Rising antibiotic resistance taking India to pre-antibiotic era, say experts

Kochi: The lack of restrictions on access to antibiotics and their irrational use, non-standardized microbiology laboratories, use of antibiotics in animal husbandry and fisheries, and lack of sanitation are leading to widespread antibiotic resistance in India, and there is a danger of the country slipping back into the pre-antibiotic era.

The situation can become alarming considering that the crude infectious disease-related mortality rate in India is 416.75 per 100,000 persons, which is about twice the prevalent rate in United States (World Bank data). There is also a 15-times greater burden of infectious diseases per person in India than in the UK.

This was concluded by experts in antimicrobial resistance (AMR) from India and abroad who are in Kochi to participate in the two-day ‘International Conference on Antibiotic Stewardship and Infectious Diseases,’ to be held at Amrita Institute of Medical Sciences on October 27-28, 2018. They highlighted the importance of ’Antibiotic Stewardship,’ which means a combination of practices to rationalize antibiotic use through the right dose, right drug, right duration, right frequency, right patient and right indication. Rationalizing the use of antibiotics is essential to reduce the burden of infectious diseases, the experts said at the event, which saw the participation of ten prominent international speakers from the UK, the US and South Africa.

Said Dr Sanjeev K Singh, Medical Superintendent, Amrita Institute of Medical Sciences, Kochi: “Over-consumption of antibiotics is rampant in India. A recent study in Kerala has found that 89% of all doctors prescribe antibiotics on daily basis. Hence, when a patient suffers from, say, symptoms of upper-respiratory infection, diarrhoea or vomiting – which usually indicate a disease that is viral in nature and therefore should not be treated with antibiotics – the patient gets prescribed a course of antibiotics. It therefore comes as no surprise that India consumes the highest volume of antibiotics in the world.”

He added: “Internationally, the spread of antibiotic resistance is high too but the access to antibiotic drugs is controlled and a third party monitors their use and consumption, leading to rational practices. An Antimicrobial Stewardship Program along with good Antibiotic Prescription Practices (GAP) is an effective strategy for optimization and rationalizing the use of antimicrobials. All healthcare professionals in India need to be educated on rational antibiotic prescribing. This, along with effective patient education to not take antibiotics unnecessarily, can help optimize the use of antimicrobials in Indian hospitals. Such optimization is urgently needed considering that as many as 90% of the estimated antibiotic resistant deaths in the world come from low and middle income countries. However, the challenge is that, presently, there is a lack of data regarding infection control practices in Indian hospitals and their hygiene and sanitation is poor. There is also an absence of standardization around these aspects in hospitals across the country.”

Added Dr Arjun Srinivasan, Associate Director, Healthcare Associated Infection Prevention Programs, Centers for Disease Control and Prevention, US Dept. of Health: “Antibiotic resistance poses an urgent threat to health of the world. The loss of effective antibiotic therapy threatens to make once-treatable infections deadly again and jeopardize the delivery of modern medicine. One of the best ways we can preserve the power of life-saving antibiotics is to improve the way we use them, a concept known as ‘antibiotic stewardship.’ Its goal is to ensure that everyone gets the right antibiotic when they need one. Improving access to effective antibiotics as well as the way we use them will require partnerships between the public and private sectors, as well as engagement from patients.”

Said Dr Alison Holmes, Director of the NIHR Health Protection Research Unit at Imperial College, London, and Public Health England: “Individually and collectively, we all have responsibility in preserving the effectiveness of antibiotics, which means we must use them wisely and that we must also reduce the need for antibiotics by maximizing action to prevent infections from occurring.”

Talking about the challenges of early and accurate diagnostics of infectious diseases, Dr Sanjeev Singh said: “The results of traditional bacterial cultures and antimicrobial susceptibility testing, which may take up to several days to obtain, remain one of the major barriers to providing optimal therapy. Currently available lab parameters like the white cell count and C Reactive Protein are non-specific. These surrogate markers may not lead to definitive treatment, but rather an empirical treatment. Advancements such as rapid diagnostics, the syndromic approach which uses multiplex Polymerase Chain Reaction (PCR) to rule out infections, better diagnostics for virology, and the use of better markers like procalcitonin can help in the early detection of infections.”

He added: “Despite the rising antibiotic resistance, I do not believe that the world will enter the post-antibiotic era due to improvements in technology and the use of rapid diagnostics. If indeed, such a state is reached, then measures like good hygiene practices, safe disposal of waste, vaccination for vaccine preventable diseases and good infection control practice can aid in treatment.”

The Amrita Institute of Medical Sciences instituted an Antibiotic Stewardship Program four years back, which has led to significant reduction in the use of high-end antibiotics. “We have achieved reduction of Colistin prescription by 74 %, Linezolid by 86%, and Dorpenum and Ertapenum by 34 and 38%, respectively. Mortality has been reduced by 24% and cost-benefit because of implementation of our Antibiotic Stewardship Program is Rs 2.3 crore in a year. In addition, the Healthcare Associated Infections have dropped significantly for ventilator Associated Pneumonia (64%), Blood Stream Infections (34%), Urinary Tract Infections (23%) and Surgical Site Infections (32%),” said Dr Sanjeev Singh.

Amrita Institute of Medical Sciences is also playing a key role in the implementation of Kerala Antimicrobial Resistance Containment Plan along with the Indian Medical Association. It has till now trained 122 trainers and is going to run capacity building in all 14 districts of Kerala over the next six months.