IISc’s potent molecules show promise for TB therapy

SEM photo of Mycobacterium tuberculosis bacteria. - Photo NIAD-Optimized

The two molecules were able to prevent biofilm formation and even disrupt biofilms that had formed.

Scientists at the Indian Institute of Science (IISc) Bengaluru have developed two new, potent molecules that can severely impact the survival of mycobacteria, including Mycobacterium tuberculosis that causes TB. The results were published in the journal Antimicrobial Agents and Chemotherapy.

Unlike most antibiotics that target the bacterial metabolism by aiming at the cellular components, the novel molecules inhibit the stress response pathway of mycobacteria. The stress response pathway is crucial for bacteria to survive during hostile conditions such as lack of nutrients and the presence of antibiotics, to name a few. So any inhibition of this pathway will lead to its death.

The master regulator of stress pathway in the case of mycobacteria is (p)ppGpp (Guanosine pentaphospahte or Guanosine tetraphosphate). Though a molecule that inhibits the (p)ppGpp formation has already been synthesised, the efficacy is not much. “Very high concentration of Relacin molecule is needed to inhibit the pathway and, therefore, the efficacy is low. So we synthesised two new molecules — acetylated compound (AC compound) and acetylated benzoylated compound (AB compound) — by bringing about a modification in the base of the Relacin molecule,” says Prof. Dipankar Chatterji from the Division of Biological Sciences at IISc and the corresponding author of the paper.

“We found both the molecules to be very good inhibitors of stress response. The two compounds affected the rate of synthesis of (p)ppGpp and also reduced the cell survival,” he says. Laboratory studies showed that the two molecules were not toxic to human cells and were able to penetrate the human lung epithelial cells.

IMG_0508

Inhibiting (p)ppGpp synthesis would target the survival of the bacteria, says Dr. Kirtimaan Syal.

“We found our compounds were targeting the Rel gene. The Rel gene makes Rel protein, which in turn synthesises (p)ppGpp. When the Rel gene is knocked out, the long-term survival of Mycobacterium smegmatis decreases,” says Prof. Chatterji.

“The Alarmone molecule “(p)ppgpp”, a modified nucleotide, is ubiquitous in bacteria and absent in humans. Inhibiting (p)ppgpp synthesis would specifically target the survival of bacteria without having any effects on humans,” says Dr. Kirtimaan Syal from the Division of Biological Sciences, IISc and the first author of the paper.

Earlier studies have shown that when the rel gene is deleted, the long-term survival ability under stress was lost; the M. tuberculosis bacteria was unable to persist in mice and unable to form tubercle lesions in guinea pigs.

“The major reason for prolonged treatment of TB is the bacterium’s ability to persist in dormant form, which is tolerant to most antibiotics used in the treatment regimen. So inhibition of (p)ppGpp-mediated persistence could help in shortening the treatment regime, dealing with the emergence of multiple drug resistance and treatment of chronic infections, Dr. Syal says.

Inhibiting biofilm

Under hostile conditions, bacteria tend to form biofilms, which protect the bacteria from stress and induce tolerance to antibiotics. Recent studies have shown that tuberculosis bacteria that cannot form a biofilm cannot survive inside the host. Evidences have shown that at the time of infection, the M. tuberculosis display a biofilm-like phenotype and this helps the bacteria to survive inside the host.

Studies carried out by the researchers showed that both the molecules were able to inhibit biofilm formation by M. tuberculosis and M. smegmatis and also disrupt the already formed biofilm. “The biofilm formed by TB bacteria is very dangerous. The ability of the molecules to destroy the biofilm and even prevent its formation is a very important achievement,” says Prof. Chatterji.

Since there are very few antibiotics that target the stress response pathway of the bacteria, the two molecules offer great promise. “The next step is to test the molecules on animals. We have not thought about it. It will also be interesting to see if the bacteria develop resistance against these molecules,” Prof. Chatterji says.

Published in The Hindu on April 15, 2017

Indian researchers find a new bacterial target for drug development

Anshika Andaleeb Richa-Optimized

(From left) The study by Anshika Singhal, Andaleeb Sajid and Richa Misra helped understand how bacteria form biofilm.

Indian researchers have found a new target that can potentially be used for developing new antibiotics that will be effective against many bacteria. The new target is made of two proteins — which form a complex that is responsible for the formation of biofilm — that perform very important functions and are critical for bacterial ability to successfully infect humans. The results were published in the journal Biofilms and Microbiomes.

Bacteria form biofilms, a kind of matrix, during infection in plants and animals. Biofilm shields the bacteria from antibiotics and help bacteria to survive harsh conditions such as extreme temperature or stress. Now a study by Indian researchers has found the molecular signaling events that play a crucial role in biofilm formation in Bacillus anthracis, the causative agent of anthrax.

Till now, all attention has been on developing antibiotics that target disease-causing bacteria and not the biofilm itself.
One of the basic questions that scientists have been trying to answer is how and when bacteria decide to form biofilm. “One possibility is that bacteria has sensors on the surface which senses some signal and helps in biofilm formation,” says Andaleeb Sajid from the Institute of Genomics and Integrative Biology (IGIB), Delhi and one of the authors of the paper.

“It was serendipity. Our lab was working on signaling in bacteria and we were studying PrkC and similar proteins. When PrkC protein is deleted, Bacillus bacteria are unable to form biofilm. So we started studying the mechanism by which PrkC protein controls biofilm formation,” she says.

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Gunjan Arora says the GroEL-PrkC complex could be a target for developing new drugs.

“Our hypothesis is that PrkC senses some signal and transmits it from outside to inside the cell. This signal goes to other proteins like GroEL. PrkC adds phosphate group (phosphorylate) to different proteins. The mystery to biofilm formation lies with one chaperone protein called GroEL. The addition of phosphate to this tiny machine initiates a course of events within bacterial cells leading to complex biofilm formation,” Dr. Sajid says.

The team found several proteins receive signals from PrkC protein. Using cutting edge genetics, molecular biology and proteomics techniques, they confirmed that GroEL was regulated by PrkC.

“From other unrelated bacteria we already had a clue that GroEL has a role in biofilm formation. We looked at the molecular level and found six amino acid residues where phosphate was getting added to the GroEL protein. Through a series of steps, we ascertained how important phosphorylation was for proper functioning of GroEL,” says Gunjan Arora from IGIB and the first author of the paper.

“We wanted to know if the bacteria has any other compensation mechanism to form biofilm in the absence of PrkC. So we made PrkC mutant bacteria to produce more of GroEL. The bacteria were able to form biofilm even in the absence of PrkC. This experiment helped us understand that PrkC is the influencer and GroEL is key to biofilm formation,” Dr. Arora says.

Both PrkC and GroEL perform very important functions and are critical for bacterial ability to successfully infect humans. “We think GroEL-PrkC complex could be a target for developing new antibiotic that will be effective against many bacterial pathogens such as the ones that cause MRSA, TB and pneumonia. One strategy to tackle drug resistant bacteria will be to develop multi-drug regimen that combines traditional antibiotics with candidate drugs that can block bacterial signaling and prevent biofilm formation,” Dr. Arora says.

Published in The Hindu on March 26, 2017

Now, ‘qualified’ quacks will treat rural folks in West Bengal

quack1-optimized

“The endeavor to train quacks is not to produce doctors of sub-optimal quality for rural people but to make them as assistants to doctors,” says Dr. Abhijit Chowdhury.

If everything works to plan, health care in rural West Bengal may soon see a change for the better. Nearly 3,000 quacks — informal health-care providers with no formal medical education — are to be trained for six months. The crash course in medicine, and to be conducted by 130 trained nurses, is to begin from December 1.

The objective is to provide these informal providers with a minimum scientific understanding of human health and the dos and don’ts when those who are sick approach them. (Listen to the podcast).

 As part of medical ecosystem

“The aim is to turn the self-proclaimed, untrained village doctors into a group of skilled health workers who can deliver primary health care in villages and detect life-threatening conditions and refer patients to qualified doctors or medical facilities,” says Dr. Abhijit Chowdhury from the Institute of Post Graduate Medical Education and Research, Seth Sukhlal Karnani Memorial Hospital, Kolkata. “Uttar Pradesh has shown interest in undertaking similar work and we are doing pilot studies in Bihar and Jharkhand.”

“The endeavour is not to produce doctors of sub-optimal quality for rural people. It is an attempt to use the available health-care human resources to become assistants to doctors by providing them with some understanding of life-saving measures,” he says. “They are not as good as qualified doctors and we will teach them not to call themselves doctors but as health-care workers.”

Fully trained informal providers were found to be on a par with qualified doctors in handling cases.

West Bengal has taken the lead in providing some essential and basic training to informal providers after a novel experiment that trained quacks to correctly handle cases and compile basic checklists. The results have put to rest the long-held concerns of the Indian Medical Association (IMA) that trained informal health-care providers would violate rules with greater impunity and frequency or worsen their clinical practice. The programme was undertaken in 2013 in 203 villages in the State’s Birbhum district by the Liver Foundation in West Bengal.

Key findings

Spread over 150 hours over nine months, the programme for 152 randomly recruited informal providers led to 14.2 per cent improvement in their ability to correctly handle cases and compile basic checklists. Where the attendance was 56 per cent, it was found that the gap between qualified doctors and quacks to correctly manage cases was reduced by half. Those who had attended all the training sessions were found to be on a par with qualified doctors in handling cases. The results were published on October 7 in the journal Science; Dr. Chowdhury is one of the authors of the paper.

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An informal health provider examining a patient

“We take two definitions of correct case management — did the patient get what was needed to make them better irrespective of anything else that they may or may not get. And, what was the overall rating (taking into account necessary and unnecessary care) by a panel of three physicians, blinded from the identity of the providers. We find improvements in both; because public sector MBBS doctors give more unnecessary medicines and antibiotics, we find slightly stronger effects for the latter,” says Dr. Jishnu Das from the Centre for Policy Research, New Delhi and the lead author of the paper.

The trained providers were able to correctly manage cases in 52 per cent of interactions, while the control group that did not undergo any training could offer only over 11 per cent of “average quality or higher” treatment. Though the training had little effect on the use of unnecessary medicines and antibiotics, quacks prescribed about 28 per cent fewer unnecessary antibiotics than qualified doctors.

The trained providers would have been able to correctly manage cases nearly 26 per cent better than the control group had all the 152 providers attended all the sessions, says Dr. Das. Standardised patients who posed as patients suffering from chest pain (angina), breathing problem (asthma) or dysentery were used to evaluate how well the providers handled cases. A day-long clinical observation to evaluate clinical practice of genuine patients was also conducted.

“These three conditions cover situations where the provider must refer (angina); diagnose and possibly manage (asthma) and treat in the primary care (diarrhea). We gave the simplest possible, non-complicated case without any co-morbidities. The reason for this is that even with this very simple depictions of the cases, there are significant deficits in the quality of care, even among MBBS providers. For instance, in the public sector, 35 per cent diagnose and treat such cases wrong,” says Dr. Das in an email.

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Dr. Jishnu Das (right) with an informal health provider.

Role in primary care

The training was not restricted to these three conditions but covered a range of topics to improve their diagnostic medical skills. Since the trainers were unaware of the conditions that would be used for evaluation, the authors say that there is “some evidence” that training increased the correct management of cases for more number of conditions that quacks encounter in their daily practice.

The increased case load of trained informal providers is again proof that overall quality of care offered by them had improved. The increase in quacks’ case loads was witnessed only in those villages where qualified doctors were not available. Since 90 per cent of patients said they would seek care only from informal providers, the increased case loads of trained quacks must have been from patients switching from untrained providers to trained providers than from qualified doctors to trained quacks, the authors say.

Nearly 75 per cent of primary care visits in rural areas, especially in States such as Rajasthan, Madhya Pradesh, Andhra Pradesh and Uttarakhand are to informal providers. Since all steps to increase the number of qualified doctors in rural areas and change the health-seeking behaviour of patients have not been successful, training informal providers might be an “effective short-term strategy to improve health care in rural areas”.

Related story and link:

Quacks treat a majority of rural India

Published in The Hindu on October 9, 2016

Pharmacies in India may not be causing TB drug-resistance

Pharmacy - Photo R. Prasad

Thirty-seven per cent of 622 pharmacies in Mumbai, Delhi and Patna handed out antibiotics to TB ‘patients’ with symptoms. – Photo: R. Prasad

If an earlier study revealed the tendency of private practitioners to liberally use antibiotics to treat tuberculosis leading to a delay in TB diagnosis and treatment and increase the chances of TB spreading within a community, pharmacies in Delhi, Mumbai and Patna are no better. A study published on August 25, 2016 in the journal The Lancet found that a majority of 622 pharmacies in the three cities dispensed antibiotics to TB patients even when they did not carry a prescription.

According to government guidelines, “pharmacies are required to counsel patients with TB, identify and refer persons with tuberculosis symptoms to the nearest public health facilities for testing” and dispense TB drugs. Much like the private practitioners, pharmacies tend to be the first point of contact for primary care in India.

Srinath Satyanarayana, the first author of the paper from McGill University, Montreal, Canada used standardised TB patients — healthy individuals trained to pose as TB patients and interact with pharmacists — to understand how pharmacies in the three cities treated patients presenting with TB symptoms or microbiological confirmation of pulmonary TB. The other main objective was to determine whether the pharmacies were contributing to the inappropriate use of antibiotics.

The standardised patient 1 presented with 2-3 weeks of cough and fever and was directly seeking drugs from a pharmacy. The standardised patient 2 presented with one month of cough and microbiological confirmation of TB from a sputum test.

Only 13 per cent of simulated patients with TB symptoms and 62 per cent of patients with microbiological confirmation were correctly managed.As expected, liberal dispensation of antibiotics was seen in the case of standardised patient 1. Only 96 of 599 pharmacies (16 per cent) refereed such patients to health-care providers. But ideal case management was in only 13 per cent of the cases as a few pharmacies handed out antibiotics to the patients even while referring them to a physician. Antibiotics (37 per cent), steroids (8 per cent) and fluoroquinolones (10 per cent) were given to standardised patients with symptoms.

“That nearly 37 per cent of the pharmacies are handing our antibiotic to persons presenting with TB symptoms is really worrisome,” says Dr. Satyanarayana in an email to me. But more worrying is the dispensation of fluoroquinolones. “Fluoroquinolones are an essential part of MDR-TB treatment regimen and emerging regimens, so quinolone abuse is a concern,” they write.

In stark contrast, in the case of standardised patient 2 who had a microbiological confirmation of TB disease 67 per cent (401 of 601) of pharmacies referred the patient to a health-care provider.  Like in the earlier case, ideal case management was seen in only 62 per cent as the standardised patient did receive antibiotics (16 per cent) or steroids (3 per cent) even while being referred to a health-care provider.

“In case of TB patients with microbiological confirmation of TB disease, antibiotics (without anti-TB properties) will be ineffective and un-necessary, and can delay the initiation of proper therapy for patients. These patients will continue to spread the disease in the community and TB disease will continue to progress in the concerned individual. Steroids reduce body immunity, suppress symptoms temporarily and can worsen the TB disease,” Dr. Satyanarayana says.

Silver lining

The only silver lining is that none of the pharmacies in all the three cities handed out first-line anti-TB drugs to these “patients.” So pharmacies are unlikely sources of irrational drug use that contributes to multidrug-resistant tuberculosis. “Also, pharmacies are not trying out high end antibiotics such as fluoroquinolones when they realise that the patient has some underlying illness such as TB,” he says.

“TB Drug resistance occurs primarily due to incorrect regimens, intake of drugs irregularly or intake of drugs for very short duration of time. From our study, it appears that pharmacies are not playing a role in deciding the anti-TB regimens and are also not dispensing anti-TB drugs over-the-counter, at least in the three cities that we studied. So the drug resistance in India could be due to either patient related factors or provider related factors or due to health system related factors (which has not created a system for all TB patients in country to access quality assured diagnosis and treatment free of cost and seamlessly),” Dr. Satyanarayana says.

One reason why pharmacies did not dispense anti-TB drugs could be because they belong to a more stringent Schedule H1 category of drugs where details of the prescription and name of the doctors and patients have to be documented and the registry has to be retained for two years.

A novel, powerful antibiotic found inside human nose

MRSA - Photo National Institute of Allergy and Infectious Diseases (NIAID)

The novel antibiotic ludunin, found inside human nose, has antibacterial activity against methicillin-resistant Staphylococcus aureus (MRSA). – Photo: NIAD

A novel antibiotic — lugdunin — produced by a bacterium found inside the human nose has been found to kill the bacterium Staphylococcus aureus, including drug-resistant forms such as the methicillin-resistant S. aureus (MRSA). The study found S. aureus does not develop resistance against the novel antibiotic. The findings could aid the development of new therapies for hard-to-treat bacterial infections. The results were published today (July 28, 2016) in the journal Nature.

The human body is home to an immense variety of microorganisms known collectively as the microbiota. Several bacteria species including Staphylococcus are found inside the human nose and these bacterial species are fewer in number when the pathogenic S. aureus bacterium is present. However, in about 70 per cent of human population, colonisation by S. aureus inside human nose is absent. The reasons for this were not clear.

On screening a collection of nasal Staphylococcus species for antimicrobial activity against S. aureus, a team of scientists led by Andreas Peschel from the University of Tubingen, Germany, found that Staphylococcus lugdunensis bacterial strain had a particularly strong capacity to prevent the growth of S. aureus.

On screening S. lugdunensis mutants, Dr. Peschel and colleagues identified the compound that resisted the growth of S. aureus and called it lugdunin. Lugdunin causes the breakdown of S. aureus.

Peptide antibiotic

The novel compound represents the first known example of a new class of peptide antibiotics.

Nose

The bacteria producing the novel antibiotic reduced the S. aureus colonisation by six times. – Photo: R. Prasad

The lugdunin’s role in inhibiting S. aureus growth was first proved in the lab. To test the efficacy in animals, the researchers infected mice skin with S. aureus and then treated it with the novel antibiotic 24, 30 and 42 hours after infection had set in. Lugdunin was found to completely clear all viable S. aureus from the surface and in the deeper layers of the skin.

Next, lugdunin’s ability to inhibit S. aureus’ growth in the nose was tested using cotton rats. When both S. aureus and S. lugdunensis bacteria were introduced into the cotton rat nose, relatively fewer S. aureus cells were retrieved proving that lugdunin production effectively prevented S. aureus colonisation inside the nose.

The nasal swabs of 187 hospitalised patients were tested for the presence of S. aureus, S. lugdunensis or both. When both the bacterial species were found in a patient’s nose, S. aureus colonisation was nearly six times lower than in those people who had only S. aureus.

The researchers found lugdunin had bacterial activity against many major pathogens, and S. aureus isolates had “pronounced susceptibility” to lugdunin in all nasal and clinical samples. So it may be quite difficult for S. aureus to develop resistance against lugdunin, they say.

Published in The Hindu on July 28, 2016

Will mcr-1 gene cause a new superbug?

E. coli - Photo Janice Haney Carr, CDC

A highly magnified view of E. coli bacteria. – Photo: Janice Haney Carr/CDC

Alarm bells have been sounded after a woman in the U.S. was detected with bacteria resistant to a last-resort antibiotic. The 49-year-old was carrying E. coli bearing a new gene, mcr-1, which is resistant to colistin, the last available antibiotic that works against strains that have acquired protection against all other medication. This is the first reported case of the mcr-1 gene in an E. coli strain found in a person living in America, but it raises worries about how far it may have spread. The results of mcr-1 gene identification were published recently in the journal Antimicrobial Agents and Chemotherapy. Though resistance to colistin have been detected for about 10 years in several countries, the danger of this has been somewhat played down since such resistance was brought about by gene mutations that cannot spread easily between bacteria. But mcr-1 poses a threat of an entirely different order; in this case a small piece of DNA (plasmid) found outside the chromosome carries a gene responsible for antibiotic resistance. Since the gene is found outside the chromosome, it can spread easily between different types of bacteria, as well as between patients. In the case of E. coli, the colistin resistance is not insurmountable, as it is still treatable by other known drugs. But were the gene to spread to bugs treatable by only last-resort antibiotics, we could be facing the dreaded — and indeed, long anticipated — superbug. Thus the discovery of mcr-1 gene in more countries and settings increases the chances of the emergence and spread of resistance against all available antibiotics. It could well lead to an era without effective drugs to treat bacterial infections — the post-antibiotic age, as it were. Though Colistin has been around for more than 50 years, it has not been used widely due to its serious adverse effects. But the increase in carbapenem resistant bacteria resulted in increased use of colistin.

The mcr-1 gene was first identified in China in November last year following which there were similar reports from Europe and Canada. In each case, including the latest one, it is important to investigate if the mcr-1 gene emerged locally or if the patient had acquired it from outside the country as all efforts to contain its spread will depend on this information. The unchecked use of antibiotics in livestock is a major reason for the development of drug resistance. Indeed, given the widespread use of colistin in animals, the connection to the drug-resistant mcr-1 gene appears quite clear. A November 2015 paper in The Lancet noted that a significantly higher proportion of mcr-1 positive samples was found in animals compared with humans, suggesting the mcr-1 gene had emerged in animals before spreading to humans. Besides being administered for veterinary purposes, colistin is used in agriculture as well. The global community needs to urgently address the indiscriminate use of antibiotics in an actionable manner and fast-track research on the next generation of drugs.

UPDATE: July 12, 2016:

A second case of E. coli with mcr-1 gene has been discovered in the U.S. The results of this discovery was published on July 11, 2016 in the journal Antimicrobial Agents and Chemotherapy

Published in The Hindu on May 30, 2016

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