The Indian Council of Medical Research (ICMR) has advised doctors to exercise caution while prescribing antibiotics in yet another warning against their rampant use. The ICMR has issued guidelines against the use of antibiotics for conditions such as low-grade fever and viral bronchitis while advising doctors to follow a timeline while prescribing them.

These guidelines were devised based on the monitoring and surveillance of antimicrobial use in private as well as public hospitals in India over the last few years, and the resistance pattern seen in the domestic hospitals. This is the third edition of the guidelines, with the previous ones being issued in 2017 and 2019. The ‘Treatment Guidelines for Antimicrobial Use in Common Syndromes, 2019’ is a revised document of the original 2017 National Action Plan for Antimicrobial Resistance (NAP-AMR). As per the ICMR, the strategic objectives of NAP-AMR are aligned with the global action plan. At the same time, it is based on national needs and priorities.

The ICMR guidelines aim to rationalize the use of antibiotics on the National List of Essential Medicines and to establish consistency in the treatment of various infectious conditions. ICMR calls the latest document particularly important in the post-COVID-19 scenario because of the unchecked use of antimicrobials. Experts warned that COVID-19 showed a drastic increase in resistance to several important antibiotics, antimicrobials, and antifungals.

As per the recent guidelines, skin and soft tissue infections should be treated with antibiotics for five days, community-acquired pneumonia should be treated for five days, and hospital-acquired pneumonia should be treated for eight days. It goes on to state that empiric antibiotic treatment is often only advised for a small subset of patients who have severe sepsis, septic shock, community-acquired pneumonia, ventilator-associated pneumonia, or necrotizing fasciitis. The new recommendations ask that only severe conditions should receive empiric antibiotic therapy. The latest document also aims to address anti-microbial resistance (AMR), which results in over two million infections every year, leading to at least 23,000 deaths, as per ICMR data.

What is AMR?

Antimicrobial resistance arises naturally through the process of evolution, but drug misuse can accelerate the process. Incorrect use of the drugs causes a risk of some of the bacteria surviving. The remaining bacteria then propagate, leading to an increase in drug-resistant pathogens in the environment.  As a result, antibiotics and other antimicrobial medicines become ineffective and infections become impossible to treat.

Irrational use of antibiotics, unregulated over-the-counter sale of antibiotics, and lack of guidance and awareness on antibiotic use are major drivers of AMR incidences. Thus optimizing the usage of antibiotics is the need of the hour.

Microorganisms can develop resistance to an antimicrobial drug such that it is no longer useful to treat diseases caused by them. The organisms can thus become multidrug-resistant (MDR), extensively drug-resistant (XDR), or pan/ totally drug-resistant (PDR/TDR).

In a Lancet study released in January, researchers said that an estimated 1.2 million people died in 2019 from antibiotic-resistant bacterial infections, more deaths than HIV/AIDS or malaria. The estimates for 204 countries and territories confirm AMR as a global health threat, with worst impacts in low- and middle-income countries (LMICs), though higher-income countries also face alarmingly high levels of AMR.

Low and middle-income countries have a higher infection rate than most developed countries due to poor sanitation, insufficient hygiene, low immunization, and pollution. In such a scenario, the irrational use of antibiotics which people can buy over the counter makes things worse. Moreover, poor infection control practices in hospitals, lack of resources, lack of well-trained health workers, or shortage of staff lead to hospital-acquired infections.

The Prevalence of AMR

The World Health Organization has reported the trend of AMR as one of the top 10 global health threats as of today. AMR is a potential public health threat and is recognized as a silent pandemic. According to Lancet Journal, AMR has directly caused 1.27 million deaths worldwide in 2019. As per reports, antibiotic-resistant neonatal infections alone are responsible for the deaths of nearly 60,000 newborns each year in India. In May 2015, the World Health Assembly adopted a resolution to endorse a global action plan on antimicrobial resistance.

Around two million people are infected with antimicrobial-resistant bacteria in India every year in India and at least 23,000 deaths can be directly attributed to this. It is estimated that by the year 2050, Asia will have 4.7 million deaths that could be directly attributed to AMR. India is the largest consumer of antibiotics in the world i.e., 13 billion standard units in 2010 and from 2000 to 2010 the per capita consumption increased by 66 percent.

In India antibiotics are prescribed by physicians irrationally, dispensed over the counters without a prescription, and used in livestock and poultry as growth enhancers. Hence a concerted effort at all levels is required to prevent the transmission of antimicrobial resistance.  Moreover, prolonged consumption of antibiotics has been weakening people’s immunity and children are becoming the greatest victim of the overuse of drugs. People with weak immunity are more likely to catch all types of infection, both bacterial and viral.

A study published by the ICMR in 2021 also found that resistance to carbapenems — drugs administered to treat common infections such as pneumonia in ICU (intensive care unit) settings — increased in 2021, limiting the availability of treatment options. Carbapenems are a very effective class of antibiotic agents commonly used to treat severe bacterial infections. This class of antibiotics is reserved for known or suspected multidrug-resistant (MDR) bacterial infections. Resistance to it indicates exhaustion of further lines of treatment. The report presents data from January 1, 2021 to December 31, 2021.

Efforts to counter AMR

The ICMR has been supporting research on antimicrobial resistance through the Antimicrobial Resistance Research & Surveillance Network (AMRSN) since 2013. The data collected from the network has enabled the compilation of drug resistance data on six pathogenic groups on AMR. Data collected from the network is used to track resistance trends and to better understand mechanisms of resistance in the key priority pathogens using genomics and whole genome sequencing. There are 20 regional laboratories from tertiary care hospitals in India to provide data.

To counter the growing incidence of AMR in the country, the ICMR has also established a national repository of antimicrobial-resistant bacteria at ICMR-National Institute of Cholera and Enteric Diseases (ICMR-NICED), Kolkata, in 2019. Following this, a National AMR Hub has been inaugurated. It is established with the broader objective of steering and promoting AMR research in the country. The National Repository of AMR bacteria aims to preserve AMR bacterial isolates shared by the nodal centres of the AMRSN across India.

Recently, the Union minister of state for health, while presenting India’s national statement on combating AMR at the Third Global High-Level Ministerial Conference on Antimicrobial Resistance recently said that India was prioritizing the development and implementation of state action plans for containment of AMR across sectors and that “the National Action Plan for containment of AMR focuses on an integrated ‘One Health’ approach and involves coordination among various sectors at the state, national and international level”.

The NAP for containment of AMR serves to leverage the strengths of various institutions such as the National Centre for Disease Control and Indian Council of Medical Research to coordinate AMR surveillance lab networks, monitor antimicrobial consumption in health facilities, strengthen infection prevention and control, as well as promote antimicrobial stewardship to optimize the use of antimicrobial

Way Forward:

Antimicrobial stewardship is a pressing need and is the only proven strategy to prevent antimicrobial overuse and abuse which is one of the main drivers of antimicrobial resistance. The rational use of antibiotics needs to be taught at all levels in the medical school curriculum.

The private sector has an important role in boosting the government’s efforts by helping in the implementation of the national action plan on AMR and ICMR guidelines on a priority basis. In conjunction with the government or as a supplementary move, private healthcare players should launch mass awareness campaigns along the lines of similar campaigns on HIV, Polio, TB, and the most recent, COVID vaccination program aimed at educating patients and consumers. Public education needs to focus on programs on when not to take antibiotics, adverse effects of unsupervised antibiotic usage, correct dosing, frequency, and duration of treatment.

The Government of India and MOHFW should have an oversight overview of Antimicrobial Stewardship (AMS) training as per NMC notification in all medical colleges. Compiling reliable data on AMR would help in drawing up more effective plans to combat it.











Photo Credits: Phys.org

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