A simple condition like pneumonia had a 19-year-old woman from Gorakhpur, Uttar Pradesh, going in and out of hospital until she was finally referred to specialists all the way in Delhi. Even here, the critical care unit at Sir Ganga Ram Hospital had a tough time treating her.
“She was in the ICU for three months because the bacterium she was infected with was resistant to multiple drugs,” says Dr Sumit Ray, vice-chairman of the critical care unit at Ganga Ram Hospital. She finally responded to a combination of a fifth-generation drug and a first-line antibiotic.
“Antibiotics have to be very judiciously prescribed. Most patients from small towns come to us after having undergone multiple courses of strong antibiotics and are already resistant to a specific line of drugs,” says Dr Yatin Mehta, chairman Institute of Critical Care & Anesthesiology, Medanta in Gurgaon, Haryana.
With drugs that were effective earlier not being effective anymore, because of internal or environmental factors, doctors are being forced to prescribe stronger and stronger antibiotics. “The real worry with these drugs is that the stronger antibiotics are toxic as they can damage the kidneys and liver,” says Dr Behram Pardiwalla, internal medical expert at Mumbai’s Wockhardt Hospital.
Overuse and misuse are leading to growing antibiotic-resistance worldwide, including in India, with the most recent red flag coming from the All India Institute of Medical Sciences (AIIMS), where researchers found antibiotics in water samples collected from the Yamuna - in quantities high enough to cause drug resistance.
Three classes of antibiotics were found - fluoroquinolone, which is used to treat respiratory and urinary tract infections, and Macrolides and Penicillin, both broad-spectrum antibiotics used for a large range of bacterial infections such as pneumonia, scarlet fever and rheumatic fever. “Resistance to antibiotics is definitely on the rise, more so in the past two to three years, and there has been at least a 5% to 10% year-on-year increase,” says Dr Pardiwalla. “It’s very worrying.”
Prescription antibiotics are widely available in India, often without prescription in India, with a World Health Organisation survey released this week reporting that India and China were the only two countries of the dozen surveyed where people bought antibiotics online. In India, 2% people reported buying antibiotics online compared to 5% in China. “Studies show 90% of diseases get better with about 250 medicines, but India has more than 70,000 medicines approved for use. Clearly, there is room for abuse and misuse,” says Dr Sidhartha Satpathy, head, department of hospital administration, AIIMS.
“People over 65 are immune-compromised, and transplant patients rarely respond to first-line antibiotics any more. We are finding high resistance to second-line antibiotics too,” says Dr Chand Wattal, honorary consultant in clinical microbiology at Ganga Ram Hospital. “Earlier I’d say the antibiotics pipeline would dry up in 10 years, now I see it happening in 5 years.”
The result is doctors prescribing stronger antibiotics that are more expensive and have stronger side effects. “In about 30% to 40% ICU patients, we had to step up to stronger antibiotics,” says Dr Wattal. Adding to the problem is that hard-to-treat infections have moved out of the ICUs and hospitals and into the community.
Medicines now account for about half of total ICU billing, with new-age antibiotics called Carbapenems being prescribed for infections known or suspected to be caused by multidrug-resistant bacteria. “If we don’t use what we have with reserve, we’re going to need the newer molecules more and more, and they are beyond the reach of many in terms of affordability,” says Dr Wattal.
Mumbai businessman Bhagwan Punjabi, for instance, recently took multiple courses of the same antibiotic for a urinary tract infection. Since the medicines, prescribed by his family physician, offered him temporary relief, he continued taking the drugs, which were handed over to him by the physician’s compounder. “Every time the thrice-a-day dose ended, the symptoms - fatigue, pain and horrible burning when I urinated - returned. This continued for 20 days,” says the 54-year-old businessman from Mumbai.
Finally, he consulted Dr Anil Ballani, a consultant physician at Mumbai’s Hinduja Healthcare hospital, who, after running a urine culture test, had to increase the antibiotic dosage, prescribing injections twice a day for 15 days. “His body was resistant to the first type of antibiotic,” says Dr Ballani. “Only after I ran a culture test could I determine which medicines would work, in what dosage.”
This combination of over-medication by doctors and self-medication by patients are key reasons why instances of antibiotic resistance are on the rise in India. “In India everyone is a doctor until proven otherwise,” adds Dr Ballani. “Your neighbour who was running fever a month ago will offer the leftover pills if you show similar symptoms. Homeopaths prescribe antibiotics freely. Unfortunately, in our country we have no regulation on prescription and sale of antibiotics.”
Some hospitals, like Wockhardt, have put antibiotic-resistance awareness policies in place. The hospital keeps certain antibiotics on a ‘reserved’ list. “A doctor has to state in writing the reason he or she wants to prescribe these drugs,” says Dr Pardiwalla. “The idea is to make them think twice before prescribing.”
“Most hospitals in the country don’t have a comprehensive antibiotic policy and a large number of doctors prescribe antibiotics based on their own experience. Easy availability of antibiotics adds to the misuse, which isn’t the case abroad. When we go abroad we take essential medicines along because we don’t get anything over-the-counter,” said Dr Satpathy.