It is a rain-battered Sunday afternoon in Mumbai and Prakash* has just finished his shift as a security guard at an ATM. He says he has always enjoyed his work, even when he was addicted to drugs, and even after he tested positive for HIV about a decade ago. But a few years later, he hit a roadblock.
“My first line of treatment started in 2012, but my CD4 (number of cells in a cubic millimetre of blood and a key indicator of HIV progression) kept dropping, touching 193 (normal range is 500-1500),” he says.
For 18 months, he battled weakness and frequent bouts of fever. He quit work and almost gave up medication. He was finally stamped drug-resistant, and moved to the second line of treatment, to which he is responding.
At another end of Mumbai, a young girl keeps vigil outside the ICU of a private hospital, trying to understand why her father, diagnosed with pneumonia and multi-organ failure, is not responding to the strongest drugs. She says this is third hospital the family has moved him to.
He is being administered ceftazidime, a third generation antibiotic, as he was found to be resistant to not just carbapenems – which work on most resistant infections – but also colistin, the last antibiotic in the medical armoury to treat resistant infections.
Experts mapping drug resistance say Mumbai’s case studies of hard-to-treat infections reflect the concern over rising cases of antimicrobial resistance (AMR) across a spectrum of medical conditions.
Critical-care concern
Patients in ICUs are particularly at high risk of resistant infections. “National data since the last quarter of 2013 have shown that drug resistant infections are increasing in hospitals,” says Dr Kamini Walia from the division of epidemiology and communicable diseases of the Indian Council of Medical Research, which has been on the drug resistance trail. The ICMR data shows that bugs such as Acinetobacter baumanii and Klebsiella pneumoniae show as much as 70 per cent resistance to carbapenems, once effective on drug-resistant ventilator-acquired pneumonia or catheter-associated urinary tract infection (UTI).
Resistance leads to a complicated treatment pattern, adds to patients’ stay in the hospital, and also the cost of treatment says Dr J.V. Divatia, Head of the Department for anaesthesia, critical care and pain Tata Memorial Hospital (TMH).
Dr Rahul Pandit, intensivist with Fortis Hospital in Mulund, Mumbai, says there are no new antibiotics on the horizon and the stronger antibiotics being used have toxic side effects.
The resistance problem goes beyond ICUs. Once-effective azithromycin or Norflox no longer work on most infections. Anti-malarial drug Chloroquine does not work in malaria treatment. Ciprofloxacin does not work on UTI and Augmentin has no effect on community-acquired pneumonia. And just when India started putting a red line on antibiotic packages to check their OTC sale, another problem has surfaced: antifungal drugs and creams are losing their punch.
A global AMR report released in the United Kingdom earlier this year highlighted the sanitation link to resistance particularly in countries such as India, with a high burden of infectious diseases. It went on to applaud India’s Swachh Bharat Mission (SBM), and not without reason.
“We have made antibiotics work overtime for lack of investment in infection control,” says microbiologist Dr Camilla Rodrigues, chairperson of P.D. Hinduja Hospital’s infection control committee. The sanitation connection, though overlooked, is elementary: cleaner surroundings both in the community as well in hospitals can check the incidence of infectious diseases and bring down drug use. And the fewer the drugs used, the lesser the resistance to them.
*Name changed on request
This is the third part of the series, Malady Nation, on India's multi-dimensional healthcare crisis. This part focuses on the increasing resistance to certain microbes in India, and the policy response.
