Antibiotic resistance is a major public health threat in India. A high burden of infectious diseases, unregulated sale of antibiotics, financial incentives for healthcare providers to prescribe antibiotics, patient expectations, rising incomes, and limited public health response have helped drive the emergence of resistance, suggests an article in The BMJ, a leading international medical journal, that has published a special collection on antimicrobial resistance. The series has been brought out in collaboration with the WHO (South-East Asia) Region. The article, authored by Manish Kakkar and colleagues discusses factors contributing to antibiotic resistance in India, and examine policy initiatives to address it. Resistance to commonly used antibiotics is increasing. This complicates clinical management, and newer, more expensive antibiotics need to be used. Resistance to newer, broad spectrum drugs such as carbapenems, which are the antibiotics of last resort, has been seen in parallel with their increased use, the article says. Shigella has highest levels of more than 50 per cent to nalidixix acid, norfloxacin and ampicillin.Salmonella typhi is resistant to flouroquinolones and cephalospporins, chloramphenicol and trimethoprism sulfamethoxazole. The article suggests, Pseudomonas spp is resistant to imipenem (15 per cent), amikacin and ciprofloxacin (20 per cent each). It has high resistance to piperacillin-tazobactam (42 per cent), and meropenem (50 per cent). As many as 12 per cent samples carry the genes for New Delhi metallo-beta-lactamase-1 (NDM-1), the enzyme that confers resistance. Acinetobacter spp has maximum susceptibility to colistin (99 per cent), followed by imipenem, and meropenem (53 per cent) and 13 per cent of samples carry the NDM-1 gene.   More importantly, the article suggests that there is a rising trend towards antibiotic resistance with rise in methicillin resistant Staphylococcus aureus from 29 per cent in 2008 to 47 per cent in 2015; Carbapenem resistant isolates of Escherichia coli increased from 10 per cent in 2008 to 13 per cent in 2013 while Carbapenem resistant isolates of Klebsiella pneumonia increased from 29 per cent in 2008 to 57 per cent in 2014. In S typhi isolates, resistance to flouroquinolones has increase from 8 per cent in 2008 to 28 per cent in 2014 though resistance to antimicrobials that are not used commonly (trimethoprim-sulfamethoxazole, aminopenicillin) is decreasing.
The region is home to a quarter of the worldÂs population. Dr. Kamran Abbasi, executive editor of The BMJ said, “As our articles highlight, this region is probably most at risk of emergence and spread of antimicrobial resistance.Â
Several antibiotics are ineffective against common infections, resulting in prolonged, more severe infections, and deaths.
Dr. Poonam Khetrapal Singh, Regional Director of WHO-SEARO, highlighted multiple reasons for this. ÂPoor prescription practices, irrational use of antibiotics in livestock, and an overall lack of awareness have led to the present situation. A One Health approach is needed in which health, veterinary and agricultural sectors work together to address the issue, she said.
The collection brings forth examples from Thailand, Indonesia, and India in developing national action plans to combat antimicrobial resistance. New ways to analyse the magnitude of antimicrobial resistance in each country and mechanisms for better surveillance using information technology are proposed.
ÂIt is a critical situation requiring urgent action from the remarkable nations of the region. We hope that this collection of articles will inform national and regional responses to antimicrobial resistance and improve the health of people. The BMJ is committed to helping create a healthier world through our coverage of major challenges in international and global health,” said Dr. Abbasi.
The initiative is expected to bring together policy makers and governments to commit to urgent actions on this front, and invest in research for new antimicrobials and containment strategies. The collection will be launched at the 70th WHO regional meeting in Maldives and followed by a meeting with key stakeholders in Delhi, India at the end of September 2017.