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Invisible threat of antimicrobial resistance

Antimicrobial resistance (AMR) has emerged as a global public health concern as antibiotics are becoming inefficient against a wide range of pathogenic bacteria. Rampant usage of antibiotics for human and veterinary purposes has resulted in the development of antibiotic-resistant bacteria (ARB) in the guts of humans and animals, which are subsequently released in to the environment.

AMR poses big challenges to treating common infectious diseases, resulting in prolonged infection, disability and death. Without effective antimicrobials, to check and treat infections, medical procedures such as organ transplantation, chemotherapy, diabetes management and major surgeries become high-risk affairs. Not only this situation becomes a public health issue but it also threatens to undermine the achievement of the UN's Sustainable Development Goals.

In India, factors such as high consumption of a broad spectrum of antibiotics, antibiotic fixed-dose combinations and antibiotic consumption in animal food contribute to AMR. India and China are the largest producers of antibiotics and contributes for 80 per cent of total antibiotics production globally. In India, effluents generated from these industries are treated as per the pharmaceutical wastewater discharge guidelines prescribed by the Central Pollution Control Board.

Unfortunately, the current standards do not include antibiotic residues, and they are not monitored in the pharmaceutical industry effluents. There is no consensus guidelines on the antibiotic residue discharge limits in industrial waste even outside India.

What goes out

In 2015, European Union adopted a 'watch list' of potential priority substances, including pharmaceuticals products that need to be monitored in the wastewater before releasing in to the environment to determine their environmental risk. The existing good manufacturing practices (GMP) under the WHO (2016) framework is, however, restricted to drug safety and does not include environmental safeguards. GMP covers all aspects of production, from raw materials, premises, and equipment to the training and personal hygiene of the staff.

The uncontrolled discharge of untreated urban waste is another major source for AMR in many low and middle income countries. Here, large proportions of the wastewater from hospitals, communities and urban runoff is discharged untreated or partially treated and finally ends up in rivers, lakes and seas.

In India high antibiotic resistance rates were reported among bacteria that commonly cause infections in the community and healthcare facilities, according to the scoping report on Antimicrobial Resistance in India commissioned by the Department of Biotechnology. The Indian Researcher has found prevalence of methicillin resistant Staphylococcus aureus (MRSA) infections has gone up from an estimated 29 per cent in 2012 to 47 per cent in 2014. The Indian Council of Medical Research (ICMR) AMR surveillance network recently reported that resistance to the broad-spectrum antibiotics fluoroquinolones and third generation cephalosporin was more than 70 per cent in Acinetobacter baumannii, Escherichia coli, and Klebsiellapneumoniae, and more than 50 per cent in Pseudomonas aeruginosabacteria isolated from blood stream infection.

Without exception, all classes of antibiotics have been reported for resistance in at least some of the pathogens they have been intended to treat. The emergence and spread of resistance mechanisms to last-resort antibiotics, such as carbapenems, therefore pose a major threat for infection control and treatment worldwide.

Given the complex nature of the ABR problem, no individual nation has the capacity to address this problem independently. 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, a national action plan focuses on six priority areas - 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 and commitment at international, and national.

It also highlights the need for the integrated approach in multiple sectors such as human health, animal husbandry, agriculture and environment in consideration of the "One-Health" approach to overcome the AMR issues. The health ministry has identified AMR as one of the top 10 priorities for the ministry's collaborative work with WHO, which is highlighted in the National Health Policy 2017.

The Government has increasingly recognised the challenges pertaining to antibiotic resistance, and started to take actions across many sectors. The challenge to AMR researchers is to study AMR transmission mechanisms among humans, animals and environment containing AMR spread through scrupulous hospital health practices and develop smart and early diagnostic methods.

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