Antimicrobial resistance continues to rise as countries increasingly report high rates of resistance among antimicrobials used to treat common infections, according to the State of the World’s Antibiotics report, 2021, which highlights a 30 percent increase in per capita use of antimicrobials from 2010 to 2020 in India.
Since the first State of the World’s Antibiotics reports in 2015, antimicrobial resistance has levelled off in some high-income countries but continues to rise in many low- and middle-income countries (LMICs), where access to antibiotics has risen with increases in gross domestic product per capita.
The report released by researchers at the Center For Disease Dynamics, Economics & Policy (CDDEP) presents extensive data on global antimicrobial use and resistance. The report is based on the center’s extensive research through ResistanceMap, a web-based collection of data visualization tool that allows interactive exploration of antimicrobial resistance (AMR) and antibiotic use trends in countries across the globe.
“Per capita, antibiotic consumption in LMICs is lower than in high-income countries, despite a higher infectious disease burden; however, consumption rates are rapidly converging. These trends reflect better access to antibiotics for those who need them and increases in inappropriate antibiotic use,” said Ramanan Laxminarayan, Director at CDDEP.
Levels of resistance in LMICs are “extraordinarily high”, exceeding 20 per cent in many instances and going as high as 80 per cent, Laxminarayan said in a webinar discussing the report.
One major driver of resistance is the overuse and misuse of antibiotics in human healthcare. The other important driver of resistance is antibiotic use in humans and terrestrial and aquatic animals raised for human consumption. Global antibiotic consumption in humans increased by 65 per cent between 2000 and 2015, whereas consumption in animals is expected to increase by 11.5 per cent between 2017 and 2030. If nothing changes to alter these trajectories, antibiotic consumption is likely to increase worldwide by 200 per cent between 2015 and 2030, the report warns.
Among the changing patterns in antimicrobial resistance, the report underscored the rapid emergence of resistance to first-line antimicrobial agents among the pathogens that cause HIV, malaria, and typhoid fever, threatening global progress in eliminating these infectious diseases.
Lack of Access to Antimicrobials Still a Problem in Low and Middle Income Countries
Although AMR poses an urgent global public health threat, more people in LMICs die from lack of access to antimicrobials than from resistant infections, stressed the report. Global efforts to reduce the inappropriate use of antimicrobials and to mitigate AMR must also increase consistent access to affordable and clinically appropriate antimicrobials. Antibiotic research and development lag behind the clinical need and the antibiotic pipeline is not equipped to mitigate the effect of increasing resistance o current antimicrobials.
“Increasing antibiotic consumption itself is not a problem; in fact, we argue always that increasing access to antibiotics among people who previously did not have access is an important role. You have to remember that even in a country like India, about a 150,000 children die every year because of the lack of access to just penicillin. On the one hand, we have a lack of access to a simple drug that literally costs pennies and on the other hand, we have resistance because people buying extremely expensive antibiotics that they absolutely do not need,” said Laxminarayan.
It’s not an easy problem to solve.
“It requires making the penicillin available but also curtailing the access to newer antibiotics that may not necessarily be needed but then that has incentive problems from the side of pharmaceutical companies that are trying to develop those drugs,” noted Laxminarayan.
The report also discusses the Drug Resistance Index (DRI); the index provides an aggregate trend measure of the effectiveness of available drugs, akin to the way composite economic indices are used to track movement in consumer prices and stock market values.
“The higher the drug resistance index, the worse is the problem of resistance. It is a combination of having a high level of drug resistance pathogens and also not having newer antibiotics that could deal with those drug-resistant pathogens and in some cases, if countries are using more advanced antibiotics also they could have a lower DRI,” observed Laxminarayan.
High-income countries (among them, Sweden, Canada, Norway, Finland, and Denmark) had the lowest DRIs, and LMICs, such as India, had the highest, reflecting the very low effectiveness of antibiotic therapy. In LMICs, higher DRI values may reflect a relatively lower level of antibiotic effectiveness due to limited access to newer, more effective antibiotics, revealing where resistance poses a more significant problem.
Referring to the high Drug Resistance Index among LMICs, community medicine expert Khan Amir Maroof, emphasised that a higher prevalence of infections and overuse and misuse of antibiotics in LMICs mandate that the policies should be contextual and consider the socioeconomic factors.
“Lower socioeconomic status is associated with lack of access to safe water, hygiene, proper nutrition. Even access to healthcare is limited,” Maroof, Professor, Department of Community Medicine,
University College of Medical Sciences & GTB Hospital, Delhi, told The Quint.
Maroof, who was not associated with the report, said that on a priority basis, every hospital should have an AMR policy regarding infection control and antibiotic use.
“Strengthening of intersectoral coordination between healthcare providers, the pharmaceutical industry, the agriculture sector, is needed to control this problem. On the other hand, more research to develop newer drugs for resistant strains is also needed. Even though policies are in place to prevent such sale of antibiotics without prescriptions, more needs to be done regarding its implementation. With the increasing trends in resistant tuberculosis and other diseases, in India, we need to address this as a high priority measure. AMR has the potential to reverse the gains we have had in controlling infectious diseases in India,” he added.
The introduction of the Global Action Plan in 2015 by the World Health Organization (WHO), Food and Agriculture Organization, and Organization for Animal Health gave impetus to the global response. India unveiled its National Action Plan (NAP) on AMR (2017-2021). States such as Kerala, Madhya Pradesh and Delhi have framed their action plans.
COVID-19 and Antimicrobial Resistance
Meanwhile, the COVID-19 pandemic has served as a reminder of the tremendous economic and social damage that infectious diseases can unleash. “Among the casualties of COVID-19 is some of the progress made on antimicrobial resistance. Healthcare systems across the world are under immense pressure leading to changes in practices that can drive antimicrobial resistance and impact stewardship activities,” said Laxminarayan.
“Recent research suggests that the pandemic may be encouraging the overuse of antibiotics, partly because of misinformation about antibiotics’ benefits as treatment options for COVID-19 patients. Antimicrobials continue to be prescribed for viruses, and countries have reported increasingly high rates of resistance among drugs used to treat common infections,” Laxminarayan told The Quint.
Maroof added: “Reports show that COVID-19 increased the consumption of antimicrobials in India. It increased among the COVID-19 suspected or confirmed cases as these patients were at a higher risk of bacterial superinfection. The panic-buying phenomenon of potential treatments among the general public to protect themselves from this disease implies that there was a surge in antimicrobial consumption. As this pandemic led to the disruption of routine health care delivery, there may have been interruptions in drug supplies related to TB and HIV among others. There is a possibility of the emergence of resistance cases in such situations. Reduced vaccinations during COVID-19 pandemic also might have led to higher infection rates and antimicrobial consumptions.”
Sahana Ghosh is a microbiologist-turned-journalist. She writes on science and environment and is interested in science in remote areas.)
(At The Quint, we question everything. Play an active role in shaping our journalism by becoming a member today.)