On September 26, 2024, a historic political declaration to combat the rising antimicrobial resistance (AMR) was made at the United Nations General Assembly held in New York. It highlighted the need for equitable and timely access to effective antimicrobials, diagnostics and vaccines in developing countries.
A clinician's perspective is presented below on some of the points in the declaration, in the Indian context.
Diagnostic tests can distinguish between viral and bacterial infections, thereby preventing the misuse of antibiotics for viral infections.
In relevant clinical settings, diagnostic tools such as culture tests or molecular tests are frequently used to determine if a bacterial infection caused by a multidrug-resistant organism is present. This information assists clinicians in optimising the most effective antibiotic treatment for the patient.
The test sensitivity and specificity as well as delayed turnaround time for results of over 48 hours of the culture reports have been some major limitations of these tests.
Molecular tests have revolutionized the treatment of certain infectious diseases such as tuberculosis (TB). These tests can determine within a few hours if a patient has TB and whether the first-line treatment will be effective by detecting resistance to one or more anti-TB drugs.
Since delays in administering antibiotics to critically ill patients can lead to deadly outcomes, an ideal diagnostic test would be an affordable, point-of-care solution that provides reliable results within minutes, even before starting antibiotic treatment.
In the absence of such ideal diagnostic facilities, atleast the basic diagnostic tests that are currently available for detection of resistance, such as culture tests, need to be made easily available and affordable in the rural and urban regions.
The personnel trained in microbiology can play a crucial role in the correct interpretation of reports, guidance of clinicians as well as help in timely infection control practices whenever relevant, to prevent the spread of multidrug resistant organisms.
While equitable and timely access to effective antimicrobials are needed, stricter regulations are required for antimicrobials that can be purchased over the counter without a valid prescription.
Manufacturers of the antibiotics recommended by national and World Health Organization (WHO) guidelines as the first line of choice for treatment need to be encouraged for sustained production as these are usually difficult to avail these in pharmacies while more expensive antibiotics are reportedly more easily available.
The antibiotics recommended as first line for many community acquired infections such as amoxicillin, cloxacillin, cefazolin are classified in the Access group of the Access, Watch, Reserve (AWaRe) antibiotic classification of WHO.
The political declaration aims for a consumption of the Access group of atleast 70 per cent of overall human antibiotic consumption globally by 2030. This can be achieved only by improving the availability of these antibiotics and effective antimicrobial stewardship practices.
Special attention needs to be provided for antimicrobial availability for special groups such as children, with increase in availability of dispersible tablets in different strengths for more accurate dosing. Research on newer molecules or alternative therapeutics for multidrug resistant organisms needs to be encouraged.
While there are many effective vaccines available in the National Immunisation Schedule against bacterial infections like pertussis, pneumococcal, H influenza B, it is also important to consider inclusion of vaccine against other bacterial diseases of public health importance like typhoid for which an effective and safe vaccine is available.
Despite a global high priority pathogen list for vaccine development that includes commonly isolated multidrug resistant bacteria like Escherichia coli, Staphylococcus aureus and Klebsiella pneumoniae, the progress has been painfully slow.
The awareness about rational use of antimicrobials as well as antimicrobial resistance needs to be improved with sustained efforts both among the healthcare providers and the community.
Basic concepts like how infections spread, hand hygiene, meaning of antimicrobials and antimicrobial resistance can be introduced as early as in the school curriculums through cartoons or stories.
Effective practical training on basics of choosing the right antimicrobial during medical college days can avoid the gullibility of using a particular antibiotic based purely on the interactions with the representatives from pharmaceutical industry.
Antimicrobial waste disposal at industry level and healthcare setting needs particular attention as these can promote the antimicrobial rise in the environment and food chain. Similarly, the unrestricted use of antibiotics in the animal health sector has a direct negative impact on AMR in human health.
The vectors that transmit infections are mainly air, water, food, insects and contact. If basic standards of hygiene can be improved with better reduced air pollution, water sanitation, avoiding breeding of mosquitoes, better sewage disposal and hand hygiene, we would be able to control the spread of infections to a significant proportion.
Such preventive strategies, which also include effective vaccination, would reduce the healthcare burden of infectious diseases to a very large extent and, therefore, opportunities to use antimicrobials which are main drivers of AMR.
AMR is currently a very complex problem requiring intersectoral coordination and multi-pronged approach at several levels. Leadership commitment in form of an united igh level political declaration is a welcome step in this direction.
At the same time, a responsible use of antimicrobials at an individual level, whether as a provider or a recipient can contribute greatly to atleast control the rapid rise of AMR.
Dhanya Dharmapalan is senior consultant in Paediatric Infectious Diseases, Apollo Hospitals, Navi Mumbai National Coordinator of Apollo Antimicrobial Stewardship Programme.
Views expressed are the author’s own and don’t necessarily reflect those of Down To Earth.