The perils of the indiscriminate and improper use of antibiotics

The World Health Organisation observed the World Antibiotic Awareness Week from November 13 to 19, 2017, emphasising the point that people should “seek advice from a qualified health care professional before taking antibiotics”. The observance of the day was as part of the global action plan on antibiotic resistance (GAP-AMR).

Discovery of antibiotics

The serendipitous discovery of penicillin in 1928 from a common fungus Penicillium notatum by Sir Alexander Fleming was a huge scientific event of the 20th century. Fleming said in his Nobel prize-winner’s speech: “It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body. The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily under-dose himself and by exposing his microbes to non-lethal quantities of the drug and make them resistant.” This is exactly the outlook in India and globally today. Humanity faces the prospect of the world restituting to a pre-antibiotic era where people can die of trivial wound infections and cellulitis. A small cut on your hand that can today be effortlessly managed with oral antibiotics could become lethal. A simple surgical procedure or child birth may endanger lives.

Antimicrobial Resistance

In simple terms, the ability of a microbe to withstand an antibiotic is referred to as resistance. According to Darwinian evolutionary theory, the survival of the fittest and natural selection happens over time among micro-organisms. But what is alarming is the rate at which resistant strains of bacteria are emerging, facilitated by human behaviour.

Although the causes of antibiotic resistance are complex, using an antibiotic in an unreasonable, partial or incongruous dose does not kill all the organisms as may be expected. These organisms undergo mutation and develop resistance in multitudinous ways (reducing affinity to drug, synthesising enzymes and efflux pumps, varying its own proteins and membrane permeability, altering metabolic pathways, and so on). Other bacteria acquire these antibiotic-resistant genes through processes of transformation, transduction, conjugation and so on, owing to mobile genetic elements such as plasmids and transposons. These continue to propagate, and resistance to multiple drugs appears in some organisms, giving rise to superbugs.

The conundrum

According to the Drugs and Cosmetics Act, all antibiotics are Schedule H drugs, which means antibiotics should be sold only with a prescription from a registered medical practitioner. But in India, most of the antibiotics are considered ‘over the counter’ drugs, readily accessible by anyone at any pharmacy. A person might have usually had two to three doses of an antibiotic even before he or she consults a doctor.

The government of India provides medicines including antibiotics free of cost in the public sector with the aim of uplifting medical care and moderate the medical expenses of the common person. This has made antibiotics widely available to the public. Antibiotics are not taken properly in certain communities, especially in resource-famished social spheres. Medicines provided for a single person will be shared among multiple adults who may have varied ailments.

There are regular hospital visitors who come just for the antibiotic. This has grown to such an extent that denial of the antibiotic by a medical practitioner gets him a ‘bad name’. It sometimes ends up in arguments with the patient, who may be adamant that he will be cured only by an antibiotic.

What happens next is switching to another doctor (whom the patient may consider more empathetic to his or her needs), which is an effortless task in the Indian scenario of medical care. It may be a viral upper respiratory infection or a simple myalgia that needs only adequate rest and hydration. But some are so petulant and they need instantaneous action. They roam from doctor to doctor (with an erroneous conception that the best response is achieved with help from antibiotics) — until they are psychologically satisfied by the prescription. The cold, being selflimiting, takes its course. This practice does not help anyone, but the bacteria get a favourable environment to proliferate.

In certain cases, where the patient’s immunity is depleted or where there are chances of the person being exposed to a resistant organism, the physician is obligated to use a higher-strength antibiotic that is believed to be suitable for the illness. Emergency departments start patients on empirical antibiotics, which are usually broad spectrum because it is difficult to assess the exact susceptibility of the organism in such critical situations. This increases the prescription of broad spectrum drugs.

The crux of the matter is that the patient or the physician may not realise the grievous aftermath of the act, which may be widely separated in time. The proximate outcome of individual benefit is appreciated based on the fallacy that a singular act cannot combat AMR and the cost of antibiotic resistance is not borne by a single person. So there is a rise of self-interest and lack of impetus.

The emergence of superbugs from other sectors, especially the veterinary sector where the medicines are also used to increase body mass and food yield from animals, are yet to be perceived fully. A study, led by researchers from the Center for Disease Dynamics, Economics & Policy (CDDEP) and published in Environmental Health Perspectives, found high levels of antibiotic-resistant pathogens in chickens raised for both meat and eggs on farms in India. The use of antibiotics in animal farming is not only directly hazardous to the people who eat farm produce such as milk or meat. The bacteria that acquire resistance will enter the food web indirectly through contaminated water supply or runoffs. Humans are in close contact with the natural habitats of animals and can contract mutant strains from wildlife, which may spread rapidly among susceptible populations. This even leads to the re-emergence of human pathogens that are resistant to all present-day medicines.

Water sanitation and hygiene (WASH) also plays a major role in AMR. Improper sanitation and hygiene leads to infections, which entail antibiotic use. They contaminates the environment, leading to resistant strains, which again demands higher antibiotic use. Antibiotics contaminate water from farms, residential areas, hospitals, pharmaceutical companies and so on, which if improperly treated, results in the medicines finding their way into our water system, making it a perfect breeding ground for superbugs. The problems that are explored and studied are just the tip of an iceberg.

Combating superbugs

India, owing to its vulnerable demographic and social conditions, is fighting a battle against both communicable and non-communicable diseases along with threats of antibiotic resistance and epidemics. Cases of drug-resistant pneumonia, malaria, tuberculosis, HIV-TB co-infections and hospital-acquired infections have been on the rise.

The Government of India has formulated a national action plan on antimicrobial resistance in April 2017 in accordance with GAP-AMR. Apart from the ruination of the health sector, the economic and social impact of antimicrobial resistance is enormous. The cost of treating a disease is amplified when second-line or third-line antibiotics are required. Stronger antibiotics come in injectable forms, which prolongs in-patient stay. This not only elevates the cost of treatment but also exposes the patient to hospital-acquired bugs.

When bacteria are becoming cleverer, humans should become cagier. Ground work to acquire compounds to overcome resistant genes should be promoted. Recent breakthroughs such as CRISPER-based approaches that trick bacteria into killing itself are promising. Although many projects are on a roll, scientific research for newer antibiotics is on the wane. Incentives should be provided in such causes to promote sustainable investments.

The important point is the ability of the bacteria to develop resistance. The enemy should not be fostered. Although we may develop newer and broader spectrum antibiotics, prevention is always better than cure.

Altering human behaviour at different levels of society is the need of the day. Providing accurate information and technical knowledge to the public are indispensable. Proper regulatory and surveillance programmes, marketing strategies that curb demanding and sharing of antibiotics, and identification of economic and social liabilities with the help of coordinated action at national and international levels, are critical. Public service announcements can be promoted at social gatherings to curb the tendency to self-medicate or use leftover antibiotics.

The approach should be foundation based rather than superficial parleys. The catastrophe that shoots down mankind’s greatest weapon is not too far. Each one of us is responsible, and AMR should be contained globally. Let’s join hands to be part of this pharmacovigilance.

(The author is a postgraduate student in otorhinolaryngology and head and neck surgery. Email: lakshmi6489@gmail.com )