Antibiotic Resistance in India

There is a dramatic increase in the prevalence of superbugs in India since the past few years, and there is an equal increase in the consumption of antibiotics available. The fact is that retail sales of antibiotics in India have grown at a rate of 6-7 per cent per annum between 2005 and 2010. Increased sales of cephalosporins were particularly striking, with sales (in units sold) increasing by 60 per cent over that five-year period, but some increase was seen in most antibiotic classes. 45 to 80 per cent of patients with symptoms of acute respiratory infections and diarrhoea are likely to receive an antibiotic, even though it remains ineffective if they have a viral illness rather than a bacterial one. The latest data produced by the World Health Organization and India’s own medical community shows that an alarming 70 per cent of Indians are resistant to multiple, cutting-edge antibiotics. It is estimated that 30 percent of patients admitted to Intensive Care Units in India die because of antibiotic resistance to infections they have picked up.

 

The following are the possible reasons for the growth of antibiotic resistance cases in India:

  1. There is higher burden of infectious diseases in India with a lack of microbiology facilities or unwillingness of patients to undergo test
  2. Self medication: 53 percent patients in India self medicate and out of which 25percent do not finish their complete course of antibiotics.
  3. There is no restriction on over the counter (OTC) dispensing of antibiotics in India. Any antibiotic including higher- end ones and injectables; can be purchased OTC without prescription. A report from WHO says that in India 50% chemists sell antibiotics without prescription
  4. Indian Doctors write brands; which is unlike the US, where the doctor writes molecules and hence the control remains in the hands of doctors to prescribe a particular generation of antibiotics.
  5. Nearly 70 percent of Indian population lives in rural areas which are being served by Informal and unregistered health care providers. Studies have shown that these IHCP and RMP prescribe antibiotics injudiciously in cases of diarrhoea and flu.
  6. Literacy rate in India is only 74.4percent which automatically creates a lack of awareness and knowledge resulting in inappropriate use of antibiotics
  7. Inadequate adherence to universal hygiene and infection control measures
  8. There is a lack of actual data on prevalence of specific organism and specific antibiotic usage

 

Indian hospitals have reported very high Gram-negative resistance rates, with very high prevalence of ESBL (Extended Spectrum Beta Lactamase) producers and also high carbapenem resistance rates. Increasing carbapenem resistance invariably results in increased usage of colistin, currently the last line of defence, with a potential for colistin-resistant and Pan Drug Resistant bacterial infections. The majority (80-90%) of Staphylococcus aureus strains in the community are beta-lactamase producers and thus are resistant to penicillin and ampicillin. 90% Staphylococcus aureus isolates from South Maharashtra have been found resistant to ampicillin, tobramycin, penicillin, erythromycin, kanamycin and gentamicin; whereas, only 39.1% strains are resistant to methicillin. Acute respiratory tract infections cause 3.5 million deaths in children each year. The most important pathogens associated with pneumonia are Haemophilus influenzae and Streptococcus pneumoniae. Many penicillin resistant pneumococci are also resistant to chloramphenicol. Typhoid fever continues to remain a health problem as the causative organism  Salmonella Typhi has developed resistance to many of the antibiotics used. In India 78.4% of Salmonella typhi isolates collected from infected patients between 1990 and 1991 demonstrated resistance to chloramphenicol, ampicillin and trimethoprim/sulfamethoxazole. Ciprofloxacin resistant S. aureus has also been reported from India, which necessitates the use of an alternate therapy for S. aureus infection Indian hospitals have varying standards of infection control. Some centres report successful initiatives, while there is paucity of published data on the existence of an antibiotic policy in the majority of Indian hospitals or on their compliance with existing policies. As per data available from NABH assessors’ conclave most accredited hospitals, though having a well written antibiotic policy on paper, are not compliant in practice. India, with more than 20,000 hospitals, more than a billion population, wide cultural diversity, socio-economic disparity, and a large medical community of more than three-fourths of a million doctors, will find the resistance problem an issue very difficult to tackle unless there is a whole hearted and joint efforts to tackle the menace on a war footing.

 

The following are examples of pressures and constraints under which physicians prescribe drugs in India:

  1. In an attempt to prescribe the best medicine: Physicians are most often motivated to give the best possible treatment often disregarding cost or spectrum of activity of chosen antibiotics
  2. Lack of access to diagnostics especially near patient diagnostics
  3. Lack of standard treatment guidelines forces physicians to choose empirical antibiotic therapy based on experience
  4. The marketing pressures of pharmaceutical industries and other financial incentives for prescribing can influence the choice of antibiotics prescribed
  5. The fear of failure of empirical treatment therapy is often quoted as a reason, which is further fuelled by the pharmaceutical industries through their biased presentation of drug information. “the newer the better” is another myth in prescribing that increases patient costs and resistance
  6. “The more the better “ is a myth that arises from a mistaken belief that if the effective dose of a particular drug is rather small, then a larger dose and prolonged treatment should definitely be better. The pharmacokinetics and pharmacodynamics of most antibiotics is complex and require extra effort on the part of physicians to understand them.
  7. Shorter patient consultation time and busy practice is associated with greater antibiotic prescription
  8. There are often limited opportunities for continuing professional development for physicians, especially in middle and low income countries