Antimicrobial Resistance (AMR) refers to a condition when micro-organism like bacteria, fungi, viruses, parasites develop resistance to, substances designed to kill them or inhibit their growth that are called antimicrobial agents or drugs like antibiotics. Micro-organisms develop resistance by 2 means- One, they may have innate ability to resist different classes of antimicrobial agents due to unique structure or functional characteristics and this is called as intrinsic resistance. Second, is acquired resistance in which micro-organisms adopt or acquire gene modification or coding in order to develop resistance. Acquired resistance is common in nature and it can spread and propagate by means of mating or transduction. AMR is usually interchangeably used to refer to antibiotic resistance which is subset to AMR. Antibiotic resistance is specific to a particular type of antibiotic whereas AMR refers to resistance in all micro-organisms like Bacteria, fungi, parasites, viruses.
With rampant spread of diseases, antibiotics have become equally spread-out over-all areas. As per a report in the Lancet ‘in 2010, India consumed about 13 billion units, China 10 billion and USA around 7 billion units of antibiotic’. This rapid rate of antibiotic use brings along with it the threat of AMR. The ease of availability of antibiotics, its indiscriminate use and its spread among human population for tackling injections as well as among animals to promote growth in poultry farms, ponds etc. has resulted in spread of AMR like wildfire.
Various reports and studies have shown worrisome statistics like study of the Centre of Science and Environment (CSE) conducted across different government and private hospitals in India stated that resistance of micro-organisms was high against some of the commonly used antibiotics like ciprofloxacin, doxycycline, tetracycline as a result the organisms like Pseudomonas Enterobacter, Escherichia Coli, Klebsiella were found to be resistant to ciprofloxacin. Also, in 2014, the Union Health Minister, in response to a Parliamentary question stated that (multi-drug-resistant tuberculosis) MDR-TB cases had increased five times between 2011-13 and almost 1/3rd is used to treat humans. The widespread threat to AMR has been acknowledged worldwide. International bodies and inter-country agencies like UN-General Assembly, G7, G20, ASEAN, WHO, FAO etc. have raised concerns over AMR issue. The Sustainable Development Goals have also articulated the importance of containing AMR. The agencies WHO, FAO, and World Organization for Animal Health have also developed a Global Action Plan on AMR. India has put it place its own National Action Plan on AMR in 2017.
How AMR developed and spread?
AMR spread rampantly primarily due to the misuse of antibiotics. The micro-organisms evolve in order to survive similar to all other organisms. But improper use, sometimes overuse or else underuse of antibiotics cause the surviving micro-organisms to develop resistance. Flawed prescription regime due to callousness of people, buying antimicrobials from untrained shopkeepers without constitution of trained doctor, use of antibiotics to treat viral infections like cold and flu which did not require antibiotics, indiscriminate use of antimicrobials as growth promoters in animals or to prevent diseases in healthy animals, overuse of antimicrobials in agriculture, poor infection control and unhygienic conditions in hospitals and at home have all contributed to spread of AMR among different micro-organisms.
The development of AMR is a simple survival technique of micro-organisms. Say for example- a person suffering from cold or flu takes antibiotics without need, then after the dosage period the micro-organisms that are leftover in the body develop resistance to the drugs. This can also occur in case if low or irregular dosage is being consumed. The AMR developed organisms then multiply and spread. Such resistance may also be seen among people who never took antibiotics. This is because the crops or animal products from animal husbandry, fishes or poultry farm’s animals. Where antimicrobials were imported, and micro-organisms had developed AMR also became a medium for transmission or spread of AMR strained micro-organisms into humans. Certain microorganisms develop resistance to multiple antibiotics and some are capable of spreading AMR to other species of micro-organisms.
Threats from AMR
As discussed, AMR is capable of spreading across humans and animals equally. This makes it a grave threat. AMR developed micro-organisms can lead to delays in treatment, aggravation of infection or may even cause death in case they infect a person. Antibiotics were considered a boon due to its ability to fight infections, but AMR fails the purpose of antibiotics and renders it useless. As a result, minor infections even by soil bacteria could lead to death of people. Complex surgeries, fatal diseases like cancer, HIV, Malaria, TB, etc. cannot be treated by using available antibiotics if AMR spreads further.
As per reports in 2016, upto 5 lakh people developed multi-drug-resistant TB globally. The ability of resistant micro-organisms to transmit and spread infection makes the issue more dangerous. In India, around 6000 newborns die per year due to sepsis from resistant bacteria as per a 2013 estimate. Over 7 lakh people die per year globally due to resistant infections.
Apart from the huge loss of life AMR causes it also causes economical loss. With ineffectiveness of cheaper antibiotics like penicillin, tetracycline or due to AMR, costly 3rd and 4th generation antibiotics options like cephalosporin, Carbapenem, etc. are being used. This has 2 disadvantages- 1st it is rendering available antibiotics useless and 2nd it is increasing cost of disease treatment. ‘The impending antibiotic apocalypse can cause global economic shocks at par with 2008-2009 financial crisis in coming 30 years if not checked immediately. About 10 million people are expected to die from resistant infections by 2050 and world will lose about 4% of annual GDP by 2050. Healthcare cost and cost of food production will spike, and existing income disparity will widen and about 24 million people will be pushed into extreme poverty by 2030′. These statistics were stated in a report from the Interagency Coordination Group on Antimicrobial Resistance.
Till date several diseases’ treatment has been adversely affected due to AMR. Klebsiella Pneumonia which causes life-threatening infections like Pneumonia has been found to have developed resistance and does not work more than half people to carbapenem antibiotics that is last resort treatment drug. E. coli which causes urinary tract infections has developed resistance against fluroquinolone antibiotics. Gonorrhea treatment has been failing and cases of failure of third generation antibiotics- Cephalosporin has been reported in atleast 10 countries. Staphylococcus aureus which causes severe infections in health facilities has been reported to have developed resistance to first-line drug treatment. Colistin is used as a last resort treatment for life threatening infections spread by Enterobacteriaceae and resistance against tis has also been reported. Besides these diseases, treatment of other diseases like TB, Malaria, HIV, etc. have also been affected due to resistance developed among micro-organisms against antibiotics and drugs used in their treatment.
Preventive and Curative Steps needed
The primary and most necessary step needed to prevent AMR is to create awareness and thereby end indiscriminate use of antibiotics. People need to understand effect and adverse effect of antibiotics and use it under supervision of trained doctors and effective prescription and must not use it based on past experiences or after having some general idea about the treatment and self-medication needs to be avoided at all costs. Second important thing is to control and strictly monitor and regulate sale of antibiotics and their use in agriculture, for growth of animals, in ponds, in aquaculture farms etc. with assistance from FAO. India has developed a surveillance network, that is, ‘Indian Network for Fishery and Animals Antimicrobial Resistance’. Such monitoring and surveillance networks should be expanded.
Capacity augmentation for controlling infections, diagnostic support, ensuring biodiversity in animal rearing practices is needed and engagement of different bodies, private entities and coordinated work will prove to be fruitful. Private pharmaceutical industries need to realize the threat posed by AMR and must distribute drugs responsibly. To tackle overuse of antibiotics, India has classified important antibiotics under schedule H1 of the Drugs and Cosmetic Rules 1945. However, this needs to be properly enforced. India’s National Action Plan on AMR,2017 is an appreciable step and it needs to be speed up and implemented properly. Such national plans need to be looked upon and states must form their individual plans in tune with the national plan to deal with AMR issue. More plans like ‘Delhi Declaration’, ‘Chennai Declaration’ aimed to strategize a containment approach for AMR must be brought up. Lastly, though it may not appear to be significant, it is of utmost importance to maintain cleanliness in hospitals and sanitation at home along with maintaining a hygienic way of life.
AMR has been spreading rapidly and it needs to be dealt with an urgency else it will have catastrophic consequences. Since 1980s new antibiotics have not been developed due to complexity, large amount of time needed, and huge costs and hence aim has to be to preserve the usefulness of existing ones. Rational drug usage and efficiency implemented long term national and global plans will prove to be beneficial in the long run. Antibiotics have become inseparable part of human life and its usefulness needs to be maintained for safety of human beings as well as animals. Proper awareness and responsible approach in drug or antibiotic use will be the key to deal with the eminent threat posed by AMR.