Are we heading towards a post antibiotic world?

The antimicrobial resistance is fast spreading like a wild fire with no easy solutions except that we recognize it as a serious threat with alarming consequences and work towards ensuring drastic preventive measures

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New Delhi: It has been five days since Mehtaab Singh was last administered antibiotics to help relieve him of the intense body pain due to a health complication. Yet there are no visible signs that could assure his doctors about any improvement. Staring helplessly are the relatives who are puzzled as to why the medicines are not working since he has no history of any irregular antibiotics consumption. During the course of treatment, it was observed that he has been fond of and consuming the chicken meat quite frequently. How does that matter one may ask? It did as the chickens were supplied from a Punjab based poultry farm where the antibiotics had been used in abundance.

The above example clearly shows that the causes of antimicrobial resistance (AMR) are no longer limited to any one medium. Recently a study in Mumbai detected antibiotic resistant bacteria in commonly consumed food items like raw chicken and sprouted beans. Scientists had isolated bacteria resistant to antibiotics from food products available in the market. High levels of resistance to many important antibiotics were found across the board, ranging from 39 percent for ciprofloxacin, which is used to treat respiratory infections, to 86 percent for nalidixic acid, which is used to treat urinary tract infections. Almost 60 percent of the Escherichia coli (E. coli) samples analyzed contained ‘resistance conferring’ genes, that not only render many antibiotics ineffective but can also be easily passed on to other types of bacteria.

Consumption of such items could make people resistant to drugs and make treatment of infections with antibiotics difficult.

What drives this menace?

Ignorance about the menace is also an indirect cause for its spreading. As per a survey done by the World Health Organization (WHO) in 12 countries, almost two thirds (64 percent) of some 10 000 people who were surveyed across 12 countries say they know antibiotic resistance is an issue that could affect them and their families, but how it affects them and what they can do to address it are not well understood. For example, 64 percent of respondents believe antibiotics can be used to treat colds and flu, despite the fact that antibiotics have no impact on viruses. Close to one third (32 percent) of people surveyed believe they should stop taking antibiotics when they feel better, rather than completing the prescribed course of treatment.

Inappropriate use of antibiotics whether through taking them when they are not required, taking an incomplete course, or taking them too regularly makes bacterial infections immune to antibiotics. Globally 700 000 people die every year as a result of once-treatable health conditions.

India is a major drug producer with some of the highest sales of antibiotics globally and the highest levels of AMR. Contributing factors include failures of India’s drug regulatory system which have been identified in government reports, the sale of antibiotics without prescription, and the use of fixed-dose combination (FDC) antibiotics – formulations composed of two or more drugs in a single pill.

AMR explained in nutshell

Antibiotic resistance happens when bacteria change and become resistant to the antibiotics used to treat the infections they cause. Over-use and misuse of antibiotics at various levels increase the development of resistant bacteria. Also, the gaps in understanding and misconceptions too contribute to this phenomenon.

According to an analysis by researchers at Queen Mary University of London (QMUL) and Newcastle University where the team analysed antibiotic sales in India between 2007 and 2012, and found that total antibiotic sales increased by 26 per cent, with the increase mainly due to the growth in sales of FDCs, which rose by 38 per cent. By 2011–12, FDCs comprised a third of total sales in India.

The most ignored route of antibiotic entry is the agricultural produces. While the dosages of antibiotics applied to soil and absorbed by plants might be debatable but the health implications for people consuming them are largely unknown. The antibiotic accumulation in plants is just another negative consequence of our animal agriculture industry and not surprising given the quantity fed to livestock. Researchers at the University of Zurich have found antibiotic-resistant bacteria in fresh vegetables imported from India, Thailand, Vietnam and the Dominican Republic. A quarter of the 169 vegetable samples imported into Switzerland from the four countries revealed one or more extended-spectrum beta-lactamase (ESBL) producing bacteria called Enterobacteriaceae. Over 78 percent of the bacteria were found to be multi-drug resistant.

Unimaginable long-term consequences

The WHO in June 2017, adopted a new classification for antibiotics to preserve the effectiveness of those that are a ‘last resort’. The new model comprised three categories: ‘Key Access’ antibiotics that should be widely available, ‘Watch Group’ that includes critically important antimicrobials which should only be used for certain infections, and ‘Reserve Group’ antibiotics for severe circumstances when all alternatives have failed.

 As per Dr Sumanth Gandra who was on the WHO’s expert committee, “The categorization was done not only to improve access, but at the same time to reduce the potential for development of antibiotic resistance, and preserve the effectiveness of ‘last resort’ antibiotics.”

“In India, resistance to last resort drug “colistin” is increasing in a bacterium called K. pneumonia which causes serious infections among hospitalized patients. Unfortunately, we do not have any antibiotics to treat colistin resistant K. pneumonia infections,” says Dr Gandra, who is also a Resident Scholar and Fellow, Center for Disease Dynamics, Economics & Policy (CDDEP)

Antimicrobial growth promotion (AGP) use in farm animals is increasing worldwide in response to the rising demand for food animal products. Previous studies by CDDEP researchers have projected that antimicrobial consumption in food animal production will rise globally by 67 percent by 2030, including more than a tripling of use in India.

A scientific study published during 2016 in PLOS Medicine Journal estimated that AMR could cause 10 million deaths a year by 2050. Antimicrobial resistance threat is real and no longer limited to the over the counter availability factor. The non-therapeutic use of antibiotics, including in livestock and fisheries industries has a huge passive effect on the human health. Just that it has been largely unnoticed doesn’t mean it doesn’t happen or have any effect on sick.

A new study published in the journal ‘Science’ by researchers at the CDDEP in New Delhi and partners have predicted 82 percent increase in antibiotic consumption in India by 2030. While India reported using 2,633 tons of antibiotics in food animals in 2013, the researchers predict that this is likely to soar by 82 percent by 2030.

“India is the fourth largest consumer of antibiotics in animal food production globally and is on an increasingly dangerous path. We must remove antibiotics from the human food chain, except to treat sick animals, or face the increasingly real prospect of a post-antibiotic world,” CDDEP Director Ramanan Laxminarayan warns, “The country has a huge unregulated livestock sector that freely uses these drugs which are easily accessible. Two-thirds of poultry farms in Punjab, for example, still use antibiotics for growth promotion. Such farms also reported high levels of multidrug resistant bacteria which can easily escape into the environment. We are losing medically important antibiotics at a very fast pace.”

 A look at the AMR policy decisions in India

The Indian Council of Medical Research (ICMR) launched a programme on Antimicrobial Stewardship, Prevention of Infection and Control (ASPIC) in 2012. Functional infection control programmes not only cut down the rates of nosocomial infections, but also reduce the volume of antibiotic consumption and are a critical part of any comprehensive strategy to contain AMR.

Further, a red line campaign has been launched to regulate over the counter sale of Schedule H antibiotics. Health Ministry says it has set up a National Surveillance System for AMR, enacted regulations (Schedule-H-1) to regulate sale of antibiotics, brought out National Guidelines for use of antibiotics etc. The campaign is aimed at discouraging unnecessary prescription and over-the-counter sale of antibiotics causing drug resistance for several critical diseases including TB, malaria, urinary tract infection and even HIV.

The Ministry of Health and Family Welfare has also launched a programme named ‘National Programme on Containment of Antimicrobial Resistance’ to address the problem of growing AMR.

“AMR is a serious threat to global public health that requires action across all government sectors and society and is driven by many interconnected factors. Single, isolated interventions have limited impact and coordinated action is required to minimize the emergence and spread.” This was stated by Mr J P Nadda, Union Minister of Health and Family Welfare at at the ‘Inter-Ministerial Consultation on AMR containment’, on April 19, 2017 at New Delhi. The Ministers later signed a ‘Delhi Declaration’ for collectively strategizing to contain AMR. It pledges to adopt a holistic and collaborative approach towards prevention and containment of AMR in India.

Exploring the possible solutions

While the policy decisions seems to gain steam, the implementation matters in the longer run. The increase in awareness levels among consumers, better healthcare delivery system and allocation of enough funds for concerned authorities are few of the immediate keys. At the broader level, it must include strong measures to stop over-the-counter availability of antibiotics, while strengthening and enforcing legislation to prevent the manufacture, sale and distribution of substandard antibiotics. These measures must be accompanied with campaigns to make behavioral and cultural changes in prescribers and patients so that antibiotics are no longer considered the first treatment option.

Last year’s meeting on AMR at the United Nations General Assembly recognized the inappropriate use of these drugs in animals as a leading cause of rising AMR. Therefore, steps are also needed to stem the antibiotics usage in dairy, agriculture and fisheries sector. The researchers have estimated that few interventions that could together reduce antibiotic use in animals by up to 80 percent. One is the regulations capping the use of antibiotics in farm animals could achieve a 64 percent reduction in consumption. Another is imposing a 50 percent user fee on the price of veterinary antibiotics to reduce consumption by 31 percent.

“We must act decisively and we must act now, in a comprehensive manner, to preserve antibiotic effectiveness,” says Ramanan Laxminarayan. And we wouldn’t agree more.