“Antimicrobial resistance threatens to place 2 million Indians at risk of dying every year by 2050” a British economist warned recently. This antimicrobial threat is directly linked to rampant and irrational use of antibiotics. The recent study has shown that the per capita antibiotic use is increased by 37 per cent between 2005 and 2010. India now is the largest consumer of antibiotics in the world in terms of volume. The antibiotic consumption (though not true for all classes) is either stable or decreasing in developed countries, in India has increased substantially. The fasted growth in use is due to several factors including increased income and unrestricted availability of antibiotics like over-the-counter (OTC) medicines. The growth in use of antibiotics mainly occurred in broad spectrum groups like penicillins, cephalosporins, quinolones, and carbapenems.
Antimicrobial resistance (AMR) is not just restricted to India but a global health threat. It has been identified as a major global health security issue. The World Economic Forum’s Global Risks 2014 identifies increasing antibiotic resistance as one of the main societal risks. That means there is a clear signal of danger of “post-antibiotic” era when these presently known antibiotics would become ineffective. Things as common as strep throat or a child’s scratched knee could once again kill. Routine medical care, surgery, cancer treatment, organ transplants and industrialized agriculture would be impossible in the present form in absence of effective antibiotics. A potentially catastrophic situation not far away!
The development of resistance is a natural process. Even Alexander Fleming warned of bacterial resistance while receiving Nobel Prize in 1945 for discovery of penicillin. All these days, antimicrobial resistance was a matter of research and the clinical practice ignored the issue because new and alternative antibiotics were available for treating the resistant infection. This was possible due to continuing replacement of ineffective antibiotics by new ones. Unfortunately the pipeline for new antibiotic development is dry. Most of the antibiotic classes were discovered before 1970 and over the past three decade only two new classes. The pharmaceutical companies are not much interested in investing for new antibiotic development due to the risk of antimicrobial resistance. If resistance develops, the pharmaceutical companies loose the molecule and there is even the risk of not recovering the entire investment. In 2004, there were only five antibiotics in development compared to more than 500 drugs for chronic disease conditions. In absence of pipeline of new antibiotics, tackling resistance requires better use of antibiotics and at the same time preventing and controlling the spread of resistance already present.
In addition to increased sickness and death rates, prolonged illness and greater risk of complications, the antimicrobial resistance causes potential loss of productivity and increased cost of diagnosis and treatment. The overall cost of antimicrobial resistance in Europe is estimated to be 1.5 billion Euro and cost to US healthcare is 21-34 billion US dollar each year. Though similar estimates are not available for India, the cost of treatment to resistant infection is increasingly high and often unaffordable. Treatment of multi drug resistance TB is an example to cite. A recent study reported the death of 58,000 infants with bacterial infections that were resistant to most known antibiotics. India’s position on antimicrobial resistance is termed as tsunami of antibiotic resistance.
India’s problem is not just antimicrobial resistance. The country is continued to have even poor access to essential medicines including antibiotics. Poor sanitation practice, uncontrolled use of antibiotics both at individual and health facility level, frequent hospital acquired infection and lack of monitoring mechanism further complicate the issues.
The Government of India realised the antimicrobial resistance is a special problem. This is reflected in the Government’s draft Health Policy. Some of the initiatives, the Government proposes are: standardising the treatment guidelines at various levels of healthcare, limiting the use of certain antibiotics as over the counter medicines, restricting their use as growth promoters in animal livestock and improving hospitals’ infection control system etc. Some of them are already initiated like introducing the Schedule H1 in Drugs Rule to restricting the sale of certain medicines. But the rule is not effectively implemented. The antibiotics in new schedule continue to be available like OTC medicines. There have been two declarations too: Jaipur Declaration and Chennai Declaration. In response to Jaipur Declaration of 2011, South East Asian countries have initiated public education campaign on use of antibiotics. Jaipur Declaration was composed by the SEARO (WHO) member countries urging action on antimicrobial resistance. The Chennai Declaration was the road map to tackle the challenge of antimicrobial resistance. All Indian Medical Societies and high level Central and State government policy makers including the members of National Accreditation Board of Hospitals, the Medical Council of India, the Indian Council of Medical Research, the Drugs Controller General of India, and the World Health Organization met together in 2012 to develop the road map. In spite of all the initiations, the result is invisible as there is no implementation.
Doctors prescribe, patients demand and the pharmacists sale but no one ensures the completion of the full course. There must be vigorous and sustainable campaign sensitizing all stakeholders from pharmaceutical companies to doctors to drug sellers to patients on the danger of not using antibiotics appropriately and the benefits of using them judiciously. An integrated approach involving all stakeholders is a recommendation. Acting now designing an effective and implementable strategy would not only be cost effective but also would be sustainable solution tackling antimicrobial resistance and ensuring health security.
(The authors are with Department of Pharmacy, Annamalai University, Annamalai Nagar, Tamil Nadu 608 002)