Updated: March 3, 2022 9:18:23 am
Ever since the pandemic struck, concerns have been raised about the improper use of antimicrobials amongst Covid-19 patients. The worry is that unnecessary prescription of antimicrobials will lead to a further increase in the already high levels of drug resistance in most parts of the world. In the past few years, alarmingly high resistance rates in pathogens of public health importance have been reported from Indian hospitals. Unfortunately, the resistance rates reported by the hospitals and laboratories do not automatically translate to disease burden unless each resistant isolate is correlated with the clinical outcomes in the patients from whom they were isolated. This has to do with inadequate hospital information systems in most public sector funded healthcare facilities in India and many low-middle income countries.
In 2014, economist Jim O’ Neill estimated that 10 million annual deaths from AMR could occur by 2050. Studies such as the ones conducted by him paved the way for the consolidation of the Global Action Plan in 2015 and the UN Resolution on AMR in 2016. However, nothing changed on the ground. National Action Plans against AMR, including the one in India, have not been translated into coherent action. The major impediment to AMR containment is that the most affected countries have the least data on the burden posed by this malaise.
The “Global burden of bacterial antimicrobial resistance in 204 countries and territories in 2019 (GRAM)” report, released last month, provides the most comprehensive estimate of the global impact of antibiotic resistance to date. According to the report, 4.95 million people died from drug-resistant bacterial infections in 2019, with 3,89,000 deaths in South Asia alone. AMR directly caused at least 1.27 million of those deaths. Lower respiratory infections accounted for more than 1.5 million deaths associated with resistance in 2019, making it the most burdensome infectious syndrome. Amongst pathogens, E coli was responsible for the most deaths in 2019, followed by K pneumoniae, S aureus, A baumannii, S pneumoniae, and M tuberculosis. As per the yearly trends reported by the Indian Council of Medical Research since 2015, India reports a high level of resistance in all these pathogens, especially E coli and K pneumoniae.
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However, only a fraction of the Indian data, available through the WHO-GLASS portal, has been included in the GRAM report. India has been reporting high levels of resistance to fluoroquinolones, cephalosporins and carbapenems across the Gram-negative pathogens that cause almost 70 per cent of infections in communities and hospitals. Therefore, the Indian data on the AMR burden may not look very different from the estimates published in the report. Now that we know that AMR’s burden surpasses that of TB and HIV, a sense of urgency in containing such resistance is called for. With no new drugs in the pipeline for drug-resistant infections, time is running out for patients.
Addressing AMR requires a multipronged and multisectoral approach. The urgency to develop new drugs should not discourage us from instituting measures to use the existing antimicrobials judiciously. Improved infection control in communities and hospitals, availability and utilisation of quality diagnostics and laboratories and educating people about antimicrobials have proved effective in reducing antimicrobial pressure — a precursor to resistance. All this requires a comprehensive plan, driven by a designated coordinating agency backed with suitable funding.
The National Action Plan for AMR, approved in 2017, completes its official duration this year. The progress under the plan has been far from satisfactory. Too many players, missing governance mechanisms and absence of funding have been recognised as key impediments to the effective rollout of action plans in other countries as well. However, there are also examples of countries launching effective AMR containment plans by fixing responsibility and monitoring progress at the highest levels.
There is enough evidence that interventions like infection control, improved diagnosis and antimicrobial stewardship are effective in the containment of AMR. The GRAM report has underlined that postponing action could prove costly.
This column first appeared in the print edition on March 3, 2022 under the title ‘The lingering pandemic’. The writer is a scientist with the ICMR
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