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Pankaj Mandale

The constant misuse and overuse of antibiotics has led to an increase in drug-resistant bacterial strains, which are causing infections that cannot be cured. Alexander Fleming, who discovered penicillin, had warned about antibiotic resistance developing from improper use. Factors contributing to the rise of antibiotic resistance include overprescription by doctors due to patient pressure, failure to complete drug courses, antibiotic use in livestock, and release of pharmaceutical waste. Studies show high rates of antibiotic resistance in India, including an 80% prevalence of ESBL bacteria in India compared to 3-5% in France. Urgent action is needed to promote judicious antibiotic use and develop new drugs to tackle the growing threat of antibiotic-resistant bacteria.

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HEALTH & FITNESS Wednesday, November 6, 2013, Chandigarh, India Deadly miracle drugs The constant misuse of antibiotics has unleashed lethal, drug- resistant bacterial strains that are causing infections for which no cure is in sight Dr Pankaj Mandale A slight nick from a razor could leave you struggling for life. The most basic of operations could become impossible to perform. Your survival will depend more on luck than the doctor treating you. We are staring at a future without antibiotics, and the situation is nothing short of a catastrophe. Antibiotics, usually obtained from micro-organisms or semi-synthetic modifications of natural compounds, are medicines that can destroy bacteria or inhibit their growth to cure deadly infections, but the irrational use of these drugs has led to a bacterial backlash with the microbes developing resistance against them. Called "superbugs", these dangerous bacterial strains are causing infections for which no cure is in sight. Even most powerful antibiotics have been rendered ineffective against them. The WHO has warned that "many common infections will no longer have a cure and, once again, could kill unabated." British microbiologist Alexander Fleming, who had discovered penicillin, the first antibiotic known to mankind, had warned in 1945 about the threat in his lecture after winning Nobel Prize. "It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body. The time may come when penicillin can be bought by anyone. Then there is the danger that the ignorant man may easily underdose himself and, by exposing his microbes to non-lethal quantities of the drug, make them resistant." Belligerent bacteria Termed antimicrobial resistance (AMR), this is essentially a natural phenomenon caused by mutations in genes. But the wrong and excessive use of antibiotics accelerates the growth of antibiotic-resistant bacteria. When exposed to antibiotics, vulnerable bacteria are killed, but the resistant ones continue to multiply, causing prolonged illness or even life-threatening conditions. Infections caused by resistant
bacteria may require stronger and more expensive antibiotics, which may have more severe side effects. The problem is compounded by the fact that a bacterium can swap its genetic code with other bacteria, even the ones from different species. These bacteria may spread and cause infections in other people who have not taken antibiotics. The emergence of new bacterial strains resistant to several antibiotics at the same time has made the situation more worrisome. Such bacteria may become resistant to all existing antibiotics in due course, making even simple surgeries, for which antibiotics are administered beforehand to prevent the possibility of an infection, impossible to perform. Causative factors AMR has been rising at an alarming pace over the past 10 years. The miracle drugs are losing their magic due to repeated misuse. If you are in the habit of popping them even when you do not need these, these might just not work when you need these the most. Doctors are under pressure from patients to overprescribe antibiotics. Many patients insist on antibiotics for viral infections like common cold, against which these medicines do not work. The "smarter" ones do not even feel the need for a prescription to buy these drugs. Unfortunately, most chemists are more than willing to oblige them. Even when the drug has been rightly prescribed, some patients do not bother to finish the course, which again leads to infection and, in the bargain, stronger bacteria emerge that require a higher dose later on. This vicious circle unleashes increasingly resistant strains of bacteria with lethal potential. It is distressing that hospitals, the last hope of critically ill patients, have themselves turned into breeding grounds for deadly infections. Studies conducted by the US- based Centre for Disease Control and Prevention (CDC) reveal that 2 million people in America contract hospital-acquired infections annually, resulting in 20,000 deaths. There is no reliable data available for India. While some experts claims that hospital- acquired infections accounted for 50 per cent of all infections five years ago, others maintain that the average incidence ranges from 10-30 per cent. The bacteria responsible for hospital-acquired infections are much more resistant than the ones found in community settings. A 10-year study conducted by Sir Ganga Ram Hospital on 77,618 patients has shown an alarming rise in AMR. The study found that the bacterium Klebsiella pneumoniae, which damages human lungs, had stopped reacting to carbapenem, the strongest antibiotic available, and the resistance to this last-resort drug had grown from 2.4 per cent to 52 per cent in a matter of just one decade. In some cases patients admitted to hospital with a breathing problem acquired pneumonia from the ventilator. The hospital staff kept on administering antibiotics but without hope. Patients in hospitals have low immunity, making the treatment more complicated. On account of high levels of exposure to antibiotics and their prolonged misuse, bacteria in hospitals develop more resistance as a natural survival strategy.
Antibiotics have also entered the human food chain due to misuse of antibiotics in animal husbandry. While Europe has banned the use of antibiotics to boost livestock growth, this practice is widely prevalent in other parts of the world. The release of pharmaceutical waste into water bodies is also a matter of deep concern. Disturbing findings AMR, which claims thousands of lives every year, is a global concern, but the problem is more acute in India. According to a 2010 WHO report, multidrug-resistant tuberculosis causes 1.5 lakh deaths worldwide every year. Almost half of these cases are estimated to have occurred in China and India. The prevalence rate of extended- spectrum beta-lactamase (ESBL), an enzyme that deactivates antibiotics, in e coli is 3-5 per cent in France, but around 80 per cent in India. Studies reveal that 30 per cent infants die in India every year from germs that do not respond to antibiotics. In the last 10 years, there has been a 95 per cent rise in pneumonia and blood and wound infections in India, which cannot be cured by last-resort drugs. The findings are alarming and call for urgent action. Long way to go Resistant bacteria are developing at a faster pace than the solutions to tackle them. The last class of antibiotics was developed in the late 1980s. Research on antibiotics is not a profitable proposition owing to their short duration of use, longer research span and high R&D costs. The onus is on doctors, pharmaceutical companies, government agencies, NGOs and chemists to promote the judicious use of antibiotics. However, India lacks a national policy on antibiotics to check their indiscriminate use and over-the-counter sale. Poor hospital hygiene practices, absence of infection-control protocols and lack of awareness among the nursing staff and patients are the major problem areas. Some organisations are generating awareness about the proper use of antibiotics, but these initiatives will not be enough without government support. For instance, the Emerging Antimicrobial Resistance Society (EARS), an NGO, is doing its bit to collect data on resistance. The government should complement these efforts by initiating a national survey on the prevalence of AMR.
Tread with caution Avoid self-medication. Take antibiotics only when prescribed by a registered medical practitioner. If the doctor has prescribed antibiotics, complete the course even after you get well. Not completing the full course encourages the emergence of drug- resistant bacteria. Do not take antibiotics for viral diseases like flu. These medicines work only for bacterial infections. Basic hygiene like washing hands and maintaining cleanliness while preparing food can stop the spread of bacteria, including resistant strains. The writer is Vice-President, Emerging Antimicrobial Resistance Society www.tribuneindia.com/2013/20131106/health.htm

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The Tribune

  • 1. HEALTH & FITNESS Wednesday, November 6, 2013, Chandigarh, India Deadly miracle drugs The constant misuse of antibiotics has unleashed lethal, drug- resistant bacterial strains that are causing infections for which no cure is in sight Dr Pankaj Mandale A slight nick from a razor could leave you struggling for life. The most basic of operations could become impossible to perform. Your survival will depend more on luck than the doctor treating you. We are staring at a future without antibiotics, and the situation is nothing short of a catastrophe. Antibiotics, usually obtained from micro-organisms or semi-synthetic modifications of natural compounds, are medicines that can destroy bacteria or inhibit their growth to cure deadly infections, but the irrational use of these drugs has led to a bacterial backlash with the microbes developing resistance against them. Called "superbugs", these dangerous bacterial strains are causing infections for which no cure is in sight. Even most powerful antibiotics have been rendered ineffective against them. The WHO has warned that "many common infections will no longer have a cure and, once again, could kill unabated." British microbiologist Alexander Fleming, who had discovered penicillin, the first antibiotic known to mankind, had warned in 1945 about the threat in his lecture after winning Nobel Prize. "It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body. The time may come when penicillin can be bought by anyone. Then there is the danger that the ignorant man may easily underdose himself and, by exposing his microbes to non-lethal quantities of the drug, make them resistant." Belligerent bacteria Termed antimicrobial resistance (AMR), this is essentially a natural phenomenon caused by mutations in genes. But the wrong and excessive use of antibiotics accelerates the growth of antibiotic-resistant bacteria. When exposed to antibiotics, vulnerable bacteria are killed, but the resistant ones continue to multiply, causing prolonged illness or even life-threatening conditions. Infections caused by resistant
  • 2. bacteria may require stronger and more expensive antibiotics, which may have more severe side effects. The problem is compounded by the fact that a bacterium can swap its genetic code with other bacteria, even the ones from different species. These bacteria may spread and cause infections in other people who have not taken antibiotics. The emergence of new bacterial strains resistant to several antibiotics at the same time has made the situation more worrisome. Such bacteria may become resistant to all existing antibiotics in due course, making even simple surgeries, for which antibiotics are administered beforehand to prevent the possibility of an infection, impossible to perform. Causative factors AMR has been rising at an alarming pace over the past 10 years. The miracle drugs are losing their magic due to repeated misuse. If you are in the habit of popping them even when you do not need these, these might just not work when you need these the most. Doctors are under pressure from patients to overprescribe antibiotics. Many patients insist on antibiotics for viral infections like common cold, against which these medicines do not work. The "smarter" ones do not even feel the need for a prescription to buy these drugs. Unfortunately, most chemists are more than willing to oblige them. Even when the drug has been rightly prescribed, some patients do not bother to finish the course, which again leads to infection and, in the bargain, stronger bacteria emerge that require a higher dose later on. This vicious circle unleashes increasingly resistant strains of bacteria with lethal potential. It is distressing that hospitals, the last hope of critically ill patients, have themselves turned into breeding grounds for deadly infections. Studies conducted by the US- based Centre for Disease Control and Prevention (CDC) reveal that 2 million people in America contract hospital-acquired infections annually, resulting in 20,000 deaths. There is no reliable data available for India. While some experts claims that hospital- acquired infections accounted for 50 per cent of all infections five years ago, others maintain that the average incidence ranges from 10-30 per cent. The bacteria responsible for hospital-acquired infections are much more resistant than the ones found in community settings. A 10-year study conducted by Sir Ganga Ram Hospital on 77,618 patients has shown an alarming rise in AMR. The study found that the bacterium Klebsiella pneumoniae, which damages human lungs, had stopped reacting to carbapenem, the strongest antibiotic available, and the resistance to this last-resort drug had grown from 2.4 per cent to 52 per cent in a matter of just one decade. In some cases patients admitted to hospital with a breathing problem acquired pneumonia from the ventilator. The hospital staff kept on administering antibiotics but without hope. Patients in hospitals have low immunity, making the treatment more complicated. On account of high levels of exposure to antibiotics and their prolonged misuse, bacteria in hospitals develop more resistance as a natural survival strategy.
  • 3. Antibiotics have also entered the human food chain due to misuse of antibiotics in animal husbandry. While Europe has banned the use of antibiotics to boost livestock growth, this practice is widely prevalent in other parts of the world. The release of pharmaceutical waste into water bodies is also a matter of deep concern. Disturbing findings AMR, which claims thousands of lives every year, is a global concern, but the problem is more acute in India. According to a 2010 WHO report, multidrug-resistant tuberculosis causes 1.5 lakh deaths worldwide every year. Almost half of these cases are estimated to have occurred in China and India. The prevalence rate of extended- spectrum beta-lactamase (ESBL), an enzyme that deactivates antibiotics, in e coli is 3-5 per cent in France, but around 80 per cent in India. Studies reveal that 30 per cent infants die in India every year from germs that do not respond to antibiotics. In the last 10 years, there has been a 95 per cent rise in pneumonia and blood and wound infections in India, which cannot be cured by last-resort drugs. The findings are alarming and call for urgent action. Long way to go Resistant bacteria are developing at a faster pace than the solutions to tackle them. The last class of antibiotics was developed in the late 1980s. Research on antibiotics is not a profitable proposition owing to their short duration of use, longer research span and high R&D costs. The onus is on doctors, pharmaceutical companies, government agencies, NGOs and chemists to promote the judicious use of antibiotics. However, India lacks a national policy on antibiotics to check their indiscriminate use and over-the-counter sale. Poor hospital hygiene practices, absence of infection-control protocols and lack of awareness among the nursing staff and patients are the major problem areas. Some organisations are generating awareness about the proper use of antibiotics, but these initiatives will not be enough without government support. For instance, the Emerging Antimicrobial Resistance Society (EARS), an NGO, is doing its bit to collect data on resistance. The government should complement these efforts by initiating a national survey on the prevalence of AMR.
  • 4. Tread with caution Avoid self-medication. Take antibiotics only when prescribed by a registered medical practitioner. If the doctor has prescribed antibiotics, complete the course even after you get well. Not completing the full course encourages the emergence of drug- resistant bacteria. Do not take antibiotics for viral diseases like flu. These medicines work only for bacterial infections. Basic hygiene like washing hands and maintaining cleanliness while preparing food can stop the spread of bacteria, including resistant strains. The writer is Vice-President, Emerging Antimicrobial Resistance Society www.tribuneindia.com/2013/20131106/health.htm