Typhoid patient had intestinal bleeding, all because he had been self-medicating and misusing antibiotics: What’s behind India’s superbug menace?

Antimicrobial Resistance is a growing concern. Health care professionals need to educate themselves on rational and responsible use of antibiotics

Antimicrobial resistance (AMR) is the ability of microorganisms like bacteria, viruses, fungi and parasites to withstand drugs designed to kill them, such as antibiotics, antivirals and antifungals.

A young man was admitted to Fortis Hospital, Mohali, with low haemoglobin counts and a fever that had not settled despite oral antibiotics. But soon after admission, he had massive intestinal bleeding and required surgery to fix it. His blood culture and tissue biopsy reports showed that he had typhoid fever complicated by a large intestinal perforation. The problem? He had taken the antibiotic ciprofloxacin, which had worked for his intestinal infections earlier and which he assumed would work for his stomach pain this time too. Except its overuse had made him resistant to it and damaged his gut lining.

“This could have turned out to be fatal,” explains Dr Parvinder Chawla, senior consultant, Internal Medicine. “Instead of taking standard paracetamol, which is the only medicine that can be taken in case of fever without a consultation, my patient made the mistake of self-medicating himself. That too over the years whenever he suspected a stomach infection,” he adds.

What is antimicrobial resistance (AMR)?

Antimicrobial resistance (AMR) is the ability of microorganisms like bacteria, viruses, fungi and parasites to withstand drugs designed to kill them, such as antibiotics, antivirals and antifungals. This occurs as microbes evolve over time, learn to fight the drug, making infections harder to treat, leading to longer illnesses and the increased risk of death. Over-the-counter (OTC) use of antibiotics is a significant contributing factor to the rise of AMR.

“Typhoid seems to be the most glaring example of AMR over the last few decades,” says Dr Chawla. In the late 1990s, typhoid was easily cured by the then newly-introduced antibiotic Ciprofloxacin. It could be taken by mouth, was very effective on the bug and very cost-effective on the pocket too. Over the years, explains Dr Chawla, this drug has become useless for typhoid because of unsupervised use. “Patients who are still prescribed this antibiotic in the periphery for suspected typhoid often end up requiring hospitalisation and prolonged intravenous antibiotics in the hospital setting. To make matters worse, not only does this antibiotic fail to work against the culprit organism, but it also changes the balance of the normal gut microorganisms and induces resistance development in other intestinal microorganisms.”

Some research shows that changes to the gut microbiome from antibiotics like ciprofloxacin can last for a year or even longer, even after the antibiotic is discontinued.

The cost of antibiotic misuse

A new study published in The Lancet’s Clinical Medicine highlights that Antimicrobial Resistance (AMR) is a growing public health concern in India. Antibiotic misuse, OTC sales, self-medication, incomplete courses, environmental contamination and healthcare gaps, are the key issues. The research, titled ‘Preprocedural screening for multidrug-resistant organisms in endoscopic retrograde cholangiopancreatography: an international, multicentre, cross-sectional observational study’, found that Indian patients recorded the highest global prevalence of multidrug-resistant organisms (MDROs) among those undergoing a common endoscopic procedure. Data from India shows that 83.1 per cent of Indian patients carried at least one superbug, and 70.2 per cent carried ESBL-producing bacteria, resulting in many common antibiotics being ineffective. Chronic lung disease, congestive heart failure, recent penicillin use, frequent hospital admissions or prior procedures, were some of the conditions associated with higher MDRO prevalence.

What typhoid data shows

This year, says Dr Chawala, his hospital investigated its own typhoid data from 2012 to 2024 and found that Ciprofloxacin resistance had risen from 20-40% in 2018 to 88% in the last two years. “We are now compelled to straight away admit and start intravenous antibiotic (Ceftriaxone) for most patients with suspected typhoid. Unfortunately, reports of resistance to this antibiotic have also started coming in from different parts of the country. If we do not take definitive, discrete action now to prevent, diagnose and treat typhoid fever effectively now, we may soon end up making this common malady a fatal one,” says Dr Chawla.

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Dr Nusrat Shafiq, professor in the Department of Pharmacology at PGIMER Chandigarh, is the convener of antimicrobial stewardship activities at PGI. Her group is involved in implementing various activities for rationalizing antimicrobial use. “Healthcare professionals need to educate themselves on rational and responsible use of antibiotics through various resources available and act based on data. It is important to take all measures possible for infection prevention such as hand hygiene, clean water and food, sanitation, vaccination. And most importantly, not take antibiotics unnecessarily. Not all fevers or diarrhoea need antibiotic treatment,” says Dr Shafiq.