Kerala wants to become the first state in the country to get the tag of an “antibiotic smart state”, signifying that all stakeholders are aware of the issue of antibiotic resistance know how to avoid the misuse of antibiotics.
As part of the goal, Kerala is also eyeing becoming the first state to achieve 100 percent “antibiotic literacy” in terms of attaining awareness of the correct antimicrobial use. And this, according to a top official, will be achieved by November this year.
Making pharmacies and hospitals “antibiotic smart” is also part of the grand goal, targeted to be achieved by November 2023.
The idea has evolved at a time when the antimicrobial resistance (AMR) — a condition when pathogens become resistant to treatment — is rising in Kerala, as per official data.
Dr Aravind R, Head of Infectious Diseases at the Government Medical College in Thiruvananthapuram, says “this warrants a multipronged approach”.
Dr Aravind is also the convener of the working committee for implementing the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP) that was first formalised in 2018 to combat AMR.
“Making all stakeholders understand AMR is the key to fighting it,” he told South First.
“It is a silent pandemic, a pandemic in slow motion.”
The global threat of AMR
Significantly, the threat of AMR is not confined to Kerala or for that matter India; today, it is recognised globally, with the World Health Organization (WHO), terming it one of the top 10 global public health threats.
According to it, the “misuse and overuse of antimicrobials” are the main drivers of drug-resistant pathogens.
The WHO identified two other factors that led to microbes getting resistant to antimicrobial treatment: lack of clean water and sanitation, and inadequate infection prevention and control.
It has also highlighted the economic impact of drug-resistant pathogens.
“In addition to death and disability, prolonged illness results in longer hospital stays, the need for more expensive medicines and financial challenges for those impacted,” the WHO has said.
Countries, too, are waking up the threat posed by antibiotic resistance. The US, for instance, has launched a programme, the “Be Antibiotics Aware”, to help fight antibiotic resistance and improve antibiotic prescribing and use.
According to the Centers for Disease Control and Prevention (CDC), the national public health agency of the US, at least 28 percent of antibiotic courses prescribed in the country each year are unnecessary.
This makes improving antibiotic prescribing and use a national priority, CDC said on its website.
How Kerala is gearing up
Officials of Kerala’s state health department told South First that 2023 was going to be a game-changer as Kerala eyes many firsts in AMR surveillance in the country..
First on the agenda is achieving 100 percent antibiotic literacy through various campaigns. This will also involve making hospitals and primary health centres antibiotic smart in the initial phase.
Alongside, efforts will be made to bring all hospitals under the accreditation programme so as to ensure infection control practices and antibiotic prescription audit.
In Kerala, AMR surveillance is spearheaded by the Kerala Antimicrobial Resistance Surveillance Network (KARSNET), a network of 21 public and private institutions. The plan is to bring more institutions under KARSNET n 2023.
On the cards is a hub-and-spoke model of AMR surveillance in all districts, up from the current four.
Under this, “service delivery assets” are arranged into a network comprising an anchor establishment (hub) which offers a full array of services, complemented by secondary establishments (spokes) which offer more limited service.
In Kerala, the state-level working committee will act as the hub and district-level committees are the spokes. The model is expected to help in gathering more data from secondary and primary care institutions in the respective districts.
On the administrative side, block-level AMR committees will be set up. They will be entrusted with the task of executing the antibiotic literacy campaign, implementing antibiotic-smart health institutions and other activities to fight AMR
AMR extent in Kerala
Among all bacterial pathogens, the surveillance by the KARSNET network tracks seven for having developed the highest antibiotic resistance rates.
The list is led by E. coli, which causes diarrhoea and urinary tract infections, among other health conditions.
As per the 2021 surveillance report — which has data from susceptibility testing for bacterial pathogens isolated from blood, urine, stool, and cervical and urethral specimens — E. coli is the most isolated pathogen (40 percent).
The next bacterial pathogen tracked is the Klebsiella species (24 percent), which causes healthcare-associated infections. The Klebsiella species has been found to show high resistance to last-resort antibiotic Carbapenem among ICU patients.
Third on the list is the Staphylococcus aureus (12 percent), which causes soft tissue infection and sepsis.
This is followed by the Pseudomonas species (11 percent), which causes infection in the ear, eyes, lungs, skin etc.
Next comes the Enterococcus species (seven percent), which causes abdominal-pelvic infections, decubitus ulcers, diabetic foot infections, and endocarditis.
The penultimate pathogen on the list is the Acinetobacter species (six percent); this causes serious infections in the lungs, blood, and the brain.
The final pathogen tracked — the Salmonella enterica serotypes Typhi and Paratyphi, which cause infection like typhoid — was isolated in 12 persons of the 14,353 persons tested
Recently, the hospitals in the state were directed to inform the health department whenever it detects a case in which bacterial infection in the blood becomes resistant to Carbapenem drugs.
The state government is also examining whether such conditions will have to be declared as a “notifiable condition”.
The data has been prepared after isolating 21,765 priority pathogens from over 14,000 patients across nine districts.
Bone of contention: OTC sales
The state government on 21 December, 2022, announced that it will cancel the licenses of those pharmacies which sell antibiotics without a doctor’s prescription.
The announcement came after the state’s Health Department concluded that the major contributor to AMR was the inappropriate use of antibiotics in humans.
However it has also identified other factors: Use of antibiotics for growth promotion and disease prevention in animals, horticulture and fisheries, use of animal manure in soil, and the inadequate treatment of effluents from healthcare facilities and farms.
“We should prevent a situation in which we run out of effective antibiotics to fight even simple infections,” said Dr Gopikumar P of the Indian Medical Association (IMA) who is the body’s representative in the KARSAP working committee
“Everyone should become antibiotic-literate. That is why even school students are being made a part of the antibiotic literacy campaign,” Dr Gopikumar told South First.
He also felt the issue of over-the-counter (OTC) sales must be addressed “once and for all”.
On the other hand, AN Mohanakurup of the All Kerala Chemists and Druggists Association said blaming pharmacists alone would not serve any purpose.
“What about antibiotic overprescribing and illegible prescription by medical professionals? Why is the government mum on this? These two issues also cause AMR,” he told South First.
According to him, while an illegible prescription may cause pharmacists to give the wrong medicine to the patient, over-prescription might lead to complications or even hospitalisation due to the adverse effects of medicines.
“In some cases, people are given medicines they do not need or want. Getting the right type and amount of medication is also important in the fight against AMR,” Mohanakurup said.
The chemists association will shortly raise the issue with the government.
Demand for prescriptions
Interestingly, Mohanakurup has found support in Dr Arvind, who says it is not uncommon for patients to pester doctors for medicines.
“Over-prescription is a problem and there is no doubt about that,” he said. “In some cases, doctors say that they are forced to prescribe antibiotics even for viral infections.”
Dr Arvind felt the situation exists as many people may be unaware that antibiotics only treat certain infections caused by bacteria.
“The antibiotic literacy programme might address such misconceptions,” he said.
According to a 2018 document of Kerala’s Directorate of Medical Education regarding AMR, the state is considered a “consumer state” for pharmaceuticals with a total consumption of drugs in the state at around Rs 20,000 crore per annum, with antibiotics making up 20 percent of the total drugs consumed annually in the state.
The document also stated that poultry farmers in the state use a variety of antibiotics either as growth promoters or for controlling infections.
Many prescription medications used for human and animal health ultimately find their way into the environment and can affect the health and behavior of wildlife
AMR in India
In India, AMR surveillance is carried out by the Indian Council of Medical Research (ICMR), and the National Centre for Disease Control (NCDC).
As per a 2021 surveillance report of NCDC, resistance to last-resort antibiotics is increasing in the country, at a time that very few newer drugs are in the pipeline. And this could lead to a crisis down the line as antibiotics fail to do what they are supposed to.
It also highlighted the need for strengthening local infection prevention and antimicrobial stewardship practices at healthcare facilities.
The ICMR’s Annual Report of 2021 said resistance to drugs used for Acinetobacter species — which caused infections in the lungs, blood, and the brain — stood at 87.5 percent nationally during the year.
This limited the availability of available treatment options, the report noted.
Also, it said, healthcare-associated infections in bloodstream and urinary tract caught during treatment in Indian hospitals are common.
Pathogens causing such infections are highly drug-resistant, the ICMR report said.