Before the discovery of antimicrobials, infections with serious disease-causing organisms were often a death sentence. Occasionally, people recovered if their natural immunity was good, but the rest either ended up dead or with severe disability. The earliest antimicrobials were made of heavy metals such as gold or antimony compounds, which also had a lot of side effects. However, they were found to be effective against infections such as syphilis and leishmaniasis. The first antibiotic was penicillin, discovered by Alexander Fleming — a mould that grew accidentally in his lab killed bacteria in plates — was later identified as Streptomyces spp . Fleming presciently warned that indiscriminate use of penicillin could one day lead to its loss of effect.
Bacteria, viruses, protozoa and fungi have existed on this planet longer than human beings. They show a remarkable degree of adaptation and survive in adverse environments. Under pressure, they mutate to overcome the effect of a particular drug/substance and have a host of survival tactics and mechanisms. Today, we have reached a situation where more than 50 per cent of some groups of bacteria are resistant to almost all the antibiotics we have. This is especially true for hospital-acquired infections, where bacteria are resistant to the latest and most advanced antibiotics. This makes infections virtually untreatable, taking us back to the pre-antibiotic era.
Economic cost, factors
It is estimated that the world loses a trillion dollars due to antimicrobial resistance (AMR). While in the United States, 23,000 people die of resistant infections each year, the number in India is likely to be much higher; 50,000 newborns alone are estimated to die of drug-resistant bacterial infections, probably acquired in hospitals. Surveillance by government agencies such as the Indian Council of Medical Research (ICMR) and the National Centre for Disease Control (NCDC) shows that many tertiary hospitals have very high rates of antibiotic resistance. There is some good news, however. Data from monitoring of resistance in typhoid bacteria, for example, shows that the bacteria can regain susceptibility to antibiotics that are no longer widely used.
There are multiple reasons for development of AMR. Indiscriminate and improper use of antibiotics by patients and unnecessary prescription by physicians are major reasons. A majority of short duration fever and respiratory symptoms are caused by viral infections, which do not need or respond to antibiotics. Further, contamination of water and soil with antibiotics from drug factory effluents and improper disposal by hospitals and nursing homes leads to bacteria in these settings acquiring resistance. Further, the animal and poultry industry has traditionally used antibiotics in feed as growth promoters. Some of this finds its way into the environment as well. Bacteria have a unique ability to transfer the resistance mechanism from one to another. Hence, a harmless soil bacteria can pass it on to a virulent one that causes disease in humans.
In the global spotlight
The UN General Assembly (UNGA) in New York debated AMR on September 21, 2016, only the fourth time that the UNGA has discussed a health topic. Many countries including India have reiterated the urgent need for action to prevent further increase in AMR, while at the same time promoting access to appropriate drugs for patients who do not have access at present. Need was also expressed for governments to work in partnership with the private sector to develop new antimicrobials. Most large pharmaceutical companies have given up research and development on antibiotics, focussing instead on “lifestyle” diseases such as obesity, hypertension and dyslipidemias. However, some companies are now waking up to the challenge of AMR. Recently 13 drug manufacturers have pledged to curb overuse of antibiotics and clean up pollution from factories manufacturing antibiotics as part of their drive to fight infections caused by superbugs. Another recent initiative is the setting up of a global antibiotic R and D (GARD) fund (which aims to raise $350 million) and mechanism for various stakeholders to work together under a unified framework. ICMR is partnering with this programme and Drugs for Neglected Diseases initiative to support innovation and clinical trials of new and repurposed drugs to treat certain resistant infections.
For a united fight
It is now clear that addressing AMR will require involvement of the agriculture, veterinary, poultry and fisheries sectors, environment agencies, drug regulators, doctors and pharmacists as well as common citizens. The Ministry of Health has developed a national action plan which is comprehensive and multi-sectoral, but which will only work if there is commitment from all. India successfully handled the HIV crisis and is once again challenged in the face of an AMR crisis. Decisive action is needed to prevent further spread of drug resistance and to preserve the antibiotics we have for future generations.
Dr. Soumya Swaminathan is Director-General, Indian Council of Medical Research.