The clear and present threat of antibiotic resistance

Antibiotics don’t work as well as they used to. This is worrying for the global medical industry that is heavily reliant on them. The surveillance efforts by ICMR can help, but the world must do more to push vaccines

Viral pathogens may have our attention today, but as it happens, more than half of the estimated 13.7 million infection-related deaths that occurred in 2019 were associated with bacterial pathogens. Deaths associated with bacterial infections account for one in seven of all global deaths. Antibiotics are the most widely prescribed medications on the planet. They are also our main method of treating bacterial infections — they don’t work on viruses. When antibiotics start failing because of bacteria evolving to become more resistant to them, it is cause for great concern. Every year, an estimated 1.27 million people die of antibiotic resistance — a problem that is caused by infections no longer responding to antibiotics. That number is more than the number of people who die each year of HIV/AIDS, malaria or breast cancer. The overall death toll may seem small compared to Covid-19, which has been responsible for 15 million deaths worldwide over a two-year period, but cumulatively, antibiotic resistance has likely caused more than 30 million deaths in this century alone.

The past few G20 summits have consistently highlighted antibiotic resistance as a key problem that requires global cooperation. India can lead on this issue given its seat at the head of the G20 table. (Shutterstock)

Many of us have probably never heard of someone dying of antibiotic resistance. But chances are that the person you know who died of multi-organ failure or systemic infection — all code words for an untreatable hospital infections — likely died of antibiotic resistance. In other words, if antibiotics worked as well as they did when they were first introduced, we would not have lost these patients. The problem runs deeper. Antibiotics are essential to most medical procedures — whether chemotherapy, organ transplants or hip and knee replacements. It is simply impossible to perform surgeries if the risk of untreatable infection outweighs the benefits of the procedure.

Recent reports from the Indian Council of Medical Research (ICMR) indicate that resistance increased significantly during the pandemic, possibly a combination of self-medication or unnecessary use of antibiotics, and the overrunning of hospitals with patients. The effectiveness of imipenem, a powerful drug in the carbapenem class that worked nearly 100% of the time just two decades ago in treating E coli — an important cause of urinary tract infections — has now dropped to 64%. In other words, a third of patients with E coli infections no longer respond to this powerful antibiotic. Similarly, the effectiveness of this drug in treating Klebsiella pneumonia — a common infection in hospitals — has dropped from 43% in 2016 to 5% for 2021. Three per cent of new TB cases are drug resistant, as are between 12-17% of treated infections. Although there are a few bright spots where resistance has either stalled or decreased, by and large, our antibiotics are much less effective than they were just a few years ago. In a country where many patients don’t have the financial means to afford newer, more expensive antibiotics, the outcomes can be severe. In many instances, there are simply no alternative treatments available, even if one could afford them.

A global drug resistance index that provides a single measure of resistance published since 2010 shows India consistently near the top of this index globally. For a country with a large burden of bacterial infections, this is worrying and has been repeatedly called out by medical and public health experts.

In response to these concerns, the ICMR has announced it will step up its surveillance of antimicrobial resistance by setting up more labs and facilities. That is necessary, but by no means sufficient. Given the significant quantity of antibiotics used in poultry and agriculture, it would make sense to use methods such as sewage surveillance to track resistance in the environment, as well as in hospital effluents. Surveillance information is useful only when it guides action. Resistance data need to be fed back to clinicians to modify their prescribing in response.

The biggest holes are in our lack of response to the crisis. Pharmacies profit from antibiotic sales and push them, even when they are not needed. The long-standing requirement that an antibiotic be issued only against a prescription is not observed even in cities where there are more than enough physicians to examine patients and guide treatment. Antibiotics continue to be widely used in the animal industry even though there are regulations discouraging such use. Vaccines that could reduce the need for antibiotics are not used enough. Research published in Nature showed infections due to pneumococcal pneumonia cause 56.9 million antibiotic-treated episodes annually in children under five around the world, but most of these could be prevented by vaccination. Similarly, making rotavirus vaccination widely available can avert inappropriate antibiotics due to this pathogen. In fact, vaccines may be our best first line of attack in addressing the problem of antibiotic resistance in India, although other measures such as better hospital infection control will also be needed.

Antibiotic resistance is a clear and present danger to each of us, regardless of gender, age, social class, or religion. While we think of pandemic preparedness in terms of the next pathogen emerging from bats or pigs, let us remember over 300,000 Indians died last year of infections that were previously treatable. At the current trajectory, that number is set to grow in coming years.

The past few G20 summits have consistently highlighted antibiotic resistance as a key problem that requires global cooperation. India can and should lead on this issue given its seat at the head of the G20 table. Technology, including vaccines and other solutions, that are innovated here and work for India will surely be applicable in much of the rest of the world. There is simply no greater infectious disease threat facing the country at this time and our failure to act will prove costly in the coming years.

Ramanan Laxminarayan is founder and president of the One Health Trust and a senior research scholar at Princeton University

The views expressed are personal