India must act urgently on WHO’s report on resistance to antibiotics.
The latest World Health Organisation’s (WHO) report on the resistance to the use of antibiotics, Antimicrobial Resistance: Global Report on Surveillance,is a horror story. Resistance to crucial drugs – when microorganisms like viruses, bacteria and parasites mutate and make medication ineffective to cure infections – has become so common that illnesses which were treatable for decades are now threatening to kill again. These are not rare diseases that are difficult to treat. Doctors worldwide are seeing resistance to antibiotics used to treat illnesses like gastroenteritis, malaria and typhoid. They are therefore being forced to fall back upon older drugs which had been set aside years ago because of their side-effects.
All this spells bad news for medical advances like stem cell transplants and bone marrow transplantation and also for patients of chronic illnesses who are prone to infections that could otherwise have been treated. The situation is worse in India. One, the country already has a battle on its hands with multi-drug resistant tuberculosis (TB). Two, the health system services are hardly equipped to deal even half-way with the grim scenario painted by the WHO. Three, to compound matters, drug resistance is high in hospital-acquired infections. However, there is no reliable national data as to the extent of antimicrobial resistance in India.
The WHO report finds rampant resistance to carbapenem antibiotics, considered to be the last-resort treatment for life-threatening infections due to a common intestinal bacteria, klebsiella pneumonia. It is a huge source of hospital-acquired infections like pneumonia, bloodstream infections, and infections in newborns and intensive care unit patients. There is also high resistance to third-generation cephalosporins and fluoroquinolones, the two essential anti-bacterial drugs used to treat E coli. The resistance has become a major cause of bacterial diarrhoea and nontyphoidal salmonella. The tendency of Indians to self-medicate with over-the-counter antibiotics is made worse by doctors tending to “over-prescribe” these drugs.
The controversy a few years ago that followed the discovery of the New Delhi Metallo beta lactamase-1 or NDM-1 “superbug” – the result of antibiotics resistance – led to demands for a policy on antibiotics use. In 2013, the union government placed 24 antibiotics under the new Schedule H1 category. These drugs cannot be sold without a doctor’s prescription and invite penalties on chemists for non-compliance. Individual state governments too have issued notifications bringing various antibiotics, anti-TB and psychotropic drugs under this category. Much will depend on the stringency of the inspections by the drugs inspectorate, never a strong point of state government administration. As in many other areas, it is the regulatory mechanism that is the weak link. However, there are concerns that such regulations could adversely affect the sick in rural areas where there are few doctors and people at times depend on chemists for drug advice. Important antibiotics could be driven into the grey market, thus burdening the patient further. While strengthening the regulatory mechanism to prevent the sale of over-the-counter antibiotics without prescriptions, the issues arising from the lack of an adequate number of medical practitioners in rural and remote areas to write these prescriptions will have to be dealt with.
The socio-economic costs of antibiotic resistance can be gauged from the fact that patients remain ill for longer and there is even a greater risk of death. The longer stays in hospital with the accompanying higher expenditure put a heavier burden on scarce resources. Many medical practitioners in India place some of the responsibility for the overuse of antibiotics on patients who demand “strong” medicines so that they can get well quickly and blame them for prolonging treatment with “mild” medication. There is also the aggressive marketing by pharmaceutical companies which leads to superfluous prescription of antibiotics. An insistence on hospital authorities overseeing and auditing their stocks of antibiotics is seen as one solution. The education of patients must also run parallel since it is a well-known fact that discontinuation of the regimen with even a modest improvement of symptoms is common across socio-economic strata. As has been demonstrated beyond doubt in the case of TB, this is a dangerous and fatal practice. The WHO report shows that there is no time to lose and that urgent action is imperative.