superbugs

India Has a Superbug Problem

India has some of the highest antibiotic resistance rates among bacteria that commonly cause infections in the community and healthcare facilities. But what’s causing it?

The following is an excerpt from Anirban Mahapatra’s book When the Drugs Don’t Work published by Juggernaut Books.

Shortly before the onset of the COVID-19 pandemic, a team of researchers at a US non-profit organisation, the Center for Disease Dynamics, Economics and Policy, set out to assign a simple ranking of antibiotic resistance by country. Even though the problem of superbugs is a global one, there are disparities in healthcare and antibiotic use that have led to hotspots.

The researchers combined antibiotic consumption with resistance and assigned countries a number on a scale ranging from 0 to 100. The study was funded by the Bill and Melinda Gates Foundation and the CDC, and it was published in the BMJ Global Health journal. Sweden had the lowest resistance score of 8.1 while India had the highest at 71.6. A news story summarized the findings with the headline ‘India tops the list of countries with highest antibiotic resistance, finds study’.

We can argue the merits of the approach that these researchers took and the relative position of India in a global ranking of resistance and superbugs. But one way or another, we must admit that India has a serious problem with superbugs.
Earlier, in 2017, the same organization provided an indepth analysis of the superbug problem in India in a report titled ‘Scoping Report on Antimicrobial Resistance in India’. This report was a part of a collaborative effort between India and the UK and highlighted the critical situation of antibacterial resistance in the country. It identified key areas where research was lacking. It included a foreword by K. VijayRaghavan, who was the secretary of the Department of Biotechnology at the Ministry of Science and Technology of the Government of India at the time. VijayRaghavan would later become the third Principal Scientific Adviser to the Government of India, a position he held during the COVID-19 pandemic.

Anirban Mahapatra’s
When The Drugs Don’t Work,
published by Juggernaut Books (2024)

The report was comprehensive, merging known information from multiple sources. It was designed to assist scientists and policymakers in India to develop targeted interventions against antibiotic resistance. The report acknowledged that while resistance in all kinds of microbes was concerning, the subset of bacterial resistance (which is the focus of this book) was the most serious health threat.

The report summarized the scale of the problem: India has some of the highest antibiotic resistance rates among bacteria that commonly cause infections in the community and healthcare facilities. Resistance to the broad-spectrum antibiotics fluoroquinolones and thirdgeneration cephalosporin was more than 70% in Acinetobacter baumannii, Escherichia coli, and Klebsiella pneumoniae, and more than 50% in Pseudomonas aeruginosa.

The report highlighted that the issue of superbugs had reached critical proportions and that resistance to carbapenems was also rising in Gram-negative bacteria, especially in four of the Deadly Six superbugs. The situation was further complicated by the emergence of resistance to colistin, the antibiotic used to treat infections when carbapenems didn’t work (for example in superbugs that also contained NDM-1). The presence of colistin resistance led to bloodstream infections with Klebsiella pneumoniae with a staggering death rate of nearly 70% among Indian patients. Fortunately, at the time, plasmid-mediated colistin resistance through MCR-1 or its variants was not prevalent in India. The report also found high levels of antibioticresistant superbugs in chickens and livestock. Antibiotics are extensively used as growth promoters in agriculture.

Antibiotic-resistant superbugs were isolated from fish as well. Indian rivers, repositories of major biodiversity in the country, contained superbugs with high levels of resistance to critical antibiotics. Not only are antibiotic-resistant bacteria a concern, but the very genes that enable this resistance – including those resistant to last-resort antibiotics – were detected in major waterbodies, signalling an environmental crisis that accompanies the clinical challenge.

A considerable proportion of bacteria isolated from various water sources were antibiotic-resistant superbugs. Investigations across various Indian locales – from the historic stretches of Ayodhya and Faizabad to the bucolic landscapes of east Sikkim to the urban spread of Hyderabad – uncovered a disconcerting prevalence of antibiotic resistance among bacterial species like E. coli and Klebsiella pneumoniae.

The report highlighted the intricate web connecting humans, animals, and the environment and the threat to health, mainly as a result of rampant antibiotic misuse. India isn’t only the world’s most populous nation – Indians also have the highest rate of antibiotic consumption in the world with a median per capita consumption close to eleven units per year. (In this context, a ‘unit’ is the average daily dose of a drug as administered to adults, a standardized measure that allows for comparison of drug usage across different regions and times.) In fact, India single-handedly accounted for an astonishing 23% of the global retail sales volume of antibiotics. And the numbers only keep growing.

The widespread use of these critical drugs is a product of a combination of factors. India is often referred to as the ‘world’s pharmacy’ due to its massive drug manufacturing and distribution capacity. For a very long time, the country’s pharmaceutical sales lacked stringent oversight. As a result, India makes a lot of antibiotics, and it’s easy to get them without a prescription.
To understand how we’ve treated antibiotics in healthcare, I want to recount a folk story, supposedly about the seer Mullah Nasiruddin.

On a misty evening, with fog weaving through city streets, a young traveller trudged towards his home. The glow of a solitary street light was visible in the distance. As the traveller walked closer, he noticed that beneath that street light was a familiar figure, the quirky Mullah Nasiruddin. ‘Mullah!’ the traveller exclaimed, hurrying towards him. ‘What on earth are you doing down there?’ Nasiruddin looked up, eyes filled with concern. ‘I’ve misplaced my key,’ he said with a sigh. Seeing the Mullah’s distress, the traveller crouched down beside him. For a while both quietly searched for the key under the glow of the street light. After what felt like an eternity, the traveller asked the sage a pertinent question. ‘Mullah, it doesn’t look like we are any closer to finding your key. Are you certain this is where you dropped it?’ Nasiruddin casually pointed towards the engulfing darkness and said, ‘I dropped my key over there, inside my house.’ The traveller stared at him, dumbfounded. ‘Inside your house? Then why are we searching out here?’ With an unmistakable twinkle in his eye, Mullah Nasiruddin replied, ‘The light’s far better out here, don’t you think?’

This amusing story explains how we have come to treat antibiotics in India. We use them indiscriminately, not because they are always effective against the infections we suffer, but because they are easily available. Anyone familiar with the Indian landscape knows a major source of the problem. Antibiotics are sold over the counter at Indian pharmacies, with limited restrictions. Doctors prescribe them as a form of insurance often in low-resource settings.

One study estimated that just under half of the patients that walk into a doctor’s office in Delhi get prescribed at least one antibiotic. As a result, patients are psychologically primed to expect antibiotics from doctors. Many medical professionals, often due to the insistence of their patients, resort to prescribing antibiotics even when they aren’t necessary. People often believe that antibiotics are a cure-all solution and pressurise doctors to prescribe them based on prior experience or the incorrect notion that an infection that cleared up on its own was due to the effect of antibiotics. Patients may come to expect antibiotics.

Being prescribed medications is also seen as a sign of action as opposed to waiting to see if minor infections are self-limiting. Patients may also be reluctant to wait for diagnostic tests or they may lack the financial means to access them. What’s worse is that we often do this to ourselves, wilfully self-medicating with antibiotics at the first sign of illness. We all know how this process goes. After diarrhoea, or a cold, or a sore throat, many of us head off to the nearest pharmacy to ‘self-prescribe’ a course of antibiotics ourselves. And the neighbourhood pharmacy is happy to oblige the self-medication. How do we know that the sore throat we have isn’t the result of a viral infection or an allergy? We don’t. The only way to be sure is to get a diagnosis based on a test. But do we test or culture for bacterial infections to rule out viruses at home? No, we don’t. Despite the fact that the infection could’ve been caused by a virus, an allergy, or an irritant, we reach for the antibiotic because we can. No matter that it might be completely ineffective and worse, indiscriminate in killing off the bacteria that we harbour in our gut that are actually conducive to good health.

Anirban Mahaptra is a microbiologist.

Water, Sanitation Can Systematically Prevent Antimicrobial Resistance in India

Limited access to water, sanitation and waste management services, increases risk of infections and leads to greater dependence on antibiotics which contributes to AMR.

Two images have stuck with me for years. In 2013, I was in a delivery room in a district hospital in Rajasthan – delivery beds stained with dried blood and surgical instruments lying in a disinfectant solution that had not been changed in days. The nurse briskly told me that the hospital had a high delivery caseload. They did not have enough water to wash the beds thoroughly after every birth and had insufficient resources to buy disinfectants. Mothers were administered antibiotics immediately after birth to prevent any infections.

Three years later in 2016, I visited an area hospital in a southern state to gain insights into the status of water, sanitation and hygiene (WASH) in health care settings. The doctor in charge of the neonatal intensive care unit showed me a board noting that the hospital had six newborns with sepsis, all of whom were being treated. The hospital was fairly well equipped, but had a water scarcity problem, especially during the summer months. I recall these two conversations in light of December 12 being the Universal Health Coverage Day.

Antibiotics save lives, yet their overuse and misuse lead to the growth of ‘superbugs’, antibiotic-resistant strains of infection and diseases, and consequently antimicrobial resistance (AMR). If unaddressed, AMR threatens to kill 10 million people annually by 2050, and cause colossal economic losses of $100 trillion for the global economy.

Also read: No Local Woe, India’s Poor Public Health Feeds Antibiotic Resistance Worldwide

A 2013 study in The Lancet estimated that approximately 58,000 babies in India die each year from superbugs. The Delhi Neonatal Infection Study Collaboration found a high incidence of sepsis and strikingly high rate of antimicrobial resistance among pathogens in newborns delivered in tertiary care hospitals in New Delhi.

Dr Vinod Paul, one of the study collaborators, and currently with the NITI Aayog, has repeatedly warned about the stark dangers of AMR among newborns and how this threat undermines the progress made to improve survival rates among neonates.

India has indeed made tremendous strides in reducing maternal and neonatal deaths through various initiatives that promote antenatal care, maternal nutrition, institutional deliveries, and better care for newborns. However, poor quality of care, which includes limited access to water, sanitation, handwashing facilities, and waste management services, increases the risk of life-threatening infections because of unhygienic health are settings. This, in turn, leads to greater use of and dependence on antibiotics to combat these avoidable infections and contributes to AMR.

As of 2016, 9.2% of health facilities in India did not have water, 45% lacked sanitation, and 41.7% were in need of hygiene facilities. When health care facilities have inadequate WASH facilities, pregnant women may avoid or delay seeking care, and leave such facilities sooner than they should after giving birth. Health care providers working under such conditions are unable to maintain hygiene and prevent infections. Such circumstances place a new mother and her baby at the risk of sepsis.

This then necessitates antibiotic use to save mothers and their babies.

Using antibiotics as a ‘quick fix’ is risky

A recent article in the British Medical Journal (2019) powerfully states “….antibiotics function as a quick fix for lack of hygiene, acting as substitutes for the non-hygienic conditions that health workers and individuals work and live within”. Antibiotics are needed and important to treat infections and qualify as a medical breakthrough in our times. Yet, overdependence on this “quick fix” averts problems in the short-term, but distracts from deeper systemic issues that have long-term adverse health and financial implications for India.

Also read: Antibiotic Resistant Bacteria Are in Deep Shit – and So Are We

Therefore, systemic “fixes” that strengthen health systems, such as ensuring universal health care and quality of care, are critical.

Within this, actions to ensure functional and adequate water, sanitation, hygiene infrastructure, waste management services, and equipping health care providers with skills and measures for infection prevention and control, can contribute towards reductions in avoidable infections and resultantly lower the use of unnecessary antibiotics in health facilities. Additionally, proper solid, liquid and biomedical waste management in health care settings can curb the spread of AMR through contaminated water sources and the environment.

We've started taking antibiotics for every little sniffle. Credit: oliverdodd/Flickr, CC BY 2.0

Photo: oliverdodd/Flickr, CC BY 2.0

Apart from antibiotic use in health care settings, diseases such as diarrhoea and pneumonia, linked with poor WASH in community settings, are routinely treated with antibiotics. These diseases, common in children under 5 years, are, to some extent, preventable through improved access to WASH facilities and hygiene promotion in communities, schools and anganwadis. For instance, washing hands with soap at critical moments (i.e., after contact with faecal matter, before contact with food) is estimated to reduce diarrhoeal diseases by 47% and respiratory infections by 23%, having tremendous health benefits for children.

The solutions to the complex issues of quality of care and AMR are multifaceted and call for multi-sectoral action. India is already taking steps to address AMR, improve WASH in health care settings, and ensure that all households have access to toilets.

Data from the Swachh Bharat Mission says that 100 million household toilets have been constructed across rural and urban India over five years (2014-2019). While the use and uptake of these toilets is not yet high, increasing the uptake of these toilets can reduce the risk for diarrhoeal diseases, especially among young children, and reduced household health care costs.

In response to the global AMR threat, India developed the National Action Plan for AMR in 2017. The plan outlines six strategic priorities, five of which either involve action on WASH or engagement of WASH sector actors to tackle this issue. The third strategic priority directly relates to WASH through steps to reduce the incidence of infection through effective infection, prevention and control measures in health care facilities and in communities.

Also read: Should Antibiotics Be Nationalised?

The Delhi Declaration on Antimicrobial Resistance, signed in 2017, highlights inter-ministerial consensus on AMR, affirming the government of India’s commitment to execute the six strategic priorities through inter-sectoral action. As of now, Kerala is the only state to develop a State Action Plan for AMR.

India is committed to addressing AMR. The urgent need now is to accelerate progress. Specific interventions must be intensified to stop avoidable infections and diseases that necessitate antibiotic use. Handwashing with soap, toilet use, and prevention of water contamination must be promoted as important preventative measures in communities, schools, anganwadis and health care settings.

Kayakalp needs to be revitalised in health care settings with a stronger focus on infection prevention and control measures, along with securing access to water, sanitation, hygiene and waste management facilities and services. Greater awareness, leadership and coordination across sectors, government and non-government, is urgently required for action against AMR.

For all of us – images of delivery beds and neonatal units across health facilities in India should serve as constant reminders that quick fixes with antibiotics must be replaced with deeper systems strengthening approaches that keep our mothers and babies safe from harm in the short and long-term.

Arundati Muralidharan works in the Policy Team at WaterAid India.

Wealthy Indians Must Eat Differently from Those Whose Rights They Defend

Changing how we eat won’t be simple by any means, but the alternative will be harder to swallow.

Uday Kotak knows how to ruffle feathers. Last week, the billionaire banker retweeted an article by the Bloomberg Editorial Board which asked people in rich countries to eat less meat to help fight the climate crisis. Kotak added: “I value freedom of choice but vegetarianism is good for the planet. Beef at dinner is as polluting as driving 160 km. Livestock are responsible for more greenhouse emissions than the entire aviation sector. Happy Dussehra!”.

Is Kotak wrong? Yes, and we’ll get to why in a bit. But the banker did touch on an issue that isn’t discussed often in India: the impact of our diets on the environment.

Everyone from the UN Intergovernmental Panel on Climate Change to Greta Thunberg agrees: to save humanity from climate catastrophe, we need to do many things, and one of them is eat fewer animal products.

Farming animals for food produces about 14.5% of all human-induced greenhouse gas emissions, says the UN’s Food and Agriculture Organisation. Much of this comes from a process called enteric fermentation in the stomachs of ruminant animals like cows, buffaloes and goats; it helps them digest tough plants, but also makes them burp and fart methane, a greenhouse gas at least 25 times more heat-trapping than carbon dioxide. (That’s right – cows don’t in fact exhale oxygen.)

Some critics say these warnings are not relevant in India, because of our low per-person meat consumption. Not quite. We are home to the largest population of livestock in the world: nearly 520 million. And together, they produce more greenhouse gases annually than all the cars, trucks and motorbikes in the country, according to a report by the Environment and Climate Change Ministry submitted to the UN last December. For comparison, that’s also more than the total carbon emissions of the oil-producing United Arab Emirates last year.

(The Ministry report’s says that enteric fermentation produced 8.7% of India’s carbon emissions in 2014, second only to electricity. Road transport was in third place, at 8.5%. These figures don’t account for emissions from the manufacture of vehicles; but they also don’t consider the carbon absorption forgone when land is used for animal agriculture.)

Also read: Is Climate Change Killing the Indian Farmer?

It isn’t just greenhouse gases. Animal farming is notoriously water-hungry. The Water Footprint Network has estimated that producing one kilogram of wheat in India takes about 2,100 litres of water, while a kilogram of pig meat takes over twice as much: 5,218 litres. One kilogram of Indian chicken meat consumes 8,367 litres of water, and a kilogram of bovine meat uses up 16,547 litres – as much water as an average urban Indian uses at home in four months.

Yet Uday Kotak is wrong to suggest that vegetarianism for everyone is an easy way out. Much of the country’s methane emissions come from animals that millions of poor people rely on for sustenance every day. Hobbled by faulty food-security policies, these communities lack other options for sources of nutrition.

By Mr Kotak’s logic, he and other vegetarians – able to access alternatives to meat – would also face a dilemma. Most buffaloes and cows in India killed for meat are actually raised for milk. We are the world’s largest producer and consumer of milk, and our appetite for it is swelling. In the decade between 2007 and 2017, Indian milk production jumped by 63%. If you’re concerned about the effects of animal agriculture on the climate, you may also have to rethink your masala dosa and dal makhani.

But the environmental impact of animal agriculture is an inconvenient truth for progressive people in India.

Liberals of many stripes tend to see meat-eating solely as an issue of individual freedom, largely because of the hateful history of vegetarianism in the country. For centuries, dominant castes have used dietary taboos to tyrannise meat-eating communities, particularly Dalits and Adivasis. The violent anti-beef campaigns of Hindu nationalist gangs in recent years – used mainly as an excuse to intimidate Dalit and Muslim meat workers – have only deepened liberal suspicion of vegetarianism.

This has meant, though, that our national conversations focus almost exclusively on the social politics of meat, overlooking the climate emergency and missing the striking shifts in how animals are now killed for food.

Overfishing around India’s coasts is depleting fish stocks and driving species to the brink of extinction. Chicken, cattle and other animals are increasingly raised for meat, eggs and milk in ‘factory farms’ where they are treated as mere production units and subjected to grotesque cruelties. This at a time when animal cognition research is revealing that farmed animals have inner lives as rich as those of our pet dogs and cats.

Industrial agriculture’s focus on profit at all costs is leading to the indiscriminate use of antibiotics on farm animals. These practices are sparking a public health emergency by generating ‘superbugs’ immune to antibiotics, and threatening our ability to treat common human diseases.

Our government’s attempts to tackle these problems have been largely patchy, including a national action plan on antibiotics that hasn’t been implemented, impractical draft rules on commercial egg production and silly efforts to promote vegetarianism.

Meat-eating in our country is changing in other ways too. Fatter wallets and more flexible food habits are driving a surge in animal product consumption. For example, chicken meat production between 2007 and 2017 rose by an astonishing 114.6%. Last year over 2.5 billion chickens were killed for meat in India. About 80% of all chicken meat now comes from factory farms. India now imports chicken feed from Ukraine and chicken meat from Brazil.

We aren’t talking enough about these developments, but the climate may force our hand.

One 2017 analysis of Indian diets showed that “a shift towards dietary patterns with greater consumption of animal source foods could greatly increase greenhouse gas emissions from Indian agriculture”.

Another peer-reviewed study published this May found that if everyone in the country switched from their present diets to a healthy nutritious diet with a few animal products, greenhouse gas emissions would rise by about 4%. On the other hand, shifting all Indians to the kind of diet followed by the richest 25% of households – with much more meat and dairy – would increase emissions by 36%.

Rising carbon emissions will hit hardest the same vulnerable communities who depend on livestock for their nutrition and livelihood. As heat waves spike, rains waver, and crops yields fall, small farmers will find it ever more difficult to feed and raise animals.

Also read: Climate Change Poses Serious Threats to India’s Food Security

To be clear, Indians, particularly underprivileged Indians, are among those least to blame for climate change. The environmental crisis owes its origins to rich governments and companies in the West. We are like someone who’s developed lung cancer because of a chain-smoking uncle, and has to change how they live as a result.

Of course, individual action won’t fix the climate, but like every newspaper recycled, every plastic straw refused and every protest mounted, it’s a way to start taking responsibility for the solution and push for systemic change.

Consuming animal products can no longer be seen as an issue of individual choice – the environmental and ethical costs are too obvious. This doesn’t mean that every Indian must immediately give up meat, eggs and milk (although if you can, you should try – it’s a perfectly healthy option). On some occasions, we may decide that the benefits of animal product consumption outweigh the costs, say in providing (antibiotic-free) chicken eggs in mid-day school meals to malnourished children.

On other occasions, like ordering a mutton biryani when the mood strikes, we may acknowledge that the costs are too high. We may have to follow a different diet from the people whose rights we advocate. We’ll have to learn to be okay with that.

Food is culture and identity. It is memory, habit and pleasure. Changing how we eat won’t be simple by any means, but the alternative will be harder to swallow.

Shailesh Rai is a researcher based in Bangalore. He previously worked as director of law and policy at Amnesty International India.

No Local Woe, India’s Poor Public Health Feeds Antibiotic Resistance Worldwide

The spread of resistance is more acute in places where antibiotic use is poorly regulated, local pollution is higher and inadequate sanitation is common – conditions that prevail across most of India.

Antibiotic resistance genes from around the world are accumulating in even the most remote locations, such as the Arctic soils, highlighting the pace with which these threats can globalise.

Scientists from Newcastle University have found an antibiotic resistance gene, called the New Delhi metallo-beta-lactamase (blaNDM-1), in soil samples taken in 2013 in Kongsfjorden in the Svalbard archipelago. blaNDM-1 was originally detected in surface seeps in Indian cities in 2011, less than three years prior.

The difference in the climates of these two locations can’t be understated: the remote island in the Arctic has no agriculture or industry, very few people and temperatures low enough to freeze and preserve genetic material.

Metallo-beta-lactamase (NDM) is an enzyme that makes empowers bacteria to resist a broad range of antibiotics. David Graham, one of the Newcastle researchers and an ecosystems engineer, told The Wire that their study “shows how far reaching and how fast resistance can move around the world, which impacts everyone.”

Thankfully, the levels of blaNDM-1 were localised in Kongsfjorden “and posed no health threat” there, according to their published paper. The authors say their findings highlight the value of characterising remote locations that could provide a baseline for estimating the spread of antibiotic resistance around the world.

Also read: Antibiotic Resistant Bacteria Are in Deep Shit – and So Are We

This is not the first time the resistance gene has been found in places away from India. In January 2017, the US Centre for Disease Control (CDC) confirmed the presence of NDM in the body of an American woman who was infected when she was being treated for a thigh-bone fracture in India in 2015. She would die later in 2017.

The CDC report prompted the Drug Controller General of India (DCGI) to issue a notification on January 16, 2017. In it, the DCGI ordered all companies involved in the supply chain to follow guidelines specified in the Drugs and Cosmetics Act on sale of medicines, and directed state drug regulators to act against people selling antibiotics without prescriptions.

Then again, the study also suggests that the spread of blaNDM-1 could be related to factors “that may be equally or more important” than just the direct use of antibiotics.

For example, Graham explained that the spread of resistance appears to be more acute in places where antibiotic use is poorly regulated, local pollution is higher and inadequate sanitation is common. Such conditions allow resistance in one person’s or animal’s faecal matter to enter the environment, exposing residual resistance in their faeces to others.

“Such exposures set off a chain of exposures, which our work indicates can ultimately reach remote places like the Arctic.”

“That resistance genes spread globally is no surprise,” Ramanan Laxminarayan, founder and director, Centre for Disease Dynamics, Economics and Policy (CDDEP), said. However, “we don’t know all the pathways by which they spread, and in this case, it is possibly wild birds that have carried these resistance genes to the Arctic.”

The CDDEP is a public-health research organisation with offices in Washington, DC, and New Delhi.

He added that he wouldn’t “make much of the identification of NDM in the Arctic” and that wasn’t surprising in the least. “The more important thing is to worry about is what is happening in India and to Indian patients.”

Lessons for India

Since the NDM gene was first reported in 2011, there have been several alarm bells going off on the growing problem of antibiotic resistance.

A 2016 paper in the journal PLoS Medicine, coauthored by Laxminarayan, reported that India was the world’s largest consumer of antibiotics for human health in 2010. It also said that 76% of the overall increase in global antibiotic consumption between 2000 and 2010 came from BRICS countries alone.

When access to antibiotics rises, it’s generally good and but can quickly turn simultaneously bad.

Also read: How Researchers Found That Tourists Accidentally Carried a Superbug from India to Paris

According to the study’s findings, Indians consumed 10.7 units of antibiotics per person, compared to China’s 7.5 units and the US’s 22 units. Within the BRICS countries, 23% of the increase in retail antibiotic sales was from India, and up to 57% of the increase in the hospital sector came from China.

The biggest issue with the Indian situation was the availability of carbapenems. This is a class of highly effective and often last-resort antibiotics used for severe- to high-risk bacterial infections. The study said that over-the-counter, nonprescription sales of carbapenems India “are among the highest in the world”, and contribute to growing resistance to these drugs.

A November 2017 scoping paper prepared by the Department of Biotechnology and Research Councils UK-India stated that while antimicrobial resistance is a global public health threat, “nowhere is it as stark as in India”.

According to it, India has some of the highest antibiotic resistance rates among bacteria that commonly cause infections. Additionally, resistance to the class of broad-spectrum antibiotics called fluoroquinolones and the third-generation cephalosporin was over 70% in the Acinetobacter baumannii bacteria.

India has also reported the presence of bacteria that are resistant to colistin, another last-resort antibiotic that doctors around the world believe will replace carbapenems.

Researchers have found such bacteria in India in poultry, livestock, aquaculture, rivers, sewage and hospital drains.

Graham also said that “the problem of environmental spread may be of particular relevance to India because key factors that appear to most influence environmental resistance spread are common in some places.”

He suggested that India pay more attention to curbing antibiotic use along with improving sanitation. The ultimate goal would be to choke the spread of resistance via environmental pathways, especially reducing exposure to wildlife and other “travellers”, which carry resistance around India or, in fact, around the world.

At the same time, the steps that can be taken to contain the spread of the gene are “simple to state, but hard to implement,” Graham said.

The first is to use less antibiotics on a global scale. “However, unless we simultaneously improve sanitation, water quality and food safety around the world, reducing use will likely have limited impact.

“Therefore, containing the spread of this and other genes that can make bacteria highly resistant must be tackled by a multi-pronged approach.”

Also read: An Insider’s Perspective on India’s Failing Public Health System

Laxminarayan is less optimistic: “Not much can be done to contain the spread,” he said. However, he acknowledged that measures to use antibiotics appropriately in both humans and animals to delay the emergence of these genes in the first place could help.

But here again the problem that Graham pointed out arises: the whole world must use such a holistic approach because data unearthed by CDDEP, he said, suggests that resistance migrates fast and easily. “Positive actions of one country will have limited impact unless all countries are also on board.” I.e., all or nothing.

One of the other issues related to resistance, and human and veterinary health in general, is that scientists have almost completely stopped developing new drugs. This is because bacteria become resistant to drugs, old and new, faster than a drug can be developed and introduced into the market. As a result, drug development has become uneconomical for manufacturers.

This is why “we must urgently reduce rates of new resistance evolution, which hopefully will spur new drug development in industry,” Graham said.

The first step in that direction would be delay the resistance genes from spreading within the origin country by providing better water and sanitation, and improving public health, Laxminarayan said. “If these are not done, then little is possible.”

T.V. Padma is a freelance science journalist.

Watch: ‘Indian Hospitals Are Full of Superbugs. They’re Lying If They Refute’

While antibiotic resistance is a global phenomenon, the situation in India warrants alarm. Unapproved drugs in the market and over-the-counter sales without prescriptions has meant antibiotics are often used willy-nilly in the country. This state of affairs has been worsened by the release and persistence of untreated waste in the environment, and procedural blindspots that suppress the scale of the problem in official records. Some regulators have even alleged that many Indian hospitals are crawling with such ‘superbugs’.

Listen: The Drug-Resistant Superbug That May Have Taken a Flight from India to Paris

Multi-drug resistant bacteria are growing more powerful each day with microbiologists struggling to find a way to combat these pathogens.

Credit: John Voo/Flickr, CC BY 2.0

Thirty-nine volunteers, 59 countries, 136 airports. With 400 swabs collected over three years. That is what it took for researchers to determine the course of bacteria that affect thousands of people worldwide. Multi-drug resistant bacteria are growing more powerful each day with microbiologists struggling to find a way to combat these pathogens. Samanth Subramanian and Padmaparna Ghosh talk to Frieder Schaumburg, the microbiologist who ran this study to understand the fight against these superbugs.

This is the latest episode of The Intersection, a fortnightly podcast on Audiomatic. For more such podcasts visit audiomatic.in.

At G7, UK Pushes for Global Reward System for New Antibiotic Development

Any use of antibiotics promotes the development and spread of superbugs – multi-drug-resistant infections that evade the antimicrobial and antibiotic drugs designed to kill them.

(From L) European Council President Donald Tusk, Italian Prime Minister Matteo Renzi, German Chancellor Angela Merkel, U.S. President Barack Obama, Japanese Prime Minister Shinzo Abe, French President Francois Hollande, British Prime Minister David Cameron, Canadian Prime Minister Justin Trudeau and European Commission President Jean-Claude Juncker pose for the family photo during the first day of the Group of Seven (G7) summit meetings in Ise Shima, Japan. Credit: Reuters/Pool

Ise-Shima, Japan: Britain is pushing for a global plan to reward drugs companies for developing new antibiotics, while also pledging to cut antibiotic use in England.

A review commissioned by the British government and published last week said drug companies should agree to “pay or play” in the urgent race to find new antimicrobial medicines to fight the global threat posed by drug-resistant superbug infections.

Former Goldman Sachs chief economist Jim O’Neill, who led the review, said a reward of between $1 billion and $1.5 billion should be paid for any successful new antimicrobial medicine brought to market.

British Prime Minister David Cameron will say at the G7 meeting in Japan on Friday that Britain will work with global finance and health experts to develop such as system to bring the new antibiotics to market and make them available to all who need them.

“The UK will explore with the international community how these rewards could be financed, including through the use of private sector funding,” the government said in a statement.

Any use of antibiotics promotes the development and spread of superbugs – multi-drug-resistant infections that evade the antimicrobial and antibiotic drugs designed to kill them.

O’Neill has estimated antimicrobial resistance could kill an extra 10 million people a year and cost up to $100 trillion by 2050 if it is not brought under control.

Britain will use a 50 million pound ($74 million) investment to start a global innovation fund to help develop new antimicrobials as well as diagnostic tools and vaccines.

In England, the government said it will also seek to halve the inappropriate prescription of antibiotics by doctors by 2020 and set an overall target for antibiotic use in livestock and fish farmed for food.($1 = 0.6792 pounds)

(Reuters)

First Case of Bacteria Resistant to All Antibiotics Detected in US

The study said continued surveillance to determine the true frequency of the gene in the US is critical.

The mcr-1 plasmid-borne colistin resistance gene has been found primarily in Escherichia coli, pictured. Credit: Reuters/Courtesy CDC

US health officials on Thursday reported the first case in the country of a patient with an infection resistant to all known antibiotics, and expressed grave concern that the superbug could pose serious danger for routine infections if it spreads.

“We risk being in a post-antibiotic world,” said Thomas Frieden, director of the US Centers for Disease Control and Prevention, referring to the urinary tract infection of a 49-year-old Pennsylvania woman who had not travelled within the prior five months.

Frieden, speaking at a National Press Club luncheon in Washington, DC, said the infection was not controlled even by colistin, an antibiotic that is reserved for use against “nightmare bacteria.”

The infection was reported Thursday in a study appearing in Antimicrobial Agents and Chemotherapy, a publication of the American Society for Microbiology. It said the superbug itself had first been infected with a tiny piece of DNA called a plasmid, which passed along a gene called mcr-1 that confers resistance to colistin.

“(This) heralds the emergence of truly pan-drug resistant bacteria,” said the study, which was conducted by the Walter Reed National Military Medical Center. “To the best of our knowledge, this is the first report of mcr-1 in the USA.”

The patient visited a clinic on April 26 with symptoms of a urinary tract infection, according to the study, which did not describe her current condition. Authors of the study could not immediately be reached for comment.

The study said continued surveillance to determine the true frequency of the gene in the US is critical.

“It is dangerous and we would assume it can be spread quickly, even in a hospital environment if it is not well contained,” said Dr. Gail Cassell, a microbiologist and senior lecturer at Harvard Medical School.

But she said the potential speed of its spread will not be known until more is learned about how the Pennsylvania patient was infected, and how present the colistin-resistant superbug is in the US and globally.

“Medicine cabinet is empty for some”

In the US, antibiotic resistance has been blamed for at least 2 million illnesses and 23,000 deaths annually.

The mcr-1 gene was found last year in people and pigs in China, raising alarm.

The potential for the superbug to spread from animals to people is a major concern, Cassell said.

For now, Cassell said people can best protect themselves from it and from other bacteria resistant to antibiotics by thoroughly washing their hands, washing fruits and vegetables thoroughly and preparing foods appropriately.

Experts have warned since the 1990s that especially bad superbugs could be on the horizon, but few drugmakers have attempted to develop drugs against them.

Frieden said the need for new antibiotics is one of the more urgent health problems, as bugs become more and more resistant to current treatments. “The more we look at drug resistance, the more concerned we are,” Frieden added. “The medicine cabinet is empty for some patients. It is the end of the road for antibiotics unless we act urgently.”

Overprescribing of antibiotics by physicians and in hospitals and their extensive use in food livestock have contributed to the crisis. More than half of hospitalised patients will get an antibiotic at some point during their stay. But studies have shown that 30% to 50% of antibiotics prescribed in hospitals are unnecessary or incorrect, contributing to antibiotic resistance. Many drugmakers have been reluctant to spend the money needed to develop new antibiotics, preferring to use their resources on medicines for cancer and rare diseases that command very high prices and lead to much larger profits.

In January, dozens of drugmakers and diagnostic companies – including Pfizer Merck & Co, Johnson & Johnson and GlaxoSmithKline –signed a declaration calling for new incentives from governments to support investment in development of medicines to fight drug-resistant superbugs.

(Reuters)

In 5 Years, Threat Of Drug-Resistant Superbugs Doubles

Colorised scanning electron micrograph of Escherichia coli, grown in culture and adhered to a cover slip. Credit: niaid/Flickr, CC BY 2.0

A 72-year-old woman in Bengaluru consulted a hospital physician about a severe skin infection and fever. She had previously consulted a couple of general practitioners, who prescribed a course of penicillin for three days and fluoroquinolones – both antibiotics – for two days. There was no relief.

So, the consultant ordered a culture sensitivity test of pus from the skin lesions to identify what was causing her ailment and figure out what antibiotics it would respond to. Here’s what the report said:

Pathogen: Klebsiella pneumoniae
Susceptible to: No antibiotic
Resistant to: All antibiotics, including advanced drugs like fluoroquinolones, carbapenems and even the last resort combination usually reserved for severe cases of ICU infection, colistin-tigecycline

With nothing to offer the patient, save a prescription for paracetamol to keep her fever in check, the doctor sent the patient home, and asked her to return after a week. In such cases, sometimes, the body’s immunity kicks in and throws off the infection, the physician, Sheela Chakravarthy, consultant (internal medicine) at Fortis Hospital, Bengaluru, told IndiaSpend.

Sometimes, resistance to one or more drugs abates, allowing treatment to be resumed. Chances of that happening are greater at home, not in the hospital, which is a more infectious space where sepsis—a disproportionate and potentially life-threatening immune response by your body to an infection—could set in, she explained.

Most patients, however, succumb to the infection.

Chakravarthy faces situations where she has nothing to offer patients, not because they are suffering from terminal illnesses, such as some forms of cancer, but even when they present with what should be curable infections, “almost every day”, she said.

What Chakravarthy described is the consequence of rampant, inappropriate consumption of antibiotics, spurring the development of superbugs, as the recently released State of the World’s Antibiotics Report 2015 affirms.

India is fast becoming home to superbugs

Escherichia coli, Klebsiella pneumoniae and Staphylococcus aureus are three of the deadliest pathogens facing humanity, according to the World Health Organisation (WHO). And India is gradually but increasingly becoming home to multi-drug resistant strains of these pathogens, according to the State of the World’s Antibiotics Report 2015.

Escherichia coli is notorious for causing food poisoning and urinary tract infections. In 2010, 5% of Escherichia coli samples in India were resistant to carbapenems, last-resort antibiotics for bacteria that are resistant to first-, second- and third-line drugs. By 2014, 12% of E. coli samples were similarly resistant.

Klebsiella pneumoniae causes pneumonia, septicaemia and infections in the urinary tract, lower biliary tract and at surgical wound sites, to name a few. While 29% of Klebsiella pneumonia isolates were resistant to carbapenems in 2008, this increased to 57% in 2014.

For comparison, fewer than 10% of Klebsiella pneumoniae infections in Europe are carbapenem-resistant. Staphylococcus aureus can cause skin and soft tissue infections, bloodstream infections, pneumonia and surgical site infections. A particularly nasty strain of, methicillin-resistantStaphylococcus aureus (MRSA), is common in India and increasingly hard to treat.

MRSA was responsible for 40% of post-surgical site infections, according to a 2013 study by the Jawaharlal Nehru Medical College and Hospital, Aligarh. Between 2009 and 2014, the incidence of MRSA in India has risen from 29% to 47%. People with MRSA are 64% more likely to die than people with a non-resistant form of the infection, according to the WHO.

How ignorance is spurring the development of superbugs

“My understanding of antibiotic is that it stops bacteria growing in body…I think amoxicillin is for throat infection.” – An urban participant of a study of perceptions about antibiotic use and resistance among urban and rural doctors, pharmacists and public in Vellore. Mox, short for amoxicillin, has become a household word across India.

A little knowledge, however, is a dangerous thing. It encourages self-medication, even when medicine is unnecessary, such as when people suffer viral infections—against which drugs are ineffective. Most viral fevers dissipate on their own after a few days with rest, hot fluids and a check on the fever.

Consuming too many antibiotics contributes to pathogen drug resistance. “Resistance is an outcome of accumulated use,” said Ramanan Laxminarayan, vice president, Research and Policy, Public Health Foundation of India, and director and senior fellow, Centre for Disease Dynamics, Economics & Policy, US, and co-author of the State of the World’s Antibiotic Report 2015.

Indians often rely on corner pharmacists, whose knowledge of dosages may be limited. Here’s what a rural pharmacist participant of the aforementioned Vellore study said:“Amoxicillin, 6 tablets is to be taken [for full course].” Amoxicillin’s full course depends on the kind and severity of bacterial infection.

When an antibiotic of lower strength or fewer pills than needed is prescribed, the body cannot fully eradicate the pathogen. Sensing it has come under attack, the bacterium responds by evolving into more resilient, antibiotic-resistant strains.

But with a course of antibiotics, say generic amoxicillin, costing about Rs.160, close to a day’s wage in many states, and a doctor’s consultation costing anywhere between Rs 100 and Rs 1,000, more than a day’s wage in most places, patients are bound to cut corners.

Another Vellore study participant summed up the situation thus: “If I have money I go to hospital. If not, I get medicine from pharmacy shop. If I get better, I stop and keep for future use.” Stopping a course of drugs mid-way also contributes to antibiotic microbial resistance. In a 2015 study in Chennai, 70% respondents confessed to stopping the medication when they felt better. Only 57% completed the antibiotic course.

“Less is more”: the key to preserving antibiotic efficiency

This is an IndiaSpend.org story.

Educate health professionals, policy makers and the public on sustainable antibiotic use, says the State of the World’s Antibiotics Report 2015. That is sensible advice. Denmark and Sweden boast of low rates of antibiotic use and near-zero rates of antibiotic resistance because the risks of antibiotic overuse are widely known.

Instituting regulations on antibiotic use has reduced the proportion of MRSA in Europe and the US by about a fifth over the last eight years. India requires more stringent regulations for antibiotic use.

It isn’t enough to tell physicians that they should prescribe antibiotics only when essential to cure bacterial infections. The right way is to order a culture sensitivity test, which costs money, and the patience to wait for the result.

“Patients want instant and cheap relief, and are willing to shop around for a doctor who obliges,” said Himanshu Shekhar, medical director, SCI International Hospital, New Delhi. “Some judge doctors on how fast the prescribed medicine cures. Practice pressures lead many doctors to prescribe advanced drugs, without getting a culture-sensitivity test done.”

So, it’s also not enough to have 24 advanced antibiotics, including third- and fourth-generation cephalosporins, carbapenems, and newer fluoroquinolones, under the ambit of Schedule H1 of the Drugs & Cosmetic Rules, 1945, with effect from March 1, 2014.

That means these drugs cannot be sold over-the-counter, but they are still freely prescribed. Chakravarthy’s suggestion: “Make Schedule H antibiotics available only through hospitals and health centres.”

“Changing antibiotic usage behaviours is critical to preserve the efficacy of existing and new drugs,” proposed Laxminarayan.

India also sorely needs regulations to check antibiotic use in animals raised for human consumption, to meet the State of the World’s Antibiotic Report 2015 recommendation to reduce and eventually phase out sub-therapeutic antibiotic use in agriculture. Sub-therapeutic use implies mixing antibiotics in animal feed to make them grow faster and to prevent infections from devastating the herd or flock.

India is among the world’s five biggest consumers of antibiotics for livestock. IndiaSpend has earlier reported increasing evidence of antibiotic-resistant bacteria in animals in India, and how this impacts humans. “Using antibiotics to make animals fatter faster is a waste of a precious resource,” said Laxminarayan.

How surgeons contribute to antibiotic resistance

Surgical antibiotic prophylaxis refers to the prescribing of antibiotics before, during and after operations to prevent infection. Between 19% and 86% of patients in hospitals in India receive “inappropriate antibiotic prophylaxis”, according to the State of the World’s Antibiotics Report 2015. A prophylactic is preventive treatment for a disease.

Ideally, antibiotic prophylaxis should be administered as a single dose within 60 minutes of the skin incision. However, a 2013 Mangalore-based study found timing adhered to in 22% of cases in a government hospital, 64.9% cases in a medical-college teaching hospital and 80.7% of patients in a tertiary care corporate hospital.

“Smart antibiotic prophylaxis also includes choosing narrow-spectrum antibiotics to target the organism most likely to present concerns based on the kind of surgery being performed, this avoids needless exposure to antibiotics for the other microbes and helps prevent resistance,” said Vimesh Mistry, assistant professor, Pharmacology, Baroda Medical College.

Staphylococcus aureus, which lives on the skin, is most likely to cause infection during surgery. But surgeons frequently make poor antibiotic choices. “We found appropriateness of choice of antibiotic in 68% cases and 52% compliance with the in-house prophylaxis guidelines,” said Tanu Singhal, infectious diseases specialist, Mumbai, and co-author of another study on antibiotic prophylaxis conducted in PD Hinduja Hospital, Mumbai.

Other prophylaxis inaccuracies include the unnecessary prescribing of antibiotics, inaccurate dose and inaccurate duration of prescription. “We logged 63% accuracy in prescription duration. Surgeons tend to prescribe antibiotics for too long fearing post-surgery infection,” said Singhal. In the trade off between protecting the patient better and increasing the risk to society of a pathogen developing resistance, surgeons are choosing the former.

Needed: A back-to-the-basics approach to health

Reducing the need for antibiotics through improved water, sanitation and immunisation is another strategy recommended in the State of the World’s Antibiotics Report 2015.

“Vaccination against pathogens such as the diarrhoea-causing rotavirus and pneumonia-causing Klebsiella pneumoniae helps curtail antibiotic demand, thereby reducing the chances of resistant strains developing,” said Laxminarayan. In Canada, the widespread use of pneumococcal conjugate vaccines for pneumonia in children has reduced the incidence of pneumonia caused by strains the vaccine covers.

However, just as antibiotic usage spurs the development of superbugs, vaccination is a double-edged sword. Canada is seeing a rapid increase in the incidence of other strains of pneumonia not protected against by the vaccine. So, it is better to focus on the basic constituents of health.

Making available clean drinking water and improving sanitation would prevent people from getting sick in the first place. India still has a lot to do on both these fronts. Improving individual immunity is the best bet to ward off infections, and that is also achievable by healthier eating, exercising, healthier living and the better management of chronic conditions like diabetes and asthma that increase vulnerability to infections when they are not kept in check.

Charu Bahri is a freelance writer and editor based in Mount Abu, Rajasthan.

IndiaSpend.org is a data-driven, public-interest journalism non-profit.