India faces the challenge of inappropriate use of antibiotics while Bharat copes with poor access to treatment, resulting in a policy conundrum and inaction.
India was recently in the news for the wrong reasons. The serious threat posed by the newly discovered microbe, NDM-1 (New Delhi metallo--lactamase-1), resistant to many antibiotics, triggered alarm and panic. Predictions that the country will not meet the millennium development goal for child mortality caused dismay. They highlighted the nation's paradox. The country faces two conflicting challenges. The urban rich with their easy access to medical treatments often receive inappropriate antibiotic therapy. On the other hand, the rural poor, with their lack of basic medical facilities, find it difficult to obtain such medication. The former results in microbial resistance, while the latter in preventable deaths. The official reactions to both these problems and their implications were denials. However, after the short-lived indignation and outrage, it is back to business as usual, the old inertia with its deceptive calm.
Microbial resistance
Resistance of microbes to standard antibiotics is well known. Hospital-acquired infections, in circumstances where the use of antibiotics is high, are common. The development of bacterial resistance to antibiotics is natural and occurs due to adaptation to hostile environments. However, the rapidity of its development and increased prevalence of such resistance documented in many tertiary hospitals reflect a serious problem. In addition, the life-threatening nature of many infections, a limited availability of existing antibiotics and the absence of new ones in the drug development pipeline are causes for alarm. This is true for many bacteria, including those causing tuberculosis. It indicates the emergence of new and lethal dimensions for old diseases, which had effective and affordable cures. The increase in antibiotic resistance in community-acquired infections compounds the problem. It suggests that resistant microbes, usually found in hospital environments, are now prevalent in the community.
The misuse and abuse of antibiotics by physicians is serious. Inadequacy of training in prescribing rational antibiotic therapy is a major lacuna. Prescribing antibiotics for simple viral infections to prevent possible secondary bacterial infections is common practice among physicians, despite good clinical trials showing no value of such prophylaxis. Absence of sentinel surveillance and regular guidance for prescribing also makes practice difficult. Indiscriminate prescription of newer antibiotic medication while allowing for recovery in individual patients, risks development of microbial resistance.
The generally safe profile of antibiotics, their minimal side effects and short duration of the course of medication are factors that lend themselves to abuse. The pharmaceutical industry contributes to the problem by promoting the sale of antibiotics independent of patient need. Pharmacists readily dispense antibiotics without a doctor's prescription. A widely prevalent belief among the general population that all infections respond to antibiotics also perpetuates inappropriate use. Many fail to realise that the majority of fevers are due to viral infections, which do not respond to antibiotic therapy.
Poor access
The lack of surveillance of microbial resistance at primary and secondary hospitals and the absence of guidance in prescribing encourages the use of newer broad-spectrum drugs in situations were older medication would have sufficed. The poor state of the public health care system, the private sector with its focus on profits and deficiencies in the regulation and sale of antibiotics also muddy the waters.
While NDM-1 grabs the headlines, the true magnitude of the problem of antimicrobial resistance to common antibiotics remains unknown. Widespread multi-drug resistance essentially implies a return to the pre-antibiotic era and represents a major crisis in health. On the other hand, the lack of affordable access to basic medical facilities for the poor in Bharat complicates the issues. Pneumonia, an acute respiratory infection, is the leading cause of child deaths in the world and a common cause of under-five mortality in India. The World Health Organisation (WHO) estimates that less than a quarter of children with pneumonias receive antibiotics, resulting in significant mortality. Similarly, mortality in adults with bacterial infections is also a major concern. The absence of adequate and timely antibiotic therapy due to a lack of access to affordable medical care (for the vast majority of the rural population in the country due to the urban-centric nature of our health care delivery system) contributes to preventable deaths.
The way forward
Urban and rich India, with its inappropriate use of antibiotics, requires strict practice guidelines, tighter regulation and an audit of antibiotic utilisation. On the other hand, poor and rural India needs improved access to antibiotics and affordable health care.
Rational antibiotic therapy prevents the development of resistant micro-organisms, superbugs and untreatable infections. Rational use will also result in a massive reduction in the cost of health care. High-income countries have managed to decrease the rate of antimicrobial resistance through a multi-pronged approach. Their well-regulated health-care systems allow for monitoring of antibiotic consumption and resistance, prescriber and consumer education and regulation of use.
Fighting antibiotic resistance in India with its inadequate public health care infrastructure, unenforced regulation and poor health education is a major challenge. Continuing physician education, guidance on prescribing and monitoring practice is necessary. Regulating the sale of antibiotics and microbial surveillance are mandatory.
India should start sustainable action to contain antibiotic resistance. It should raise awareness using the mass media. Hand washing routines, to prevent the spread of infection within hospitals, are observed more in the breach in most health facilities. These need to be made mandatory. Antibiotic sensitivity patterns, minimum inhibitory concentrations and a strategy of de-escalation of an antibiotic regimen should guide therapy in tertiary hospitals. The latter mandates a change to an appropriate “older” antibiotic rather than continuation of a newer broad-spectrum drug, after obtaining information on microbial sensitivity.
The formation and functioning of hospital infection control committees are obligatory. They should monitor hospital-acquired infections at surgical sites and secondary to the use of intravenous access, urinary catheters and ventilators. The committee should compile sensitivity patterns, recommend prescribing guidelines, audit practice and educate health professionals. Specialist hospitals should have consultants in infectious diseases who should advice in making rational choices for complex clinical situations. Modern technology allows for support in prescribing, tracking of antibiotic use and in containing the spread of resistance. In fact, it should be mandatory for hospitals to make public their rates of hospital-acquired infections and microbial sensitivity patterns, to allow for informed choice for patients.
The surveillance of microbial resistance should not be restricted to tertiary hospitals, as currently practiced. It should also involve primary and secondary care centres to identify local and regional patterns. The people of Bharat need a different surveillance network and practice guidelines tailored to meet their specific needs. Sentinel centres in primary and secondary care hospitals, with regional coordinating facilities, should be set up to help smaller hospitals. National and regional databases and advisory councils are mandatory. The implementation of such systems is the challenge facing the country.
The solution to improve access to basic health care for poor and rural constituencies may lie in a different set of practice guidelines. Regulation of antibiotic use for this sector must be balanced by adequate availability and access to such treatments. Antibiotic policies should factor in different microbial resistance profiles. Simplified antibiotic prescribing protocols for use by highly trained paramedical workers and nurse practitioners have been found to be useful in many low-income countries. Such strategies merit consideration for increasing access and availability in rural and remote parts of the country.
Another cause for concern is the use of antibiotics in the agriculture-food industry (e.g. poultry, pig, fish farming and in honeybee hives) where these drugs are used as growth promoters. Policies for rational use in this sector are also urgently required.
A decade has passed since the flagging-up of concerns about antibiotic resistance and increased mortality due to untreated infections. The divergent and complex demands of the different segments of the country have resulted in inertia and inaction. There is an urgent need to put in place suitable policies and mechanisms for reductions in antibiotic resistance and yet provide easy access to antibiotics in areas with poor penetration of health-care services. The challenges for India and for Bharat are different and demand different solutions. The country is yet to have a comprehensive antibiotic policy. Implementation plans remain on paper. The country needs carefully tailored strategies to meet the dissimilar challenges of its diverse contexts.
(Professor K.S. Jacob is on the faculty of the Christian Medical College, Vellore.)
Very good article. We must create awareness in the public. In India the drug resistance awareness is very poor. The state and central govt must take necessary action in this regard. Its a growing problem.
Good article! Our health case system is in a shambles where the common man scared to go and get treatment from incompetent doctors and rickety infrastructure.On other-hand rich people are unconsciously consuming unsafe overdose of antibiotics which assuages pain for small period of time. Here we need to make aware people about such malpractices where antibiotics are used to kill virus prone diseases.This must be incorporated in syllabus for doctors and para medics. These drugs are causing more harm than good because they may produce next super-bug in line. For poor India , health-care system has been subject of farce .Here we need more attention and investment.Government cannot play with health of millions of poor people. Unfortunately many Indians do not have health insurance. Reckless greed for money and effort to lull the patient in false sense of well-being are root of problem for rampant use of these powerful drugs. Another instigator is blitzkrieg marketing techniques used by drug makers who give commission or free drugs to doctors for recommending their powerful pills.These kickbacks must be stopped. We need examples of revoking licenses of hospitals, doctors for malpractice and for making harm to people ....I am really waiting for such drastic actions ...which would put examples for fair medical treatments.
------ NILESH SALPE
One cannot analyse a complex problem, compounded by greed at one end and ignorance at the other, in a single article. Yet Professor K.S.Jacob had to be complemented for starting a healthy debate, ironically involving health.As a person involved in pharma marketing till early 90's I can contribute valuable inputs in the mis-management of antibiotics. Barring a handful, many medical practitioners derive their knowledge about new medicines only through pharma companies and their marketing literatures are always one sided. Most of the pharma companies exaggerate the effects of a drug - especially the antibiotics and maintain a stoical silence on adverse effects. Seldom they care about the collateral damage created by a doctor's prescription.There are instances of a doctor prescribing a cough syrup to all and sundry thinking it to be a tonic. I am ashamed to have called on many quacks professionally for a few prescriptions. I am dismayed by many prescriptions of antibiotics for the treatment of viral fever and when questioned many practitioners come out with the stock answer that it is to take care of secondary infection.As a pharma back-ground person I have stood a star performer for many products and now I can recall it is certainly not because the product deserved the merit, but because I had developed a strong liking for the product. I have seen during my career, when asked to qualify the prescription pattern, many doctors have conceded that it is simply idiosyncrasy. I wish there is a sequel to the article, so that more could be debated.
Sir, as you are suggesting our system needs stringent guidelines to restrict the use of antibiotic at initial level of the dose under any disease or suffering. Here both urban and rural part of country is facing problems. Good part of Aam aadmi's money is spend in availing medical facilities then they have to struggle for bread and butter. If we all take pledge to do our duty with full responsibility and honesty including doctors who are treated as gods, our lovely government and aam aadmi then only what Mr Jacob has pointed can be solved.
The article will help to realize the depth of irrational use of antibiotics both the physicians and people.As a pharmacist in government general hospital in Kerala i am handling hundreds of such prescription day to day. Most of the doctors are prescribing without any rational study of the drugs. Their main sources are Representatives from pharmaceutical industry.
Injudicious use of antibiotics are just like bombarding our body to kill both harmful and useful bacterias of gut. The nasty practice has led to increase in microbial resistance due to killing of useful bacterias. The practice of rampant use of antibiotics sometimes due to demand of patients for early recovery. The patient judges the doctor by the recovery time from illness. In the era of commercialisation of health sector, doctor and patient are the partner to this vicious cycle.
After a much awaiting period I see a good wake up call on a very crucial subject of health concern. India ranks one of the highest when it comes to infectious diseases. Bacterial drug resistance is an alarming concern! In future more of NDM-1 like superbugs will thrive and spread. I would like to add one more major point to Professor Jacob's article and that is public awareness about drug resistance. The moment disease starts to subside, our people tend to stop taking drugs in time. Many of them do not finish the prescribed course. If bacteria escapes from minimal inhibitory concentration, and the required drug dosage, also, they develop drug resistance. Completion of course actually mean elimination of majority of bacteria that could recur to cause the damage again. Our people also need to follow strictly what doctors say when it comes to antibiotics. Not every doctor in India is bad. From the above posts and article please don't take a wrong impression on medical practitioners. Ordinary laymen become doctors in our country. They ask for various antibiotics in the pharmacy and PHARMACISTS GIVE THEM what they want. In developed countries pharmacists don't sell any antibiotics without prescription whats so ever. The reason is strict government implications of regulations on selling antibiotics. We need to wake up and wake the people around us.
And while we are at it, can we ask the Government to ensure that the antibiotics that are available are genuine?
This is a nice article by Professor K.S. Jacob . I am not a medical student but I got a clear message. So this article again suggesting government to take efficient steps to improve Basic education and health care facilities.This time also during budget session government was just putting light on GDP but there is no real development of any country with out improving the condition of Basic Education and Health Care facilities .I hope soon Govt will realize this fact and will do something for development of Bharat which is still far from the big offices of Delhi.
Author has touched upon a serious issue, specially when the different stakeholders for health care sector are talking about reform and inclusiveness. Not many people in this country consult a doctor before taking a antibiotic medicine. Further more the kind of marketing strategy pharma companies are using, looking at them one can conclude that a healthy person will also start taking these antibiotics to remain healthy. It means being addicted of antibiotics. In my opinion government should make a regulating body to put a check on the prescription of doctor of inappropriate antibiotics and on the sale of antibiotics without prescription. But this would be a short term approach with a narrow vision. Therefore, government should incorporate general health in the education curriculum to make the people aware about the problems related with inappropriate antibiotics or general healthcare.
The article touches upon an important aspect in the treatment of medical illnesses under the allopathic system. The standards employed by qualified medical professionals for prescription of antibiotics is appalling. I could cite a few examples. Ciprofloaxacin has been claimed to be the invention of the 20th Century. Yet even for minor wounds of the skin it is prescribed as a short course for three days. A patient had skin abscesses due to an MRSA. Doctors went about precribing antibiotic after antibiotic for three months when ever these abscesses sprung up. In the fourth month it was detected that the infection was resitant to most antibiotics and the patient was ultimately treated with Clindamycin. Misuse of antibiotics also has serious side effects. One could have life threatening heart attacks to serious skin infections when antibiotics are used. A study recently cited in 'The Hindu' says that the good bacteria in the gut develop resistance for almost two years to antibiotics used by a patient. Antibiotics get into the Honey we eat. They lower the natural resistance of the humans and make a person weak. The allopathic system has certain flawed approaches and the applicants of the system never admit this. Recently a qualified skin specialist prescribed an ointment for acne which works by altering the DNA of the person and there is a warning that in mice this substance has caused cancer. This doctor did not care to inform the patient of the possible side effects and took the patient for granted. Can Acne and Cancer be weighed on the same scale?. Even the approving authorities routinely approve drugs. They do not think about long term consequences.To top it all Pharmaceutical companies do not have a fool proof mechanism to prevent fakes. No one in today's circumstance can be sure that what is being swallowed is a genuine medicine or not. One has to understand that for different types of problems different medical systems work better. One has to avoid self medication at all costs but exercise due diligence when taking the advice of a doctor.
Dear Sir, This is a complex problem. The author has touched on only one dimension of the issue. The other sides are: pressure from Pharma cos. on doctors to dispense drugs, the demand from patients for 'quick relief' and unethical practices by doctors and hospitals which are focused on making a fast buck. All this along with the advent of health insurance has combined to make public health in this country a serious issue. The day is nor far when it will become a crucial political issue, given the huge amounts charged by hospitals and unethical and unconcerned practices by doctors. The quality of doctors itself has fallen not withstanding the surge in 'medical tourism' in the country. Many a times, they are working on 'trial and error' basis with patients, playing with their health and lives. Doctors are also one major source of black money in the country.
Who placed antibiotics on such a high pedestal in first place? Medicos, by their various acts of commission and omission. Blind chase for killing bacteria and virus was untenable and uncalled for ever since the advent of antibiotics but nobody gave it a serious thought, thanks to mercenary rat race in which truth was relegated to background and one-up-man ship took central stage. Myriad systems of healing shout from roof top that bacteria/ microbes/viruses do not cause disease but appear on scene as opportunists and passers by. Real cause of disease lies in food and lifestyle.But allopathy consistently went drum beating about microbes and a campaign to eliminate them. Now they face the wall. And they deserve it.
The article by Professor K S Jacob is timely. One of the basic requirements is better undergraduate medical education formulated on sound principles derived from the existing pattern of infectious diseases in the country! This calls for collection of data from all health facilities from primary to tertiary and analysis of such data should be a priority for the department of health in each state. These should be the basis on which regional and national antibiotic policies are formed and these guidelines need to be emphasized in undergraduate medical education. It is mandatory that every hospital and Nursing Home should have access to a good microbiology laboratory, an infectious disease consultant and good coordination between the two. Each health care facility should have a rational antibiotic policy which is updated periodically after review of in vitro sensitivity of microbes. There is a fine distinction between colonisation by bacteria (mere presence of organisms in a hospitalied patient's exposed surfaces) and active infection by organisms that demand immediate treatment. The failure to distinguish between the two is a common cause for antibiotic misuse in hospitals. The present alarming scenario calls for a study of antibiotic prescribing patterns of doctors which will readily identify professionals who are trigger-happy with antibiotic use. The Indian Medical Association and the Medical Council of India should have firm guidelines as to how to deal with erring professionals. This calls for self-imposed discipline by practising doctors and effective continuing medical education.Will the profession rise to the occasion?
Dr Seshadri
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