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EDITORIAL
Year : 2022  |  Volume : 20  |  Issue : 3  |  Page : 123-124

Antimicrobial resistance in India – “A silent pandemic within the pandemic”


Department of General Medicine Unit V, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission03-May-2022
Date of Decision10-May-2022
Date of Acceptance15-May-2022
Date of Web Publication01-Aug-2022

Correspondence Address:
Dr. Karthik Gunasekaran
Department of General Medicine Unit V, Christian Medical College, Vellore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_47_22

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How to cite this article:
Gunasekaran K. Antimicrobial resistance in India – “A silent pandemic within the pandemic”. Curr Med Issues 2022;20:123-4

How to cite this URL:
Gunasekaran K. Antimicrobial resistance in India – “A silent pandemic within the pandemic”. Curr Med Issues [serial online] 2022 [cited 2022 Oct 6];20:123-4. Available from: https://www.cmijournal.org/text.asp?2022/20/3/123/352987



India has a high burden of mortality due to infectious diseases (417/100,000 persons). Bacterial infections appear to be the leading cause of death in children as well as adults. An estimated 410,000 children aged 5 years or less die from pneumonia in India annually, accounting for almost 25% of all child deaths in India.[1] Compounding this will be the emergence of antimicrobial resistance (AMR), which is a significant public health concern in India. The resistance is not just restricted to the older and more frequently used classes of drugs. There has been a faster increase in the incidence of resistance to the newer and more expensive drugs, such as carbapenems. Available data indicate rising rates of AMR across multiple pathogens of clinical importance.

Carbapenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, and Enterobacterales remain important causes of hospital-acquired infections (HAIs) and are marked by the WHO as critical pathogens of concern, requiring further advanced research.[2] The geographic and temporal antibiotic-resistance patterns over 20 years (1997–2016) from the SENTRY Surveillance Program which included carbapenem resistance rates globally, excluding Africa and the Middle East, have recently been published, where the prevalence in the Asia-Pacific region was 18.8%.[3] The high burden of AMR in India is driven by multiple factors. Antibiotic overprescription is rampant, which is caused due to inadequate knowledge and contribution to AMR on the part of the pharmacists as well as the patients. There was an interesting study published by Barker et al.,[4] on antibiotic dispensing practices in community pharmacies in Haryana.

  • Many felt that prior work experience under a pharmacist's supervision was an adequate substitute for formal training
  • 85% of employees sold abbreviated antibiotic courses, often just 1–2 days of tablets.


Within the hospitals, an unscrutinized and irrational use of higher antibiotics drive the development and spread of resistance. In 2008, about 29% of isolates of Staphylococcus aureus were methicillin resistant, and by 2014, this had risen to 47%.[5] In contrast, in countries with effective antibiotic stewardship and/or infection prevention and control programs, the proportion of methicillin-resistant S. aureus isolates has been decreasing. India spends only 4.7% of its total gross domestic product on health, with the government sharing only one-fourth (1.15%). The economic impact of a resistant HAI is huge, which was in fact studied for over a year in our institution.[6] The average daily wage of a rural male casual worker in India is approximately INR 95 (USD 1.6). A difference of about INR 41,993 (USD 700) is incurred by patients with resistant bacterial infection as opposed to the sensitized group, which equates to 442 days of wages spent. This financial loss is more than 1 year's wages of a casual worker in India.


  Mechanisms of Antimicrobial Resistance Top


The development of microbial resistance is a natural process and has been observed in microorganisms in soil samples from before synthetic antibiotics were produced. Microorganisms-containing antibiotic-resistance genes (ARGs), including multiresistance genes, have also been found in environmental samples not influenced by human activity. Resistance can be disseminated through the spread of resistant pathogenic bacteria themselves or by the horizontal transfer of resistance genes from one type of bacteria to another. Resistance has traditionally been viewed as a clinical problem, but a more holistic approach is needed. Recently, nonclinical environments have been highlighted as an important factor in the dissemination of ARGs.[7] Horizontal gene transfer events occur in aquatic environments including manure and sewage sludge and even wetted soils. Integrons in particular are well suited for mediating the environmental dissemination of ARG. A growing body of evidence suggests that ARGs are ubiquitous in natural environments. Particularly, elevated levels of ARG and integrons in aquatic environments are correlated to proximity to anthropogenic activities, for example, through wastewater or runoff from agricultural livestock facilities.[7] Misuse and overuse of antibiotics in hospitals and animal agriculture are considered to be the primary reasons for antibiotic-resistance problems.[8] Although mitigating the dissemination of antibiotic resistance is of utmost importance, AMR can never be eradicated, and ARGs for most of the antibiotics available today are already present in pathogens and commensals.


  A Strategic Plan – Need of the Hour Top


India has a National Action Plan on Antimicrobial Resistance, as well as the Delhi Declaration on AMR, which was endorsed at the Inter-Ministerial Consultation on AMR in April 2017. India is enrolled in the WHO's Global Antimicrobial-Resistance Surveillance System or GLASS and has been contributing AMR data from the National Centre for Disease Control, Indian Council of Medical Research, and Gonococcal AMR Surveillance Program networks. A unified protocol spanning the entire nation is practically not possible. However, a method of networking, with AMR laboratories of surveillance at each tertiary or quaternary care setup with centralized surveillance, might give accurate numbers for surveillance and action. At the moment, the development of an effective in-hospital surveillance and stewardship with unified antimicrobial protocols appears to be the need of the hour. Education on infection control practices by all health-care providers will be a mandate, which could be correlated with the incidence of resistant infections.



 
  References Top

1.
Antimicrobial Resistance India. Available from: https://www.who.int/india/health-topics/antimicrobial-resistance. [Last accessed on 2022 Apr 23].  Back to cited text no. 1
    
2.
Brink AJ. Epidemiology of carbapenem-resistant Gram-negative infections globally. Curr Opin Infect Dis 2019;32:609-16.  Back to cited text no. 2
    
3.
Fuhrmeister AS, Jones RN. The importance of antimicrobial resistance monitoring worldwide and the origins of SENTRY antimicrobial surveillance program. Open Forum Infect Dis 2019;6:S1-4.  Back to cited text no. 3
    
4.
Barker AK, Brown K, Ahsan M, Sengupta S, Safdar N. What drives inappropriate antibiotic dispensing? A mixed-methods study of pharmacy employee perspectives in Haryana, India. BMJ Open 2017;7:e013190.  Back to cited text no. 4
    
5.
Kumar SG, Adithan C, Harish BN, Sujatha S, Roy G, Malini A. Antimicrobial resistance in India: A review. J Nat Sci Biol Med 2013;4:286-91.  Back to cited text no. 5
    
6.
Chandy SJ, Naik GS, Balaji V, Jeyaseelan V, Thomas K, Lundborg CS. High cost burden and health consequences of antibiotic resistance: The price to pay. J Infect Dev Ctries 2014;8:1096-102.  Back to cited text no. 6
    
7.
Berglund B, Gengler S, Batoko H, Wattiau P, Errampalli D, Leung K, et al. Environmental dissemination of antibiotic resistance genes and correlation to anthropogenic contamination with antibiotics. J Microbiol Methods 2015;113:28564.  Back to cited text no. 7
    
8.
Landers TF, Cohen B, Wittum TE, Larson EL. A review of antibiotic use in food animals: Perspective, policy, and potential. Public Health Rep 2012;127:4-22.  Back to cited text no. 8
    




 

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