ANTIMICROBIAL RESISTANCE
What is Antimicrobial resistance?
Antimicrobial resistance (AMR or AR) is the ability of a microbe to resist
the effects of medication that once could successfully treat the microbes
Antimicrobial resistance is the phenomenon whereby bacteria exposed to
the same antibiotic for a prolonged period of time mutate and become
resistant,
 Bacteria, not humans or animals, become antibiotic-resistant.
 These bacteria may infect humans and animals, and the infections they
cause are harder to treat than those caused by non-resistant bacteria.
 Antibiotics resistance occurs naturally, but misuse of antibiotics in humans
and animals is accelerating the process.
A growing number of infections – such as pneumonia, tuberculosis, are
becoming harder to treat as the antibiotics used to treat them become less
effective. It leads to higher medical costs, prolonged hospital stays, and
increased mortality.
• Superbugs is a term used to describe strains of bacteria that are
resistant to the majority of antibiotics commonly used today
• Example of AMR: MDR-TB(multi drug resistant TB)
Major causes of AMR
Some bacteria due to the presence of resistance genes are
intrinsically resistant and therefore survive on being exposed to
antibiotics.
Bacteria can also acquire resistance. This can happen in two ways:
By sharing and transferring resistance genes present in the rest of the
population or
By genetic mutations that help the bacteria survive antibiotic
exposure.
Once the resistance has been acquired, it can spread in the rest of
the population of bacteria through reproduction or gene transfer.
Reasons for the Spread of AMR
1.Excessive use of antibiotics
Consumption in poultry and cattle:
over two-thirds of the antibiotics manufactured by the pharmaceutical
industry are used as growth promoters for poultry and cattle.
 An article published this year in Science points out that globally 73% of all
antimicrobials sold are used in animals raised for food.
Consumption in humans:
 The remaining one-third is used to treat human ailments.
Of this, the common public purchases more than half without a doctor’s
prescription, according to the WHO
Social factors
Include self-medication.
Access to antibiotics without prescription.
Lack of knowledge about when to use antibiotics
Cultural Activities:
• Mass bathing in rivers as part of religious mass gathering occasions
Hospitals and bulk-drug manufactures
Hospital effluents also contain high concentration of antibiotic
resistant genes and antibiotic resistance bacteria and it is reported
that less than 45 per cent of hospitals have wastewater treatment
facility.
Indiscriminate dumping of untreated waste led to emergence of
superbugs
it is reported that less than 45 per cent of hospitals have wastewater
treatment facility.
Sludge from treatment technologies is less studied for occurrence of
antibiotics, ARB and ARG. As sludge is used as soil amendment in
agricultural fields, treatment of sludge should be prioritised and
protocols must be established
Example:
MDR-TB
NDM-1 superbug: NDM-1 gene is an antibiotic resistance gene. When
present in a bacteria like E.coli, it acts as a superbug because it
enables the bacteria to produce a highly chemical /enzyme called
New Delhi metallo Beta Lactamase Enzyme making the bacteria
resistant to stronger and newer antibiotic belonging to Carbapenems
group
Scientists have recently isolated resistant causing MCR (Mobilised
Colistin Resistance)-1 gene in a strain of E.coli in India. MCR-1 gene is
responsible for resistance against the antibiotic colistin which is
considered to be the last mile antibiotic that the human race has
currently access to. This is alarming news and could make India’s fight
against AMR all the more difficult.
Environmental Sanitation
Untreated disposal of sewage water bodies - leading to
contamination of rivers with antibiotic residues and antibioticresistant organisms.
Infection Control Practices in Healthcare Settings
A report on hand-washing practices of nurses and doctors found that
only 31.8% of them washed hands after contact with patients
Impacts
Antimicrobial resistance has economic impact too:
A study published in The Lancet Infectious Diseases in August 2014
reported that BRICS countries — Brazil, Russia, India, China and South
Africa — consumed 76 per cent of the overall increase in global
antibiotic consumption between 2000 and 2010, of which 23 per cent
was attributed to India.
Of the total medicine sales worth $12.6 billion in India between 2013
and 2014, antimicrobials contributed to around 16.8 per cent.
• one way to understand the economic costs attributable to AMR is
through the production function approach — increased AMR-related
mortality would reduce the size of the working population, whereas
increased AMR-related morbidity would reduce the working
population and may also reduce the labour force’s efficiency.
• A World Bank report suggests that the impacts of AMR on poverty are
particularly concerning. In the high AMR-impact scenario, an
additional 24 million people would be forced into extreme poverty by
2030 and unfortunately, most of the increase would occur in lowincome countries
Economic costs in context of India
• Based on the HISTI(statistical) model and other relevant information
from recent scientific literature, the current estimate of ‘human’
antibiotic consumption for India would be about 20-22 billion
Standard units (population estimated as 1.35 billion).
• A standard unit of an antibiotic (SU) is the number of doses sold in a
country; a dose being a pill or capsule or ampoule.
• So, the estimated economic cost due to antibiotic resistance for India
(@ Rs 32 / SU) could be about Rs 64,000–Rs 70,400 crore
• we can take the estimated compounded economic costs to India,
considering a one-fold enhancement due to each sector, to be
between Rs 128,000 and Rs 140,800 crore after contribution of the
non-human sector,
• Rs 192,000- Rs211,200 crore after further contribution from the
environmental sector
• and Rs 256,000-Rs 282,000 crore after further contribution due to the
socioeconomic-behavioural factors.
Other impacts
Medical procedures such as organ transplantation, cancer
chemotherapy, diabetes management and major surgery (for
example, caesarean sections or hip replacements) become very risky.
The failure to treat infections caused by resistant bacteria also poses
a greater risk of death.
Antimicrobial resistance increases the cost of healthcare with
lengthier stays in hospitals, additional tests and use of more
expensive drugs.
Without effective antibiotics for prevention and treatment of
infections, the achievements of modern medicine are put at risk.
Without urgent action, we are heading to antibiotic apocalypse – a
future without antibiotics, with bacteria becoming completely
resistant to treatment and when common infections and minor
injuries could once again kill.
Antimicrobial resistance is putting the gains of the Millennium
Development Goals at risk and endangers the achievement of the
Sustainable Development Goals.
Prevention and control of AMR
By WHO:
WHO launches tool for safer use of antibiotics, curb resistanceAWaRe.
It is an online tool aimed at guiding policy-makers and health
workers to use antibiotics safely and more effectively.
The tool, known as ‘AWaRe’, classifies antibiotics into three groups:
Access — antibiotics used to treat the most common and serious
infections.
Watch — antibiotics available at all times in the healthcare system.
Reserve — antibiotics to be used sparingly or preserved and used
only as a last resort.
WHO launched Global action plan for AMR(2015)
To achieve this goal, the global action plan sets out five strategic
objectives:
to improve awareness and understanding of antimicrobial resistance;
to strengthen knowledge through surveillance and research;
to reduce the incidence of infection;
to optimize the use of antimicrobial agents; and
develop the economic case for sustainable investment that takes
account of the needs of all countries, and increase investment in new
medicines, diagnostic tools, vaccines and other interventions.
One Health’ approach: to designing and implementing programmes,
policies, legislation and research in which multiple sectors
communicate and work together to achieve better public health
outcomes against the food safety, the control of zoonosis (diseases that
can spread between animals and humans, such as flu, rabies),
antimicrobial resistance etc.
Initiatives by India
National Action Plan on AMR resistance 2017-2021
Six strategic priorities have been identified under the NAP-AMR
1. Enhancing awareness among masses and strict adulteration laws.
2. Strengthen knowledge and evidence through surveillance.
3. Optimize the use of anti-microbial agents.
4. Reducing infections
5. Promote investments, research, and innovations.
6. Strengthen leadership on AMR through international collaborations
India has adopted the guidelines-Schedule H1 and Schedule X under
Drug and cosmetic rules where the drug packaging has a red border
and with a warning to be sold based on the proper prescription of a
registered medical practitioners
There is a high degree of regulation for Schedule X which requires a
special licence and this is only with few pharmacies under large
hospitals and also based on triplication of prescription
Red Line Campaign on Antibiotics 2016, was launched to create
awareness regarding rational usage and limiting the practice of selfmedication of antibiotics among the general public
The Food Safety and Standards Authority of India (FSSAI) banned the
use of antibiotics and several pharmacologically active substances in
fisheries
India joined the Global Antimicrobial Resistance (AMR) Research and
Development (R&D) hub.
This expands the global partnership working to address challenges
and improve coordination and collaboration in global AMR R&D to 16
countries, the European Commission, two philanthropic foundations
and four international organisations (as observers
Improving awareness through effective communication and
education among all the stakeholders including public , policy makers
and health care professionals
Strengthening surveillance on AMR which means strengthening the
laboratories in animal health , human health , food and environment
for the detection of AMR which can support evidence based
policymaking
To reduce the burden of infection in the society by maintain proper
sanitation and hygiene
How technology can play a role in combating
antimicrobial resistance
ANTIMICROBIAL RESISTANCE (AMR) AND
COVID-19
The research has raised concerns of the impact of COVID-19 on AMR
globally. The World Health Organisation recently expressed fears that
the pandemic will increase the global threat of AMR as many COVID19 patients receive antibiotics as part of their treatment regime