Antimicrobial resistance, a threat

Antimicrobial resistance (AMR) has emerged as a global public health problem as antibiotics are becoming inefficient against a wide range of disease-causing pathogenic bacteria.

Antimicrobial resistance against medicines occurs when a pathogenic microorganism trigger its specific responses resulting in either mutational adaptation or acquisition of genetic material and alteration of gene expression. As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others. AMR increases the cost of healthcare due to longer stays in hospitals and the necessity of more intensive care.

Extensive use of antibiotics for human and veterinary purposes results in the development of antibiotic-resistant bacteria (ARB) in the guts of humans and animals, which are subsequently released into the natural environments thro ­ugh the faecal matter/sewage.

The presence of these residual antibiotics in the environment leads to the proliferation of ARB. Resistant microbes have the potential to rapidly spread across the entire planet, a process that is considered to be closely linked to the widespread misuse and overuse of antibiotics in humans, animals and agriculture.

In India, various factors like the consumption of broad-spectrum antibiotics, faropenem consumption, antibiotic fixed-dose combinations and antibiotic consumption in animal food contribute to AMR among
others. In many places, antibiotics are overused and misused in people and animals, and often given without professional advice about when to use them. Major cultural activities, such as mass bathing in rivers are also associated with potential acquisition and spread of ARBs.

India contributes to major antibiotics production in the global market. Unfortunately, there are no prescribed national or international discharge limits for antibiotics in wastewater released from the pharmaceutical industries. Further, the existing good manufacturing practices (GMP) under the World Health Organization (WHO, 2016) framework is restricted to drug safety and does not include environmental safeguards.

In addition, a large portion of uncontrolled discharge of untreated urban waste has led to gross contamination of rivers, lakes and seas with antibiotic residues, antibiotic-resistant organisms, and antibiotic resistance genes (ARGs). As a consequence, in India, higher antibiotic resistance rates were reported among bacteria that commonly cause infections in community and healthcare facilities as per the scoping report on Antimicrobial Resistance in India commissioned by the Department of Biotechnology.

Without exception, all classes of antibiotics have been reported for resistance in at least some of the pathogens they have been intended to treat. For instance Carbapenems, a broad spectrum antibiotic class, constitute such a last resort. Carbapenems are used frequently to treat multidrug-resistant pathogens.

The emergence and spread of resistance mechanisms to last-resort carbapenems, therefore, pose a major threat to infection control and treatment worldwide. As per the WHO source, drug-resistant tuberculosis (XDR-TB) has been reported in 105 countries. The XRD-TB is a form of tuberculosis that is resistant to at least four of the core anti-TB drugs.

Since 2010, scientists and healthcare specialists have been extensively working on AMR issues with national and international collaboration. In 2015, a global action plan (GAP) on AMR was developed by the WHO, the Food and Agricultural Organization and the World Organization for Animal Health.

In India, the national action plan focuses on six strategic priority areas, namely awareness and understanding through education, communication and training, strengthening knowledge and evidence through surveillance, infection prevention and control, optimised antimicrobial use in health, animals and food, AMR-related research and innovation and strengthened leadership.

It also highlights the integrated approach in multiple sectors such as human health, animal husbandry and environment called the "One-Health" approach. The Ministry of Health and Family Welfare identified AMR as one of the top 10 priorities which is highlighted in the National Health Policy 2017.

The challenge for AMR researchers now is to study transmission mechanisms among humans, animals and environment, containing AMR spread through scrupulous hospital health practices and developing smart and early diagnostic methods.