While global and national efforts to counter AMR have been gaining momentum since the early 2010s, Kerala took a decisive leap in 2018 with the launch of the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP).
Published Dec 09, 2024 | 7:00 AM ⚊ Updated Dec 09, 2024 | 7:00 AM
Antimicrobial resistance. Representative Image. (AI generated.)
As the world grapples with the silent pandemic of antimicrobial resistance (AMR) — a deadly yet often overlooked threat — Kerala has emerged as a trailblazer in the fight to curb its devastating impact.
While global and national efforts to counter AMR have been gaining momentum since the early 2010s, Kerala took a decisive leap in 2018 with the launch of the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP).
Starting with this pioneering initiative, the state has set its sights on becoming India’s first antibiotic-literate state, embodying the much-lauded “Kerala model” of healthcare once again.
AMR occurs when bacteria, viruses, fungi, and parasites no longer respond to medicines like antibiotics, antivirals, antifungals, and antiparasitics, making infections harder to treat and increasing illness and deaths.
Recognised by the World Health Organisation (WHO) as one of the top 10 global health threats, AMR causes 1.3 million deaths annually and contributes to an additional five million, surpassing combined deaths from HIV, tuberculosis, and malaria.
Overuse and misuse of antibiotics, inadequate infection control, and agricultural practices drive AMR.
The latest data from Kerala’s Antimicrobial Resistance Surveillance Network (KARS-NET) reveals alarming trends concerning the state’s fight against AMR, signalling the need for urgent public health interventions.
The five-year analysis of AMR data, excluding 2020 due to the Covid-19 pandemic, underscores the increasing prevalence of resistant pathogens, posing significant challenges to healthcare systems.
The surveillance data highlights a steady increase in carbapenem-resistant Enterobacteriaceae (CRE) and extended-spectrum beta-lactamase (ESBL) production, except for Escherichia coli, which has shown some stability.
CRE are the bacteria which are resistant to commonly used antibiotics while ESBLs are enzymes that make bacteria resistant to many antibiotics.
Trends of Carbapenem resistance – evidence from KARS-Net over 5 years
Alarmingly, 12 percent of E coli and 43 percent of Klebsiella spp isolated from blood samples were CREs in 2023, reflecting a growing threat of drug-resistant bloodstream infections.
The trend of methicillin-resistant Staphylococcus aureus (MRSA) also shows fluctuation, with a temporary decrease in 2021 likely due to data inconsistencies during the pandemic.
MRSA are Staphylococcus bacteria that do not get better with the type of antibiotics that usually cure Staphylococcus infections.
However, MRSA rates rose again in 2023, accounting for 33 percent of Staphylococcus aureus blood isolates compared to 27 percent in 2022.
The data identifies E coli as the most commonly isolated pathogen across various sample types, contributing to 40 percent of all isolates in 2023.
Among urinary samples, E coli dominated with a 58 percent prevalence, while Klebsiella spp was the leading pathogen in blood samples (26%).
Notably, Klebsiella spp also accounted for 32 percent of isolates from other sterile body fluids, whereas Staphylococcus aureus was the predominant pathogen in pus and aspirates (30%).
In intensive care units (ICUs), both E coli and Klebsiella spp emerged as the most common pathogens, each representing 29 percent of the isolates. This trend underscores the critical need for robust infection control measures in high-risk healthcare settings.
While most resistance trends are troubling, the data shows a decline in vancomycin-resistant Enterococcus (VRE) rates. Enterococcus isolates from blood cultures exhibited a 3 percent resistance to vancomycin in 2023, down from previous years. However, continuous monitoring is essential to ensure this progress is sustained.
Coming to the Indian context, various studies including that of the Department of Biotechnology and the Indian Council of Medical Research’s (ICMR) Antimicrobial Resistance Research and Surveillance Network highlight that India has some of the highest antibiotic resistance rates among bacteria that commonly cause infections in the community and healthcare facilities.
The growing antibiotic resistance and decreasing susceptibility of common pathogenic bacteria demand urgent and effective interventions.
Unlike many regions still awakening to the AMR threat, Kerala has been in the fight for years, emerging as a beacon of hope and a model for strategic intervention.
The seeds of Kerala’s war on AMR were sown in 2018.
Recognising the escalating misuse of antibiotics in healthcare, animal husbandry, and agriculture, Kerala decided to address the issue head-on.
In that year, it unveiled the Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP), becoming one of the first states in the country to adopt a localized framework tailored to its unique challenges.
At the heart of Kerala’s strategy was collaboration.
Public health experts, medical practitioners, veterinarians, officials of various departments, policymakers, pharmacists, medical shop owners, druggists and chemists, hospitals and others joined forces to tackle the crisis.
The state started the initiative with the basics: Increasing awareness among the public and healthcare professionals about the dangers of antibiotic misuse.
Then in 2019, in order to strengthen and expand the AMR surveillance network in the state, the Kerala Antimicrobial Resistance Surveillance Network (KARS-Net) was established.
The objectives of this network were to foster standardisation, strengthen and expand AMR surveillance in the state, analyse and report KARS-Net data to state government and National Centre for Disease Control (NCDC) regularly, contribute towards the estimation of extent, burden and monitoring of AMR in Kerala and detect emerging resistance and it’s spread in Kerala.
The officials said that the network of laboratories over the years has expanded from 21 labs in nine districts to 49 labs across 12 districts in a phased manner.
Kerala AMR Surveillance Network (KARS-Net): Institutions under KARS-Net
Priority pathogens under surveillance currently include nine commonly isolated pathogens from identified specimens.
The WHONET software is used for the collection and analysis of antimicrobial susceptibility data.
It was while carrying out a range of awareness programmes against AMR, that another milestone was achieved by the state in 2022.
In that year, Kerala became the first state in India to release an antibiogram, highlighting the growing concern about AMR within its borders.
The 2021 antibiogram report reveals a notable rise in antibiotic resistance among bacteria causing both community and hospital-acquired infections.
An antibiogram is a clinical tool that summarizes the resistance profile of bacterial pathogens and their susceptibility to various antibiotics. It aids clinicians in choosing the most effective empirical treatment and tracking resistance trends.
The data for Kerala’s antibiogram was compiled from 18 sentinel sites across nine districts, providing critical insights into AMR patterns and guiding public health strategies.
On 2 December, the state released the Antibiogram (AMR Surveillance Report) for 2023. This is the third consecutive time that the state has released the Antibiogram.
This report, from tertiary health centres included in the KARSNET network, shows that the level of antibiotic resistance remains a major threat.
Earlier this year, the state became the first state in India to officially ban over-the-counter (OTC) antibiotic sales without prescriptions.
Then to ensure the same, Operation Amrith (Antimicrobial Resistance Intervention for Total Health) was launched with the help of the Kerala Drugs Control Department.
The initiative aims to eliminate the OTC sale of antibiotics in Kerala by the end of 2024, marking another milestone in the State’s efforts to combat AMR.
This innovative programme emphasises public participation, empowering citizens to report pharmacies that sell antibiotics without valid prescriptions.
Health workers with campaign materials for door-to-door campaign against AMR
A toll-free number (1800-425-3182) was introduced for lodging complaints, encouraging greater community involvement in what is being hailed as an example of participatory antimicrobial stewardship.
According to the plan, a special squad under the Drugs Control Department will conduct covert inspections at medical shops to identify and penalize violators.
Pharmacies are also mandated to meticulously record all antibiotic sales and display prominent notices stating that antibiotics will not be sold without a prescription.
Strict action, including penalties, will be taken against outlets flouting these norms.
The state, during this time, also mandated that antibiotics would have to be sold only in distinctive blue envelopes to help differentiate them from other medications.
This was introduced as part of the Rage on Antimicrobial Resistance (ROAR) programme.
In the first phase, the State Drugs Control Department distributed 50,000 blue envelopes to private pharmacies, which would later be required to procure similar envelopes independently. Public sector pharmacies will also follow suit.
These envelopes will feature dosage details and awareness messages, including a statutory warning that selling antibiotics without a doctor’s prescription is punishable under the Drugs and Cosmetics Act.
Other messages include advice against sharing antibiotics, improper disposal of unused medicines, and the dangers of AMR, which leads to higher treatment costs and fatalities.
Pharmacies across the state were also directed to display standardized posters highlighting the dangers of AMR.
The state is also undertaking grassroots-level programmes like health workers’ door-to-door visits to create awareness against the excessive use of antibiotics.
Awareness is also being done in educational institutions and public places.
The state is also the first Indian state to roll out an AWaRE-based bacteriological culture susceptibility reporting format, which aims to revolutionize the way antibiotics are prescribed in the state.
Health Minister Veena George releasing the Antibiogram Report 2023
Health Minister Veena George revealed a significant milestone in Kerala’s fight against antibiotic misuse: The state has successfully curbed unnecessary antibiotic consumption worth ₹1,400 crore in just one year.
This achievement, according to her, stems from the government’s strict directive ensuring antibiotics are sold only with a doctor’s prescription, leading to a remarkable 20-30 percent reduction in usage this year.
Talking to South First, Dr Aravind R, convener of the working committee for KARSAP, said, “A range of activities and interventions are in progress in the state as part of Antibiotic Literate Kerala. It’s with this intention that we strive to create antibiotic-smart hospitals, antibiotic-smart panchayaths, antibiotic-smart local bodies and eventually antibiotic-smart citizens. The underlying theme is a people-centric approach in containing AMR.”
Dr Aravind also added that Operation Amrith had played a major role in reducing antibiotic usage in the state.
AN Mohan, the state president of the All Kerala Chemists and Druggists Association, shared a critical perspective with South First, pointing out a significant gap in the government’s efforts to tackle antibiotic misuse.
He said, “The government’s monitoring is largely focused on roadside medical shops, leaving a blind spot for pharmacies operating within hospitals, especially in multi- and super-speciality setups. How can we address the rampant over-prescription and sale of antibiotics in these settings?”
Mohan also highlighted another concern that affects chemists daily: “Illegible prescriptions continue to flood our counters, forcing us to guess the doctor’s intent, which could lead to serious consequences. If Kerala’s fight against AMR (Antimicrobial Resistance) is to succeed, these issues must be urgently addressed.”
Meanwhile, a health department officer offered a sobering outlook on the state’s progress.
“Kerala is making strides in the battle against AMR, but it risks falling short if the rest of the country doesn’t catch up. While Kerala leads, other states are lagging far behind. The challenge is that, as a consumer-driven state, Kerala depends on other regions for products like poultry, eggs, and vegetables — many of which are laced with antibiotics. The real danger is that, despite our efforts, the threat of AMR looms large over the people of Kerala every time they consume these goods,” the officer told South First.
While Kerala has made notable strides in addressing AMR, the state’s efforts remain a mixed bag, with successes tempered by significant challenges that still lie ahead.
(Edited by Muhammed Fazil.)
