Features

doi:10.1038/nindia.2012.171 Published online 26 November 2012

Addressing antibiotic resistance

Ranjeet Kumar

India has seen several instances of emerging superbugs and antibiotic resistance in the recent past. Be it the controversial superbug NDM11 or the deadly antibiotic resistance study from effluent treatment plants in Patancheru, Hyderabad2, these instances prompt a critical question: should we wait for these signals to culminate into a bigger disaster or address them on an emergency basis?

The evidence

Studies throughout India have revealed the existence of superbugs in hospitals and water samples3, 4. The potential risk can be understood in light of the urban drinking water supply and the dilapidated distribution system that is prone to such contamination. The government hospitals and private nursing homes waste management and disposal is also a concern throughout the country.

In the US, recent research has shown the presence of a multi-drug resistance strain of Staphylococcus aureus in samples from sewage water treatment plants, suggesting potential risk to personnel working there5. In India, sewage treatment throughout the length and breadth of the country is poorly addressed. Even if the plants run, they are overburdened and stretched beyond limit.

The two major rivers Ganga and Yamuna continue to be threatened as sewage and toxic industrial effluents are dumped into them ceaselessly. Studies by the Indian Council of Medical Research (ICMR) claim to point at enhanced risk of cancer in the Ganga river basin stretch of UP, Bihar and Bengal.

The indiscriminate use of antibiotics, both in humans and in livestock, has brought us to the crossroads. The enhanced concentration of these antibiotics in environment is favourable for developing resistance among life threatening microbes6.

The concerns

How will major operations be carried out in future with these nasty beasts around? What if none of the frontline antibiotics — considered magic bullets till now — work? These questions necessitate search for alternatives.

Cases of drug-resistant tuberculosis on the rise7, 8, coupled with reports of increasing antibiotic resistance9, has created a wave of urgency among public health administrators. However, the government's denial strategies raise a question on how serious the country is to troubleshoot these notorious bugs.

The present antibiotic-resistance scare should be an eye opener for policy makers. Immediate interventions are needed to address the issue of effluent disposal. The gravity of the issue is further amplified by the use of reclaimed wastewater in agriculture thus fueling concerns about 'slow poisoning' through contaminated crops.

The indiscriminate use of antibiotics both in humans and in livestock could result in irreversible damage. India, being one of the biggest manufacturers and suppliers of active pharmaceutical ingredients (API) to the western world, needs to come up with solutions fast.

The other side of the story is the environmental concern associated with the effluent disposal from these giant units. The flora, fauna and life of people in these areas has been adversely affected. The issue has an economic impact too as major European countries suspect the quality of API manufactured in India that eventually get integrated into their drug regime. Globally there are brainstorming sessions to go for greener drugs and take note of the environmental impact during the manufacturing process.

Ironically, India seems to be slow in dealing with the crisis and coming up with a stringent and pragmatic antibiotic policy10.

Possible solutions

What can be done?

First up, we could regulate over-the-counter sales of antibiotics and ensure rational prescription of antibiotics by medical practitioners. Antibiotics should be made the last resort. Correct doses and complete courses should be encouraged. However, in a vast country like India, where health service providers are more in the private than in the public, coming up with a strong regulation is a bottleneck.

Efficient waste management in hospitals and municipalities should be prioritized. Civil society at large should be made aware of the yin and yang of the problem using a nationwide campaign. It is also important to ensure that good microbiology labs are established across the nation to monitor the situation in real time.

At a recent meeting of stakeholders in Chennai (August 2012), these issues were discussed at length. The meet was to evolve a workable road map to tackle the problem and come up with an antibiotic policy. Strong policies and multi-pronged strategies are needed in this regard. Unfortunately, there hasn't been much at the action level.

Of late, India's ministry of health has taken some initiatives such as advertisements on rational use of antibiotics. Prompt interventions could save us from a pandemic spread of superbugs. Judicious use of antibiotics would lead to ecological sustainability. It would be criminal to expose people to unwanted toxics.

The author is a researcher in the Department of Molecular Biology at the Orebro Life Science Centre, Orebro University, Sweden. Views are personal.


References

  1. Conly, J. Antimicrobial resistance: revisiting the 'tragedy of the commons'. B. World Health Organ. 88, 805-806 (2010)  | Article |
  2. Larsson, D. G. et al. Effluent from drug manufactures contains extremely high levels of pharmaceuticals. J. Hazard. Mater. 148, 751-755 (2007) | Article | PubMed |
  3. Kumarasamy, K. K. et al. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: a molecular, biological, and epidemiological study. Lancet Infect. Dis. 10, 597-602 (2010) | Article | PubMed | ISI |
  4. Walsh, T. R. et al. Dissemination of NDM-1 positive bacteria in the New Delhi environment and its implications for human health: an environmental point prevalence study. Lancet Infect. Dis. 11, 355-362 (2011)  | Article | PubMed |
  5. Goldstein, R. E. et al. Methicillin-Resistant Staphylococcus aureus (MRSA) detected at four U. S. wastewater treatment plants. Env. Health Persp. 120, 1551-1558 (2012) | Article |
  6. Tello, A. et al. Selective pressure of antibiotic pollution on bacteria of importance to public health. Environ. Health Persp. 120, 1100-1106 (2012)
  7. Global Tuberculosis Report (2012)
  8. Udwadia, Z. F. Totally drug-resistant tuberculosis in India: who let the djinn out? Respirology 17, 741-742 (2012) | Article | PubMed |
  9. Ganguly, N. K. et al. Rationalizing antibiotic use to limit antibiotic resistance in India. Indian J. Med. Res. 134, 281-294 (2011) | PubMed |
  10. Westly, E. India moves to tackle antibiotic resistance. Nature 489, 192 (2012) | Article | PubMed | ADS |