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Healthcare systems across the world have been stretched thin by the unprecedented demands that the COVID-19 pandemic has exerted. Once again, India has found itself at a critical juncture in its fight against the virus as it battles a second wave of infections. While efforts are doubled up, it is crucial to assess the impact of these response measures on antimicrobial resistance (AMR). AMR – the development of antimicrobial resistant capacities in infection causing pathogens – has been widely recognised as one of the most serious health threats and will likely cause the next pandemic.
A review of studies published on COVID-19 patients found that 72% of the patients received antimicrobial therapy, even though only 8% revealed superimposed bacterial or fungal co-infections. These findings are an indication of the extensive over-reliance on antibiotics, specifically broad-spectrum antibiotics.
Beyond the ongoing pandemic as well, indiscriminate prescription of antibiotics by healthcare professionals and their availability without prescriptions from pharmacies, in the absence of accurate diagnostic tests, plays a significant role in increasing antibiotic resistance. It is well documented from studies carried out in India that antibiotics are prescribed the most for treating upper-tract respiratory infections which are most of the time of viral aetiology, are self-limiting and do not require treatment with antibiotics.
In order to discourage such practices amongst healthcare professionals, antimicrobial stewardship practices (AMSP), which have proven effective, have to be leveraged to promote the judicious use of antibiotics and help arrest the growth of AMR.
According to a report published by the World Health Organisation, drug-resistant diseases already cause 700,000 deaths globally a year and this number could rise to 10 million deaths per year if no action is taken. Analysing the economic impacts that AMR could have using economic simulation tools, the World Bank stated that the world could lose 3.8% of its annual GDP by 2050, with an annual shortfall of $3.4 trillion by 2030. Alarmingly, India is at the heart of the growing global AMR crisis, with the highest burden of multi-drug resistant tuberculosis. Further, over 50,000 newborns are estimated to die annually from sepsis due to first-line antibiotic resistant pathogens.
Even beyond antibiotic prescription and usage, there are a variety of factors responsible for this situation, including misuse of antibiotics in agriculture and poultry; environmental factors; and stagnation in the invention of new antibiotics.
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Studies show that 73% of all antimicrobials are used indiscriminately on animals for the purpose of disease prevention and produce enhancement, a popular practice in low- and middle-income countries. The continuous exposure of bacteria to these antibiotics used on animals increases resistance over time. India is also one of the top consumers of agricultural antibiotics worldwide, accounting for 3% of total consumption. The State of World’s Antibiotics report has found that animals in India and China show the highest levels of antimicrobial resistance.
At the same time, the presence of resistant bacteria in the environment has posed some unique threats. Discharge of inadequately treated effluents from pharmaceutical production plants and hospitals into water bodies are the leading causes for AMR in the environment. In a National Green Tribunal commissioned a study of the Musi river in Hyderabad, a major pharmaceutical production hub of India, all 90 bacterial strains that were isolated showed the presence of at least 4 first-line antibiotics and some even showed resistance to 13 such antibiotics.
There is evidence to suggest that wastewater effluent from hospitals provides ideal platforms for the emergence and propagation of unique AMR mechanisms. A study of hospital wastewater in Scotland had found that AMR gene abundance was higher in hospital wastewater than in community influent. Hospitals can also become places of transmission for drug resistant organisms which are more difficult to treat and places an extra burden on healthcare systems.
Fortunately, the narrative around AMR has gained urgency in India. Since 2017 following release of National Action Plan on AMR by the Central Government, several state governments have released comprehensive action plans to contain AMR. In line with the national action plan, the Ministry of Environment even circulated a comprehensive draft regulation limiting antibiotic concentration in effluents to institute environmental stewardship on bulk drug industries and it is also important that the draft becomes a legislation soon. Such decisive and coordinated measures are an illustration of the ‘one-health’ approach that India is advancing with commitment.
There is now ample evidence that stewardship is needed at every level to regulate the use of antimicrobials across all sectors. While stewardship activities have been initiated in some hospitals through programs funded by the Indian Council of Medical Research or the National Centre for Disease Control, the scale of these efforts is grossly inadequate to address the extent of the problem.
While expanding the scope of antimicrobial stewardship to the entire health sector, stewardship programs should also be adopted quickly and voluntarily across sectors to encourage responsible practices. At a time that infectious diseases have shown their might, we need systems in place that recognise early warnings and respond effectively through sustainable practices and collaboration.
Kamini Walia, Scientist ‘F’, Division of Epidemiology and Communicable Diseases, Antimicrobial Resistance Surveillance and Research Network, Indian Council of Medical Research.