Drug resistance: The antibiotic red line of control

Medicines with the Red Line

A much-needed public awareness campaign to highlight the dangers of misuse and irrational use of antibiotics was recently launched by the Ministry of Health and Family Welfare.

Called ‘Medicines with the Red Line’, it comes at a time when the consumption of antibiotics in India has increased sharply while the effectiveness of these drugs to treat bacterial infections has been steadily declining.

High disease burden, rising income, cheap, unregulated sales of antibiotics and poor public health infrastructure are some of the reasons for the sharp increase in antibiotic use. A report (August 2014) in the journal The Lancet Infectious Diseases, said that in 2010, India consumed 13 billion units of antibiotics, the highest in the world. Between 2005 and 2009, consumption shot up by 40 per cent.

A case of contradictions

And the impact of this unregulated usage is already showing. Between 2008 and 2013, E.colibacteria resistant to third-generation cephalosporins increased from 70 to 83 per cent; it went up from 8 to 13 per cent in the case of carbapenems and 78 to 85 per cent in the case of fluoroquinolone, notes a paper published on March 3, 2016 in PLOS Medicine.

The consequences of increased prevalence of antimicrobial resistance are best illustrated in the case of neonatal sepsis. On average 57,000 neonates die each year in India, the highest in the world, due to sepsis infection that is resistant to first-line antibiotics; in 2012, India had the highest neonatal deaths (nearly 7,79,000).

The irony is that at the same time, the lack of access or delayed access to effective antibiotics is causing more deaths in India than from drug-resistant bacteria. This is best revealed in the case of pneumonia in children under five years of age. Most of the 1,70,000 pneumonia deaths that occurred in this age group in India in 2013 could have been averted had these children had access to effective antibiotics, notes a paper published on November 18, 2015 in the journal The Lancet. Only 12.5 per cent of affected children received antibiotic treatment for pneumonia.

One way to reduce the dependence on antibiotics, particularly in the case of pneumonia, is by increasing the coverage of immunisation, which is currently hovering around 72 per cent for DTP (diphtheria-tetanus-pertussis).

So like many other developing countries, India has to turn the spotlight on ensuring sustainable access even while maintaining sustainable effectiveness of all antibiotics. The only way to achieve this twin objective is by ensuring that all stakeholders — government, patients, veterinarians, doctors, pharmacists, pharmaceutical companies and health-care facilities — play their respective roles more responsibly.

First, people should be made aware that stopping antibiotics midway, missing doses, taking suboptimal dosages, or consuming antibiotics for cold and other viral infections, to name a few, makes them resistant to antibiotics; when ill the next time, their only recourse will be more expensive drugs or probably nothing at all. This is best exemplified in the case of multidrug-resistant tuberculosis that requires longer period of treatment using very toxic drugs that are more expensive.

Cracking down

For the government, the top priority should be to crack down on drug companies manufacturing irrational fixed-dose combination drugs. “A recent study reported fixed dose combinations and loose antimicrobials for tuberculosis. Loose antimicrobials come without packaging and do not mention the name of the drug, its manufacturer, the date of manufacture, or the date of expiry,” notes the PLOS Medicine paper.

The government should also urgently regulate drug companies discharging antimicrobial waste into the environment and regulate the use of antibiotics in animal feed to combat antibiotic resistance and obtain healthier animal products — misuse of antibiotics in food animals is linked to the antibiotic resistance problems we face today. Better sanitation and effective infection control measures in health-care settings will also drastically cut the spread of drug-resistant strains.

As a 2013 study in Indian Journal of Medical Ethics revealed, knowledge of antibiotic resistance was “reasonable among doctors, but low in priority”. Inadequate diagnostic facilities, lack of antibiotic guidelines and patients’ demand for quick relief often determined doctors’ prescription habits, besides incentives from drugs companies and chemists to push certain products.

The collusion of drug companies and chemists is also apparent in the rampant over-the-counter (OTC) sale of antibiotics, particularly carbapenems (that is among the highest in the world), even for ailments where they are not indicative. The introduction of Schedule H1 category from March 2014 to prevent the sale of 24 third- and fourth-generation antibiotics without prescription is a step in the right direction. Licences of 213 retail pharmacies have been cancelled for non-compliance.

But restricting OTC sales of antibiotics, particularly the commonly used ones, is a double-edged sword. Any intervention to limit access by enforcing prescription-only laws unwittingly cuts off a vast majority of the population, particularly in the rural areas, that lacks access to doctors.

Published in The Hindu on March 6, 2016

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