My patient took OTC antibiotics for common cold. Years later, they could not treat his pneumonia. What made him drug-resistant?

Find out why antibiotic resistance is going up in India and why the superbug is here to stay

One reason, of course, is antibiotic overuse and misuse of the kind mentioned above. The second one is hospital-acquired infection.

When a 45-year-old patient came into the ICU with severe pneumonia, I did some history-taking. He had had no hospital history, had fairly robust health and had no co-morbidities. Yet none of the antibiotics prescribed weren’t quite working on him. We did antibiotic sensitivity tests and found the most common ones to be ineffective. He needed a stronger, potent dose of the next level of antibiotics. Why had he become resistant to the drugs that were designed to kill his infection?

It turned out that he had been self-medicating himself for years, taking over-the-counter antibiotics whenever he had the seasonal flu and cold. Although antibiotics do not help with the flu virus and work only on bacteria, he kept on taking them to suppress his cold and flu attacks all his life. Worse, he stopped them the moment his symptoms subsided, not bothering to check what was the full course doctors usually prescribe for the drug. He took the medication following his uncle, unaware that using someone else’s medication could lead to the development of antibiotic-resistant bacteria. Repeated use of broad-spectrum antibiotics had blunted their efficacy. This time the bacteria he had been infected with had turned multi-drug resistant, leading to acute pneumonia, making it much harder to treat him. This is what’s called antimicrobial resistance (AMR).

Why is antibiotic resistance going up in India?

One reason, of course, is antibiotic overuse and misuse of the kind mentioned above. The second one is hospital-acquired infection. Sometimes critical infections may require prolonged hospital stays and require invasive devices, which significantly contribute to AMR by creating an environment where bacteria are highly exposed to antibiotics, facilitating the spread of resistant strains. In critical cases, the pressure of using high-end antibiotics is high and sometimes doctors are left with no choice but to use them.

For example, in the case of the pneumonia patient, we found a pan-resistant strain of the bacterium Klebsiella, which had affected both his blood and chest. Since standard treatments wouldn’t work, we resorted to last-resort antibiotics called carbapenems. Their use creates a strong selective pressure, favouring bacteria that can survive exposure to these powerful drugs.

How resistant bacteria spreads

Resistant bacteria can spread rapidly from patient to patient via contaminated surfaces (like bed rails, grabs, sinks, drains) or the hands and clothing of healthcare workers if proper hygiene and infection control protocols are not strictly followed at the hospital. These stubborn bacteria form a biofilm to protect themselves, which can increase their resistance by 10 to 1,000 times compared to free-floating bacteria. That’s the reason they can also survive on inanimate surfaces for extended periods and persist in plumbing systems and wastewater, creating transmission hubs within the hospital facility itself.

Now the patient may recover from their original infection but can carry AMR bacteria for years. This is called colonisation as the patient becomes the silent carrier, who can unknowingly spread these resistant bacteria to others in the community or healthcare settings. Global travel spreads this faster.

How to control AMR

This requires a lot of discipline among doctors. Using antibiotics only when necessary reduces the risk of side effects and the development of secondary infections. Once antibiotics are used correctly, they can increase cure rates, reduce treatment failures and shorten hospital stays. Choose narrow spectrum antibiotics first and follow the correct dose.

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Doctors must always do a culture sensitivity of the blood, urine and sputum to guide their diagnosis and prescription of antibiotics. Hospitals, apart from sterilisation and infection control protocols, must have an antibiogram, which is a summary of antibiotics that are effective against bacteria in the hospital environment. It is used to help clinicians choose the most effective empiric therapy (treatment before specific test results are available) for a severe infection.

We need policy help to ban over-the-counter sales of antibiotics. At the individual level, vaccinations to prevent infections are more important than popping the pill just because your pharmacist says so.

(Dr Tickoo is Director, Internal Medicine, Max Healthcare)