India launches strategy to curb antimicrobial resistanceBMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j2049 (Published 26 April 2017) Cite this as: BMJ 2017;357:j2049
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Antimicrobial resistance is one of the burdens of India's health care system. Easy access, availability and higher consumption of medicines have led to a disproportionately higher incidence of inappropriate use of antibiotics and greater levels of resistance compared to developed countries. Infectious disease burden is biggest threat in the world and recent report showed the inappropriate and irrational use of antimicrobial agents against these diseases, which led to increase in development of antimicrobial resistance. Besides, it has shown that health sector in India suffers from gross inadequacy of public finance which will result in the conditions favorable for development of drug resistance.
A recent study highlighted the importance of rationalizing antibiotic use to limit antibiotic resistance in India. Antimicrobial resistance will result in difficulty in controlling the diseases in Agencies like World Health Organization, European Centre for Disease Control and World Health Assembly resolutions, which have all highlighted antimicrobial resistance as a major public health issue. It is a great challenge to tackle the problem for policy makers and health care providers. World Health Organization has proposed regional strategy on antimicrobial resistance with the goal to minimize the morbidity and mortality due to antimicrobial resistant infection to preserve the effectiveness of antimicrobial agents in the treatment and prevention of microbial infections. From the public health point of view, it is important to look for the existing situational analysis in Indian context, so that appropriate interventions can be initiated at community level to tackle the problem. With this background, the study analyzed the situation of problem burden and various factors with recent developments, challenges and strategies required to tackle Antimicrobial Resistance.
India develops National Action Plan to combat Antimicrobial Resistance (AMR).
India’s health ministry has announced the country’s first plan to curb antimicrobial resistance, including measures to prevent misuse of antibiotics by doctors, consumers, and healthcare institutions
The National Action Plan on Antimicrobial Resistance (2017-21) has assigned coordinated tasks to multiple government agencies involving health, education, environment, and livestock to alter prescription practices and consumer behaviour and to scale up infection control and antimicrobial surveillance. The plan aims to tackle concerns that antibiotic misuse in the human and animal health sectors in India is affecting antimicrobial resistance that threatens public health in India and other countries. Releasing the plan, India’s health minister, Jagat Prakash Nadda, said, “We are ready with a blueprint that meets global expectations."
Antimicrobial resistance (AMR) is the ability of microorganisms like bacteria, viruses, and some parasites to stop antimicrobials such as antibiotics, antivirals and antimalarials from working against them. As a result, standard treatments become ineffective, infections persist and may spread to others. Microorganisms that develop antimicrobial resistance are sometimes referred to as “superbugs”. The antibiotics have become ineffective and infections persist in the body, increasing the risk of spread to others.
The resistance spectrum of pathogens varies in different regions. Therefore local resistance patterns have to be known for appropriate antimicrobial use. There are some hospital based data which showed that antibiotic resistance is increasing and will be a greater problem if not tackled properly according to present needs as in other developed countries. Meta analyses of the drug susceptibility results of various laboratories in India reveal an increasing trend of development of resistance to commonly used antimicrobials in pathogens like Salmonella, Shigella, Vibrio cholerae, Staphylococcus aureus, Neisseria gonorrhoeae, N. meningitidis, Klebsiella, Mycobacterium tuberculosis, HIV, plasmodium and others. Resistance to antimicrobials complicates treatment of HIV infection, following the regular use of antiretroviral medicines in recent years, and national surveys are being done to detect and monitor resistance. New resistance mechanisms, such as the metallobeta-lactamase NDM-1, have emerged among several gram-negative bacilli, rendering powerful antibiotics ineffective, which are often used as last line of defense against multi-resistant strains of bacteria .
New resistance mechanisms are emerging and spreading globally, threatening our ability to treat common infectious diseases, resulting in prolonged illness, disability, and death. Without effective antimicrobials for prevention and treatment of infections, medical procedures such as organ transplantation, cancer chemotherapy, diabetes management and major surgery (for example, caesarean sections or hip replacements) become very high risk. Antimicrobial resistance increases the cost of health care with lengthier stays in hospitals and more intensive care required. Antimicrobial resistance is putting the gains of the Millennium Development Goals at risk and endangers achievement of the Sustainable Development Goals.
It has been shown that hospital based studies have higher and varied spectrum of resistance in different regions, while there are limited number of community based studies in India. There exist lacunae in the structure and functioning of public health care delivery system with regard to quantification of the problem and various determining factors related to antimicrobial resistance. There is an urgent need to develop and strengthen antimicrobial policy, standard treatment guidelines and national plan for containment of AMR in India. Focus on research related to public health aspects of AMR at community and hospital level. Information Education Communication activities are important. Monitoring and evaluation of the existing health care delivery system for both health care providers and consumers to improve drug use should be undertaken simultaneously.
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Competing interests: No competing interests
This is a very useful attempt and I am sure they will be able to allocate funds for the implementation of the project adequately.
Competing interests: No competing interests
The article by Dutta S was read with interest (1). India was the worlds largest consumer of antibiotics in 2010 (2). Antibiotic resistance to various antibiotics ampicillin, naladixic acid, co-trimoxazole, aminoglycosydes, third generation cephalosporins, carbapenems and fluoroquinolones are on rise in India (2). Some of the contributing factors responsible for antibiotic resistance include increasing incomes, ready access to antibiotics over the counter without prescription. Increasing use of antibiotics for promoting growth and preventing disease in poultry industry is one of the major factors contributing to antibiotic resistance (3). The farmers use one tenth to one hundredth of the therapeutic dose resulting in obvious antibiotic resistance (3). This irrational use results not only in antibiotic resistance in poultry birds, but also both in people who handle them and consume their meat. Antibiotic pollutants in waste water treatment plants serving antibiotic manufacturing facilities are also implicated in transfer of resistance genes into human microbiota (2).
Stricter formulation and implementation of laws are necessary to curb the growing antibiotic resistance problems in India. Antibiotics should be made available to consumers only when they bring to the pharmacy the prescriptions with dose, duration and frequency, signed and sealed with date by registered medical practitioners. Medical practitioners should strictly adhere to the best practices of antibiotic prescription. Antibiotics should be prescribed only when absolutely necessary i.e., in conditions where it is clearly indicated. Whenever possible, microbial culture and antibiotic sensitivity tests should be carried out. Continuing medical education programs highlighting the antibiotic resistance problem and how to curb them should be made mandatory for every medical practitioners for at least once in two years. This will refresh the knowledge of medical practitioners and empower them on using the antibiotics judiciously. Patients exhibit tendency not to complete the full course of the prescribed antibiotics, especially when they feel better after the initial intake. Also, patients tend to self reuse the old prescriptions made by their doctors and even recommend it to their close relatives without medical supervision. This can be effectively discouraged by mentioning in every prescription paper about the exact date of prescription and also the words- "To be taken for the full course as prescribed by the doctor. Prescription not to be reused after its original indication has been fulfilled. Prescription not to be transferred." These simple measures would also educate the patients about the best use of antibiotics and could certainly lead to decreased antibiotic resistance.
Antibiotic use as growth promoters in livestock should be phased out. Stricter regulating laws should be implemented to direct the antibiotic manufacturing plants to take care of not releasing antibiotic pollutants into environment. These measures would also contribute to limit the growing antimicrobial resistance in India.
1. Dutta SS. India launches strategy to curb antimicrobial resistance. BMJ. 2017;357:j2049.
2. Laxminarayan R, Chaudhury RR. Antibiotic Resistance in India: Drivers and Opportunities for Action. PLoS Med. 2016 Mar 2;13(3):e1001974.
3. Pulla P.Doctors’ leaders in India call for ban on prophylactic antibiotics in poultry. BMJ 2014;349:g5052 .
Competing interests: No competing interests