Antimicrobial resistance (AMR) is steadily increasing and has the potential to snowball into a pandemic.
Human history has been punctuated by pandemics. Not only are they a test of human resilience, but also have an adverse impact on economic activity, ultimately degrading the quality of life. COVID-19, though far from over as a pandemic, has already shown its chilling effects on human lives and economic activity impacting livelihood.
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However, the COVID-19 pandemic should not be the only reason to worry. Antimicrobial resistance (AMR) is steadily increasing and has the potential to snowball into a pandemic.
AMR arises when disease-causing microbes become resistant to the antibiotics that are supposed to treat them. This increased resistance happens because of over-exposure of the microbe to the antibiotics and as a result, the sensitivity of the patient decreases towards the antibiotics. Subsequently making the antibiotics ineffective. It is estimated that globally around 7 lakh deaths are associated with antimicrobial resistance (AMR) annually.
The growing incidence of AMR is fuelled by several reasons. Overuse and misuse of antibiotics because of incorrect prescription behaviour by physicians, self-medication by patients, and indiscriminate usage in the agriculture and livestock sector are two causal factors that have grabbed attention over the years.
The importance of discharge of untreated effluents from industries, including pharmaceutical, and healthcare remains an under-identified part of the problem.
COVID-19: A Precursor to AMR
The global attention and resources are focussed on the COVID-19 pandemic, and rightly so. Nevertheless, the specter of another pandemic in the form of AMR appears increasingly likely.
During the current pandemic, certain actions are driving antimicrobial resistance. COVID-19 is a viral disease and it's alarming that most individuals with mild or moderate infection have received antibiotics.
A study revealed that while 72 percent of the patients hospitalised due to coronavirus received antimicrobial medication, only 8 percent of them demonstrated superimposed bacterial or fungal co-infections.
Despite clinical trials establishing that antibiotics like azithromycin, and doxycycline do not reduce hospitalisation or death in COVID-19 patients. These drugs are being prescribed with abandon. As medical resources have been stretched due to the pandemic, there has been a mad rush to self-medicate which further drives antimicrobial resistance.
Unsustainable antibiotic usage aggravates AMR
While COVID-19 has certainly accelerated improper prescribing behavior and self-medication, unsustainable usage of antibiotics has been an elephant in the room for some time now.
It is incumbent on the actors in the medical industry to promote the narrative of sustainable use of antibiotics amongst the masses. Often the physicians are either in denial about AMR or their sensitivity towards AMR is not translated in their practice.
A study revealed that 82 percent of the doctors in the Pashchim Bardhaman district of West Bengal continue to prescribe antibiotics for viral infections. Nurses and pharmacists follow suit and exacerbate the problem manifold.
Also Read: Managing the COVID-19 ‘Syndemic’
Effective antimicrobial stewardship in hospitals needs to be enforced in letter and spirit. A rigorous collection of data will nudge doctors towards better prescribing behaviour. There is also an urgent requirement to update the medical curriculum from the undergraduate level upwards about AMR so that physicians are cognizant of the problem. It may also be needed to incorporate these into the school curriculum to sensitise the next generation.
Hospitals turn hotbeds of AMR
Hospitals are themselves turning into hotbeds for AMR. When medical wastewater containing antimicrobial agents is released untreated into the sewage, it contributes to AMR. A study conducted in the hospitals of New Delhi revealed that wastewater had more than 9-fold higher concentrations of CRE bacteria and blaNDM-1 than in local sewers.
The study also revealed that 18 to 41 percent of wastewater CRE isolates were on the WHO Global Priority Pathogen list - bacteria with critical, high, and medium antibiotic resistance. There is an expedient requirement to regularise the management of hospital wastewater.
Pharmaceutical effluents as accelerators of AMR
While overuse and misuse of antibiotics undoubtedly drive the incidence of AMR, unsustainable practices during the production of pharmaceuticals are also a major cause of concern, especially in the Indian context.
Indian pharmaceutical industry often addressed as ‘Pharmacy of the World’ is the largest provider of generic medicines to the world. The pharmaceutical industry ranks third in the world in terms of volume and 14th in terms of value.
During the manufacturing process, when untreated effluent is discharged into water bodies, it results in a cocktail of concentrated antibiotics and antibiotic-resistant genes. This eventually finds its way back into the food chain. Given the scale of pharmaceutical manufacturing in India, it is only prudent that stringent regulatory mechanisms are in place to check the discharge of contaminants.
As part of the implementation of the National Action Plan on AMR (NAP-AMR), the government displayed exemplary leadership when the Ministry of Environment Forest and Climate Change (MoEFCC) released the draft standards for antibiotic residue in industrial effluent in January 2020.
The global and national plans to tackle AMR aspire for a One Health Approach. This would only be possible when multiple stakeholders come together to resolve several interlinked issues. The monitoring and regulation of discharged pharmaceutical effluents would not only alleviate the condition of the environment but also has the potential to positively impact other interconnected spectrums.
Author Dr Subramanian Swaminathan is Director of Infectious Diseases at the Gleneagles Global Health City, Chennai
Views expressed are personal
(Edited by : Kanishka Sarkar)