German philosopher Friedrich Nietzsche, in his 1888 book ‘Twilight of the Idols’, says “What doesn’t kill you, makes you stronger.” This holds true for pathogens (tiny organisms that can cause disease) as well. What doesn’t kill them, makes them stronger.
In August, the Guru Gobind Singh General Hospital in Jamnagar, one of the 19 tertiary care civil hospitals in Gujarat, got a case of a 6-day-old newborn from the Neonatal Intensive Care Unit (NICU) of a private hospital with multi-drug resistant bacterial sepsis infection.
Doctors immediately ordered a culture sensitivity report of the child’s blood. The results baffled them. The child, who had been in this world for less than a week, had developed resistance to a broad spectrum penicillin, Piperacillin Tazobactam, a third-generation broad- spectrum antibiotic Meropenem and an antifungal medication, Fluconazole, and a last line drug, to some degree.
Associate Professor of Paediatrics at the Jamnagar Civil Hospital Dr Maulik Shah who handled the case, says the child had sepsis caused by drug resistant bacteria.
“We carried out culture sensitivity tests and had to start with the highest possible antibiotics due to massive resistance, and the child managed to survive. But the case of this child is the tip of the iceberg,” says Dr Shah.
Experts attribute the rise in antimicrobial resistance to either wrong medication or dosage, over prescription, lack of course completion, drug use sans culture sensitivity testing and over-the-counter use of antibiotics.
Data from Gujarat’s biggest hospital
During the AMR Awareness week (November 18-24), an audit was conducted for over 700 prescriptions for infection prevention and control across OPDs at the Ahmedabad Civil Hospital, the largest hospital in Gujarat servicing three neighbouring states.
Of the 708 prescriptions given out, 138 containing at least one antimicrobial drug, were assessed in detail. The evaluation was done according to the World Health Organisation (WHO) AWaRe (Access, Watch, Reserve) classification, and adherence to WHO prescribing indicators (on appropriate use). An average of 4.27 medicines were prescribed per patient, with about 79% using generic names. Over 90.15% drugs were drawn from the ‘Essential Medicines’ list.
The findings showed majority antimicrobials were prescribed from the WHO ‘Access’ category, indicating relatively rational antimicrobial usage, while ‘Watch’ antibiotics accounted for one-third of prescriptions. ‘Reserve’ antibiotics were used minimally. About 10% of prescriptions were “difficult to interpret” and posed a potential risk for medication errors. The audit concluded that while antimicrobial selection remained largely appropriate, key issues requiring improvement included quality of documentation, clarity of dosing and follow-up instructions.
Comparative data shared by Ahmedabad Civil Hospital, which is a nodal centre for national Antimicrobial resistance (AMR) reporting from Gujarat, shows an alarming rise in resistance, which increased in an average range of 10%-20% in just the last two years.
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The microbiology lab at the hospital conducts 800 to 1,000 culture sensitivity tests per day and it takes an average of 72 hours for results.
Comparative data shared by Ahmedabad Civil Hospital shows an alarming rise in resistance, which increased in an average range of 10%-20% in just the last two years. (Express)
Bugs get stronger
Explaining how the resistance rises, Dr Maulik Shah says, “If the correct dose is 10 mg and I prescribe 8 mg, on one hand the patient is not going to be cured due to lack of medication to kill the bug, and on the other hand, the pathogen gets the chance to grow resistance to it. If the dose duration is 10 days and the patient stops taking the medication because he feels well after 5 days, this also causes resistance in pathogens. Thirdly, if there are two forms of medication and I use oral instead of the recommended Intravenous (IV) delivery mechanism, that too is problematic.”
Dr Tushar Patel, a senior critical care intensivist and former President of Ahmedabad Medical Association (AMA), told The Indian Express, “Winter is the season of viral infections. But people self-prescribe antibiotics like Azithromycin to treat viral infections by purchasing them over-the-counter. After a week, the fever returns in some cases and may turn into pneumonia. People also take completely unrelated drugs for gram positive bacterial infection like boils, leading to resistance and sepsis infection. Then, there is an issue of drugs themselves not having enough active pharmaceutical ingredients (APIs) in them. When therapeutic levels are not achieved, it causes resistance.”
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Dr Shah said, “We are seeing that in many places, there is no antibiotic policy like in public sector hospitals where we carry out blood cultures to know sensitivity to drugs and then begin relevant drug regimens. It is surprising to many, but we still use Ampicillin (the base Penicillin class of antibiotics) and they work. We only step up the level of drugs only if the need arises, and only based on scientific evidence.”
He notes how some medical practitioners use higher antibiotics by “bypassing protocol”. “When we investigated some hospitals, we found certain units directly using higher antibiotics. Over a period of time, pathogens (bugs) become drug resistant, which is very alarming,” Dr Shah says.
Resistance profile report
The Gujarat Health Department’s GUJSAR Surveillance Report (July–December 2024) from 22 tertiary level public sector hospitals, found “high resistance levels among key pathogens”. For instance, 41% E coli and 46 % Klebsiella spp Isolates were found resistant to Carbapenem. Methicillin resistant Staphylococcus Aureus (MRSA) in blood cultures was 45%, while Vancomycin-resistant Enterococcus (VRE) accounted for 13% of Enterococcus isolates. The report also identified 11 Colistin-resistant XDR isolates, and two Enterococcus isolates resistant to both vancomycin and linezolid, indicating the emergence of highly drug-resistant strains.
The GUJSAR Surveillance Network data was taken from 14,685 isolated samples which included six government medical colleges, 13 run by the Gujarat Medical Education and Research Society (GMERS) and 3 run by municipal corporations (two in Ahmedabad, one in Surat). This is the first state-scale data accumulated and submitted to the National Centre for Disease Control (NCDC) of the Government of India. This network also shares data with the Global Antimicrobial Resistance Surveillance System (GLASS) of the WHO.
A Gujarat government AMR report, citing a 2022 statewide study by Gujarat Biotechnology Research Centre (GBRC), notes how about 60% of samples tested were resistant to more than one class of antibiotics, and nearly 5% were pan-drug resistant. “The study also revealed that sources of resistant organisms spanned across sectors – 52% from human health, 27% from animal and fisheries sources, and 21% from the environment – underscoring the fact that AMR is not just a hospital or medical issue but a broader health concern,” the report said. This shows that efforts need to be made in all three sectors to make sure that drug resistance does not increase in the ecosystem.
Civil hospital takes the first step
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In January, Medical Superintendent at the Ahmedabad Civil Hospital Dr Rakesh Joshi put out a mandate that high level microbials would be “authorised” for resistant infections alone, and would require approval. The need to prescribe them would have to be verified by culture sensitivity tests prior to authorisation for use. These included eight potent drugs including Colistin, with the scope of expanding this rule to four more medications.
Dr Joshi says, “These antimicrobials will be available for use by patients even in the middle of the night but the need for them have to be justified with culture sensitivity tests. Most patients reach a tertiary hospital like ours after getting treatment elsewhere and many of them already have resistance to several lines of treatment. Additionally, this will also help us get AMR data that will help in the effort to curb resistance to these drugs.”
Executive Director of the State Health System Resource Centre of the Gujarat Health department Dr AM Kadri sets an 18-month deadline to train and sensitise district hospitals to contain AMR and create a network of hospitals as part of the State Action Plan for Containment of Antimicrobial Resistance (SAPCAR-G), which was initiated in May 2024.
Notably, Gujarat became the sixth state in India to develop a dedicated state-level plan for AMR containment.
Gujarat is taking a top-down approach in stewardship where it is trying to reduce antibiotic consumption at the tertiary level and then go down to secondary level and then to primary healthcare at the micro level.
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Dr Kadri said, “Apart from the AMR Stewardship Programme (AMSP) already running in 19 medical colleges and their associated tertiary level civil hospitals, we are also trying to bring in private sector hospitals who are doing it voluntarily. We are using AMR surveillance and culture sensitivity and antibiotic consumption data to get a consolidated picture of the entire state from tertiary care healthcare centres.”
In the second phase, the 19 tertiary hospitals will sensitise and mentor district hospitals and then go down to sub-district level.
On strengthening of testing labs in new medical colleges in peripheral districts, Dr Sumeeta Soni, Associate Professor of Microbiology at Ahmedabad Civil Hospital and Nodal Officer at GUJSAR, told The Indian Express, “In Phase-2 of the AMR, Superbugs and One Health Project, frontlined by the Gujarat State Biotechnology Mission (GSBTM), we have added microbiology labs in peripheral medical colleges as testing and surveillance centres for the state. They are being strengthened with equipment, manpower, financial support as well as data validation and verification processes. These new centres have tertiary hospitals in Valsad, Vadnagar, Godhra and Jamnagar. Three other hospitals in Ahmedabad Medicity (the expanded Civil hospital campus) including UNMICRC, IKDRC and GCRI have also been added to the reporting list.”
On December 2, the Gujarat health department held a meeting on developing a modular course on training of trainers who can take the Antimicrobial Stewardship Programme (AMSP) down to the lower rungs of healthcare.
Dr Chetna Desai, Head of Department of Pharmacology at BJ Medical College, said the common goal is to reduce AMR and promote responsible use of antimicrobials. “We are currently deciding the course modules for various cohorts, including clinicians, nurses, pharmacists, post-graduate students, and even MBBS students. There are different course plans for all which will be followed by training in their respective institutions. To ensure uniformity, we have made a committee of faculty from various medical colleges,” she said.
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In the long run, said Dr Kadri, the state hopes that all major private hospitals join in the AMR Stewardship effort so that the AMR patterns can be identified down to the district scale so that even private medical practitioners and general physicians can know the resistance in their field of practice and geographical jurisdiction. For this purpose, the state is also building an AMR dashboard so that data can be seen by government officials and doctors and action can be taken at each level.
Private sector
Regarding the inclusion of private sector hospitals in the race against AMR, Dr Chetna Desai said, “Currently, most of the larger corporate hospitals already have AMR programmes in place. We are trying to tie up with doctors’ associations and regional medical groups to see how we can rope in general practitioners and spread awareness among them as well.”
Dr Mehul Shah, who is also President of the Gujarat State Branch of the Indian Medical Association (IMA-GSB), told The Indian Express, “The private sector makes up for 80% of healthcare in Gujarat and unfortunately, the message about AMR hasn’t reached tier-3 cities and towns. We need preventive awareness at the grassroots level among the four pillars including small hospitals, pharmacies, patients and nursing homes. All four stakeholders need to be engaged in their particular niche. Today, we not only need a one- year roadmap but a 10-year strategy on how to make forward on this subject”.
He added that a national conference at the end of this year will also have AMR in its core discussion.
Comparative data shared by Ahmedabad Civil Hospital shows an alarming rise in resistance, which increased in an average range of 10%-20% in just the last two years. (Express)
