It’s a long road ahead for the fight against antimicrobial resistance. A few months ago the WHO declared that worldwide resistance to antibiotics had reached ‘alarming levels’ and poses a ‘major global threat’ to public health. Antibiotic resistance, the organisation said, is no longer a prediction for the future but is happening right now across the world, jeopardizing the ability to treat common infections. More broadly, antimicrobial resistance (AMR) which is resistance to drugs to treat infections caused by other microbes including parasites, viruses and fungi, has become ubiquitous all over the world. To combat this, the Indian Medical Association (IMA) has also begun campaigning against the over-prescription of antibiotics, asking doctors to pledge themselves to fighting against AMR and to follow the principles of rational use
of antibiotics. IMA Goa State branch president Dr Jagdish Cacodkar explained that antibiotics used in chemotherapy of bacterial infections
are broadly classified as those that act on Gram positive and Gram negative bacteria and on anaerobic infections.
Among these, the Gram negative bacteria
are the more dangerous types. There
are limited antibiotics that act on these
bacteria that are associated with urinary
tract infections, some serious hospital
acquired infections and with life threatening
infections like sepsis in infants
and adults.
This, he explains, is in contrast to the
greater number of antibiotics available
to combat Gram positive bacteria that
cause common infections like those of
the skin, the respiratory tract and gastro-
intestinal and post-operative infections.
“Irrational use of these antibiotics
leads to the emergence of antibiotic resistance
among bacteria. Higher level
antibiotics should only be used when
serious infections are confirmed by culture
tests or when there is strong clinical
suspicion in seriously ill patients. They
shouldn’t be used indiscriminately and
should be reserved for cases where their
use is scientifically warranted,” Dr Cacodkar
says.
Instead, antibiotics are being misused
with doctors prescribing the highest end
antibiotics to treat even common colds
and fever. Such drugs don’t act against
viral infections, only bacterial ones and
a majority of the most acute respiratory
infections are viral. Rationally, patients
should be prescribed antibiotics only
during bacterial infection. The IMA as a
first step is beginning to educate doctors
and patients not to resort to antibiotics
for ordinary coughs, colds and diarrhea.
Defensive practice
Dr Wiseman Pinto, Professor and Head
of Pathology, GMC terms the medicine
practiced today as ‘defensive medicine’
where doctors don’t want to take any
risks. They prescribe stronger antibiotics,
leaving nothing to chance. “Fourth generation
antibiotics are not required to
be prescribed when first and second
generation antibiotics are adequate. Doctors
prescribe these to safeguard their
own interests.” Many doctors are apprehensive
over losing their patients to
other doctors.
Microorganisms, says Dr Pinto, can
outsmart doctors. They change their genetic
constitution, becoming resistant
to the same antibiotics. When higherend
antibiotics are given indiscriminately,
bacteria develop resistance, and when
serious cases need to be treated, the
drugs don’t work anymore.
Another factor responsible for antibiotics
resistance, cardiologist Dr Francisco
Colaço stresses on, is patients not completing
the entire course of antibiotics
prescribed. Many patients discontinue
antibiotic treatment midway simply because
they ‘feel better’.
Patients too are to blame for seeking
instant respite from their ailments and
compelling doctors to prescribe higherend
drugs or certain drugs not strictly
necessary. Gone are the days when patients
bore their ailments with patience.
Instant remedies are now sought. Parents
ask for antibiotics for their children who
have the flu and are not ready to listen
to the doctor telling them that their
child needs to rest and stay away from
school or college for a few days. They
also seem unconcerned over the virus
spreading to other children.
Other patients seek a rapid cure as
they want to return to work immediately.
“If they don’t get what they want, patients
don’t hesitate to change their doctors,”
Dr Cacodkar says. He advises his patients
trust their doctor and take the required
rest that viral fever requires. He also
suggests simple hand hygiene and cough
etiquette to be followed to prevent the
spread of infections.
Growing resistance
Dr Cacodkar cites examples of resistance
already prevalent against certain bacteria
and other parasites. Falciparum Malaria
until a few years ago would respond to
chloroquine. Today it is treatable only
with artesunate combination therapy
(ACT) which was earlier a second line
of anti-malarial treatment.
The drugs used to treat typhoid too
don’t work anymore because of the
widespread use of quinolones like
ciprofloxacin that is used indiscriminately
to treat simple respiratory and skin infections.
Gonorrhea would respond to
penicillin three decades ago but due to
indiscriminate use of the drug a new
strain called PPNG has rendered penicillin
ineffective in the treatment of these
sexually transmitted diseases.
Up to 4 per cent of tuberculosis cases
in the country are now MDR TB (Multi
Drug Resistant Tuberculosis) which is
resistant to first line antibiotics and requires
more toxic and costlier second
line anti-TB drugs.
Between 1 to 2 per cent of TB cases
are today XDR-TB (Extensively Drug Resistant
Tuberculosis) which is resistant
to first-line as well as second-line antibiotics.
XDR- TB has a high death date.
There are also ominous case reports in
Mumbai of Total Drug Resistant TB for
which no anti-TB drugs work at all.
Practitioners are therefore urged to follow
the standard TB treatment protocols.
In 2010 the news of NDM-1 (New
Delhi Metallo-ß-lactamase 1) took the
world by storm. First discovered in a
Swedish patient of Indian origin who
had recently travelled to New Delhi,
the NDM-1 produces bacteria that are
highly resistant to many antibiotics including
carbapenems. This class of drugs
is reserved for emergency cases and to
treat infections caused by other multiresistant
bugs like MSRA and C-Difficile.
NDM-1 positive bacteria was also
found in Chennai, Haryana, Bangladesh,
Pakistan and in the UK.
Lax laws in India
Pharma companies too are responsible
for growing AMR. They provide incentives
to doctors to prescribe costlier higherend
drugs. This is business to companies
but at the cost of patients. Many hospitals
make more money on their pharmacies
than on room rent, doctors say.
Surveillance and audits in India are
poor. Doctors are rarely penalized and
the patient is the sufferer. There is lack
of accountability and anyone today can
easily purchase antibiotics over the
counter in pharmacies without a prescription.
Something that isn’t possible
in the US.
Last month President Barack Obama
made it a federal priority to combat
the growing health threat from bacteria
that is resistant to antibiotic treatment.
Dr Celina Pereira, an adolescent medicine
and college health physician, USA,
says the difference in the prescribing
habits of Indian and American physicians
is that American doctors don’t usually
prescribe the stronger (second and third
generation) antibiotics but first-line antibiotics
such as penicillin, ampicillin,
amoxicillin, erythromycin, azithromycin
and sulfa antibiotics. “But even these,’’
she says, “are inappropriate for viral infections.
Inappropriate use of antibiotics
can lead to complications that may end
in a law suit, a great deterrent for American
physicians.”
Solutions
With no new class of antibiotics discovered
since the 1980s, AMR threatens
a return to the pre-antibiotic era where
the most basic operations and even a
cut to one’s finger could be most hazardous.
Dr Colaço suggests antibiotics be
classified for non-restricted, restricted
and very restricted use and shouldn’t
be sold in pharmacies without a special
prescription. There should be stringent
penalties to be imposed if this is violated.
“The MBBS syllabus too should lay more
emphasis on the use and misuse of antibiotics.
Drugs and therapeutic committees
as well as hospital infection
control committees should be set up in
all hospitals. Policies for RAP (rational
use of antibiotics) should be introduced
in the agriculture and food industry
(including poultry, pig, fish farming and
in honeybee hives) where these drugs
are used as growth promoters.”
He also points out to the paradox
between urban and rural India where
one faces the challenge of inappropriate
use of antibiotics while the other struggles
with poor access to treatment.
Dr Cacodcar suggests a dire need for
standardized treatment protocols to be
developed. This he says should be
backed up by a good laboratory network
with reliable bacterial and virological
reports which will help doctors in
treating patients suffering from infectious
diseases. The IMA Goa State has begun
conducting refresher training for doctors
on combating anti-microbial resistance
with WHO support and has recently organised
pharmaco-vigilance training on
the adverse effects of drugs.
