Year : 2019 | Volume
: 11 | Issue : 2 | Page : 54--58
Fighting antimicrobial resistance: Status paper with action points by organized medicine academic guild
Sunil Kumar Raina1, Sagar Galwankar2, Akshay C Dhariwal3, Ramesh Bhatt4, Raman Kumar5, Ishwar Gilada6, Praveen Aggarwal7, S Vimal Krishnan8, Santosh Soans9, RP Srivastva10, Udhay Bodhankar11,
1 Department of Community Medicine, Dr. R.P. Government Medical College, Tanda, Himachal Pradesh, India
2 Department of Emergency Medicine, Sarasota Memorial Hospital Florida State University, Florida, USA
3 National Vector Borne Disease Control Programme (NVBDCP), Directorate General of Health Services, Ministry of Health and Family Welfare, Govt. of India, India
4 Department of Dermatology, Father Muller Medical College, Manglore, Karnataka, India
5 Association of Family Physicians of India, New Delhi, India
6 Unison Medicare and Research Centre, Alibhai Premji Marg, Grant Road-E, Mumbai, India
7 Department of Emergency Medicine, AIIMS, New Delhi, India
8 Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
9 Department of Paediatrics, A. J. Institute of Medical Sciences, Manglore, Karnataka, India
10 Sarvoday Hospital, Bokaro, Jharkhand, India
11 Bodhankar Childrens Hospital, Sharhari, Central Bazaar Road, Nagpur, Maharashtra, India
Dr. Sunil Kumar Raina
Department of Community Medicine, Dr. RP Government Medical College, Kangra, Himachal Pradesh
|How to cite this article:|
Raina SK, Galwankar S, Dhariwal AC, Bhatt R, Kumar R, Gilada I, Aggarwal P, Krishnan S V, Soans S, Srivastva R P, Bodhankar U. Fighting antimicrobial resistance: Status paper with action points by organized medicine academic guild.J Global Infect Dis 2019;11:54-58
|How to cite this URL:|
Raina SK, Galwankar S, Dhariwal AC, Bhatt R, Kumar R, Gilada I, Aggarwal P, Krishnan S V, Soans S, Srivastva R P, Bodhankar U. Fighting antimicrobial resistance: Status paper with action points by organized medicine academic guild. J Global Infect Dis [serial online] 2019 [cited 2020 Jan 18 ];11:54-58
Available from: http://www.jgid.org/text.asp?2019/11/2/54/259150
About Organized Medicine Academic Guild
The need for having an umbrella organization of all like-minded professional associations working for human health was realized in a meeting of Global Health Security Agenda held in 2017 at Mangalore, Karnataka, to work on cross-cutting issues between various specialties and superspecialties in the health sector. It was observed that presently all professional associations are working in silos, and there is no platform to interact with each other on issues common to all. Antimicrobial resistance (AMR) was discussed as an example where Indian Academy of Paediatrics (IAP), Association of Physicians of India (API), Association of Surgeons of India (ASI), Indian Association of Medical Microbiologists, Indian Public Health Association, Indian Association of Preventive and Social Medicine (IAPSM), Indian Orthopedicians Association, Association of Family Physicians of India, Emergency Medicine Association, Neonatologist Forum, etc., can contribute significantly to contain the problem. Hence, it was thought to have Organized Medicine Academic Guild (OMAG) of India as an umbrella multispecialty organization. It was formally constituted at the Annual Conference of IAP (PEDICON) on January 7, 2018 at Nagpur, Maharashtra. It is comprised of leading professional medical organizations and mandated to support the sustainability of health agenda of the Government of India.
AMR is one of the focus areas for OMAG. A group of experts from OMAG was constituted to facilitate discussion on difficulties being faced in preventing AMR and solutions thereto.
Dr Sunil Kumar Raina, IAPSM and founder member OMAG.
Dr. Sagar Galwankar, chief executive officer, INDUSEM and founder member OMAG.
Dr. Akshay C. Dhariwal, advisor, NVBDCP and Former Director, NVBDCP and NCDC and founder member OMAG.
Dr. Ramesh Bhatt, president IADVL and founder member OMAG.
Dr. Raman Kumar, President, Academy of Family Physicians of India and founder member OMAG.
Dr. Ishwar Gilada, president, AIDS Society of India and founder member OMAG
Dr. Praveen Agarwal, dean and vice president, ACEE, India, and founder member OMAG.
Dr. Vimal Krishnan S, principal secretary general, EMA, India, and founder member OMAG.
Dr. Santosh Soans, president API and founder member OMAG.
Dr. RP Srivastva, past president ASI and founder member OMAG.
Dr. Udhay Bodhankar, president, Commonwealth Association of Health and Disability and founder member OMAG.
AMR is a serious threat as it will lead us to an era where no antibiotic will work effectively and without effective antibiotics, the success of major medical and surgical interventions will stand compromised. This will not only lead to an increase in morbidity and mortality due to infectious diseases but also increase the disability due to complication in procedures (due to ineffective antibiotics) such as organ transplantation and cancer chemotherapy and further complicate the management of noncommunicable disease such as diabetes management.
As a global phenomenon, AMR has impacted management of a number of infectious agents. Some of the key examples are 1) Klebsiella pneumoniae – with carbapenem antibiotics being the last resort despite the fact that because of resistance, carbapenem antibiotics do not work in more than half of people treated for K. pneumoniae infections 2) Escherichia coli treatment with fluoroquinolones in many parts of the world is now ineffective; 3) Resistance for gonorrhea has been confirmed in at least 10 countries (Australia, Austria, Canada, France, Japan, Norway, Slovenia, South Africa, Sweden, and the United Kingdom of Great Britain and Northern Ireland); 4) methicillin-resistant Staphylococcus aureus and5) the biggest of them all tuberculosis.
“Antimicrobial resistance is a slow-motion tsunami and a global crisis that must be managed with the utmost urgency.” These are the remarks of Dr. Margaret Chan, former Director General of World Health Organization (WHO) at a high-level dialogue on AMR with the UN Member States in New York, USA, on April 18, 2016. As correctly reflected by her in that meeting, as we keep losing our first-line antibiotics, treating a broad range of common infections is becoming much more difficult to treat. The WHO developed a global action plan to tackle AMR. The plan has been endorsed by all the WHO Member States in the World Health Assembly of the year 2015. The WHO action plan thus developed in collaboration with Food and Agriculture Organization of the United Nations and World Organization of Animal Health (OIE) recognized that a crisis of this magnitude requires an effective One Health Approach involving coordination among many national sectors and actors, and also different sectors and actors internationally. However, the efforts will be undermined without the support of participant's nations and their foreign offices.
India as one of the nations with the highest burden of bacterial infection has a crude mortality from infectious disease standing at 417/100,000 persons. As per a report by the Indian Network for Surveillance of AMR, a network which monitors 15 tertiary hospitals, 41% of patients had methicillin-resistant Staphylococcus aureus. They reported high rates of resistance to ciprofloxacin, gentamicin, co-trimoxazole, erythromycin, and clindamycin. With a population as high as India has, India's drug resistance is a threat to other nations as well.
An increased in the prevalence of dermatophytosis (ringworm infections) in India has also been observed over the last 5–6 years. This superficial fungal infection has evolved into chronic, recurrent, and recalcitrant difficult to treat infection. Most important factors responsible for this menace are, the rampant abuse of the topical steroid antifungal combination creams as well as emerging drug resistance. Easy availability of inexpensive and irrational corticosteroid–antifungal–antibacterial combinations sold over the counter (OTC) in India promoted as anti-itch creams, fairness cream, and blanket treatment for any skin disorders with combination creams is alarming. The use of topical corticosteroids may affect the antigen receptor recognition capacity of Langerhans cells, and superpotent corticosteroids may lead to loss of cells expressing Langerhans' cell markers as well as potentiate immune suppressive action of dermatophytes leading to chronic infection.
Topical antibiotics incorporated in these combination creams cause serious damage to the barrier function of the skin. The antibiotic usage may result in a selection of drug-resistant bacteria and also contribute to disruption of the normal flora. Surprisingly, out of the available 119 formulations, only 27 featured among the CDSCO's approved list of fixed drug combinations [FDCs]) from 1961 to July 2014 in India. FDCs having corticosteroids for dermatological use are not common in the USA. Furthermore, none of the FDCs available there contains both antibacterial and antifungal agents along with corticosteroids. Furthermore, according to Drugs and Cosmetics Act 1940, the topical corticosteroids fall under the category of schedule H drugs, meaning that they should be sold by retail shops only on the valid prescription of a qualified doctor.
Sensing the importance of AMR, the Government of India has set into action the plan to curb AMR aimed at preventing misuse of antibiotics by doctors, consumers, and health-care institutions. The National Action Plan (2017–2021) has envisaged assigning coordinated tasks to multiple government agencies. These agencies include health, education, environment, and livestock with an idea to change prescription practices and the consumer behavior and therefore to scale up infection control and antimicrobial surveillance.
“We are ready with a blueprint that meets global expectations. The challenge now is in its efficient implementation through a coordinated approach at all levels of use of antibiotics,” words of Shri Jagat Prakash Nadda, Minister for Health and Family Welfare, Government of India.
Are we ready for efficient implementation? Given the fact that an effective implementation of plan will need enforcement of regulations that prohibit the sale of antibiotics without prescriptions in addition to development and promotion of guidelines for appropriate use of antibiotics, and in presence of ample evidence of pressure from patients that “forces medical practitioners to overprescribe antibiotics,” especially for viral illnesses, upper respiratory tract infections, and diarrhea.
Indian plans to curb AMR are a welcome step but experts have warned that our country will require a “huge commitment” from the government to transform words into action. A word of caution from Ramanan Laxminarayan, Director of the Centre for Disease Dynamics Economics and Policy in Washington, DC, USA, who is tracking global trends in AMR, “Many goals in the action plan look gigantic at present, and achieving even 10% of what is being promised will require huge commitment.”
The key stakeholder for carrying forward the agenda of Government on AMR forward is the National Centre for Disease Control (NCDC). The mandate of the Institute broadly covers three areas, namely, services and trained health manpower development and research.
Outbreak investigations are a key component of the services delivered by NCDC in addition to providing quality control of biological. However, one of the key functions of NCDC is research in areas such as the bacterial infections. Apart from NCDC, other key stakeholders in India's fight to prevent AMR is the Indian Council of Medical Research (ICMR) as it continues to be the sole dedicated body to adequately address the research needs, concerns, and goals of the medical professionals in India. In addition, the National Health Systems Resource Centre established in 2007, to assist in policy and strategy development in the provision and mobilization of technical assistance to the states and in capacity building for the Ministry of Health. However, more important than these stakeholders are patients and prescribers, whose participation and involvement is the key to prevention of AMR.
However, despite coordination of all stakeholders, the AMR in India will continue to be individual driven or institution driven unless medical societies drive this coordination between various stakeholders.
OMAG being a diverse and dynamic multispecialty body will provide the necessary resources to enable joint work on addressing health-care needs around the country through an extensive web of networking. Interactions of this nature between experts from diverse disciplines will develop synergies not otherwise possible. AMR is a complex problem across the globe, in humans, animals, and the environment. Therefore, compartmentalized and isolated interventions will have a limited impact. Compartmentalized approaches will prevent governments from delivering the coordinated care that is necessary to tackle AMR. OMAG constituted a committee to look into AMR with specific terms of reference to identify key concerns in the current strategy to overcome AMR and solutions thereafter.
Concerns and Solutions
Laws, regulations, and/or procedures for the prescription/treatment of patients with infectious disease may be out of date or inadequate as the epidemiology of diseases continues to evolve
Solution: Develop guidelines and recommendations that address the legal issues of AMR.
National surveillance systems are inadequate to accurately determine the frequency and patterns of drug-resistance across India
Solution: Develop nationwide surveillance systems for determining the drug susceptibility patterns of persons for selected infectious agents.
Medical college hospitals and large institutional settings have been the focus of AMR. However, the extent of AMR in small health-care settings and in the community has not been well studied. Therefore, epidemiologic studies backed up by robust surveillance data are needed to assess the risk of infection and disease and factors promoting transmission in institutional settings, as well as the extent of community transmission
Solution: Conduct epidemiologic investigations and studies to better define the scope and magnitude of the problem.
High-risk groups such as persons with HIV infection/drug abuse have been the focus of recent AMR; however, the impact various risk factors on AMR has not been well characterized
Solution: Identify and characterize risk factors for AMR.
The most rapid currently available laboratory technologies to identify AMR are not in widespread use in state and local health department laboratories
Solution: Increase the awareness and understanding of AMR in the laboratory community through up gradation of the mycobacteriology capacity of state and local public health laboratories.
The quality of laboratories used by clinicians across India may not be adequate to perform drug-susceptibility tests.
Solution: Evaluate the ability of laboratories to carry out drug-susceptibility tests; enhance their capability as needed.
Inadequate treatment by the patient. Treatment for infections must be given for a minimum fixed period. However, the patients do not complete therapy, take medications incorrectly making the organisms drug resistant
Solution: Provide guidance regarding a step-wise approach to assure completion of therapy for all patients.
Inadequate inpatient facilities are available for long-term treatment of patients with complicated infections, for example, those with multidrug-resistant tuberculosis (MDR-TB)
Solution: Explore varying options for long-term institutionalization of infectious patients, including patients with MDR-TB, and assist health departments in securing funds for financing institutional care.
Drugs needed to treat infections, particularly those with resistance, are often unavailable, and some of them are expensive, which may be an obstacle to effective treatment
Solution: Pharmaceutical manufacturers need to work together to assure an ongoing supply of currently licensed drugs at an acceptable cost.
Migrant, seasonal farm workers, and homeless patients are often not able to complete therapy because of lack of stable income and housing
Solution: Coordinate public health systems so that migrant and seasonal farm workers and homeless have access to diagnosis and treatment.
Inadequate notification, more so in view of large number patients receiving treatment from unorganized sector
Solution: Development of a legal regulatory framework to avoid misuse of high-risk drugs, especially antibiotics
Lack of a standard approach to the evaluation and management of persons exposed to resistant infections
Solution: OMAG will be tasked to develop and publish an approach to the evaluation and management of persons exposed to resistant infections
Inconsistently implemented of protocols/guidelines at the institutional levels
Solution: Assess the effectiveness and feasibility of various infection control strategies in institutional settings and ensure that appropriate procedures are implemented through educational and regulatory approaches.
Expertise regarding treatment of resistant infections is lacking in many parts of the country
Solution: Develop of expertise among health-care professionals in the management of resistant infectious conditions including MDR-TB.
A critical need exists for training researchers to develop new diagnostic assays, therapeutic agents, and vaccines to meet present and future public health needs
Solution: Train adequate numbers of researchers to respond effectively to AMR research needs.
Lack of integrated system for professional information and communication and research on AMR
Solution: Research on AMR needs to be conducted and promoted by a variety of agencies, including NCDC, ICMR, DBT and DST, and others. Coordination of research efforts among these agencies will be important in ensuring that critical knowledge gaps are addressed effectively.
There is a critical lack of knowledge about the basic characteristics of resistant infectious agents (e. g., growth, physiology, biochemistry, genetics, and molecular biology). This knowledge gap is a barrier to the development of new treatment and control modalities
Solution: Provide increased support for basic research on the biology of resistant microorganisms and the host responses to infection.
Existing diagnostic methods to identify persons with drug resistance are very slow, impeding treatment, and control efforts
Solution: Develop and evaluate new technology to rapidly and reliably diagnose cases of drug resistance and identify patterns of drug susceptibility.
Currently available drugs are not sufficiently effective in treating resistance. For example, the duration of therapy required to treat TB with currently available drugs leads to noncompliance with therapy and development of drug-resistant disease
Solution: Encourage the development and evaluation of new drugs and modalities to treat and prevent MDR-TB, as well as to reduce the duration of therapy required to cure drug-susceptible TB.
Currently available vaccines against infections like, for example, TB are not reliably effective in preventing acquisition of TB
Solution: Develop and evaluate new and improved vaccines to prevent infection and disease.
The efficacy of various technologies for preventing transmission (e.g., general and local ventilation, UVGI, and personal protective equipment) has not been adequately evaluated
Solution: Conduct basic and applied research on the efficacy and role of various control methods for preventing transmission.
Various combinations of steroid/antifungal creams are freely available in India and without prescription which need to be banned
Solution: Reporting these adverse effects to regulatory health agencies, along with ensuring strict regulation on OTC sale of irrational combination creams. To strictly enforce only prescription-based sale of medications that are enlisted under schedule H.
There is no sufficient evidence toward correlation of in vitro drug resistance with clinically observed recalcitrant dermatophytosis.
Solution: To conduct multicentric epidemiological studies as well as funding of laboratory-based in vitro drug resistance studies which may throw some light into the menace of recalcitrant dermatophytosis.
Injudicious use of antibiotics and poor patient compliance leads to development of resistance. Compliance is influenced by patient characteristics; characteristics of the health-care environment, including operational factors and compliance-enhancing intervention; and communication between patient and providers, including the quality of interpersonal communication and use of educational materials for transfer of information about the nature of the disease and treatment. However, probably, one of the most worrisome will continue to resistance in TB. Emergence of extensively drug-resistant-TB (XDR-TB) is making the matters worse as an estimated 9.7% of people with MDR-TB have XDR-TB. However, on the positive side, the endorsement by the Heads of State at the United Nations General Assembly in New York in September 2016 signals the world's commitment to initiate a broad, coordinated approach to address AMR across multiple sectors, especially human health, animal health, and agriculture. Whatsoever will need to be seen is the extent of political will on the part of individual countries to follow up on their endorsements.
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