AMR Fact Check: Sounding the alarm bell on the silent pandemic
Our world has changed drastically since early 2020 and continues to do so at a rapid pace. Health and healthcare have been at the forefront as a result of the ongoing pandemic, however, on the side-lines efforts towards containment of existing healthcare challenges have suffered major setbacks due to varied reasons. Among these is the threat of antimicrobial resistance (AMR). The threat and impact of AMR have resulted in it becoming one of the leading causes of death, above other conventional causes of death worldwide. It is feared that the continued rise in resistance by 2050 will contribute to 10 million people dying due to this, the equivalent to UAE! It is frightening to imagine such a scenario. A timely reality check on the current AMR scenario can help prevent the dire situation ahead.
According to a recent report published in The Lancet [2019], 1.27 million lives were lost due to antimicrobial resistance, with a majority of these deaths reported from sub-Saharan Africa and South Asia. 3,89,000 deaths were solely reported from Asia.[i] Among the pathogens studied, E. coli preceded in causing the greatest number of deaths, followed by K. pneumoniae, S. aureus, A. baumannii, S. pneumoniae, and M. tuberculosis.
In India, 5 of these pathogens are rendering major antibiotics ineffective. K. pneumoniae is found resistant to Carbapenem and third-generation Cephalosporin; A. baumannii has also shown increased Carbapenem resistance, both Flouriquine and third-generation drug Cephalosporins are becoming ineffective against E.Coli, S. aureus is thwarting Methicillin, M. tuberculosis is showing resistance to Isoniazid and Rifampicin.
ICMR reports, there is high resistance to Fluroquinone and Ciproflaxin in S. Typhi and increasing resistance to last-resort antibiotics like meropenem and colistin. The resistance rate for last-resort antibiotics is ranging between 40–90% for Klebsiella, Pseudomonas, and Acinetobacter.
Poor doctor-patient ratio, limited diagnostic ability, and availability, the prevalent use of broad-spectrum antibiotics, self-medication, and non-compliance from patients are amplifying the rate of development of drug resistance.
The rise in resistance towards first and second-generation antibiotics has left health care providers with fewer choices of antibiotics for treatment. In dire situations like these where common antibiotics are failing, the third line of antibiotics is the only hope to treat life-threatening infections. However, these last-resort antibiotics have been losing effectiveness due to growing resistance towards them. Adding to the challenge is the prescription of third-line antibiotics in primary health care settings, which are restricted to the hospital level, usually in ICUs. Though India has exhibited a low prescription rate per population compared to European countries, India reportedly has higher prescription rates for third-line antibiotics. The prescription rate for cephalosporins and quinolones was 38.2% and 16.3% respectively which is significantly higher than the US (14.0% and 12.7%) and Greece (32.9% and 0.5%). [ii]
Subsequently, the use of antimicrobials in the animal sector is skyrocketing. India alone accounts for 11.6% of the entire live-stock population worldwide and about 5.7% for aquaculture. As per the UNEP report [2017], antimicrobial use in livestock will rise by 67% in 2030. The antimicrobial residues from animals and humans alike are finding their way into the environment, this leads to accelerated development of resistance as they are not potent enough to kill the bacteria, but enough to propagate resistance[iii]
COVID-19 effect on AMR
The COVID-19 pandemic has further accelerated the unnecessary prescription and use of broad-spectrum antimicrobials among hospitalized COVID-19 infections, and more so in treating secondary infections. According to a 2020 study conducted in tertiary hospitals, 52.36% of watch antibiotics and 22.05% reserve antibiotics were prescribed in India among the hospitalized COVID-19 patients. [iv] Commonly used medications were fluoroquinolones, cephalosporins, carbapenems, azithromycin, vancomycin, and linezolid.
A study on antibiotic sales in the private health sector between January 2018 and December 2020, revealed that a total of 16.9 billion doses of antibiotics were sold in 2020 which was slightly less than the previous two years. Due to the lesser incidence of seasonal infections usually treated with antibiotics, the numbers should have been considerably lower. However, researchers estimate that COVID-19 may have led to an excess of 216 million doses of total antibiotics during the first peak pandemic wave.[v]
Hospitals had to operate in max capacity to accommodate the increased number of patients, thereby increasing the chances of contracting co-infections. The situation may be exacerbated by alterations in the gut microbiota of hospitalized patients, presenting a potential environment for the emergence of multidrug resistance. Unfortunately, there isn’t enough data to concretely conclude the impact of COVID-19 being a major risk factor for AMR. The current resistance data obtained from the hospitals and lab, do not paint the true picture of AMR burden in the country.
AMR thwarting SDGs progress
In 2015, United Nations gave a universal call to end poverty and safeguard our planet. In alignment with this overarching goal, 17 SDGs were identified to work collectively in these directions to achieve the ultimate goal of providing better outcomes for future generations and leaving no one behind.
However, AMR is thwarting the progress made in several Sustainable Development Goals [SDGs] like economic growth, food security, achieving zero hunger, etc: To illustrate the gravity of the condition 24 million people are estimated to be below the poverty line due to AMR; Global Economic output is estimated to decrease by 1–3% indirectly caused by drug-resistant infections; Livestock production can drastically reduce by 7%, especially in low-income countries by 2030.[vi] These data indicate that instead of making progress, AMR is significantly putting us behind in achieving these critical targets.
Opportunity amidst crisis
This pandemic has opened a window of opportunity in sensitizing people towards good hygiene and sanitation practices. We need to leverage this momentum to drive greater awareness and engagement about the AMR crisis and extend our efforts in robust intersectoral collaboration, standardization of processes, interoperability of data for cohesive action to stop the impending pandemic.
Disclaimer: The blog is a compilation of information on a given topic that is drawn from credible sources; however, this does not claim to be an exhaustive document on the subject. It is not intended to be prescriptive, nor does it represent the opinion of C-CAMP or its partners. The blog is intended to encourage discussion on an important topic that may be of interest to the larger community and stakeholders in associated domains.
[i] Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis
[ii]Outpatient antibiotic prescription rate and pattern in the private sector in India: Evidence from medical audit data (plos.org)
[iii] Antimicrobial Resistance: Investigating the Environmental Dimension
[iv]Secondary Infections in Hospitalized COVID-19 Patients: Indian Experience (nih.gov)
[v] Sales of antibiotics and hydroxychloroquine in India during the COVID-19 epidemic: An interrupted time series analysis
