India, the antibiotic capital of the world

Antibiotics are often used to treat diarrhoea and upper respiratory tract infections, which can be reduced by improving sanitation and personal hygiene

By Amandeep Aggarwal
Published: Monday 04 February 2019
Antibiotic resistance
Photo: Getty Images Photo: Getty Images

Strong and stronger antibiotics seem to be losing their effect as bacteria in human bodies have become resistant to many of the powerful ones. It looks like that we have entered the post antibiotic era, where bacteria have read Darwin’s theory on survival of the fittest and outsmarted humans by developing resistance against antibiotics. This poses a big threat to human life.

Experts feel that with the increasing number of drug-resistant bacteria, they will be forced to stop organ transplantation, chemotherapy, or even the smallest surgeries. They don’t expect this to happen in a decade, but within a few years.

Alexander Fleming, at his 1945 Nobel Prize lecture, had said, “The time may come when penicillin can be bought by anyone in the shops. There is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant."

Discovery of penicillin by Fleming in 1928 had transformed the world of medical science. Before its discovery, humans had, for thousands of years, been laid low or killed by minor infections. Even a single abrasion from a glass blade could call for an amputation. But, after its discovery, infections acquired even during complex surgeries could be treated with a simple dose of antibiotics.

The new drugs revolutionised medicine, transformed human health and saved millions of lives. The misuse and overuse of antibiotics is rampant in India, resulting in super bugs that are resistant to all known types of drugs. While unnecessary prescriptions are a leading cause for the emergence of super bugs, a lack of awareness among patients is worsening the situation.

But in a time span of just around half a century, we have exhausted, overused and abused antibiotics. We have popped antibiotic pills on the smallest of pretexts, to deal with viral fevers and colds that cannot be treated with antibiotics. We have stuffed them into our livestock to fatten them and sprayed them on our crops to keep pests away.

In short, we have used them with impunity, assuming we would enjoy its advantage forever, and if a problem occurred, the pharmaceutical industry would simply fire up its labs to stay ahead of the game. But now, unsurprisingly, even the strongest antibiotics don't appear to work. In the story of co-evolution and natural selection, bacteria have evolved to resist the threat posed by these drugs. We have now entered, as several experts point out, a post-antibiotic world.

Current estimates place the annual number of deaths from antibiotic resistant bacteria at around 700,000 worldwide. This figure is predicted to rise, according to one study, to 10 million by 2050.

India, the centre of this catastrophe

Antibiotic resistance is a global phenomenon. But the epicentre of this catastrophe is India. The country is afflicted by easy access to the strongest of antibiotics without prescriptions or diagnoses; even by qualified doctors, not just quacks, who prescribe drugs with little thought; by hospitals where overuse has created colonies of these superbugs; by excessive usage on livestock; and by poor sanitation. All this has created a kind of perfect storm for these super-resistant microbes to menace our health.

Way back in 2009, a 59-year-old Swede of Indian origin began visiting a hospital in a small city near Stockholm. The patient, a diabetic male, needed treatment for bed sores and urinary tract infection. He had recently returned from India, where he had developed an abscess in his buttocks and had been hospitalised, first in Ludhiana and later in Delhi. He had undergone a surgery in Delhi, recovered and returned to Sweden.

The development of the abscess wasn't particularly unique. Diabetics are known to be susceptible to it. The bed sores and the urinary tract infection, one could understand, he probably acquired from his stay in the Delhi hospital. But there was something odd about his infection. No antibiotic seemed to work on it. Not even carbapenems, the strongest class of antibiotics.

A routine urine test threw up something extremely unusual. The bacterium causing the infection, as the doctors analysing the case wrote in the journal Antimicrobial Agents and Chemotherapy, was familiar Klebsiella pneumonia, which is one of the most frequent causes of pneumonia and bloodstream infections in hospitalised patients.

What was highly irregular, however, was a gene it carried. Hitherto unknown, this gene, later named NDM-1 (New Delhi Metallo-beta-lactamase-1), after the city where the patient was thought to have picked up the bug, made the bacteria resistant to almost all antibiotics. And it didn't just make treatment difficult. It could also move quickly from one bacterium to another, rapidly boosting the infection's resistance.

Antibiotic resistance is a worldwide problem. But experts feared that India's excessive antibiotic usage was now leading to a powerful never-before-seen mutation within bacteria. Within a year's time, patients with this bacterial gene were discovered in the US, UK, Canada, Japan and China. So far, cases in more than 75 countries have been reported. Some had travelled to the Indian subcontinent and been exposed through medical treatment and hospital stays, but many had never been here, suggesting local transmission within those countries.

Overuse and misuse of antibiotics have long been believed to fuel antimicrobial resistance (AMR), but new research shows that simply lowering consumption is not enough. Poor sanitation, corruption and low public health spending have a bigger role in pushing up drug-resistant infections in low- and middle-income countries, including India, according a study published in Lancet Planetary Health.

More than vegetables, chicken carries a lot of antimicrobial resistant organisms. Some countries in the West have found 30 per cent of their chicken harbouring multidrug-resistant organisms. In India, the percentage is likely to be much higher. The problem could only get worse as the growing demand for meat and livestock products is expected to double the consumption of antimicrobials in India by 2030.

Dismal future

Despite these emerging threats from multiple fronts, India has no public database of mortality caused due to antimicrobial resistance.

But even as the old and existing arsenal of antibiotics is being lost to a growing array of resistant bacteria, no new drugs are entering the market. No new antibiotic has been discovered in last three decades, especially not against the gram-negative strain of bacteria prevalent in India.

Most pharmaceutical companies generally do not consider antibiotics to be a good source for revenue generation. A new antibiotic requires decades of research, but it will remain effective for merely a few years until the bacterium acquires resistance. The R&D focus, therefore, is more on lifestyle-related drugs, ranging from diabetes to cardiovascular diseases, which have to be administered throughout the course of one’s life.

Lowering of antibiotic consumption is not sufficient because the spread of resistant strains and resistance genes are the dominant contributing factor. Providing sanitation, clean water and good governance, increasing public health expenditure and better regulating the private health sector are all necessary to reduce antimicrobial resistance.

The author is a professor at RD Aggarwal Memorial Healthcare, Sangrur

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