Dealing with drugs that don't work

 E Kumar Sharma        Last Updated: December 15, 2015  | 21:07 IST

E Kumar Sharma, Associate Editor
On a recent visit to a hospital, one saw a doctor who was explaining to a patient the growing menace of antibiotic resistance. Here is a nugget from that conversation worth listening in to: "Your chest infection can be cured with this antibiotic if you take the complete course. But if you stop taking it midway, next time you end up with an infection, there is a good chance you may need to be admitted to a hospital and given the drug intravenously. And mind you, it is also likely that it may still not work. In which case you will not only be forced to stay longer in a hospital and not just incur more expenses but also make yourself vulnerable to some hospital acquired infections that many antibiotics are not able to treat today." ...."As a golden rule it is best not to stay admitted in a hospital for more than a week," the good doctor added.

We are all aware of this problem. After all, enough has been written about how antibiotics are slowly becoming ineffective in curbing some infections. But then there are new concerns and it is high time this issue gets due attention.

In India, much of the problem stems from misuse of antibiotics. For starters, many of are available across the counter at medical stores, though thankfully of late it is becoming difficult at least in some states - such as Maharashtra - where one needs to produce a valid prescription.

But the problem does not end there because it is being administered at random - either by doctors or through self-medication with little discipline observed by patients in completing the full course of antibiotics.

It is now getting to be so acute that even simple infections that were easily treatable in the past are becoming life-threatening. The most visible example of this is getting to be the 'Klebsiella' pathogen or bug that is becoming resistant to Colistin, the last antibiotic available in the world for dealing with infections that all other antibiotics are unable to treat.

Talk to experts on how severe the problem is in India and it does seem worrying. Colistin (or Polymyxin E) is today the treatment of choice for Carbapenem resistant bacterial infections. Carbapenems are antibiotics used for the treatment of infections caused by multidrug-resistant (MDR) bacteria.

These are used largely on people who have been hospitalised for a long time. "Colistin use has increased in the last couple of years in Indian hospitals due to increase in prevalence of carbapenem resistant-bacterial (mainly K. pneumoniae and Acinetobacter species) infections. In India, the prevalence of Carbapenem-resistant K. pneumoniae increased from 29 per cent in 2008 to 57 per cent in 2014 (Source: http://resistancemap.cddep.org/)," says Sumanth Gandra, an infectious disease physician, Fellow at Center for Disease Dynamics Economics and Policy, New Delhi and a co-investigator for Resistancemap Project, which makes him a go-to expert on antibiotics resistance.

He adds: "Accordingly, Colistin use has increased that lead to emergence of Colistin resistant K. pneumoniae species. Colistin resistant K. pneumoniae strains emerged in 2012 and in 2014, about 3 per cent of K. pneumoniae are resistant to colistin." This therefore, he feels, "is concerning as we do not have any antibiotics to treat Colistin resistant K. pneumoniae. Not only K. pneumoniae, we also observed that 3 per cent of E. coli bacteria are colistin resistant in year 2014."

So, what can be done about this? "Currently, Colistin resistant K. pneumoniae bacteria are confined to hospital settings and seen mostly among severely ill patients (patients in intensive care units, who underwent transplants or chemotherapy) who are hospitalised for a week or more. It is very important for hospitals to practice infection control measures (like hand hygiene, sterilizing the equipment, thoroughly cleaning patient rooms, putting patients with these infections in special wards or in private rooms) to prevent spread of these bacteria and use carbapenems and colistin antibiotics only if absolutely necessary," says Gandra.

Ask doctors on how these infections tend to occur at times in hospitals. Typical culprits could be urinary tract infection from catheter tubes, ventilator-acquired pneumonia, post-surgery infections or cardiac catheterisation.

It is not as if solutions are not available. The simplest and easiest starting point is learning and practising what experts in this space have been advocating for a long time. Take for instance, Peter J. Pronovost, a critical care researcher at the Johns Hopkins School of Medicine in the US, who has pioneered the use of simple checklists that doctors and hospitals can use.

As is to be expected, a little caution that ensures antibiotics are not prescribed indiscriminately and insisting that patients complete the full course of antibiotics and, most important, first prefer lower-level antibiotics and move up only when it does not work rather than first opting for a sledgehammer to kill a fly. Below are some worrying graphs that Gandra shared:


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