In our 2 weeks in Hyderabad, we have visited an NGO-based leprosy rehab center with an affiliated DOT program, a corporate hospital, a semi-private semi-public hospital, and an NGO-based rural HIV center. Without fail, on our tours of these hospitals and subsequent discussions with the physicians running them / working in them, the subject of antimicrobial resistance (AMR) came up. The fact that we were making our rounds with an American-trained ID specialist made these remarks ever so desperate. Across the board, there seems to be a sense of puzzlement and helplessness in the air. There is a hunger for guidance and support here, as well there should be as this is an all-hands-on-deck problem. Of course AMR is by no means restricted to India, but like everywhere else on the globe, the incidence here is rising. More so, the incidence and types of resistance present here are high, severe and rising rapidly, and data on the subject while improving has been limited, due not in small part to hesitance on the part of hospitals to reveal the true extent of the problem.
National data on bacterial resistance to antibiotics is still not available in India, although efforts at hospitals and various communities have been under way for some time. Latest surveillance data has established that at least seven microbes that cause the most common infections in communities or hospitals or through the food chain have developed resistance to standard treatments involving antibiotics such as cephalosporins, fluoroquinolones, carbapenems, methicillin and penicillin. These seven microbes include E.coli, Klebsiella pneumonia, Staphylococcus aureus, Streptococcus pneumoniae, non-typhoidal salmonella, and Neisseria gonorrhoeae. These are in addition to the already established resistance of Mycobacterium tuberculosis and certain HIV strains.
In India specifically, reasons behind high rates of AMR include poor patient compliance, availability of irrational or faulty combinations of antibiotics, unnecessary prescribing by providers (estimated at 70% in a 2012 circular issued by the Central Drugs Standard Control Organization, the national regulatory body for Indian pharmaceuticals), over the counter availability of antibiotics, poor sanitation with high rates of public defecation, overuse of antibiotics by the food animal industry and veterinary surgeons. In a study conducted by the New Delhi-based Centre for Science and Environment (CSE), out of 70 samples of chicken, 40% tested positive for presence of antibiotics, with residues of more than one antibiotic found in 17% of the samples. (List of antibiotics tested for: oxytetracycline, chlortetracycline and doxycycline, enrofloxacin and ciprofloxacin, neomycin).
India drafted the antibiotic policy in 2011 and hospitals have only now started implementing it. Now, there are clear guidelines on the judicious use of antibiotics. Most tertiary-care hospitals, or at least the major ones in India, usually have an infection control protocol in place, unfortunately, patients will often reach them after they have been exposed to infections and antibiotic overuse in smaller hospitals or even clinics or local health centers. This was echoed in our tours of the tertiary hospitals we visited in Hyderabad where we heard about cases of MDR resistant UTI’s and other infections detected on admission rather than after a prolonged hospitalization. Even our small sample survey of the cases on the wards we visited clearly argue that serious AMR is rampant in the community and no longer strictly associated with hospital-acquired infections. Furthermore, there is rising incidence of neonatal sepsis and death due to MDR bacteria in the first days of life.
Colistin use here has steadily increased since the mid-2000’s. Not surprisingly, hospitals have begun to report cases of colistin resistance, which is on the rise here. CRE has been mentioned multiple times during our short stay here. How scary is that?! The good news is that since 2010 onwards, efforts aimed at controlling this issue have more than doubled, but the problem itself is clearly nowhere near controlled.