It has been nearly three years since the first wave of the Covid pandemic hit India. One of the grave mistakes noted during the pandemic was the inappropriate use of antibiotics and steroids. In an ideal world, it would have been normal to expect our health system to prevent such abuse of drugs in future disease outbreaks. However, the recent conjunctivitis outbreak, mostly in northern States, highlighted how we have failed to learn our lessons.

A surge in cases of conjunctivitis was seen following the torrential rains in north India due to Adenovirus. Most cases of viral conjunctivitis resolve on their own. However, the go-to drugs in this viral outbreak were antibacterial eye drops alone or in combination with steroids or other drugs. They commonly contained antibacterials (like gentamicin, chloramphenicol, moxifloxacin, ofloxacin and tobramycin), steroids (like betamethasone and dexamethasone), and sometimes had compounds that had no role in the treatment of conjunctivitis, whether bacterial or viral. The culture of “one drug treats all” and lack of prompt communication from the public health system resulted in an unchecked purchase, sale, or free dispensing of such eye drops.

Despite being a Schedule H drug, i.e., a drug that requires a prescription against its sale, antibiotics are sold over the counter by pharmacists with no checks in place. While informal providers are known to prescribe antibiotics indiscriminately, degree-holding doctors are no better. Moreover, be it people from urban colonies in New Delhi or from remote rural parts of Bihar, Jharkhand, Chhattisgarh, Uttar Pradesh, Odisha, and Gujarat, all reported to us that the public health systems there were also prescribing the aforementioned eye drops.

Silent pandemic

The abusive use of antibiotics has been labelled as the ‘overlooked’ and ‘silent’ pandemic. The problem lies not only in the unwarranted use but also in how these drugs are discarded. Often thrown in dustbins or drains, these drugs interact with bacteria present in our environment. Bugs present in our body, on our skin, eyes, or in the drain, when exposed to antibiotics, can develop resistance to these drugs over time. Infections by these stronger bugs called “superbugs” become extremely difficult to treat due to the unavailability of effective antibiotics. Antibiotic eye drop use can also induce resistance in bacteria present in our bodies. It is estimated that by 2050, 10 million will die every year worldwide due to antimicrobial resistance (AMR). The World Bank has estimated that AMR, if left unchecked, will result in an annual loss that could reach $2 trillion by 2050.

Despite knowing the adverse effects of these antibiotics and despite rolling out the National Programme for Antimicrobial Resistance Containment in 2013, the Indian public health system still lacks a robust strategy to control their use. The National Treatment Guidelines for Antimicrobial Use in Infectious Diseases clearly mention “no antibiotics required” for viral conjunctivitis. Even though surveillance systems to look at antibiotic resistance in different parts of the country have been established under this programme, there is no national-level data on antibiotic consumption in India. With the unknown extent of antimicrobial misuse in an unregulated market, tackling it becomes extremely difficult.

Going forward, it is important to realise that we are in the middle of an unrealised pandemic of AMR. We have already seen how tuberculosis and typhoid bacteria have become extensively resistant to common drugs. The ongoing efforts of discovering new antibiotics will never be able to catch up with the rate at which resistance is developing due to abuse of available antibiotics.

It is high time the government focused on implementing new stringent laws to control antibiotic use and invested in systems to capture regional and national level real-time data on patterns of antibiotic use and AMR and ramped up lab capacity building. It is the responsibility of the government to ensure that the public is aware of disease outbreaks and dos and don’ts therein. Effective communication can be achieved via various platforms like text messaging using the government’s Unique ID repository, making radio and TV announcements, utilising its community health workforce, etc. The problems of irrational prescription and drug dispensing leading to AMR have been ignored long enough. It is time to address this ticking time bomb.

Parth is a public health physician and researcher, and Vasundhara is a public health physician and a microbiologist