TREATMENT WORSE THAN CURE?
Herald Review October 12, 2014
Indiscriminate use of antibiotics has resulted in growing resistance to these lifesaving drugs. Lisa Ann Monteiro makes a diagnosis of this 'major global threat'.
It’s a long road ahead for the fight against antimicrobial resistance. A few months ago the WHO declared that worldwide resistance to antibiotics had reached ‘ alarming levels’ and poses a ‘ major global threat’ to public health. Antibiotic resistance, the organisation said, is no longer a prediction for the future but is happening right now across the world, jeopardizing the ability to treat common infections.
More broadly, antimicrobial resistance (AMR) which is resistance to drugs to treat infections caused by other microbes including parasites, viruses and fungi, has become ubiquitous all over the world.
To combat this, the Indian Medical Association (IMA) has also begun campaigning against the over- prescription of antibiotics, asking doctors to pledge themselves to fighting against AMR and to follow the principles of rational use of antibiotics.
IMA Goa State branch president Dr Jagdish Cacodkar explained that antibiotics used in chemotherapy of bacterial infections are broadly classified as those that act on Gram positive and Gram negative bacteria and on anaerobic infections.
Among these, the Gram negative bacteria are the more dangerous types. There are limited antibiotics that act on these bacteria that are associated with urinary tract infections, some serious hospital acquired infections and with life threatening infections like sepsis in infants and adults.
This, he explains, is in contrast to the greater number of antibiotics available to combat Gram positive bacteria that cause common infections like those of the skin, the respiratory tract and gastro- intestinal and post- operative infections.
“ Irrational use of these antibiotics leads to the emergence of antibiotic resistance among bacteria. Higher level antibiotics should only be used when serious infections are confirmed by culture tests or when there is strong clinical suspicion in seriously ill patients. They shouldn’t be used indiscriminately and should be reserved for cases where their use is scientifically warranted,” Dr Cacodkar says.
Instead, antibiotics are being misused with doctors prescribing the highest end antibiotics to treat even common colds and fever. Such drugs don’t act against viral infections, only bacterial ones and a majority of the most acute respiratory infections are viral. Rationally, patients should be prescribed antibiotics only during bacterial infection. The IMA as a first step is beginning to educate doctors and patients not to resort to antibiotics for ordinary coughs, colds and diarrhea.
Defensive practice
Dr Wiseman Pinto, Professor and Head of Pathology, GMC terms the medicine practiced today as ‘ defensive medicine’ where doctors don’t want to take any risks. They prescribe stronger antibiotics, leaving nothing to chance. “ Fourth generation antibiotics are not required to be prescribed when first and second generation antibiotics are adequate. Doctors prescribe these to safeguard their own interests.” Many doctors are apprehensive over losing their patients to other doctors.
Microorganisms, says Dr Pinto, can outsmart doctors. They change their genetic constitution, becoming resistant to the same antibiotics. When higherend antibiotics are given indiscriminately, bacteria develop resistance, and when serious cases need to be treated, the drugs don’t work anymore.
Another factor responsible for antibiotics resistance, cardiologist Dr Francisco Colaço stresses on, is patients not completing the entire course of antibiotics prescribed. Many patients discontinue antibiotic treatment midway simply because they ‘ feel better’. Patients too are to blame for seeking instant respite from their ailments and compelling doctors to prescribe higherend drugs or certain drugs not strictly necessary. Gone are the days when patients bore their ailments with patience.
Instant remedies are now sought. Parents ask for antibiotics for their children who have the flu and are not ready to listen to the doctor telling them that their child needs to rest and stay away from school or college for a few days. They also seem unconcerned over the virus spreading to other children.
Other patients seek a rapid cure as they want to return to work immediately.
“ If they don’t get what they want, patients don’t hesitate to change their doctors,” Dr Cacodkar says. He advises his patients trust their doctor and take the required rest that viral fever requires. He also suggests simple hand hygiene and cough etiquette to be followed to prevent the spread of infections.
Growing resistance
Dr Cacodkar cites examples of resistance already prevalent against certain bacteria and other parasites. Falciparum Malaria until a few years ago would respond to chloroquine. Today it is treatable only with artesunate combination therapy ( ACT) which was earlier a second line of anti- malarial treatment.
The drugs used to treat typhoid too don’t work anymore because of the widespread use of quinolones like ciprofloxacin that is used indiscriminately to treat simple respiratory and skin infections.
Gonorrhea would respond to penicillin three decades ago but due to indiscriminate use of the drug a new strain called PPNG has rendered penicillin ineffective in the treatment of these sexually transmitted diseases.
Up to 4 per cent of tuberculosis cases in the country are now MDR TB ( Multi Drug Resistant Tuberculosis) which is resistant to first line antibiotics and requires more toxic and costlier second line anti- TB drugs.
Between 1 to 2 per cent of TB cases are today XDR- TB ( Extensively Drug Resistant Tuberculosis) which is resistant to first- line as well as second- line antibiotics. XDR- TB has a high death date.
There are also ominous case reports in Mumbai of Total Drug Resistant TB for which no anti- TB drugs work at all.
Practitioners are therefore urged to follow the standard TB treatment protocols.
In 2010 the news of NDM- 1 ( New Delhi Metallo- ß- lactamase 1) took the world by storm. First discovered in a Swedish patient of Indian origin who had recently travelled to New Delhi, the NDM- 1 produces bacteria that are highly resistant to many antibiotics including carbapenems. This class of drugs is reserved for emergency cases and to treat infections caused by other multiresistant bugs like MSRA and C- Difficile. NDM- 1 positive bacteria was also found in Chennai, Haryana, Bangladesh, Pakistan and in the UK.
Lax laws in India
Pharma companies too are responsible for growing AMR. They provide incentives to doctors to prescribe costlier higherend drugs. This is business to companies but at the cost of patients. Many hospitals make more money on their pharmacies than on room rent, doctors say.
Surveillance and audits in India are poor. Doctors are rarely penalized and the patient is the sufferer. There is lack of accountability and anyone today can easily purchase antibiotics over the counter in pharmacies without a prescription.
Something that isn’t possible in the US. Last month President Barack Obama made it a federal priority to combat the growing health threat from bacteria that is resistant to antibiotic treatment.
Dr Celina Pereira, an adolescent medicine and college health physician, USA, says the difference in the prescribing habits of Indian and American physicians is that American doctors don’t usually prescribe the stronger ( second and third generation) antibiotics but first- line antibiotics such as penicillin, ampicillin, amoxicillin, erythromycin, azithromycin and sulfa antibiotics. “ But even these,’’ she says, “ are inappropriate for viral infections. Inappropriate use of antibiotics can lead to complications that may end in a law suit, a great deterrent for American physicians.”
Solutions
With no new class of antibiotics discovered since the 1980s, AMR threatens a return to the pre- antibiotic era where the most basic operations and even a cut to one’s finger could be most hazardous.
Dr Colaço suggests antibiotics be classified for non- restricted, restricted and very restricted use and shouldn’t be sold in pharmacies without a special prescription. There should be stringent penalties to be imposed if this is violated.
“ The MBBS syllabus too should lay more emphasis on the use and misuse of antibiotics. Drugs and therapeutic committees as well as hospital infection control committees should be set up in all hospitals. Policies for RAP (rational use of antibiotics) should be introduced in the agriculture and food industry (including poultry, pig, fish farming and in honeybee hives) where these drugs are used as growth promoters.” He also points out to the paradox between urban and rural India where one faces the challenge of inappropriate use of antibiotics while the other struggles with poor access to treatment.
Dr Cacodcar suggests a dire need for standardized treatment protocols to be developed. This he says should be backed up by a good laboratory network with reliable bacterial and virological reports which will help doctors in treating patients suffering from infectious diseases. The IMA Goa State has begun conducting refresher training for doctors on combating anti- microbial resistance with WHO support and has recently organised pharmaco- vigilance training on the adverse effects of drugs. Review Bureau
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