Since the pandemic hit, concerns have been raised about the inappropriate use of antimicrobials in patients with Covid-19. The concern is that unnecessary prescribing of antimicrobials will lead to a further increase in already high levels of drug resistance in most parts of the world. In recent years, alarming resistance rates of pathogens of public health importance have been reported in Indian hospitals. Unfortunately, resistance rates reported by hospitals and laboratories do not automatically translate into disease burden unless each resistant isolate is correlated with clinical outcomes in the patients from whom it was isolated. This is due to inadequate hospital information systems in most publicly funded healthcare facilities in India and many low- and middle-income countries.
In 2014, economist Jim O’Neill estimated that 10 million annual deaths from AMR could occur by 2050. Studies such as those he conducted have paved the way for the consolidation of the Plan of global action in 2015 and the UN resolution on AMR in 2016. Yet nothing has changed on the ground. National action plans against antimicrobial resistance, including that of India, have not been translated into coherent actions. The main obstacle to AMR containment is that the countries most affected have the least data on the burden posed by this malaise.
The Global Burden of Bacterial Antimicrobial Resistance in 204 Countries and Territories in 2019 (GRAM) report, released last month, provides the most comprehensive estimate of the global impact of antibiotic resistance to date. According to the report, 4.95 million people died from drug-resistant bacterial infections in 2019, with 3.89,000 deaths in South Asia alone. RAM directly caused at least 1.27 million of these deaths. Lower respiratory tract infections accounted for more than 1.5 million resistance-associated deaths in 2019, making it the heaviest infectious syndrome. Among the pathogens, E coli was responsible for the highest number of deaths in 2019, followed by K pneumoniae, S aureus, A baumannii, S pneumoniae and M tuberculosis. According to the annual trends reported by the Indian Council of Medical Research since 2015, India reports a high level of resistance to all these pathogens, especially E coli and K pneumoniae.
However, only a fraction of the Indian data, available through the WHO-GLASS portal, was included in the GRAM report. India has reported high levels of resistance to fluoroquinolones, cephalosporins and carbapenems among gram-negative pathogens that cause almost 70% of infections in communities and hospitals. Therefore, India’s RAM burden data may not look significantly different from the estimates published in the report. Now that we know that the burden of antimicrobial resistance exceeds that of tuberculosis and HIV, there is an urgent need to contain this resistance. With no new drugs in the pipeline for drug-resistant infections, time is running out for patients.
Tackling antimicrobial resistance requires a multipronged and multisectoral approach. The urgency of developing new drugs should not discourage us from putting in place measures to use existing antimicrobials wisely. Improving infection control in communities and hospitals, the availability and use of quality diagnostics and laboratories, and educating people about antimicrobials have been shown to be effective in reducing antimicrobial pressure – a precursor to resistance. All of this requires a comprehensive plan, led by a designated coordinating agency and supported by appropriate funding.
The National Action Plan for Antimicrobial Resistance, approved in 2017, ends its official term this year. Progress under the plan is far from satisfactory. Too many actors, a lack of governance mechanisms and a lack of funding were also recognized as major obstacles to the effective deployment of action plans in other countries. However, there are also examples of countries initiating effective antimicrobial resistance containment plans by setting accountabilities and monitoring progress at the highest levels.
There is sufficient evidence that interventions such as infection control, improved diagnostics and antimicrobial stewardship are effective in containing antimicrobial resistance. The GRAM report pointed out that postponing the action could prove costly.
The author is an ICMR scientist
