‘Drug-resistant infections: The silent pandemic’

Antimicrobial resistance (AMR) threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses and fungi. In line with the World Antibiotic Awareness Week 2020, it is important to understand how drug-resistant infections are evolving.

As the world reels from the impact of COVID-19, it would be a tragedy not to apply the lessons we are learning to the fight against drug resistance.

• World Antibiotic Awareness Week is celebrated annually from 18 to 24 November.
• The week raises the consciousness about antibiotic resistance and how the medical community is educating us about the proper use of these disease-fighting drugs.  
• Antibiotic resistance has existed since life began, but has recently accelerated due to human use.
• Today, it is a growing global health threat. Preventing it takes smart choices at the local level. 

• The terms antimicrobial and antibiotic are used interchangeably but in general when we talk about AMR, we are referring to antibiotic resistance.
• The World Health Organization (WHO) defines it this way: “Antibiotic resistance occurs when bacteria change in response to the use of these medicines. Bacteria, not humans or animals, become antibiotic-resistant.”

• Exposure to antibiotics puts stress on bacteria and, like other living organisms, they defend themselves.
• Bacteria do this by sharing and acquiring defence genes, often from other bacteria in their environment.
• This allows them to change quickly, readily obtaining the ability to make proteins and other molecules that block the antibiotic’s effect.
• This gene sharing processis natural and is a large part of what drives evolution.
• However, as we use ever stronger and more diverse antibiotics, new and more powerful bacterial defence options have evolved, rendering some bacteria resistant to almost everything – the ultimate outcome being untreatable superbugs.
• When one takes an antibiotic, it kills a large majority of the target bacteria at the site of infection – and so the patient gets better.
• But antibiotics do not kill all the bacteria – some are naturally resistant; others acquire resistance genes from their microbial neighbours, especially in digestive systems, throat, and on skin.
• This means that some resistant bacteria always survive, and can pass to the environment via inadequately treated faecal matter, spreading resistant bacteria and genes wider.

• Drug-resistant ‘superbug’ infections kill an estimated 700,000 people each year, a number set to rise to 10 million per year by 2050as drug resistance to antimicrobial agents grows and weakens our ability to treat even common infections.
• A worrying number of infections are becoming harder and extremely complicated to treat due to drug resistance.
• The consequences of not addressing this silent pandemic now could result in a future where we will not be able to treat even common infections like pneumonia, urinary tract infections and infections in newborns.
• The evolving pandemic of drug-resistant infections has the potential to cripple the world in the same way that COVID-19 has done this year.

• Chemical residues released from pharmaceutical and personal care products are not only becoming a major contaminant of water bodies in urban areas but are also becoming a source of drug resistance in the environment.
• Occurrence of pharmaceuticals and personal care products, intestine occurring virus, antibiotic resistant bacteria, metal, faecal contamination and antibiotic resistance genes, as well as the long term changes in precipitation and temperature of water.
• These antibiotics make their way into the environment and trigger resistance.
• It is clear that environmental triggers to antibiotic resistance have to be urgently controlled.

• The worst effect of antibiotic abuse, however, is the growing burden of drug resistance, with more and more bacteria becoming resistant to the drugs.
• India, incidentally, has the highest burden of drug resistance.
• India is already a hub of infectious diseases. Infectious diseases such as pneumonia and diarrhoea accounted for around 50 percent of deaths in children aged less than 5 years in India.
• Drug resistance, in itself, is just not a medical problem but it escalates cost of treatment too. 
• Due to growing drug resistance, antibiotic costs, pharmacy costs and the overall cost of treatment were much more in people resistant to drugs rather than those who responded to them.
• Health consequences such as intensive care admissions, complications, mortality, and length of stay were significantly higher in the resistant group as compared to susceptible group.

• Global Action Plan on AMR in 2015: Based on the adoption of the Global Action Plan on AMR in 2015in the World Health Assembly, member states were urged to develop National Action Plans based on the global framework within 2 years and share data with the WHO on implementation steps and AMR trends.
  • Though less ambitious efforts existed earlier, the Government of India (GoI) adopted the National Action Plan on AMR(NAP-AMR) in 2017, with the Ministry of Health and Family Welfare (MoHFW) as the nodal ministry and the National Centre for Disease Control (NCDC) as the key surveillance body.
  • The NCDC has prepared guidelines for the development of State Action Plans but till date, only three states—Kerala, Madhya Pradesh, and Delhi—have prepared and submitted them.
• Maximum permissible antibiotic residue limits: In 2018, the Food Safety and Standards Authority of India (FSSAI) introduced maximum permissible antibiotic residue limitsfor meat, fish and milk. Unfortunately, there is no system of standardised testing of animal products before sale and the FSSAI hopes to rely on occasional surprise testing. As a result, frequent investigations by private watchdog groups throw up concerning results.
• Ban on Colistin: A significant victory was achieved when the MoHFW banned the use of colistinwhich is a “last-resort antibiotic” in fish and livestock industries in 2019.
• Prescribed standards: In January 2020, the Ministry of Environment, Forest and Climate Change (MoEFCC) published draft standards for antibiotic residues in pharmaceutical industry effluents under the proposed Environmental (Protection) Amendment Rule 2019.
• These standards propose stringent limits for 121 antibiotics and are applicable to both standalone manufacturing units as well as common effluent treatment plants (CETPs) catering to the pharmaceutical industry.
• If finally notified, India will become the first country in the world with such standards.

• Integrated cooperation: While solutions to antibiotic resistance exist, integrated cooperation between science and engineering, medicine, social action, and governance is lacking, which needs to be the centre focus.
• Collaborative global efforts: While many international organisations acknowledge the scale of the problem, unified global action is not happening fast enough. The focus should be given to collaborative global efforts.
• Strategy for all causes: Science continues to reveal probable causes of antibiotic resistance, which shows no single factor drives resistance evolution and spread. As such, a strategy incorporating medicine, environment, sanitation, and public health is needed to provide the best solutions.
• Working in accordance with UN SDGs: Governments throughout the world must act in unison to meet targets for sanitation and hygiene in accordance with the UN Sustainable Development Goals.
• Improved sanitation and hygiene: Regardless of context, improved water, sanitation, and hygiene must be the backbone of stemming the spread of AMR, including antibiotic resistance, to avoid the next pandemic. 

The novel coronavirus disease (COVID-19) has been our first experience of a pandemic in a generation that has been both, devastating and far-reaching. With limited tools to prevent or treat COVID-19, the pandemic has disrupted health systems and global economies in ways the world has not seen before. Despite solutions being at hand, a similar situation could be on the cards for the evolving pandemic of drug-resistant infections. The world needs unless urgent action to address lack of access to antibiotic treatments. We should use this time as an opportunity to avert this potential catastrophe through strong leadership, collaboration and investment in measures to counteract the threat of drug resistance.