The Antibiotic Resistance Crisis - An Indian Perspective

Abstract

This research study reiterates the optimal usage of antimicrobial medicines in humans and animals to lessen antibiotic resistance. A primary survey was conducted to study an individual’s role in prevention and control of antibiotic resistance. It was found that antibiotics are being irrationally used and the efficacy of antibiotics, as previously transforming the medical sciences and saving lives of many is in danger due to the quick emergence of bacterial resistance. Extensive efforts are therefore required to manage crisis by implementing new policies and renewing research efforts. Additionally, there exists a dire need to educate patients and public regarding antibiotic resistance crisis.

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░ ABSTRACT: This research study reiterates the optimal usage of antimicrobial medicines in humans and animals to
lessen antibiotic resistance. A primary survey was conducted to study an individual’s role in prevention and control of antibiotic
resistance. It was found that antibiotics are being irrationally used and the efficacy of antibiotics, as previously transforming the
medical sciences and saving lives of many is in danger due to the quick emergence of bacterial resistance. Extensive efforts are
therefore required to manage crisis by implementing new policies and renewing research efforts. Additionally, there exists a dire
need to educate patients and public regarding antibiotic resistance crisis.
Keywords: Antibiotics, Antibiotic resistance crisis, Anti-microbial resistance (AMR), multidrug resistance (MDR), infection
prevention and control (IPC)
░ 1. INTRODUCTION
WHO defines antibiotics as medicines used for preventing and
treating bacterial infections. Alternatively, antibiotics can be
described as chemical compounds that kill bacteria
(cytotoxic)/slow their growth (cytostatic).
One chief approach of contemporary medicine which is used
to combat infections is antibiotic treatment. The modern era of
antibiotics ranged from the 1930s to 1960s. Several antibiotics
like tetracycline, erythromycin etc. were discovered during
this time. Unfortunately, this golden span ended because
researchers were unable to maintain the pace of antibiotic
discovery in the face of emerging resistant pathogens.
Antimicrobial resistance (AMR) is a serious concern to
animal, human and environmental health. Emergence of MDR
bacteria/superbugs can be ascertained to uncontrolled
antibiotic access, gaps in IPC, inappropriate prescribing,
extensive use in agriculture and insufficient new drug
development by the pharma companies, ascribable to strict
regulatory requirements and reduced finances.
░ 2. LITERATURE REVIEW
Antibiotics are substances produced by microorganisms that
selectively suppress growth of other microorganisms or kill
them, at very low concentrations.
In 1928, Penicillin was the first discovered antibiotic. During
WWII, it was used to combat bacterial infections among
soldiers. Shortly then penicillin resistance became a
considerable problem. In response, many new antibiotics
(wonder drugs) were discovered and deployed [1].
Unfortunately, resistance has eventually been seen to nearly all
magic bullets/wonder drugs developed in last 60 years [2].
2.1 What is Antibiotic Resistance?
It is a microorganism’s ability to resist antibiotic
consequences. Antibiotic resistance occurs when bacteria
change in some way that reduces or eliminates the efficacy of
drugs, chemicals, or other agents designed to cure or prevent
infections. In these cases, the bacteria thrive, spreading and
causing more damage.
2.2 Causes of Antibiotic Resistance
1. Misuse and Overuse: It is seen that people mistakenly take
antibiotics to treat diseases such as virus caused influenza,
when such drugs target and kill bacteria alone. Therefore, if
anyone takes antibiotics for the wrong disease or uses too
much too often, they kill helpful bacteria that populate body,
threatening the delicate balance upon which their health
depends. Furthermore, improper disposal of residual
antibiotics eventually leads them to enter the food chain.
In addition, the bacteria are prone to mutation and evolution.
So, when we take antibiotics at the wrong time or overuse
them, resistant bacteria find it easy to replicate and spread,
giving rise to additional strains of antibiotic resistant bacteria.
2. Inappropriate Prescribing: Some work also indicates that
doctors often prescribe antibiotics erroneously or prescribe the
wrong form of antibiotic, which has possibly led to the current
health crisis. Incorrectly prescribed antibiotics have
questionable therapeutic benefit and expose patients to
potential complications of antibiotic therapy [3]. According to
one study paper, 30–60% of antibiotics that doctors prescribe
to people in ICUs are not necessary/inappropriate [4].
3. Substantial agricultural use: The rampant use of
antibiotics in the food-animal production sector is another area
of concern. Treating livestock with antimicrobials is said to
The Antibiotic Resistance Crisis - An Indian Perspective
Saini Devanshi and Dr. B. Lakshmi
Department of Pharmaceutical Management, NIPER Hyderabad, Hyderabad, Telangana, India
*Correspondence: Dr. B. Lakshmi, lakshmi.niperhyd@gov.in
ARTICLE INFORMATION
Author(s): Saini Devanshi and Dr. B. Lakshmi
Received: 06 Oct 2020; Accepted: 16 Nov, 2020; Published: 04 Dec 2020 ;
e-ISSN: 2347-4696;
Paper Id: BMN-IJBMR-2020-12;
Citation: doi.org/10.37391/IJBMR.080404
Webpage-link: https://ijbmr.forexjournal.co.in/archive/volume-8/ijbmr-080404.html

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improve the overall health of the animals, producing larger
yields and a higher-quality product [5]. The antibiotics used in
livestock are ingested by humans when they consume food,
causing infections that may cause adverse health consequences
[6].
The agricultural use of antibiotics also affects the
environmental microbiome. Up to 90% of the antibiotics given
to livestock are excreted in urine and stool, which is then
dispersed through groundwater and surface runoff [7, 8].
A 2010 report estimating global antibiotic use in poultry,
swine and cattle reveals that India accounts for 3% of global
consumption and is one of the world’s top five users along
with China, the US, Brazil and Germany. According to the
same study, projections for 2030 estimate an 82% increase in
antibiotic use for animal feed in our home country.
4. Availability of few new antibiotics: Economic and
regulatory obstacles have stopped the pharmaceutical industry
from producing new antibiotics, a strategy that had earlier
been effective at combating resistant bacteria. The industry is
rather focusing its efforts on developing profitable drugs used
to treat chronic conditions that require lifelong daily treatment
or on manifestations such as baldness or inadequate sexual
performance [9].
A review of antibiotic patents confirms that, as for other drugs,
pharmaceutical companies are still working more at modifying
or combining existing antibacterial compounds than trying to
find new chemical structures that could lead to new classes of
antibacterial agents [10].
Meaning, these new compounds developed do not represent
the true innovation, but are additions to existing classes of
drug. The risk being that resistance to these new agents will
emerge faster than for a drug with a truly new mechanism of
action.
Additionally, microbiologists and infectious-disease specialists
have advised restraint regarding antibiotic use.10 Therefore,
once a new antibiotic is marketed, physicians—rather than
prescribing it immediately—often hold this new agent in
reserve for only the worst cases due to fear of promoting drug
resistance, and they continue to prescribe older agents that
have shown comparable efficacy [6, 11]. As a result, new
antibiotics are often treated as “last-line” drugs to combat
serious illnesses. This practice leads to the reduced use of new
antibiotics and a diminished return on investment [6, 11].
5. Regulatory barriers: For the companies that are optimistic
about pursuing the discovery of new antibiotics, obtaining
regulatory approval is often an obstacle [11, 12]. Difficulties
in pursuing regulatory approval that have been noted to
include: bureaucracy, absence of clarity, differences in clinical
trial requirements among countries, changes in regulatory and
licensing rules, and ineffective channels of communication
[12].
░ 3. METHODOLOGY
A primary survey was conducted online in the month of April.
The structured questionnaire was made on Google-forms and
circulated online through social media platforms like
WhatsApp, Facebook, LinkedIn, etc.
The sampling frame consisted of Indian citizens residing in
multiple cities across the country and falling within the age
bracket of 20 years or above. Of these, a sample size of 258
individuals, ones easily approachable while maintaining social
distancing norms were chosen for the study. Majority of the
questions were close ended, however a few of them were left
open. Basic statistical tools and techniques were employed to
analyse the collected data and graphs were obtained. Data
involving various steps that can be taken at the level of policy
makers, healthcare professionals, healthcare industry and
agricultural sector was obtained through secondary research.
░ 4. RESULTS
4.1 Steps at Individual Level
[1] Be aware: The study reveals that only 190 of all
respondents know that antibiotics work against bacteria. 20
respondents believe they are effective against viruses, 2
individuals think of them to work against fungi, and 14
consider them to respond to all of the three – the bacteria, the
fungi and the viruses. Another 29 individuals chose diverse
combinations of options available. Lastly, 4 vague responses
received include 2 indicating antibiotics to be effective against
infection in general and other 2 believing them to work for
cancer. It is of great importance to note that only 1 single
respondent confessed of not knowing the correct answer.
[2] Use antibiotics only when prescribed by a certified
health professional: It is seen that 60% individuals’ resort to
self-medication (antibiotics) for routine ailments like diarrhea,
common cold, and influenza. What is to be paid attention is
that the causative organisms behind all these ailments are not
the bacteria but virus, against which antibiotics have no role to
play.
[3] Gain spectrum knowledge: 34.9% (90) respondents agree
of knowing the spectrum of antibiotic they intake while 65.1%
(168) respondents are unaware of the same.
[4] Be mindful of treatment regimen: It was observed that
79.5% individuals are mindful of taking an antibiotic until
course completion and do not stop intake as and when they
start feeling well.
[5] Never share or use leftover medicines: From the study
results we understand that after course completion, a good
majority of people (60.5%) keep antibiotics in safe custody for
the next time they fall sick. 32.2% of all individuals make a
wise decision of disposing them off while still others give
them away to friends and family members who complain of
similar problems.

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[6] Make an attempt to gain information on healthcare
challenges: One must understand that wealth is not restricted
to money. Health is wealth too. Study shows that less than
50% individuals (48.8%) understand the true meaning of
antibiotic resistance – disease causing organism’s resistance to
antimicrobial that was once able to treat infection caused by
that organism. 23.6% people on the other hand understand
resistance as – a patient’s/animal’s resistance to antimicrobial
drug used for the treatment of microbial disease, something
which is incorrect.
[7] Make a sensible choice in terms of food habit and milk
consumption: From literature it is understood that antibiotics
are undoubtedly used for rearing livestock at poultry farms. As
a result, on consumption of animal products/animals as whole,
we tend to intake antibiotics indirectly. It is in this context that
we should sensibly choose our food habit and milk
consumption pattern until governmental rules get stringent
with respect to antibiotic use at such places. Correlating an
individual’s food habit with how often he/she consumes milk,
the following graph is arrived at.
Figure 1: Risk of antibiotic resistance with respect to food
habit and milk Consumption pattern
[8] Avoid infections by regularly washing hands, preparing
food hygienically, avoiding close contact with sick people
and practicing safer sex: It is quite delightful to state that
77.5% of all respondents wash their hands with water and soap
always in contrast to washing hands with water alone. This
indicates that a good number of people are doing their bit in
preventing infections.
[9] Keep vaccinations up to date: It can be concluded that
individuals are unsure of what vaccines they’ve undertaken.
Such a bold statement can be made because DBT, BCG,
Typhoid, Cholera and TT are mandatory in India. Even though
people made random choices in answering this question, it is
sure each one of my respondents residing in cities must have
undertaken these in compliance with governmental norms.
[10] Be up to date with news and governmental measures:
77.5% of all respondents say that they are unaware of the
Union Ministry of Health Affairs Red Line Campaign – a
campaign that demands prescription-only antibiotics to be
marked with a red line, to discourage their over-the-counter
sale.
Also, when asked if people know in which month is the
‘Antibiotic Awareness Week’ celebrated, 152 people said they
were not aware, 86 gave the correct answer of it being
celebrated in the month of November and 20 people made
wild attempts that turned out to be wrong.
4.2 Steps for Policy Makers
[1] To ensure that a comprehensive national action plan is
in place to counter antibiotic resistance: The current NAP in
India is extensive and well aligned with WHO’s ‘GAP for
AMR’. It captures all five objectives as listed in the GAP and
adds one extra objective related to strengthening India's
leadership on AMR. The program aims to tackle many main
aspects of AMR in both human and non-human sectors (such
as agriculture, fisheries, animal husbandry, and environment)
implementing the 'one health approach’. Although promising,
the NAP has not yet come into full action in any of the Indian
States so far.
[2] Improve surveillance of antibiotic-resistant infections:
The national health authorities have recently recognized the
value of AMR and only in 2017, the National Health Policy
calls for a rapid standardization of guidelines on antibiotic
usage, restriction of the usage of antibiotics as OTC
medicines, prohibiting or limiting the use of antibiotics as
animal growth promoters, and pharmacovigilance including
prescription check inclusive of antibiotic usage – at hospital
and in society.
[3] Strengthening policies, programs, and implementing
infection prevention and control measures: Provisional
infection management guidelines are posted on National
Centre for Disease Control website as a template for hospitals
to begin incorporating infection control strategies.
[4] Regulate and encourage the effective use and disposal
of quality medicines: The Municipal Solid Waste
Management (MSWM) Regulation, 2016 classifies expired
and unused drugs as hazardous household waste. This waste is
to be segregated and stored in separate bins (yellow in colour)
and disposed in compliance with the Biomedical Waste
Management Rules, 2016 that say the drugs should be
incinerated at high temperatures.
[5] Make information available on the impact of antibiotic
resistance: Despite various information, education and
communication activities being conducted round the year (quiz
competitions in schools, public lectures in academic
institutions and radio programs, health fairs), the survey
results show most people being unaware of the crisis or have
misleading clue about the reasons of its existence.

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4.3 Steps for Healthcare Professionals
[1] Prescribe and administer antibiotics when appropriate,
in accordance to current guidelines: As per WHO 2017
guidelines, antibiotics are divided in three distinct groups for
which rules on how each class of drugs should be used to treat
21 of the most common infections are issued. Group I consist
of medicines which should be made available to patients by
prescription, for example – Amoxicillin. Group II comprises
of carbapenems like Imipenem and Doripenem. Group III
includes Colistin and other “last resort” antibiotics that must
be seldom used, only for medical emergencies.
[2] Prevent infections by maintaining clean hands,
tools/instruments, and environment.
[3] Report antibiotic-resistant infections to concerned
authorities.
[4] Talk to patients about proper intake of antibiotics,
antibiotic resistance and hazards of antibiotic misuse.
[5] Speak to patients about avoiding infections (for example,
taking timely vaccinations, washing hands, safe sex, and nose
and mouth protection while sneezing).
4.4 Steps for Healthcare Industry
[1] Invest in research and development of new antibiotics,
vaccines, diagnostics and other tools: The DST, DBT, UGC
and CSIR should foster R&D in above mentioned domains.
Also, new regulatory strategies are required to ensure that
antibiotic medicines continue to evolve and become available,
for example – Infectious Disease Society of America has
proposed a new, limited-population antibiotic drug (LPAD)
regulatory approval model which enables small, economic,
and quick clinical trials.
4.5 Steps for Agricultural Sector
[1] Antibiotics should only be given to animals under
veterinary supervision.
[2] Refrain from antibiotic usage for promoting
growth/preventing diseases in healthy animals.
[3] Keep animal vaccinations up to date, reducing dependency
on antibiotics.
[4] Use and encourage good practices at all stages of food
production/processing.
[5] Improve farm biosecurity and hygiene to prevent animal
infection.
░ 5. SUMMARY & CONCLUSION
Most individuals are aware of what antibiotics are yet 60%
individuals take them for the treatment of viral infections.
Although people possess information regarding antibiotic
course completion, they have little/no information at all
regarding proper disposal of unused/leftover drugs, once the
treatment course is complete.
Since we indirectly take antibiotics by consuming animal
products/animals as whole, due consideration must be given to
the food habit and milk consumption pattern we choose for
ourselves until stringent laws are enforced to regulate
antibiotic use in agriculture.
There exists a dire need to generate awareness among people
about antibiotic resistance crisis and its impacts. Extensive
promotion of the red line campaign along with spectacular
celebrations of antibiotic resistance week can help in doing so.
Antibiotic-resistant infection surveillance should be scaled up.
Continuous measures must also be undertaken for its
improvement.
Doctors must strictly be asked to prescribe antibiotics in
accordance to the regulatory guidelines.
There are a few laws regulating the use of antimicrobials in
cattle, pigs and chicken raised for domestic consumption in
India.
These regulations must be made strict and compulsory to abide
by.
On international level, WHO has time and again taken
measures to prevent/control antibiotic resistance along with
generating awareness. Such efforts must be continued to tackle
impending danger in time.
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© 2020 by the Saini Devanshi and Dr. B.
Lakshmi. Submitted for possible open access
publication under the terms and conditions of
the Creative Commons Attribution (CC BY) license
(http://creativecommons.org/licenses/by/4.0/).