for resistance in bacteria, overuse in animals increases resistance levels in bacteria in the animal’s environment, including in the farmers. These resistant pathogens or genes can then spread throughout the community via humans, manure, or the animals via abattoirs.

One scary example is the use of colistin in pig farming. Colistin was used in human medicine between the 1950s and 1970s, after which its use diminished as safer drugs were developed. It was however not completely abandoned, and with increasing rates of multidrug resistance, colistin was revived and recognized as a critically important antibiotic to be used as a last resort to be used when all other therapies failed. Meanwhile, colistin was marketed to farmers as an efficient food additive with no risk for resistance development. Unfortunately, colistin use in agriculture leads to selection of resistance. Colistin resistance has also been found together with other types of resistance elements, causing infections that do not respond to antibiotic therapy.

Need for action

To curb the development of resistance in animal agriculture, measures need to be taken to reduce the use of antibiotics. Such measures include:

• Stop using antibiotics for growth promotion.
• Minimize antibiotic use for prevention of infection.
• Implement infection prevention measures, including vaccines, to reduce disease.
• Antibiotic resistance in animal agriculture is not only threatening animal health, but also affects human health.

Challenges and Solutions:

 To counter this problem of antibiotic resistance, several strategies have been initiated.

• Government will: In the year 2012, several medical bodies and associations came together to draft a plan to tackle the problem of antibiotic resistance. Post these efforts, the government have drafted the antibiotic policy to curb the abuse, misuse and overuse of antibiotics.
• Accreditation of hospitals: The government encourages hospitals to get accredited with the National Accreditation Board for Hospitals and Health care providers to ensure safe prescribing practices by health care providers.
• Control at the pharmacy level: This is important to control over the counter sale of antibiotics. All antibiotics must be prescription driven by doctors.
• Public awareness and education: The pivotal step is to control public from demanding antibiotics for viral fevers from doctors or self-prescribing of antibiotics. In India, there is ongoing pressure by patients to urge doctors to get a prescription for antibiotics for fever. This sometimes leads to health care provider succumbing to pressure of the patients and wrongfully prescribes antibiotics in conditions like viral fevers where there is no role of antibiotics. This has led to drug resistance.

One solution to this crisis is to develop newer and stronger antibiotics. No new antibiotic is in the pipe line. The more profitable solution is to strengthen infection control practices at home and hospitals to prevent cross infection by drug resistant organisms amongst patients.

Most infections are preventable: Empower community health care workers to promote healthy lifestyle, curb issues with poor hand hygiene, sanitation and malnutrition. This will help reduce disease burden.

In sum, antibiotic resistance is a rising threat in our society with varied spectrum of resistance across the country. The chain of control starts with the public to public health care sector to the private health care sector. The public and government will be necessary to control this serious threat. Antibiotics are required to battle infections in an immunosuppressed host like post stem cell transplants, liver or renal transplants. With increasing threat of resistance, we may not be able to salvage patients from these life threatening infections. Without antibiotics, we will not be able to have surgeries- including liver, renal or cardiac transplants.

The threat is real and we need more research in India to look at resistance patterns, for better understanding of the burden of the disease and develop new diagnostic tools and antimicrobial agents for treatment.

Authored by – Dr. Swati Rajagopal Consultant-Infectious Disease, Aster CMI Hospital, Bangalore