The theme differs, but the slogan, “Antimicrobials: Handle with Care” is the same as the world observes Antimicrobial Awareness Week between 18 and 24 November every year.
Not many are aware of the annual Antimicrobial Awareness Week — very much like the lack of awareness of the overuse or misuse of antibiotics.
In a 2015 article, the World Health Organisation (WHO) noted with concern that “a new multi-country survey shows people are confused about this major threat to public health and do not understand how to prevent it from growing”.
The threat is still real even eight years after the article was published.
In November 2021, WHO declared antimicrobial resistance — abbreviated as AMR — as “one of the top 10 global public health threats facing humanity”.
Antimicrobial resistance is still a growing problem in hospitals across India, a country that pops a pill more often than other nations.
A recent study by researchers in the US and Karnataka revealed that AMR is not limited to hospital settings but is prevalent in infection-causing pathogens in rural communities as well. The finding has left doctors a disturbed lot.
The study conducted in Karnataka aimed at investigating the prevalence of AMR in patients admitted to a tertiary-care facility with infections acquired in the wider rural community.
The researchers analysed urine, blood, and wound cultures from 100 patients for bacterial identification and antimicrobial susceptibility testing.
“The results of our study are of much concern, as they demonstrate high rates of antibiotic resistance in rural areas of India,” said Sumana Mahadevaiah, one of the lead researchers.
“This highlights the urgent need for interventions to combat antimicrobial resistance and protect the effectiveness of antibiotics,” the researcher from the Mysuru-based JSS Medical College’s Department of Microbiology added.
The findings have appalled Dr Sundar Sankaran, Consultant Nephrologist and Programme Director at Aster Institute of Renal Transplantation in Bengaluru.
“The study should be a wake-up call for doctors, health planners, and pharmaceutical companies,” he told South First.
“We believed that AMR was only seen in tertiary-care hospitals and urban medical units, but this paper highlights its presence in rural areas. It is frightening, especially for a transplant nephrologist like me, dealing with organ recipients who are on powerful drugs and with relatively lower immunity,” said Sankaran, a former chairman of the Indian Society of Nephrology.
He did not hide his concern, even as as called for more such studies.
“Antibiotics should strictly be made prescription-only drugs. A proper audit by infection control teams is also required,” he added.
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What is AMR?
Dr Sanjeev G, a physician at Sanjeev Clinic in Bengaluru, explained that AMR refers to the ability of micro-organisms — bacteria, viruses, parasites, and fungi — to develop resistance to drugs (antimicrobials) that were originally effective in treating infections they cause.
“In layman’s terms, it means that medications commonly used to treat various infections have become less effective or even ineffective, leading to a prolonged illness, increased risk of complications, and higher healthcare costs,” Sanjeev said.
Doctors said that AMR is a global health concern that threatens our ability to effectively treat infectious diseases and poses a significant challenge to public health.
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The rural reality
The pilot study was aimed at assessing the prevalence of AMR in pathogens causing infections acquired in the wider rural community.
The researchers found that efforts to tackle AMR primarily focused on inpatient settings. Recent data from the Ministry of Health suggested that rural areas in India have been playing a progressively significant role in spreading AMR than previously recorded.
The study conducted a retrospective prevalence survey of urine, wound, and blood cultures collected from patients admitted to a tertiary-care facility in Karnataka.
The investigators tested 100 urine samples, 102 wound samples, and 102 blood samples from inpatients in a Mysuru hospital. These patients had infections that were acquired from outside the hospital. They were all aged above 18 and were referred to the hospital by doctors at primary-care centres.
The patients had positive blood, urine, or wounds culture, and none of them have been previously hospitalised. The researchers identified the bacteria in the samples and tested their antibiotic susceptibility.
Positive culture denotes the presence of asymptomatic bacteria.
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Implications of the findings
The study’s findings were alarming. The most common pathogens found in urine and blood cultures were Enterobacteriaceae, a large family of bacteria, including familiar pathogens such as Salmonella, Shigella, and E-Coli.
Enterobacteriaceae showed significant resistance to several commonly used antibiotics, such as quinolones, aminoglycosides, carbapenems, and cephalosporins. High resistance rates were observed across all three cultures.
“We found that the resistance rates for multiple classes of antibiotics were remarkably high among the pathogens isolated from the rural population. This raises concerns about the limited treatment options available for these infections,” the study noted.
Specifically, resistance rates exceeding 45 percent were found for quinolones, penicillin, and cephalosporins in all culture types. Blood and urinary pathogens also displayed resistance rates exceeding 25 percent for antibiotics aminoglycosides and carbapenems.
The study’s results emphasised the urgent need to address AMR rates in rural populations. Efforts to tackle the issue should focus on understanding and addressing antimicrobial overprescribing practices, healthcare-seeking behaviours, and antimicrobial use in rural agriculture settings.
“Our study highlights the importance of implementing targeted interventions to reduce antimicrobial resistance in rural areas. This includes promoting responsible antibiotic use, improving infection prevention and control practices, and enhancing surveillance systems,” the researchers recommended.
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AMR and health
Diabetologist Dr Mohan V, the Chairman and Chief of Diabetology of Chennai-headquartered Dr Mohan’s Diabetes Specialities Centre, termed AMR a serious problem increasing in prevalence across the world, particularly in India.
“The primary reason for AMR is the indiscriminate use of antibiotics. In many developed countries there are strict guidelines for antibiotic use,” he told South First.
Normally, one starts with the lowest antibiotic dosage and proceeds to higher ones only if the lower ones are ineffective. “In India, it has become a habit among many medical practitioners to straight away prescribe the highest antibiotic for sure-shot desired results.
The practice is more prevalent in private and corporate hospitals where affordability is not an issue. If this indiscriminate method of using antibiotics is continued, it could lead to serious AMR as microorganisms develop resistance against higher dosages of antibiotics.
“Every institution, hospital or clinic, private or government, should have its antibiotic policy and they must strictly adhere to it. The sensitivity of various organisms that are grown must also be tested frequently. This can prevent the emergence of serious AMR in India,” he opined.
The study also mentioned that AMR poses a significant threat to the effective treatment of infectious diseases, leading to increased illness, death, and healthcare costs.
Globally, AMR caused nearly five million deaths in 2019, with higher rates reported in sub-Saharan Africa and South Asia.
The researchers called for immediate attention and targeted interventions to reduce AMR rates and protect the effectiveness of antibiotics in rural communities.
The study’s findings serve as a wake-up call for policymakers, healthcare providers, and the general public to work together in implementing measures to combat AMR.
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Former president of the Indian Medical Association, Kochi Chapter, Dr Rajeev Jayadevan concurred with the study’s finding that antibiotic resistance is a serious problem not only in urban hospitals but also in rural India.
“Large hospitals document antibiotic resistance in areas such as intensive care units, where critically-ill patients are treated with a broad spectrum of antibiotics,” he told South First.
Bacteria often colonise such places and develop resistance to antibiotics. They thrive on hard surfaces as well as instruments and sometimes survive even earnest cleaning efforts.
Jayadevan felt the study’s significance was the discovery of such organisms in rural areas. The reason is the widespread and indiscriminate use of antibiotics across the country, irrespective of the urban-rural divide.
“When exposed to an antibiotic, some bacteria gain special abilities to survive these drugs, and can transfer these abilities to other bacteria,” he said. This is possible through portable “DNA packages” called plasmids that can be exchanged between related and unrelated bacteria thriving in the same locality.
For instance, in a poorly sanitised area, the bacteria from a diarrhoea patient using antibiotics can spread the plasmids to other relatively harmless bacteria in the neighbourhood. These bacteria enter other nearby individuals, sometimes causing infection. “The cycle repeats,” Dr Jayadevan said.
Consequently, the level of antibiotic resistance in the community gradually increases. In India, unfortunately, antibiotics are available over-the-counter and are dispensed even without a prescription.
“Patients purchase antibiotics based on prior prescriptions a doctor had made for another problem. They also share prescriptions with other people who have similar symptoms,” he added.
Then come the “opinion leaders”. They are in all families and workplaces. They profess to have medical knowledge and advise others to purchase antibiotics without consulting a doctor.
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Dr Rajeev Jayadevan made a set of recommendations to combat AMR.
- Educating the general public about the hazards of unnecessary antibiotic use.
- Regulate the dispensation of antibiotics. It is the single-most effective step to reduce antibiotic misuse and AMR. (Unfortunately, India lacks a system where antibiotics could only be dispensed only on a prescription by a registered medical practitioner, as is the standard practice in Western countries).
- Widespread veterinary antibiotic use is another factor, where greater regulation will help.
- Preventing infection through proper sanitation would reduce the use of antibiotics.
- Antibiotic policies are already in place in some high-quality healthcare settings. They must be made universal.