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 .)
