Life took a sudden turn for 49-year-old David Thompson from Bengaluru when he was diagnosed with mouth cancer. After a successful surgery at a private hospital in the city, he was optimistic about complete recovery. But two weeks after discharge from hospital, he returned, feverish and weak, with a troubling wound site infection.
The infection was resistant to all antibiotics, one of the increasing instances of antimicrobial resistance (AMR). As he was admitted to the ICU of a private hospital for monitoring, the medical team feared that if the infection spread to his bloodstream, it could become life-threatening. Fortunately, he later stabilised and is now out of the hospital and on the mend.
His treating doctor, Vishal Rao U.S., a surgical oncologist who specialises in head and neck cancer, attributed the patient’s antibiotic resistance to indiscriminate/prolonged use of antibiotics and tobacco use. “He must have been using antibiotics for a pretty long time through his early youth before cancer treatment. He also had a history of tobacco use, which is linked to antimicrobial resistance (AMR) in several ways. Tobacco users are more likely to receive antibiotics than non-tobacco users. This can lead to increased AMR in the community. Smoking can impair the immune system and defences against infections, thereby promoting the spread of AMR in the lungs,” Dr. Rao said.
What is AMR
AMR, declared by the UN as one of the top 10 global public health threats facing humanity, occurs when pathogens change over time and stop responding to medicines/antimicrobial agents, making infections harder to treat. This increases the risk of disease spread, severe illness and death. Overexposing pathogens to antimicrobial drugs due to abuse, misuse and/or overuse enables the pathogens to acquire resistance against the drug.
But the case of David Thompson is no longer an aberration. More and more doctors have had to deal with similar cases. So much so that a few hospitals have their own antimicrobial policy advising doctors on the judicious use of antibiotics considering aspects relating to cancer, while Karnataka is framing an Action Plan to Mitigate Antimicrobial Resistance (AMAR), expected to be launched early next year.
Karnataka is working on tighter regulations and responsible dispensing of drugs. This will ensure antibiotics are dispensed only with valid prescriptions, thereby discouraging over-the-counter medications.
| Photo Credit:
Getty Images/iStockphoto
Case after case
In another case, M. Govindappa, a 59-year-old Hoskote resident with a history of diabetes, hypertension and chronic kidney disease, was admitted to a local health facility due to a non-healing ulcer. A wound swab revealed the presence of a multidrug-resistant organism. The patient reported having previously used multiple antibiotics at his local facility for treatment.
During therapy with higher antibiotics for his ulcer, there was a decline in his kidney function, which necessitated the commencement of hemodialysis. He has been admitted to the State-run Institute of Nephro Urology (INU) for the last two weeks.
Kishan A., Professor of Nephrology at this government institute, said multidrug resistance limits treatment options to only a few higher antibiotics, and these stronger medications can come with significant systemic side effects, particularly affecting the brain and kidneys.
“The indiscriminate use of antibiotics is a primary factor contributing to the rise of multidrug-resistant organisms. We are observing an increasing incidence of multidrug resistance in both community-acquired and hospital-acquired infections,” said the doctor.
Ravindra M. Mehta, Chief of Integrated Pulmonology and Critical Care Consultant at a private hospital, is currently treating Lalit Kumar Sahu, a 40-year-old male with a recent brain surgery who has since developed complications. “The phlegm from the lungs has shown the presence of a drug-resistant bug – Enterobacter cloacae. The fluid surrounding the lungs was also tested and revealed another virulent organism – Klebsiella pneumoniae, which was resistant to most of the available antibiotics. This bug was later found to have also spread to his bloodstream and became life-threatening with organ failure risk.
“The patient had a dual-hit due to the infection per se and the antimicrobial resistance, making treatment extremely difficult,” Dr. Mehta explained. It was a long-drawn battle of six weeks before the patient was discharged.
“The incremental risk to life with infection, multidrug resistance and side effects of powerful antibiotics is the ‘terrible triad’ of modern antimicrobial resistance. COVID-19 brought us together like never before, and AMR is a more powerful threat that needs global cooperation beyond boundaries,” said the doctor.
The World Health Organisation’s Global Action Plan on AMR provides a broad framework for combating AMR to ensure the continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used responsibly, and accessible to all who need them.
| Photo Credit:
Getty Images/iStockphoto
Action plan
The World Health Organisation’s (WHO’s) Global Action Plan on AMR provides a broad framework for combating AMR to ensure the continuity of successful treatment and prevention of infectious diseases with effective and safe medicines that are quality-assured, used responsibly, and accessible to all who need them.
The Government of India launched the National Action Plan in 2017, adopting a one-health framework that recognised the interconnecting of human, animal and environmental health with six strategic focus areas.
These include improving awareness and understanding of AMR through effective communication, education and training, strengthening knowledge and evidence through surveillance; reducing the incidence of infection through effective infection prevention and control; optimising the use of antimicrobial agents in health, animals and food, promoting investments for AMR activities, research and innovations and strengthening India’s leadership on AMR.
Karnataka’s plan ahead
In Karnataka, Health Minister Dinesh Gundu Rao declared AMR as a focus area in November 2023. He directed the Department of Health Family Welfare to revive efforts to strengthen the State’s capacity to tackle AMR and draft a State action plan that has been pending for six years.
Swetavalli Raghavan, appointed as the advisor on AMR to Karnataka’s Health Department, is developing the Action Plan to Mitigate Antimicrobial Resistance (AMAR) in Karnataka, likely to be launched in the first quarter of 2025.
“Self-medication, not completing the prescribed course, and the use of antibiotics for viral infections, against which they are ineffective, are common practices. In India, AMR is among the top five causes of death. The primary objective of the State action plan in the short term would be to reduce antibiotic misuse through heightening awareness, improving infection control measures and promoting best stewardship practices to curb the growing burden of resistant infections,” he said.
Simultaneously, the plan will outline a blueprint to build capacity within the State, including the development of digital and physical infrastructure, human resources, and communication networks required to undertake monitoring and surveillance to strengthen preparedness to tackle resistant infection outbreaks in humans and animals, as well as develop responsible leadership at all levels in championing the cause, Dr. Raghavan explained.
Asserting the importance of adopting a One Health framework that looks at human, animal and environmental health as being interconnected and interdependent, she said, “Building robust surveillance and monitoring of antimicrobial sale, use, disposal and resistance across all sectors is essential to inform ambitious, evidence-based and risk-based targets and interventions to address gaps in response to AMR.”
Responsible dispensing
Karnataka is also working on tighter regulations and responsible dispensing of drugs. This will ensure antibiotics are dispensed only with valid prescriptions, thereby discouraging over-the-counter medications.
In August this year, a survey conducted by a research team from St Joseph’s University, headed by Dr Raghavan, revealed that nearly 80% of the 108 pharmacies where a “test-purchase” drive was conducted sold antibiotics over-the-counter.
“Out of the remaining 20% who refrained, one out of three did not sell because they did not have stock. Also, over 50% of these 108 pharmacies did not give us a bill until we insisted. A quarter of these were handwritten,” Dr. Raghavan said.
“Although the pharmacists were aware that over-the-counter sales in a punishable offence, fear of losing business (as customers can easily purchase the drugs from another pharmacy) and familiarity with the customer (which prompts the pharmacist to maintain trust and relationship with the customer) are among the reasons for them to do so. Besides, lack of easy access to healthcare, which drives customers/patients to seek help from the pharmacist directly and lack of awareness among customers of the legal and health consequences of purchasing and using antimicrobials without a prescription also contribute to this menace,” she explained.
Behavioural change
Behavioural change at all levels, from prescribers to patients, is essential to control AMR. Pointing out that over 17,000 pharmacists and pharmacology students have been sensitised to the dangers of AMR through an interactive workshop, Dr. Raghavan said this subset of healthcare professionals, who are often overlooked, can influence public awareness, attitude and behaviour on the use of antimicrobial drugs.
Following this, the Health Minister made a public appeal to responsibly use antibiotics and directed pharmacies to display mandatory warnings within their premises on the purchase/use of antibiotics. A follow-up survey is planned to be conducted in the next quarter, with the aim of understanding the effectiveness of awareness activities.
Following the “test-purchase” drive, cases have been booked against several pharmacies by the State Drugs Control Department for indulging in activities that are contrary to the provisions of the Drugs and Cosmetics Act, 1940, the Drugs and Cosmetics Rules 1945, as well as other applicable laws, which are directly contributing to the increase in antimicrobial resistance, the Minister said.
“People should complete the course of antibiotics as prescribed by the doctor and should not use old prescriptions to self-medicate, and this public appeal is part of the display boards. We will soon do a random check to find out if the boards are displayed in all pharmacies,” he said.
“The display boards are meant to sensitise people as well as the pharmacies on AMR. It is caused by the widespread misuse of antibiotics in human medicine, agriculture, and veterinary practices and challenges in healthcare infrastructure,” he said.
(Names of patients have been changed to protect privacy)
Published – November 22, 2024 06:39 am IST
