Why is it in the News?

With antimicrobial resistance on the rise, the Union Health Ministry has urged doctors to write down the exact reason when prescribing antibiotics.

New Summary:

• The Union Health Ministry urged all doctors in medical colleges and medical associations to make it a mandatory practice to "write indication/reason/justification" while prescribing antibiotics.
• The Director General of Health Services also appealed to all pharmacists to strictly implement Schedule H and H1 of the Drugs and Cosmetics Rules and stop the over-the-counter sale of antibiotics.
• Antimicrobials are listed under Schedule H and H1 of the Drugs and Cosmetics Act, both of which are categories of medicines that cannot be sold without a prescription.

What is Antimicrobial Resistance?

• According to the World Health Organisation (WHO), antimicrobial resistance occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines.
• This makes infections harder to treat, increasing the risk of disease spread, severe illness and death.
  • As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spreading to others.
• AMR affects countries in all regions and at all income levels.
  • Its drivers and consequences are exacerbated by poverty and inequality, and low- and middle-income countries are most affected as per WHO.
• Currently, AMR is one of the top global public health threats facing humanity.
  • It is estimated that bacterial AMR was directly responsible for 1.27 million global deaths in 2019 and 4.95 million deaths were associated with drug-resistant infections.
• According to the Indian Council of Medical Research (ICMR), 1.25 million lives were lost to drug resistance in 2019.
• India has one of the highest rates of antimicrobial resistance worldwide.
  • Despite being prescription drugs, antibiotics are commonly available over-the-counter (OTC) at retail pharmacies.
• In a recent survey, conducted by the National Centre for Disease Control (NCDC) under the Union Health Ministry, over half of the antibiotics prescribed in the country cause antimicrobial resistance.
• Treatment failures also lead to longer periods of infectivity and the prohibitively high cost of second-line drugs may result in failure to treat these diseases in many individuals.

Scenarios in Which Antimicrobials are Most Commonly Misused?

• There are two common scenarios in which antimicrobials are misused or overused even by doctors.
  • One is when they cannot make a diagnosis on whether an infection is caused by a bacteria or virus and prescribe antibiotics to err on the side of caution.
  • Two, when they know it is a bacterial infection but want to avoid secondary infection.
    • This is where antibiotics can be conserved because very few people get such secondary bacterial infections.
• In the case of a serious patient, who is admitted to the hospital, broad-spectrum antibiotics may be prescribed for 48 hours, during which they can be tested for which pathogen is causing the infection.
  • The antibiotics needed to be switched after that.
• Prescription for antimicrobials before and after a procedure or surgery is another way that antibiotics are commonly overused.
  • Just a single dose of antibiotic 60 to 120 minutes before surgery is enough to prevent surgical site infections.
• However, doctors end up prescribing antibiotics for seven to 14 days.
  • If proper sterilization of equipment, and preparation of the surgical site are done, infections cannot happen.
  • Shaving the surgical site before surgery should be avoided because it can lead to abrasions that can get infected

The Result of Antimicrobial Overuse and Misuse?

• Common infections are not curable anymore.
• Tuberculosis and urinary tract infections have become multi-drug resistant.
• In hospitals, infections are resulting in longer treatment times with the use of costlier and more toxic antibiotics.
  • Despite all efforts and successful surgeries, people are dying

Factors contributing to Antimicrobial Resistance (AMR):

• Unnecessary Prescriptions: In many cases, antibiotics are prescribed when they are not necessary or are not used correctly.
  • This can lead to the survival and proliferation of resistant bacteria.
• Agricultural use: The use and overuse of antimicrobials in agriculture, including to promote growth and prevent disease in livestock, is also a major contributor to the development and spread of AMR.
• Selective pressure: In the presence of antimicrobials, microbes that carry resistance genes can survive, replicate, and quickly dominate the microbial population.
• Mutation: Rapid microbial reproduction allows for swift-evolution, and mutations during replication may aid individual microbes in surviving antimicrobial exposure.
• Inappropriate use: Unnecessary and injudicious use of antibiotic fixed dose combinations may lead to the emergence of bacterial strains resistant to multiple antibiotics.
• State of the Environment: There is growing evidence that the environment plays a key role in the development, transmission and spread of AMR. Its proliferation is linked to the triple planetary crisis of climate change, nature and biodiversity loss, pollution and waste.
  • For example, higher temperatures, storms and floods can fuel the spread of bacterial, viral, parasitic, fungal and vector-borne diseases.
  • Severe weather events can also cause wastewater and sewage to overwhelm treatment plants, allowing untreated sewage rich in antimicrobial-resistant microbes to contaminate surrounding communities.
  • As well, wastewater laced with medicines, including that from animal production facilities, hospitals and pharmaceutical companies, can feed drug resistance.

Measures Taken by the Government of India to Address AMR:

• National Action Plan on AMR: The National Action Plan on Containment of Antimicrobial Resistance (NAP-AMR) was launched in 2017.
  • Emphasis is placed on a One Health approach, involving various stakeholder ministries/departments.
• AMR Surveillance and Research Network (AMRSN): ICMR has set up the AMR Surveillance and Research Network (AMRSN) comprising 30 tertiary care hospitals, both private and government.
  • Its purpose is to generate evidence and capture trends and patterns of drug-resistant infections in the country.
• Research and International Collaboration: Initiatives by ICMR aim to develop new drugs and medicines through international collaborations.
  • This is intended to strengthen medical research in the field of AMR.
• Red Line Campaign: The Union health ministry initiated the "Red Line Campaign."
  • It urges people not to use medicines marked with a red vertical line, including antibiotics, without a doctor’s prescription.
  •  The campaign aims to discourage unnecessary prescription and over-the-counter sales of antibiotics, addressing drug resistance for diseases like TB, malaria, urinary tract infections, and HIV.

Way Forward

• Antimicrobials have saved countless lives and are essential to modern medicine but we need to use them more judiciously.
• Healthcare professionals should only prescribe antibiotics when necessary and at the right dosage and duration.
• The use and overuse of antibiotics in agriculture must also be limited.
• Countries must adopt the One Health approach, which recognizes that the health of people, animals, plants and the environment are interdependent.
• Preventative measures, such as improving water, sanitation and hygiene, as well as putting in place strong international and national regulatory frameworks to enforce controls on the sale and distribution of antibiotics, will go a long way in reducing AMR.

Conclusion

AMR is a global problem; therefore, international cooperation among nations is essential. Developing multi-stakeholder national action plans is key. Countries must also work together on strategies, information sharing and surveillance of antimicrobial use and resistance. However, fixing the AMR crisis is not just dependent on governments alone. Pharmaceutical companies, the chemical industry, regulators, municipal governments, human and animal healthcare professionals and students, scientists and the public all have a role to play.