A medicine worse than the disease

One of the most critical concerns facing the global health fraternity today is the escalating burden of antimicrobial resistance (AMR). AMR develops as result of microorganisms such as bacteria, viruses, fungi and parasites becoming immune to antimicrobial drugs such as antibiotics. These microorganisms are commonly known as superbugs.

Over the past decades, antimicrobial agents have been revolutionary in alleviating communicable diseases across the world. However, when the medicines at one’s disposal become ineffective, the prospects for treatment become grim. While antibiotic resistance is a global hazard to public health, India, the largest consumer of antibiotics in the world, is notoriously seen as the epicentre of this threat.

Last year, India attracted unwelcome limelight when a 70-year-old woman from the US died after contracting a superbug during a two-year residence in the country. Doctors in the US say the patient was infected with a multidrug-resistant organism known as carbapenem-resistant Enterobacteriaceae (CRE) which is immune to all available antibiotics. In the recent past, India has witnessed many large outbreaks of emerging infections and most of them were of zoonotic origin (diseases transmitted from animals to humans). While exact figures are hard to come by, WHO’s Global Burden of Disease report of 2004 suggests a 15-times greater burden of infectious diseases per person in India than in the UK. According to the calculations based on World Bank data and the Global Burden of Disease report of 1990, the crude infectious disease mortality rate in India today is 416.75 per 100,000 persons, which is twice the rate prevailing in the US.

The US Center for Disease Control and Prevention estimates that in the US, more than two million people fall sick every year due to antibiotic-resistant infections, resulting in at least 23,000 deaths. In India, the threat is much more pressing. According to the Indian Network for Surveillance of Antimicrobial Resistance (INSAR), there is widespread existence of superbugs throughout the country including a startling 41 per cent of methicillin-resistant Staphylococcus aureus (MRSA). Multi-resistant Entero-bacteriaceae has also become rampant.

On the one hand, infectious diseases are on the rise; on the other, AMR is posing a serious impediment in their cure. The burden on the healthcare system also increases significantly. Hospital-acquired infection in vulnerable patients with resistant strains is another major threat. Resistance to antimicrobial drugs also means that the success of treatments for medical procedures such as chemotherapy and organ transplantation and post-surgical recovery come under immense risk. All these effects of AMR have substantial repercussions on the socio-economic set up.

A mix of poor public health systems and hospital infections, high rates of infectious diseases, inexpensive antibiotics and rising incomes are all coming together to increase the prevalence of resistant pathogens. Some important factors responsible for the rising antibiotic resistance in India are indiscriminate use of antimicrobial drugs, over-the-counter availability of antibiotics, laxity of regulatory bodies in approval of antibiotics, lack of public awareness about antibiotic resistance, injudicious use in veterinary practices, overburdened health infrastructure and inequity in healthcare.

The dire issue of AMR needs to be addressed immediately. The first step towards optimising the use of antimicrobials to halt the spread of infections caused by multidrug-resistant organisms is antibiotic stewardship. This involves coordinated intervention designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the most appropriate antimicrobial drug regimen, dose, duration of therapy, and route of administration. Capacity building and sensitisation of all the stakeholders is an integral pre-requisite of this programme. The multidisciplinary team members comprise an infectious diseases physician, a clinical pharmacist, a microbiologist, an infection control team, a hospital epidemiologist, an information system specialist, quality improvement staff, laboratory staff and nurses.

If ever a post antibiotics era becomes inevitable, bacteriophage therapy or simply phage therapy holds promise as an alternative treatment option. Bacteriophages are viruses that infect and kill bacteria. The revitalisation of phage therapy has received increased global attention since the appearance of multidrug-resistant bacteria. The most striking advantage of bacteriophage therapy is the ability to tailor treatment accurately to kill the pathogenic bacteria — provided the diagnostic procedures are highly accurate.

The writer is a clinical associate professor of internal medicine at Amrita Institute of Medical Sciences, Kochi

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