AMR

WHO in its 2017 overview of antimicrobial resistance states that “AMR occurs naturally over time, usually through genetic changes. However, the misuse and overuse of antimicrobials is accelerating this process. In many places, antibiotics are overused and misused in people and animals, and often given without professional oversight. Examples of misuse include when they are taken by people with viral infections like colds and flu, and when they are given as growth promoters in animals or used to prevent diseases in healthy animals.” http://www.who.int/antimicrobial-resistance/en/

Most of the evidence for this comes from research and stories emerging from the urban centers across our nation and other nations. The Delhi superbug story from 2011 of the Klebsiella strain that was multi resistant, created much hue and cry but was soon recognized as an emerging global Klebsiella resistant strain.  Though now recognized as global issue predominantly from urban studies, not much is known about the rural practices and issues that contribute to this fast looming global crises of AMR. We do not have AMR surveillance systems to understand the context from the rural areas of our nations. This article tries to bring perspectives from a rural context where the authors are involved in health care practice.

A 30-year-old young health care worker, involved in regular village visits to rural Northern Bihar villages, presented to us with symptoms and signs suggestive of Typhoid Fever. Ceftriaxone and Azithromycin being the first line of management for our context, he was initiated on the same, after sending off blood cultures. The lack of response to the regular regimen and the subsequent culture reports surprised us. The Salmonella strain was resistant to most of the regular drugs that are used including Azithromycin, and those that were sensitive were the drugs from yester years – Cotrimoxazole and Chloramphenicol.  A follow up review of 6 months data on drug sensitivity for Salmonella was disturbing. 50% resistance noted for Azithromycin, which has not been reported much from other parts of India.

A 70-year-old lady brought to us from a premier corporate center in Delhi for end of life and palliative care, in her endo tracheal aspirate grew Klebsiella resistant to all antibiotics; the classic story of Delhi superbug travelling from a tertiary hospital in Delhi to a rural hospital in North Bihar. Whether it is a community acquired or nosocomial, one is starting to see the “super bugs” emerging in the rural practice context too.

A routine review of urine cultures done from our center over the last one year showed that E Coli was resistant to all common antibiotics other than Nitrofurantoin, needing management of a common disease like Urinary tract infections with Imipenem’s. A staff with late stage HIV infection with disseminated TB was found to have MDR TB. Having had no previous TB treatment nor been exposed to MDR in the work context, we were left wondering, how does such a person in rural Bihar get MDR TB?

Stories like these are becoming common in many rural locations though no definite data or information is available that can influence policy decisions.

It is important for us to reflect on the reasons of such fast-changing AMR patterns in our nation.

The primary issue is one of knowledge. A mediocre student, who has completed MBBS, if asked to make a clinical diagnosis for an infection he or she is analyzing, will most likely stumble. Of those who make a clinical diagnosis, only a small percentage will be able to make a presumptive microbiological diagnosis. And of those who make a microbiological diagnosis, only a sub set will be able to identify the best antibiotic suited for that organism. Even if he or she has studied these during their MBBS courses, the ongoing education in a context where CMEs are not mandatory, is by information they receive from medical representatives. Medical representatives have their agenda of promoting specific antibiotics and brands for economic reasons. With 80% of primary treatment in rural areas in the hands of un- trained rural practitioners, this becomes worse.

This lack of knowledge results in poor competence and confidence. What is the result of such lack of competence and confidence?  Anyone who goes to such practitioners receive a shot gun therapy. The common treatment for anyone who presents with fever in rural Bihar is – sub optimal doses of Cefixime, Azithromycin, Amikacin and Dexamethasone. Sure enough to hit somewhere and fever to crash, but only to recur later and leave a superbug in development!

Other so called eminent and senior practitioners continue with their ‘eminence and experience-based therapies’ instead of emerging evidence-based ones since there is no requirement for or regulation to practice based on evidence.  

A related issue is that of practice ethics. The Physician – Pharmaceutical nexus and allowing that to affect practice has become a universal phenomenon. Pharmaceuticals offering cuts and commissions and other financial and material benefits, leading to over prescribing or prescribing unwarranted anti biotics is not unusual. The choice of an antibiotic is based on the financial return each brand or molecule brings rather than evidence.

This also happens because neither our medical education nor continuing education teaches us to consider the macro issues amid the daily challenge of curing infections. Medical practitioners are trained to take care of the patient in front of him or her. They are not concerned nor knowledgeable about how his or her practice affects the larger picture of anti-microbial resistance. Many of them do not know about the macro issues of AMR and Anto Microbial stewardship-based practices.

Contributing to all this is the structural issues of our nation’s health care system.  For diseases like TB and HIV – the lack of trust in the state systems lead patients to access local practitioners who provide them with sub optimal doses and drugs, leading to MDR TB and resistant HIV. Access to MDR treatment centers becomes difficult for communities in rural areas. for e.g for our center in north Bihar the nearest MDR center is 220 kms away, nearest second line ART center 100 kms away. Such issues lead to partial and incomplete therapy and emerging resistance.

Lack of Policies to support and or regulate such practices make the context more challenging. Over the counter availability of most antibiotics, anti TB drugs, lack of adequate policies or implementation of existing policies to control or regulate the sale of antibiotics make AMR more complex and difficult to contain.

Veterinary and agricultural practices that contribute to AMR in India is not well documented or studied. Greed for quick money coupled with sheer ignorance have pushed marketeers to pump in a cocktail of antibiotics into vegetables and animals. This contributes majorly to the widespread AMR. For example, a regular usage of Hexaconazole as pesticide in rural Bihar might be contributing to the high resistance of Tinea to Fluconazole, Itraconazole and other antifungals which is a common phenomenon in our location.

So, for such a complex issue, there need to be a comprehensive response. Medical educators, health care practitioners, both formal and non-formal, pharmaceuticals, pharmacies, regulatory and policy development systems and structures, various other stake holders of allied fields have to come together if we are to have a comprehensive response.

In a nation where health care expenditure is one of the least among other similar nations, where value systems under-girding health care is crumbling, where health care is commercialized and corporatized, it requires vision, courage and wisdom to address such a large looming health care catastrophe.

Question left with us is, how can each of us, in our own small ways make a change, how can we be channels of change and AM stewardship in the locations where we are placed? At the same time move from our micro perspectives to a macro perspective and be voices for a macro level change.

Seventy-five years ago, after the discovery of Penicillin, Alexander Fleming made this statement. “The thoughtless person, playing with Penicillin treatment, is morally responsible for the death of the man to infection with the Penicillin resistant organism. I hope this evil can be averted.”

Unfortunately, in just seventy years A. Fleming’s words have come true today, not just for Penicillin but also for various other commonly used antibiotics. We may not be granted another seventy years of reprieve. The time to act is now.