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Improving antimicrobial stewardship and surveillance: the Chennai Declaration

BMJ 2013; 346 doi: (Published 28 January 2013) Cite this as: BMJ 2013;346:f591

Rapid Response:

Re: Improving antimicrobial stewardship and surveillance: the Chennai Declaration

To the Editor – I read with great interest the recent article by Hopkins commenting on the publication of the Chennai Declaration by Ghafur. 1,2 Further correspondence on this “landmark step” have also appeared in the Lancet (Goossens), Clinical Infectious Diseases (Ghafur) and more recently in Journal of American Medical Association (Mitka). 3,4,5 Firstly, Ghafur and colleagues must be roundly applauded in establishing a consensus framework to try and establish key components of a national antibiotic resistance program under very trying circumstances. However, whilst the article by Goossens raises poignant issues not addressed elsewhere, the commentaries by Hopkins, Ghafur and Mitka fails to acknowledge key underlining issues as to why India is unique in being a major global contributor in antibiotic resistance. 3,4,5

The global refocusing of efforts to tackle antibiotic resistance largely centres round the increasing prominence of carbapenem resistance in Enterobacteriaceae; however, we have seemingly forgotten that key messages of curbing antibiotic resistance have been in the public domain for at least 10 years - the WHO 2001 report, as one of many examples. These documents/policies advocated sensible directives and suggestions, which many countries, not least India has repeatedly ignored and I am not surprised that the Chennai Declaration “was very much not to look back but rather look forward” – to look back would have been an inconvenient truth unpalatable to most. 2 Sadly though this also means that India’s past mistakes will not be recognised and therefore the way forward less defined. For example, the extended spectrum β-lactamase (ESBL), CTX-M-15, was first reported in India in the late 1990s and has, 15 years hence, become the globally dominant ESBL. 6, 7 Hawser et al., claim it is in the Indian community at approx. 80% and our own data in Southern Asia indicate that over 90% of inhabitants carry CTX-M-15 as part of their normal flora – if extrapolated to the population of India alone; over 1 billion people carry ESBLs as normal faecal flora. 8, Walsh, unpublished data Of course, the authors of the Chennai Declaration would admit that the Declaration is not perfect and that they have focused on priority areas (e.g. infection control) that are manageable; however, if 90% of patients being admitted to Indian hospitals carry ESBLs, it is difficult to envisage a pragmatic infection control program that can address this staggering challenge.

Goossens comment “......coupled with unusually high income inequality and regional and social group inequalities” addresses one of the key reasons as to why such a declaration will be virtually impossible to implement. 3 The disparity between the opulent private practices e.g. Apollo and Fortis hospitals that tout medical tourism, and the woefully underfunded public hospitals, is reflected by India’s rating as #3 in the GDP PPP listings (International Monitory Fund) yet, according to the WHO, is ranked #148 in the world for public health spending. 9, 10 This stark contrast denotes how improbable, if not impossible, it will be to implement any of the agreement’s priorities in poorly under-resourced rural/semi-urban India dependent on government money.

The Chennai Declaration rightly emphasises the need for a national antimicrobial resistance surveillance program. If a surveillance program is implemented, it will be interesting to see how transparent and objective the reporting will be in light of India’s multi-billion dollar medical tourism industry which, as witnessed by the NDM-1 saga, India’s politicians and hospital surgeons/managers were so desperate to suppress. 11 High resistance rates in India will impact on this highly lucrative industry and these opposing forces will naturally impact on how India ultimately reports antibiotic resistance levels.

Since the NDM-1 story, India has, contrary to WHO advice, shut down most forms of international collaborations on antibiotic resistance and has now imposed sample export bans - even on tap/potable water. Ironically, despite banning both the export and biological materials for resistance studies, India manages to very successfully export NDM-1 around the world such that the vast majority of international clinical cases can be traced directly back to Southern Asia. 12 Whilst Ghafur is keen to highlight antimicrobial resistance as a global problem, India is unique in terms of its bacterial dynamics. Once key resistance types spread into Enterobacteriaceae, the lack of sanitation in India (and other parts of Southern Asia) was always to become a dominant factor in how resistant Gram-negative bacteria spread rapidly throughout Indian communities. 13 UN data claims that over 700 million people are without any appropriate sanitation and more people own mobile phones than toilets. 14 Sanitation in India, whilst a colossal issue, has to be tackled concurrently with the Chennai Declaration aspirations or else one of the key drivers of antibiotic resistance in Indian society will go unchecked.

Ghafur’s comment “Chennai Declaration can be a solution to India’s antimicrobial resistance problems” is breathtakingly optimistic, if not delusional. 2 As argued above, India’s problems are deep rooted and to truly tackle India’s antibiotic resistance nightmare one must go beyond normal antibiotic stewardship and infection control programs. The Chennai Declaration is at least a recognition that something finally must be done and that the status quo will no longer be tolerated….neither by Indians or by the International Medical Fraternity, and to that end Ghafur and colleagues must be congratulated, encouraged and supported. Reassuringly, European and US experts were present to consult and offer their opinions, and hopefully their long term commitment to the Chennai Declaration will ensure an element of transparency and accountability that has, hitherto, been in very short supply.

Competing Interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Not commissioned; externally peer reviewed.

1. Hopkins S. Improving antimicrobial stewardship and surveillance: The Chennai Declaration. British Medical Journal; 346:f591.
2. Ghafur A, Mathai D, Maruganathan A, Jayalal JA, Kant R, Chaudhary D, et al. “The Chennai Declarartion.” Recommendations of “A roadmap to tackle the challenge of antimicrobial resistance”-A joint meeting of medical societies of India. Indian J Cancer 2012; 49; doi:10.4103/0019-509X.104065.
3. Goossens H. The Chennai Agreement on Antimicrobial Resistance. Lancet 2013; 13: 105-6.
4. Ghafur A. The Chennai Declaration: A solution to the Antimicrobial Resistance Problem in the Indian Subcontinent. Clinical Infectious Diseases 2013; Jan 30th. [Epub ahead of print] PMID: 23307765
5. Mitka M. Indian Public Health Leaders Move to Reduce Antimicrobial Resistance. Journal of American Medical Association 2013; 309:531-2.
6. Karim A, Poirel L, Nagarajan S, Nordmann P. Plasmid-mediated extended-spectrum beta-lactamase (CTX-M-3 like) from India and gene association with insertion sequence ISEcp1. FEMS Microbiol Lett. 2001; 201:237-41.
7. Walsh TR, Toleman MA, Jones RN. Comment on: Occurrence, prevalence and genetic environment of CTX-M beta-lactamases in Enterobacteriaceae from Indian hospitals. J Antimicrob Chemother. 2007; 59:799-800.
8. Hawser SP, Hawser SP, Bouchillon SK, Hoban DJ, Badal RE, Hsueh PR, et al. Emergence of high levels of extended spectrum-β-lactamase-producing |Gram-negative bacilli in the Asia-Pacific region: data from the Study for Monitoring Antimicrobial Resistance Trends (SMART) program, 2007. Antimicrob Agents Chemother 2009; 53: 3280-3284.
9. World Economic Outlook Database, October 2012, International Monetary Fund. Accessed on March, 2013
10. WHO Department of Health Statistics and Informatics (May 16, 2012). "World Health Statistics 2012". Geneva: WHO. Accessed March 2013
11. Kumarasamy KK, Toleman MA, Walsh TR, et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect Dis 2010;10:597-602.
12. Nordmann P, Poirel L, Walsh TR, Livermore DM.The emerging NDM carbapenemases.
Trends Microbiol. 2011; 12:588-95.
13. Walsh TR, Toleman MA. The new medical challenge: why NDM-1? Why Indian? Expert Rev Anti Infect Ther 2011; 9:137-141.
14. UN. Mobile telephones more common than toilets in India, UN report finds. UN News Centre 2010.

Competing interests: No competing interests

11 March 2013
Timothy R Walsh
Professor of Medical Microbiology
Cardiff University
Department of Medical Microbiology and Infectious Diseases, Institute of Infection and Immunity, Heath Park Hospital, Cardiff CF14 4XN