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:
- 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.
- 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
- 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
- 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.
- 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
- 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.
- Environmental Sanitation: Poor sanitation conditions in India plays a significant role in the spread of antibiotic-resistant bacteria and other microbes.
- Pharmaceutical Industry Pollution:The effluents from the pharmaceutical industries contain a substantial amount of antibiotics, leading to contamination of rivers and lakes in India
- 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.
- 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
- 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.
- Resistance to last resort antibiotics:Resistance to last resort antibiotics such as carbapenem class of antibiotics is on a rise.
- Increased Cost and time of treatment: Resistant infections cost more to treat and can prolong healthcare use
- 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
- Mortality:Number of researches in United Kingdom estimated that by 2050, as many as 10 million people globally could die annually from AMR complications.
- Impact on Life threatening diseases:Resistance is an emerging concern for treatment of HIV infection, TB etc.
India’s Approach towards tackling AMR
- 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.
- 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
- 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.
- 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.
- 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.
- The Drugs and Cosmetic Rule, 1945 were amended in 2013 to incorporate a new Schedule H1 under which include 3rd and 4th 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.
- State-level:Kerala is India’s first state to release a comprehensive action plan to contain Antimicrobial resistance.
Global Action Plan on AMR, WHO, 2015
It has the following objectives:
1. Improve awareness and understanding of antimicrobial resistance;
2. Strengthen knowledge through surveillance and research;
3. Reduce the incidence of infection;
4. Optimize the use of antimicrobial agents
5. Increase investment in new medicines, diagnostic tools, vaccines and other interventions.
Challenges with tackling AMR:
- 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
- India has no public database of mortality caused by AMR and the surveillance system is in its nascent stage.
- 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
- CPCBs effluent standards for pharmaceutical industry waste do not include antibiotic residues, and thus they are not monitored in the pharmaceutical industry effluents
- 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.
- Awareness:The first step to combat AMR is to improve awareness and understanding of AMR through effective communication, education and training
- Diagnostic stewardship: Reducing unnecessary prescribing of antibiotics, and ensuring appropriate prescribing through appropriate use of microbiological diagnostic
- 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.
- 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.
- R&D: Increased R&D focussing on development and use of new diagnostics, new antibiotics and alternatives to antibiotics.