Are antibiotics over-prescribed in India?

Antimicrobial Resistance (AMR) is characterized by the resistance of microorganisms to antimicrobial agents to which they were initially sensitive. The current concern surrounding AMR arises from the fact that various bacteria, especially in the Indian context such as E. coli, Klebsiella, Acinetobacter, Staphylococcus aureus, and enterococcus, have developed resistance even to some of the latest generation antibiotics. Patients infected with these resistant strains face a higher likelihood of experiencing adverse health outcomes due to the resistance.

 Factors Leading to AMR in India

• The inappropriate use of antibiotics in treating non-bacterial infections is a significant factor contributing to AMR. This includes both prescription practices and the widespread availability of over-the-counter antibiotics.
• The absence of well-equipped laboratory facilities for rapidly informing clinicians about suitable antibiotics based on cultures has led to a situation where clinicians often lack precise information, resulting in suboptimal antibiotic selection.
• Insufficient training in antibiotic selection, escalation, and de-escalation for healthcare professionals is another contributing factor. This lack of training can result in ineffective use of antibiotics, exacerbating the problem of resistance.
• Despite repeated warnings, health systems have struggled with monitoring AMR and controlling antibiotic prescription and dispensing practices. This has allowed inappropriate use to persist, contributing to the rise of resistant strains.
• The pharmaceutical industry's incentivization of certain prescribing practices has played a role in the overuse and misuse of antibiotics. This has further fueled the development of drug-resistant bacteria.

Impact of Inappropriate Antibiotic Use: Inappropriate use of antibiotics, not only in the human sector but also in animal and agricultural sectors, leads to the generation of drug-resistant bugs. Additionally, inadequate sanitation in communities and improper infection prevention measures in healthcare institutions contribute to the spread of these superbugs.

The Complexity of AMR as a Societal Challenge: AMR is not solely a scientific issue to be addressed by doctors and researchers. Instead, it is a complex socio-economic and political challenge. Addressing the roots of AMR requires a multi-faceted approach, encompassing changes in prescribing practices, improved laboratory facilities, enhanced training for healthcare professionals, better monitoring, and stricter control measures. Tackling AMR also demands a societal shift towards responsible antibiotic use and a comprehensive understanding of the issue beyond the realm of healthcare alone.

2. National Centre for Disease Control

The National Centre for Disease Control (NCDC) is a premier institution in India dedicated to the prevention and control of communicable diseases. Established in 1963, it operates under the Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. The primary objective of the NCDC is to provide leadership in public health, strengthen epidemiological and laboratory surveillance, and respond to disease outbreaks swiftly and effectively.

Key Functions and Responsibilities

• The NCDC plays a crucial role in disease surveillance, monitoring, and epidemiological research. It collects, analyzes, and disseminates data on various communicable diseases, aiding policymakers and public health officials in making informed decisions.
• During disease outbreaks, the NCDC takes the lead in coordinating and conducting epidemiological investigations. Its rapid response teams deploy to affected areas to assess the situation, implement control measures, and prevent further spread of the disease.
• The NCDC houses state-of-the-art laboratories equipped for diagnosing and characterizing various infectious diseases. These laboratories play a pivotal role in confirming suspected cases, conducting research, and developing strategies for disease control.
• To strengthen the public health workforce, the NCDC conducts training programs, workshops, and capacity-building initiatives for healthcare professionals, epidemiologists, and laboratory personnel. This ensures a skilled cadre of professionals capable of responding to emerging health challenges.
• The NCDC engages in research activities to enhance the understanding of disease dynamics, contributing to the development of evidence-based public health policies. It regularly publishes research findings, guidelines, and advisories to disseminate knowledge within the scientific community and the public.
• The NCDC collaborates with international organizations, health agencies, and research institutions to share information, best practices, and expertise in the global fight against infectious diseases. This collaboration strengthens India's preparedness and response capabilities.

Significant Contributions

• The NCDC plays a crucial role in preparing for and responding to pandemics. Its expertise and infrastructure become particularly vital during global health crises, as demonstrated during the COVID-19 pandemic.
• The NCDC has been instrumental in the successful eradication of diseases such as smallpox and the near-elimination of polio in India, showcasing its commitment to disease control and public health achievements.
• The establishment of robust surveillance networks, including the Integrated Disease Surveillance Programme (IDSP), has enhanced the country's ability to detect, track, and respond to disease outbreaks promptly.

3. Addressing Antibiotic Prescribing Practices

The Call for Standardization

In light of the recent National Centre for Disease Control (NCDC) report highlighting the prevalent misuse of antibiotics, there is a pressing need for standardization to ensure uniformity in prescribing antibiotics. While there are existing guidelines, including those provided by the NCDC, the challenge lies in the consistent application of these guidelines to avoid unnecessary antibiotic prescriptions.

Existing Guidelines and Training

Multiple guidelines, including those from the NCDC and the Indian Council for Medical Research (ICMR), already exist to guide doctors in initiating antibiotics for various types and sites of infection. However, the core issue lies in the accurate diagnosis of bacterial infections versus non-bacterial conditions. Despite guidelines and training on appropriate antibiotic use, the differentiation often relies on clinical judgment, with laboratory and radiological investigations serving as supportive tools.

The NCDC survey results, while not unexpected, emphasize the widespread nature of unnecessary antibiotic prescriptions. The challenge in diagnosing bacterial infections clinically is compounded by factors such as overcrowded outpatient units in both government and private hospitals. The time constraints on physicians, coupled with limited access to rapid diagnostics and a robust network of laboratories, contribute to suboptimal diagnostic practices.

 Root Causes of Over-Prescription

Examining the root causes of over-prescription reveals systemic challenges. In many healthcare settings, outpatient units are overwhelmed, hindering thorough patient history-taking and comprehensive examinations. Rapid and extensive investigations are often constrained, making antibiotics a more accessible and less time-consuming option for both doctors and patients. The cost-effectiveness of a course of antibiotics compared to extensive diagnostics further incentivizes this practice.

The Role of Standardization and Systemic Changes

While guidelines exist, their implementation remains a challenge. Standardization in antibiotic prescribing practices is crucial, but it must be accompanied by systemic changes. Addressing the root causes, including improving access to rapid diagnostics, building an extensive network of laboratories, and alleviating overcrowding in healthcare units, is essential for sustainable change. Simply having guidelines is insufficient; concerted efforts are needed to ensure their effective implementation, fostering a healthcare environment where responsible antibiotic use is prioritized over expedient yet unnecessary prescriptions.

4. The Urgency of Prudent Antibiotic Use in the Face of Global Threats

The Immediate Danger

Following the challenges posed by COVID-19 and recognizing the vulnerability to outbreaks due to climate change, zoonotic spillovers, and resistance from agricultural products and poultry, the judicious use of antibiotics becomes crucial. The immediate danger lies in the rise of Antimicrobial Resistance (AMR), evidenced by the study showing that approximately 75% of surveyed patients with E. coli or Klebsiella infections in hospitals were resistant to third- or fourth-generation antibiotics. Moreover, resistance to the next generation of antibiotics, particularly carbapenem resistance, is alarmingly high.

Trickle-down Effects from Agriculture

The impact of AMR extends beyond hospitals, with significant repercussions traced back to poultry and agriculture. Industrialized agriculture, prevalent in countries like the U.S. and China, contributes to the high levels of resistance observed. However, prescription practices also play a pivotal role in exacerbating the problem, necessitating a comprehensive approach to tackle the issue.

The Realities in Clinical Settings

In clinical settings, such as intensive care units, the consequences of AMR are stark. Patients, especially those with compromised immune systems like cancer patients, face life-threatening situations due to antibiotic resistance. However, addressing this challenge requires a broader perspective that goes beyond merely regulating antibiotic consumption.

Beyond Antibiotic Prescription

AMR is not isolated; it is interconnected with various factors, including governance, infrastructure, sanitation, poverty, and access to clean drinking water. In countries grappling with high AMR rates, reducing antibiotic consumption alone will not suffice. While rationalizing antibiotic use is crucial for patient safety and combating AMR, attention must be given to fundamental factors like sanitation in hospitals, access to personal hygiene, and effective infection control measures.

A Holistic Approach

Combatting AMR necessitates a holistic approach that acknowledges the multifaceted nature of the issue. Governance, infrastructure development, poverty alleviation, and access to clean water are integral components of the strategy. Drawing parallels with the lessons learned during the COVID-19 pandemic, basic measures such as handwashing, mask-wearing, and infection control practices become fundamental in the fight against AMR. Initiating change at these fundamental levels is imperative to address the global threat of antibiotic resistance effectively.

5. Recent Measures by the Central Government to Control Antimicrobial Resistance (AMR) in India

As a longstanding member of the technical advisory committee for the national policy on antibiotics, The insights into the measures implemented by the Central government to address Antimicrobial Resistance (AMR) in India.

• The first National Policy for Containment of Antimicrobial Resistance was introduced in 2011.
• The Central government banned the over-the-counter use of antibiotics, known as the H1 rule, in 2011. However, enforcement of this rule was not effectively implemented.
• In 2013, a modified H1 rule was introduced, inspired by the Chennai Declaration. This rule specifically prohibited the over-the-counter use of only second- and third-line antibiotics. Unfortunately, like its predecessor, this rule faced challenges in implementation.
• While health is a State subject, effective control of AMR necessitates strong coordination between the Central and State governments. Recognizing the interconnected nature of health issues, a collaborative approach involving all stakeholders, including patients, is crucial.
• A significant step was taken in 2019 when the Indian government imposed a ban on the use of colistin as a growth-promoting agent in poultry farming. Colistin is a potent antibiotic used in treating human infections. This measure aimed to regulate antibiotic use and reduce the chances of resistance.
• While India has undertaken robust and long-term measures, there is a need for better enforcement of existing laws, particularly those related to the ban on over-the-counter use of antibiotics.
• There is a critical need to restrict access to reserve antibiotics to minimize the risk of resistance. A strategic approach to managing antibiotic distribution is essential.
• The observation that countries with the highest per capita antibiotic usage often have highly privatized healthcare systems underscores the importance of improving public health systems. Strengthening public health delivery, including sanitation, is key to combating the rise in AMR.
• Recognizing the disparity in AMR rates among states with differing public health systems, the way forward involves planned expenditure, structured service delivery, and enhanced accountability within the public health system.

6. Conclusion

The NCDC study serves as a wake-up call. To effectively combat AMR, sustained and collaborative efforts are needed at all levels – from policymakers and healthcare professionals to patients and the community. By addressing the root causes, promoting responsible antibiotic use, and implementing effective regulations, we can work towards a future where antibiotics remain potent weapons in the fight against infections.