Many of us are guilty of having popped in antibiotics for an infection after a quick self-diagnosis. Amoxicillin for UTI, erythromycin/tetracycline for Strep throat or even a cold, are fairly common. Antibiotics are ineffective for cold or other viral infections, but this is not common knowledge. There is definitely a certain convenience and ease associated with unregulated availability of antibiotics, but it also leads to a huge menace – development of antibiotic resistance among bacteria. Though, this will affect the health of just about everyone, there is not much that is being done to curb such rampant antibiotic use/abuse. However, things are going to change from now on… maybe I should say hopefully going to change.
At a recent conference of Clinical Infectious Disease Society (CIDS), in Chennai on 25th to 26th August, it was decided that the India’s drug regulators would put restrictions on the sale of antibiotics. This of course is not new, there are over 536 drugs that require prescriptions for sale in India and antibiotics fall into that list. The proposal now is to treat antibiotics, especially some of the broad spectrum ones such as Carbapenems within a special category, which will have prominent red labels1. Their sales will also be monitored via surprise inspections of pharmacies. Though useful, going a step further and restricting their availability only within hospital pharmacies would also be a good idea, as monitoring will then become easier. Restricting drug availability though, has its downslide: health care is not amply available in rural India and wherever it is the centers are not well staffed. Which means, pharmacies, if they exist, are the resident’s best bet to treatment. So regulating antibiotic availability seems to be a double-edged sword.
Either way, it is a start for a country that is not only endemic to many infectious diseases but is also faced with a massive threat of emerging drug resistance among bacteria. Multidrug resistant, Mycobacterium tuberculosis is spreading, so is artemisinin resistant Malaria. A new resistant gene isolated from a patient hospitalized in New Delhi with Klebsiella pneumoniae infection, in 2010 is causing concern among clinicians. This gene dubbed – New Delhi metallo-ß-lactamase (NDM‑1) is present on a plasmid and easily transferrable across species2. The gene confers bacterial resistance to a broad range of antibiotics including Carbapenems.
Carbapenems belong to the same class of antibiotics as penicillin and cephalosporin: ß- lactam. They are, however, unique in many ways, the structure of carbapenems, makes them highly resistant to most ß‑lactamases that render penicillin and other similar antibiotics ineffective. In fact, in some cases they can even act to inhibit ß‑lactamases3. Unlike the traditional ß‑lactams, the carbapenems are effective against a broad spectrum of Gram negative and Gram-positive bacteria. These are undeniably the best drug in our armory against the bacteria and clinically, they have often been used as a last resource against multidrug resistance infections. Therefore, it is not surprising that the emergence of strains such as the NDM is alarming.
Another point of concern is that unlike in the western countries, where multi-drug resistance is still largely restricted to hospitals, in India, many resistant bacteria are found in community infections. To add to the concern is the fact that much of this resistance is developing within the Gram Negative group of bacteria. This group traditionally has lesser antibiotics available for treatment. There aren’t many drugs in the pipeline against the Gram Negatives (also see related article by Pavan).
It is possible for us to make a concerted effort and prevent further spread of antibiotic resistance bacteria. That is exactly what a report by the Global antibiotic resistance partnership (GARP)4-India says. This group chaired by Professor Nirmal Ganguly, carried out a situation analysis of antibiotic use in India. The main aim was to develop implementable policy proposals as well as create awareness of a worldwide threat. The report outlines the situation, as it exists in India, pointing out key issues related to development of antibiotic resistance and the measures that need to taken to combat it. Dr. Ramasubramanium touches upon some of these in his article. Some of the interventions mentioned in the report include – Vaccination, safety protocols in hospitals, and public education.
As the GARP-India committee points out in the report4, the benefit of vaccines in saving antibiotics is often overlooked. Vaccines against bacterial diseases such as Hemophilus influenzae (HiB), S. pneumoniae (which cause Pneumonia), and V. Cholerae (cholera) could effectively save lives, increase health and as a bonus minimize the use of antibiotics. Moreover, vaccinations are already part of a widespread public health agenda, therefore the investments –both manpower and infrastructure, required to inform and promote bacterial vaccines will be far less.
Vaccinations, coupled with increased control of hospital acquired infections by following safety rules and protocols (this one needs clarification). The most simple and effective of these is washing hands before seeing a new patient or collecting a sample. This can prevent or minimize spread of infections. The same applies to the use of gloves, in the name of judicious use, the same glove is used over long period of time, worn, removed and re-worn. Such mis-use defies the purpose of gloves, which is to prevent the contact with the sample.
Finally, an aspect that cannot be stressed upon enough is educating both the healthcare workers as well as the public about the proper use of antibiotics. The emerging antibiotic resistance though a threat can still be controlled. The life span of the available antibiotics can be extended by the adopting ways that would involve not just drug regulation authorities, but scientists, pharma & biotech industry, public health workers and the general public to work together to circumvent this threat.
- Erica Westly, India moves to tackle antibiotic resistance, Nature, Sept. 13, 2012
- Kumaraswamy et al., Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study, Lancet Infect Dis. 2010 September; 10(9): 597 – 602.
- Papp-Wallace et al, Carbapenems: past, present, and future, Antimicrob Agents Chemother. 2011 Nov;55(11):4943 – 60.