A 43-year-old battling cancer is admitted for a bone marrow transplant procedure. The transplant goes off well and she is almost ready to be discharged but suddenly develops a fever from a minor dental infection. Within days, the infection becomes raging. No antibiotic used seems to be working. The microbiology lab discovers that her bloodstream carries a deadly bacteria called Klebsiella; worse news still, the bacteria is resistant to most available antibiotics and the patient finally succumbs to the infection.
The above-cited scenario has been happening across India since the proportion of drug-resistant bacteria increased as the years passed by. With 7,00,000 people losing the battle to antimicrobial resistance (the antibiotics losing their potency to kill the bacteria) and another ten million projected to die by 2050 around the world, it is killing more people than cancer and road traffic accidents combined. At this rate, anti-microbial resistance would shrink the GDP by 2-3.5 percent costing USD 100 trillion to the world. The magnitude of this problem in India has been underreported and not adequately acknowledged. As per the Scoping report on antimicrobial resistance in India (2017) under the aegis of the government of India, more than 70 percent of isolates of Escherichia coli, Klebsiella pneumoniae and Acinetobacter and half of all Pseudomonas aeruginosa were resistant to the higher antibiotics used. Klebsiella is acquiring resistance to another higher antibiotic called colistin. Infection with such bacteria causes nearly 70 percent mortality mostly within 30 days of infection onset. India has been referred to as the AMR (Antimicrobial resistance) capital of the world. It is double trouble for India as the country is still striving to fight against the old public health scourges of tuberculosis, malaria, and cholera pathogens which are also getting increasingly resistant to the drugs used. Dr Sanjay Bhattacharya senior consultant of microbiology, at Tata Medical Center, Kolkata, adds that less than two years since the cancer centre was established, antimicrobial resistance was noticed from the early days suggesting a higher prevalence of antibiotic resistance in the community.
How and why did India land in such a situation? It is not a sudden making, but something that has been happening over decades which culminated in the development of MDR (Multi-drug-resistant) and XDR (extremely drug-resistant) bacteria. The Indian health scenario is dependent on a significant contribution from the private sector. Self-prescription of drugs without any professional knowledge regarding the dose and duration of antibiotics is all too common; those who seek medical advice are often prescribed broad-spectrum, high-end antibiotics without proper diagnostic tests to identify the microorganism or the susceptibility to the drug used.
India, being the big pharmaceutical leader of the world, has also fuelled the problem. The waste water generated by the industry is reaching the water bodies. The effluent is acting as a continuous reservoir of antimicrobial resistance. Similarly, the water effluents from big hospitals with heavy use of antibiotics reach water bodies. The two largest rivers of India — the Ganga and Yamuna which span large tracts of land across the belt, receive multiple inlets with varying concentrations of drug-resistant bacteria. In a sampling, one such deadly bacteria called ESBL (extended spectrum Beta-Lactamase) was found. Similarly, in another major river down south — Cauvery — the water sample had E. coli with a100 percent of them resistant to third-generation cephalosporin antibiotics.
In the absence of regulations over the quality of drugs produced, counterfeit antibiotics available in the market do not get fully metabolised in the body and half of it gets excreted through faeces and urine which gets into the soil and
food chain, another factor adding to the problem. The sub-optimal potency of poor-quality antibiotics also reduces therapeutic efficacy.
The heavy usage of antimicrobials in the food and animal industry and agriculture is also finding a way into water bodies to function as a perfect niche for drug-resistant bacteria to thrive. The antibiotic colistin is widely used as a growth promoter in livestock. At least one in ten top producers of colistin for agricultural use is in India. The Centre for Disease Dynamics Economics and Policy has reported India as one of the top agricultural antibiotic consumers in the world, accounting for 3% of global consumption, increasing annually. The latest treatments for cancer involve medications that deplete the immune system quite significantly. The outcomes from intense chemotherapies, bone marrow, and solid organ transplants are not good in India for the same reason. There has not been much hope with the newly developed antibiotics. “When there is no guarantee that newer antibiotics will last longer and be successful, no major pharma companies are willing to invest in developing antibiotics,” laments Dr Priyank Tripathi, Head of Clinical Pharmacology at the HCG Cancer Center, Bengaluru.
Dr Suresh Karanth, a consultant in haematology and transplant physician working at AJ Hospital Mangaluru, adds that he has noticed the dramatic changing trend of infections and susceptibility of organisms and a significant increase in MDR gram-negative infections and increasing difficulty in managing infections with available armamentarium.
“We have a very high incidence of MDR bacteria in India. The genesis of the drug resistance in the Indian context is complex and multifactorial,” adds Dr Kamini Walia, senior scientist at ICMR, New Delhi who has been working on antimicrobial resistance in India. The healthcare infrastructure faces issues pertaining to heavy dependence on tertiary care, non-availability of good diagnostics at all levels of healthcare, uncontrolled prescription of antibiotics, and more importantly an issue with acceptance regarding the problem and poor investment in infection control practices.
ICMR’s initiative of AMRSN (Anti-microbial resistance surveillance and research network) is generating data regarding drug-resistant patterns which can be used for devising protocols, education, and training. Dr Kamini who is part of this initiative says they are facing hurdles to get accurate data regarding the resistance patterns from secondary care. “We seem to be missing the data regarding the number of antibiotics a patient might have received which is vital information to classify the resistance pattern. Also, there has not been enough collaborative work between the clinicians and the microbiology community except in a few tertiary care hospitals” laments Dr Kamini.
(The author is a consultant haemato-oncologist with a special interest in stem cell transplantation at Royal Wolverhampton NHS Trust, UK. He can be reached at praveen.kaudlay1@nhs.net)