The National Centre for Disease Control (NCDC) recently found that over half of the nearly 10,000 hospital patients surveyed for a study were given antibiotics to prevent, rather than treat, infection. The survey mapped patients treated on one to five days each at 20 tertiary care institutes across 15 States and two Union Territories between November 2021 and April 2022. It found that 55% of the patients surveyed were prescribed antibiotics as prophylaxis, or as a preventive; only 45% were prescribed antibiotics to actually treat infections; and of them, only 6% were prescribed the drugs after identifying the specific bacteria. This is worrying as India carries one of the largest burdens of drug-resistant pathogens worldwide. Are antibiotics being over-prescribed in India? Sumit Ray and Abdul Ghafur discuss the question in a conversation moderated by Bindu Shajan Perappadan. Edited excerpts:
What is antimicrobial resistance (AMR) and how did India reach this stage?
Sumit Ray: AMR is defined as resistance of micro-organisms to an antimicrobial agent to which they were first sensitive. The present serious concern about AMR is that multiple types of bacteria, particularly in the Indian context — E. coli, Klebsiella, Acinetobacter, Staphylococcus aureus, enterococcus — have even become resistant to some of the latest generation antibiotics. Patients who get infections with these resistant strains of bacteria have a higher possibility of poorer health outcomes due to the resistance.
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We reached this stage due to a combination of factors. First, the inappropriate use of antibiotics in non-bacterial infections, both because of prescribing practices and the use of over-the-counter antibiotics. Second, inadequate laboratory facilities to inform clinicians rapidly about what would be an appropriate antibiotic even in bacterial infections, based on cultures. So, most clinicians are shooting in the dark. Third, the lack of adequate training in antibiotic selection, escalation, and de-escalation. Fourth, inadequate monitoring of AMR and control of antibiotic prescription and dispensing practices by health systems in spite of repeated warnings. And fifth, the incentivisation of prescribing practices by the pharmaceutical industry.
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Abdul Ghafur: Inappropriate use of antibiotics and other molecules used to treat or prevent infections in the human, animal and agricultural sectors generates bugs that are resistant to these drugs. Inadequate sanitation in the community and improper infection prevention in healthcare institutions helps spread these superbugs. AMR is a complex socio-economic and political challenge and not just a scientific issue to be solved by doctors and researchers alone.
In the light of the recent NCDC report, should there be standardisation for ensuring uniformity in prescribing antibiotics?
Sumit Ray: There are already NCDC guidelines and multiple other guidelines to initiate antibiotics in different types and sites of infection. Doctors prescribing antibiotics need to be trained in appropriate use. But the problem is in diagnosing whether the patient has a bacterial infection or not. The criteria for differentiating bacterial from non-bacterial infections or a non-infective cause is still strongly based on clinical judgment. Laboratory and radiological investigations only aid us in this. So, the initial diagnosis of a bacterial infection will remain clinical till more accurate and rapidly available methods are developed.
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Abdul Ghafur: The NCDC survey results are relevant, but not at all unexpected. It is a known fact that more than half the antibiotics prescriptions in most countries are unnecessary. But why do doctors make these unnecessary prescriptions? Are they doing this purposely to harm the patient? Are they doing this to increase the AMR rate? Of course not. Both the NCDC and the Indian Council for Medical Research (ICMR) have guidelines for the use of antibiotics. There is no scarcity of guidelines, but implementation is a different story.
We should look into the root causes of this over-prescription. First, look at any government or private hospital outpatient unit and you will see that they are overcrowded. Taking the patient’s health history, examining the patient, getting speedy investigations done... these don’t happen as much as they should. What is lacking is access to rapid diagnostics and a large, good network of laboratories. A course of antibiotics is cheaper than any blood culture and investigation. So, for a doctor who doesn’t have the time to examine patients, the time to examine their health history, and for patients who can’t afford investigations in a country where most parts do not have enough laboratories, antibiotics are the cheaper and less time-consuming option. Unless we correct these factors, nothing is going to change.
Following COVID-19 and now with the knowledge that humankind is vulnerable to the ever-present threat of an outbreak due to climate change, zoonotic spillovers, resistance creeping in from agriculture products and poultry, how important is the judicial use of antibiotics in the world and what is the immediate danger that we face?
Sumit Ray: The immediate threat is clear. I am an intensivist and I see people dying because of AMR. The study that we are quoting has also shown that nearly 75% of the surveyed patients who had an E. coli or a Klebsiella infection in hospital were resistant to what we simply called a third- or fourth-generation antibiotic. What is more worrying is that resistance to the next generation of antibiotics (carbapenem resistance) is also high. The trickle-down effects from poultry and agriculture are also high, particularly in industrialised agriculture, which is more common in the U.S. and China. But more importantly, our prescription practices are proving to be a hurdle. What is essential is the linking of labs to all levels of clinical setups and the fast transmission of infection-related data between the lab and the clinician.
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Abdul Ghafur: I treat infections in cancer patients, who are the most immuno-compromised patients you can come across. Patients are losing their lives because of AMR. But to tackle this challenge, we should think far beyond the prescription or consumption of antibiotics.
AMR is not a stand-alone entity. The rate of AMR is directly proportional to steady and strong governance, infrastructure, sanitation, poverty, access to clean drinking water, etc. So, in a country with high AMR, reducing consumption of medicines alone will not make any significant change in the rate of resistance. While rationalising antibiotics is indeed important not just from the AMR perspective but also as a patient safety measure, other factors such as sanitation in hospitals, basic access to personal hygiene and infection control, are vital. COVID-19 taught us the importance of small steps, such as washing our hands and wearing a mask when in public, to counter a huge threat. Fighting AMR needs us to start with these basic steps.
What measures have been put in place by the Central government most recently to control AMR in India? And are they enough?
Abdul Ghafur: I have been a technical advisory committee member for the national policy on antibiotics for years, so I can give a detailed picture. In 2011, we brought out the first National Policy for Containment of Antimicrobial Resistance. We also banned over-the-counter use of antibiotics (H1 rule), though this was not implemented. In 2013, inspired by the Chennai Declaration, a new H1 rule banning only second- and third-line antibiotics was brought out. Even this modified rule has not been implemented. While health is State subject, to control AMR we need strong Centre-State coordination. AMR cannot be tackled in isolation. The pandemic has taught us that everything is interconnected. So, we must work with all the stakeholders, including patients. While India has taken some strong and long-term measures to tackle AMR, there is scope to do more, including better enforcement of laws. The 2019 ban by the Indian government on the use of colistin as a growth promotional agent in poultry farming is a significant step in regulating antibiotic use. May I remind you that colistin is the most powerful antibiotic that is available to treat infections in humans?
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Sumit Ray: There is a need to restrict access to reserve antibiotics, so that chances of resistance are reduced. What is interesting is that the highest per capita in antibiotic usage is seen in countries with the highest privatised healthcare. This trend clearly indicates that improving public health systems and public health delivery, including sanitation, is key to curbing any rise in AMR. Even within the country, States with good public health systems have lower AMR. This is the way forward. Planned expenditure, structured delivery of services, and robust accountability of the public health system are all important factors that will help.
Dr. Sumit Ray is Head of Department, Critical Care Medicine, Holy Family Hospital, Delhi, and Secretary, Indian College of Critical Care Medicines; Dr. Abdul Ghafur is Consultant in Infectious Diseases, Apollo Hospital, Chennai
