Med Piper Technologies Pvt Ltd and Journo Med conducted a webinar on “Antibiotics Awareness Week 2022 in association with All India Institute of Hygiene and Public Health, Kolkata and Journo Med. The theme of the event is “Preventing Antibiotic Resistance Together.” The event was conducted on 24th November 2022.
An Awareness Program was conducted on Antibiotic Resistance and Antibiotics Awareness Week with the Theme “Preventing Antimicrobial Resistance Together”. An eminent speaker Dr Sayan Bhattacharya, MD Microbiologist, and Associate Professor from All India Institute of Hygiene and Public Health, Kolkata joined us and discussed the detailed aspects of antibiotics that many of us are aware that there was the rapid spread of bacterial infections during the pandemic and many of us are in a panic.
Dr Sayan Bhattacharya, an eminent speaker, Associate Professor, Microbiology from the All-India Institute of Health and Public Health, Kolkata spoke about “Antibiotics Awareness Week 2022.”
What are Antibiotics?
Antibiotics are antibacterial compounds produced by bacteria sometimes and also synthesized artificially sometimes.
Antimicrobials: It is a broad term covering antibiotics, antiparasitic agents, antiviral compounds and antifungals.
Things like inadequate dosage and over-the-counter (OTC) availability of antibiotics had made AMR (antimicrobial resistance) a global problem now.
N.B.: Some compounds are antibiotics but also act as antiparasitic agents like Metronidazole (act as anaerobic bacteria as well as gut protozoa.
Epidemiology of Antibiotic Microbial Resistance
- Over 7 lakh people lose lives every year to Antimicrobial resistance.
- Antibiotic Microbial Resistance now kills more people per year than road accidents and cancer combined.
- By 2050, AMR will decrease GDP (Global domestic product) by 2-3.5%.
- AMR if more means prolonged illness and long hospital stay, leading to more cost burden for the patient.
- According to the WHO, AMR is one of the top 10 global public health threats facing humanity.
- Lack of clean water and sanitation and inadequate infection prevention and control promotes the spread of antibiotic-resistant microbes (also called bugs and superbugs).
World Health Organization has denoted AMR as an urgent priority area. One needs to work together to reduce the menace of AMR.
Why AMR is such a crisis now?
The antibiotic resistance crisis is mostly attributed to
- The overuse and misuse of antibiotics as well as
- A lack of new drug development by the pharmaceutical industry due to reduced economic incentives and challenging regulatory requirements
- Easy availability
- Prescription of antibiotics by quacks and other unqualified persons
- A Sufficient number of new antibiotic classes are not coming up. In 2019, the WHO identified 32 antibiotics in clinical development addressing the WHO list of priority pathogens, of which only six were classified as innovative.
- Bacteria have developed smart strategies to overcome antibiotic resistance, like biofilms, efflux pumps, and gene-mediated resistance via plasmids, episomes and others.
- Most healthcare facilities do not have or do not implement antibiotic stewardship policies.
Resistance of a microorganism to an antibiotic that was originally effective in training infections caused by it.
Why do Indians need to curb antibiotic overuse?
India’s bacterial disease burden is the highest in the World.
The large population suffers from diseases like diabetes, heart ailments and cancer, making them prone to infections.
40% of children are malnourished and at risk of infections.
More and more drug-resistant bacteria are being identified.
Why India faces such a stiff challenge from AMR?
One study published in the lancet regional health- Southeast Asia, examined antibiotic use in India and found in India consumes a high volume of the broad spectrum which should ideally be used sparingly.
There are stark gaps in infection, prevention and control (IPC) practices and the high burden of communicable diseases.
NDM or New Delhi Pomellato beta-lactamase was possibly found first in India in e-coli and Klebsiella pneumonia.
- India carries one of the largest burdens of drug-resistant pathogens worldwide, including the highest burden of multidrug-resistant tuberculosis, and alarmingly high resistance among gram-negative and gram-positive bacteria even to newer antimicrobials such as carbapenems and Faropenem.
- Even the environment and veterinary-derived strains are highly antibiotic-resistant in India.
- Powerful drugs like newer generation cephalosporins are sold far more frequently in India for no apparent reason- between 2005 and 2009, sales of cephalosporins increased by 60 per cent.
Other Regulatory Issues
Antibiotic regulatory laws are not always enforced strictly in India. This is a grey area.
Bacteria have many mechanisms for resistance
- They can modify or thicken cell wall (VISA), develop biofilms (preventing entry via thick EPM), have efflux pumps and modify target sites (like aminoglycosides) or modify or alter the antibiotics (like aminoglycosides), beta-lactamase and ESBL along with other ways.
- “ESKAPE” group of bacteria are most important concerning antimicrobial microbial resistance like Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumonia, Acinetobacter baumanii, Pseudomonas aeruginosa and Enterobacter species.
List of priority pathogens published by WHO
The pathogens are available in the list which should be managed very carefully. This data was released by WHO in 2017.
Critical Priority Pathogens: Priority 1
- Acinobacter baumannii: carbapenem-resistant
- Pseudomonas aerugonisa: carbapenem resistant
- Enterobacteriaceae: carbapenem-resistant pathogens. 3rd generation cephalosporin-resistant
High Priority Pathogens: Priority 2
- Enterococcus faecium: Vancomycin resistant
- Staphylococcus aureus: Methicillin-resistant, Vancomycin Intermediate and resistant
- Helicobacter pylori: Clarithromycin resistant
- Campylobacter, fluoroquinolone resistant, Salmonella species, fluoroquinoline-resistant
- Neisseria gonorrhoeae: 3rd generation cephalosporin-resistant and fluoroquinolone-resistant
Medium Priority Pathogens: Priority 3
- Streptococcus pneumonia, penicillin, non-susceptible
- Haemophilus influenza, ampicillin-resistant
- Shigella species, fluoroquinolone-resistant
Mycobacteria (including Mycobacteria tuberculosis, the cause of human tuberculosis) was not subjected to review for inclusion in the prioritization exercise as it is already a globally established priority for which innovative new treatments are urgently needed.
Enterobacteriaceae include Klebsiella pneumonia. Escherichia coli, Enterobacter spp. or Serrabia spp., Proteus spp and Providencia spp, Morganella spp.
The Problems with Superbugs are enormous
- With MDR TB coming up, the problems escalate and mount.
- Now it will also be very difficult to contain pneumonia, tuberculosis, gonorrhoea and Salmonella infections.
- For common bacterial infections, including urinary tract infections, sepsis, sexually transmitted infections and sometimes diarrhoea, high rates of resistance against antibiotics used to treat these infections have been observed worldwide.
- This shows the scarcity of effective antibiotics.
Our Tryst with AMR
- Invitro nitrofurantoin resistance in E Coli in CA-UTI is worrisome (more than 10%).
- Invitro ciprofloxacin resistance in E Coli in CA-UTI is also a problem.
- Candida isolates from UTI are still most susceptible to Fluconazole (even non-Albicans Candida spp)
Antibiotic stewardship and broadly antimicrobial stewardship (AMS) can guide in the proper use and prevent misuse.
AMS is by definition, all measures and steps are taken to minimize abuse and promote, judicial use and adverse effects of antimicrobials.
Antibiotic Stewardship Subsets
- Enhancing infection, prevention and control
- Supporting an interdisciplinary approach
- Educating Staff
- Supporting surveillance of AMR and HAIs and monitoring of antibiotic consumption.
- Controlling the source of infection
- Prescribing antibiotics when they are truly needed
- Prescribing the appropriate antibiotics with adequate dosages
- Using the shortest duration of antibiotics based on
- Reassessing treatment when culture results are
Examples of Misuse of Antibiotics
Nitrofurantoin for upper UTI (does not attain therapeutic concentration in upper UTI).
Vancomycin for gram-negative bacterial infections (intrinsically resistant almost always).
Irrational antibiotic combinations and using 2 classes of beta-lactams together (like Ampicillin with Meropenem)
Rational Use Needed
- Use in proper dosage.
- Common cold (due to virus) and most diarrhoea (due to virus) do not need antibiotics.
- Clinicians should try to administer antibiotics only after getting antibiotic susceptibility results from the lab if lab support is there.
- Escalate and de-escalate judiciously.
- Use the narrowest spectrum of antibiotics for urgent empirical use.
Other Things to do
- Two institutions within India’s Ministry of Health: The Indian Council of Medical Research (ICMR) and the National Centre for Disease Control (NCDC), each have developed national networks of public and private hospitals to measure AMR trends, prevent healthcare-associated infections (HAIs) and promote appropriate use of antibiotics.
- One health approach
- Antibiotic ward rounds
- National Action Plan (NAP) for antimicrobial resistance in India (2017-2021 release)
Strategic Priorities in NAP
- Improve awareness and understanding of AMR through effective communication, education and training.
- Strengthen knowledge and evidence through surveillance.
- Reduce the incidence of infection through effective infection prevention and control.
- Optimize the use of antimicrobial agents in health, animals and food.
- Promote investments for AMR activities, research and innovations.
- Strengthen India’s leadership on AMR.
The Focus areas of the Six Strategic Priorities of NAP- AMR
Improve awareness and understanding of AMR through effective communication, education and training. By communication, IEC (information, education and communication) resources, to raise awareness amongst all stakeholders, including policymakers, the general public and farmers b. Education and training- to improve the knowledge and behaviour of professionals.
Strengthen Knowledge and Evidence through Surveillance, by strengthening laboratories- in human, animal, food and environment sectors- for evidence-informed policymaking, surveillance of antimicrobial resistance- in human, animal/ food and environmental sectors- for evidence-informed policymaking.
Reduce the incidence of infection through effective infection prevention and control, in
Healthcare- to reduce the burden of infection. b) Animal health/ food- to reduce the AMR and antimicrobials through animals and food. c) Community and community- to reduce the spread of AMR and antimicrobials in the community and environment.
Promote investments for AMR activities, research and innovations by new medicines and diagnostics- to ensure the availability of effective diagnostics and drugs to treat infections. b) Innovations- to develop alternative approaches to manage infectious diseases. c) Financing- to ensure sustainable resources for the containment of AMR.
Strengthen India’s Leadership on AMR by a) International collaborations- to ensure India’s contributions towards global efforts to contain AMR, and b) by National collaborations- to facilitate collaborations among vertical disease control programmes and national stakeholders and state-level collaborations- to ensure action at the ground level against AMR.
One Health Approach is crucial to mitigate AMR
Clinicians, lab people, veterinarians and environmentalists should all come together to tie up and fight to combat the menace of AMR.
Key points: Education, Improving and strengthening hygiene, reducing the unnecessary use of antimicrobials in agriculture and dissemination to the environment, improving the global surveillance of drug resistance, promoting new and rapid clinical diagnoses, recognizing an increasing number of infectious disease workers, global innovation funds, incentives and global coalition.
Government Policies other than NAP are
ICMR Programme on Antibiotic Stewardship, Prevention of Infection and Control (ASPIC). This has training and workshop.
Conclusion: Take Home Message
AMR is now a pandemic. Very little resistance data about AMR is available from countries like India where the burden of AMR is high. Every Healthcare facility should have an infection control policy. Awareness should be spread among the masses regarding the dosage and the adverse effects of antibiotics.