“Antibiotic therapy, if indiscriminately used, may turn out to be a medicinal flood that temporarily cleans and heals, but ultimately destroys life itself.” — Felix Marti-Ibanez, 1955
The World Health Organisation (WHO) chose combating antimicrobial resistance as the theme of this year's World Health Day (April 7) with the slogan “No action today, no cure tomorrow.” It coincides with India's national effort to promote the prudent use of antibiotics.
During the past six decades, antimicrobial agents have played a critical role in reducing the burden of communicable diseases the world over. The emergence of resistance and its rapid spread are negating the impact of these drugs, obstructing progress towards reaching the targets of the health-related United Nations Millennium Development Goals set for 2015 for HIV, TB and malaria and hindering effective application of modern technologies in mitigating human misery.
There are alarming reports about serious consequences of antibiotic resistance from all around the world. However, there is still a dearth of data on the magnitude and burden of antibiotic resistance, and its economic impact on individuals, health care and society. This, they suggest, may explain why there has been little response to this public health threat from politicians, public health workers and consumers.
About 44 lakh new cases of multi drug-resistant tuberculosis (MDR-TB) emerge annually, causing at least 1.5 lakh deaths. Extensively drug-resistant tuberculosis (XDR-TB) has been reported in 64 countries to date.
Resistance to earlier generation medicines such as chloroquine and sulfadoxine-pyrimethamine is widespread in most malaria-endemic countries.
Ciprofloxacin is the only antibiotic currently recommended by the WHO for the bloody diarrhoea due to shigella organisms, now that widespread resistance has developed to other previously effective antibiotics. But a rapidly increasing prevalence of resistance to ciprofloxacin is reducing the options for safe and efficacious treatment of shigellosis, particularly in children.
Antimicrobial resistance has become a serious problem in treating gonorrhoea (caused by Neisseria gonorrhoeae), involving even “last-line” oral cephalosporins, and is increasing in prevalence worldwide. Untreatable gonococcal infections would result in increased rates of illness and death, thus reversing the gains made in the control of this sexually transmitted infection. New resistance mechanisms, such as the beta-lactamase NDM-1, have emerged among several gram-negative bacilli. This can render powerful antibiotics, which are often the last defence against multi-resistant strains of bacteria, ineffective.
Mankind's fight against diarrhoeal diseases, respiratory infections, sexually transmitted infections, urinary tract infections and wound infections acquired in communities or in hospital settings is largely dependent upon the efficacy of specific antimicrobial agents that have, during the past seven decades, saved millions of lives, substantially reduced the burden of diseases and improved the quality and longevity of life.
In the recent past, the emergence and spread of resistance in several microorganisms have rendered the management of many infectious diseases difficult with the common anti-infective drugs. Resistance poses a growing threat to the treatment and control of endemic, epidemic-prone as well as pandemic diseases. Resistance in microorganisms costs money, livelihood and lives, and threatens to undermine the effectiveness of health delivery programmes.
Resistance flourishes wherever antibiotics are abused, misused and dispensed at levels lower than what treatment guidelines dictate. This means that instead of wiping out the infection altogether, medications kill only non-resistant organisms – leaving their tougher counterparts to replicate and spread resistance genes.
Hospitals are a breeding ground for antibiotic resistant bacteria. In an analysis of 10 studies undertaken at teaching hospitals worldwide, researchers determined that between 40 and 91 per cent of antibiotics prescribed were inappropriate.
Misdiagnosis is just another symptom of weak public health systems in industrialised and developing nations what with the overworked and under-informed physicians and healthcare workers and a dearth of proper diagnostic facilities and laboratories.
In a nutshell, antimicrobial resistance challenges the control of infectious diseases. Infections caused by resistant microorganisms often fail to respond to the standard treatment, resulting in prolonged illness and a greater risk of death, thus potentially spreading resistant microorganisms to others. This threatens a return to the pre-antibiotic era, increases the costs of health care owing to the longer duration of illness and treatment, often in hospitals, and increases health-care cost and the financial burden to families and societies.
The WHO is engaged in guiding the response to antimicrobial resistance through policy guidance, support for surveillance, technical assistance, knowledge generation and partnerships, including thorough disease prevention and control programmes, essential medicines quality, supply and rational use, infection prevention and control, patient safety; and laboratory quality assurance.
Healthcare providers have an important role in reducing antibiotic resistance along with consumers, prescribers and dispensers, veterinarians, managers of hospitals and diagnostic laboratories, patients and visitors to healthcare facilities, as well as national governments, the pharmaceutical industry, professional societies and international agencies
The next 20 years will see an increase in infection control research and interventions to improve patient safety. Hand hygiene with alcohol-based hand rubs has been shown to decrease the transmission of resistant organisms. Some experts have suggested that multimodal approaches that use a combination of different measures (for example, aggressive infection control with active surveillance cultures, hand hygiene, and possibly antimicrobial control) will effectively slow down and even halt the increasing trends of healthcare-associated antimicrobial resistance.
Given the cross-cutting nature of the problem and complexity of the response, it is essential that every member of the medical fraternity and the public in the health sector all over the world with clarity about their role should join hands in the marathon efforts of the WHO to combat this menace. Urgent action is needed to ensure that antibiotic effectiveness is maintained for the greatest benefit of humanity by slowing the development and spread of antibiotic resistance. A global and national multi-sectoral response is urgently needed to combat the growing threat.
(The writer is Medical Director & CEO, Kalra Hospital, Sri Ram CardioThoracic Neurosciences Centre, New Delhi. His email is: dr_rnk@hotmail.com)
