By Dr. Rajib Dasgupta
Like several other jargons in the post-COVID-19 era, antimicrobial resistance (AMR) is part of the household vocabulary now. An analysis by the Indian Council of Medical Research (ICMR) of 17,534 patients in ICUs and wards during the first wave of COVID-19 (June to August 2020) observed a mortality of 56.7% among patients with secondary infections compared to an
overall mortality of 10.6% among hospitalised COVID-19 cases.
Gram-negative organisms (that are better protected from the effects of several antibiotics) were detected in 78% of those with
infections, coupled with high levels of carbapenem resistance to A. baumannii (92.6%) and K. pneumoniae (72.8%). The most recent worrying update comes from the report released by the ICMR on 22 September 2023. Based on its surveillance network of 21 representative hospitals across the country, it reported widespread resistance to antibiotics, antivirals, and antifungals.
These findings are based on a robust sample of nearly 100,000 culture isolates of ICU patients. Of the 1,747 pathogens identified, expectedly Escherichia coli and Klebsiella pneumoniae were the most frequent. Resistance of E. coli to the high-end antibiotic carbapenem has gone up from about 20% in 2017 to 40% in 2022 and that of K. pneumoniae from 40% to 60%. A meticulous study on neonatal sepsis (a major cause of neonatal mortality, and a priority for India) of 12,622 births (two-thirds were born at home with no prior exposure to hospitals) across 223 villages of Odisha in 2017 reported lower resistance than those observed in hospitals (such as the ICMR study) but was serious enough as one third of the isolates were resistant. S. aureus was 100% resistant to penicillin and 36% to ampicillin; 22% of K. pneumoniae isolates were resistant to cephalosporins; and resistance to cephalosporins to E. coli was more than 50%.
What are the key challenges?
Both central and state governments face considerable challenges in designing supportive policies and programmes that are backed by coordinated actions and mechanisms for resolving inter-agency conflicts and sectoral interests. Challenges range from microbiological surveillance to tracking the chain of antibiotic production, prescription, and consumption in all sectors, and its environmental consequences (in air, water, and soil).
Prevention of infections in post-surgical situations and through appropriate use of vaccines are key challenges too. Pharmaceutical discharge into water bodies and technologies for preventing the entry into and removal of antibiotics from the environment are a focus area as are developing low-cost diagnostics for detecting AMR. Advocacy and education are key action as are trained human resources.
The policy landscapes
The G20 Leaders’ Declaration of 9 September 2023 under the Indian Presidency pledged to implement and prioritise tackling AMR by adopting the One Health approach. The G20 leadership had reached a consensus as early as in 2016 that AMR was a substantial risk to global economies in general and public health systems in specific. The Berlin declaration of 2017, ‘Shaping an interconnected world’, focused on combatting AMR and the G20 meeting of health ministers in 2018 welcomed the commitment of the agriculture ministers focussing on prevention and prudent use of antibiotics in agriculture. The Bali
Summit in 2022 emphasised on multisectorality to achieve One Health approaches for pathogen surveillance and systematic operationalisation of National Action Plans (NAPs) to tackle AMR. India’s National Health Policy 2017 (NHP 2017) flagged the AMR challenges and recommended rapid standardisation of guidelines regarding antimicrobial use, limiting over-the-counter medications, banning, or restricting the use of antibiotics as growth promoters in animal husbandry, and pharmacovigilance including prescription audits.
The Union Ministry of Health & Family Welfare backed it up by formulating the National Action Plan on Antimicrobial Resistance (NAP-AMR). Nearly half a dozen state governments have formulated their respective State Action Plans and more are likely to follow. The drawing up of the India Priority Pathogen List (IPPL) though a joint exercise by the Department of Biotechnology and the WHO Country Office has been an important step forward. Klebsiella pneumoniae, Escherichia coli, Acinetobacter baumannii and Pseudomonas aeruginosa are in the critical priority list while Acinetobacter baumannii and Pseudomonas aeruginosa, Enterococcus species and Salmonella species are in the high priority list.
It’s the economy stupid!
AMR has grown from its initial clinical/biomedical concern to that of health security in general and moreover an overarching global economic imperative. The silent pandemic of AMR was directly attributed to 1.29 million deaths in 2019 and projected to increase to up to 10 million annual deaths by 2050. These obviously come with tragic human costs and very real economic costs. In the absence on robust and effective interventions the Review on Antimicrobial Resistance commissioned in July 2014 by the UK Prime Minister chaired by Jim O’Neill estimated the cost in terms of lost global production between 2015 to 2050 to be of the order of 100 trillion USD. The G20 as well as the UN organisations including the WHO are focussed on AMR and wide-ranging actions have been initiated. COVID-19 demonstrated that India is capable of successfully mounting
whole-of-government and whole-of-society responses. The AMR calls for a similar mission mode approach.
The author is Professor (Community Health), Jawaharlal Nehru University, New Delhi and Co-investigator UKRI-GCRF One Health Poultry Hub, an international One Health Research Programme. Views expressed are personal and do not reflect the official position or policy of the FinancialExpress.com.)
