In the pre-antibiotic era, organisms with the potential to spread infection caused widespread outbreaks—epidemics or pandemics—killing millions of people globally, more so in developing and over-populous countries. In 1928, the first true antibiotic—penicillin—was discovered by Dr Alexander Fleming, microbiologist at St. Mary’s Hospital in London. The introduction of antimicrobials for clinical use was undoubtedly the greatest medical breakthrough of the 20th century. These miraculous drugs, often called “life-savers” were capable of eliminating the biological organisms in our body without harming us.
The next three decades noticed development and discovery of a wide variety of antimicrobial agents, after which there was a steep downfall and finally a discovery void.
The antibiotics are being used on an exponentially increasing scale ever since their discovery in 1928. In his Nobel Prize acceptance speech in 1945, Sir Alexander Fleming foresaw the dangers of inappropriate penicillin use and the emergence of resistance, which by then was already a concern for penicillin. The overuse and misuse of these antibiotics contribute to the acceleration of antimicrobial resistance (AMR).
Mutations, that we have widely learnt during the Covid-19 pandemic, are inevitable as the organisms spread and multiply. Most of these mutations may not greatly modify the characteristics including pathogenicity of the organisms. But in the background of rampant antibiotic usage, there are mutations that enable organisms to thrive even in presence of the drug, thus rendering the drug useless and pushing the patient at risk of non-improvement from the respective infection. This not only increases the mortality, but also increases costs manifold on increased hospital stays and treatment with higher antibiotics. More so, these organisms spread to other individuals in the hospital or community slowly but effectively, causing an increase in drug-resistant infections. The infections caused due to these resistant organisms are the sole reason for primary drug resistance to some antibiotics. Secondary drug resistance is when antimicrobials are either taken irregularly or inadequately.
Globally, about 700,000 people lose the battle to AMR per year and it is estimated that annually more than 10 million will die from it by 2050. AMR alone is killing more people than cancer and road traffic accidents combined together. The scenario is no different for India. Reports indicate more than 70% isolates of some common bacteria were resistant to commonly used antibiotics. That means if a person gets a common urinary tract infection, several of the otherwise routinely prescribed, oral drugs will be rendered ineffective.
Sadly, each one of us has been guilty of contributing to this predicament in some way or the other. Almost all of us have taken antibiotics for viral infections without realising that by characteristic the antibiotics work on bacteria and not on viruses. Covid-19 pandemic is the classic example of abuse of antibiotics. In India, buying pills over the counter on the “expert” advice of the shopkeeper or on basis of old prescriptions which provided clinical relief for self or even any relative from similar symptoms is a common practice. Wrong antibiotic choices, multiple antibiotics, and insufficient doses and interrupting treatment once the patient is feeling better, have all been responsible for the rise of superbugs.
It is unfortunate that even doctors have been major contributors to this—using inappropriate antibiotics empirically without the culture and drug sensitivity reports, giving broad-spectrum and even combination of antibiotics that cover multiple organisms without even confirming which of them are causative agents, moving to higher antibiotics without sufficient evidence to do so and prescribing antibiotics for the mildest of viral infections without any secondary infections.
Antibiotics are now used in livestock and poultry to prevent and control common diseases, in sub-therapeutic doses to promote growth and therapeutically to treat infections. Common usage of these antibiotics in animals is also a contributory factor towards primary resistance as one can get it from milk, eggs and meat.
In his radio address “Mann Ki Baat” in 2016, Prime Minister Narendra Modi spoke about the menace of antibiotic resistance and the urgent need to tackle it. The PM added that self-medication should be avoided when it comes to antibiotics. He also touched on the necessity to complete a course on antibiotics as advised by doctors and pay attention to the Red Line campaign initiated by the Ministry of Health to tackle AMR.
With ever-increasing antimicrobial resistance, we are left with few options to treat such patients. The new antibiotic pipeline is almost dry as research and manufacturing of antibiotics is not profitable to pharmaceutical companies in comparison to production of drugs for chronic diseases and cancers. And therefore, in many times we find ourselves in the pre-antibiotic era where people died of untreatable bacterial infections and the realization that even you, me and our loved ones could be facing this eventuality, should be an eye-opener for all of us. Each of us has a role to play in the fight against antimicrobial resistance.
COMMON MAN
Protect yourself from infections.
Follow hand hygiene, this has a proven efficacy towards prevention of infection as well as AMR.
Get vaccinated to prevent common vaccine preventable diseases like typhoid and influenza.
Practise safe sex.
Avoid self-medication and poly-pharmacy.
Only consume antibiotics on a medical doctor’s prescription.
Ask your doctor if the antibiotic is really needed and never insist on antibiotics. Over 90% of fever and regular cough cold cases are viral and will resolve on their own.
Ensure you complete the entire prescribed course. Never share or use leftover antibiotics as inadequate dose.
HEALTHCARE PROFESSIONALS
Whenever possible, advise a culture and drug susceptibility test before antibiotic prescription.
Use antibiotics judiciously and prescribe only when required.
Ensure that the correct dosage and duration of antibiotic is prescribed.
Practise infection control and prevention measures.
Establish and follow a good antimicrobial stewardship program.
POLICYMAKERS
Establish a robust national action plan to tackle AMR.
Establish SOPs to collect appropriate data on antibiotic-resistant infections and use of antibiotics.
Strengthen policies, programmes, and implementation of infection prevention and control measures in government as well as private establishments.
Regulate over the counter dispensation of antibiotics which are schedule H drugs (drugs that need prescription for sale) with strict enforcement of penal provisions for violations.
Promote the appropriate use and disposal of quality medicines.
Make scientific information available in simple to understand and in multilingual formats.
If all this is not achieved timely, AMR will end up being a major man-made, doctor-sponsored and government-neglected calamity with nothing to offer as remedy.
*Dr Prapti Gilada-Toshniwal is a clinical microbiologist at the UniLabs Diagnostics and Masina Hospital, Mumbai. She is extremely passionate about the fight against antimicrobial
resistance.