One evening in March 2019, one of us brought home their eight-and-a-half-month-old infant from an institution in southern India through adoption. The baby had a raging fever and both her ear drums were perforated, oozing pus and mucous. She had projectile diarrhoea and was severely malnourished and underweight.
Over the course of the next three months, the parents ran from pillar to post across the country to find a cure for her recurrent ear infections. Bacterial cultures of the pus revealed that the baby had contracted a multidrug resistant Pseudomonas Aeruginosa infection while she was in the care of the institution.
Multidrug resistance refers to the occurrence of pathogens against which multiple, otherwise effective, antimicrobial drugs are rendered ineffective.
After five rounds of bacterial cultures, intravenous antibiotics, and multiple rounds of oral antibiotics, her parents discovered that she was unresponsive to first-line, second-line or third-generation antibiotics. When allopathy failed, they consulted alternative care practitioners. Nothing helped. Meanwhile, the baby gained weight with quality nutrition and care.
The parents still do not know what finally helped but an old-school paediatrician told this harried pair that it was likely the baby’s own immune system that overcame the infection after six months of round-the-clock care. The ear healed, leaving no lasting damage to her hearing.
This is a story with a happy ending. But that is not the case in most instances of multidrug resistant infections in India. Multidrug resistant infections are commonly seen in patients in long-term care such as intensive care units or neonatal intensive care units.
A study examined some of the most common and lethal pathogens in India, such as Enterococcus spp., Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter spp over a 10-year period in hospitalised patients. It found that patients who carried one of these pathogens died nearly two to three times more frequently than those who did not.
A World Health Organization multi-country study conducted in 2015 found that the general public had little understanding of multidrug resistant infections, how to prevent them or the real threats they posed.
As is being seen in strains of the coronavirus, all microbes (bacteria, viruses or fungi) undergo changes in their genetic material. In due course, those strains of microbes that are well equipped to deal with insults – a medical term used to describe attacks against pathogens, such as those by drugs – survive the test of time. Hence, the microbes capable of resisting antimicrobial drugs are selected by evolutionary processes.
Multidrug resistance can kill patient zero – a term used to refer to the first carrier of a disease – and when it spreads to others, it can kill them as well.
Globally, India has the highest burden of both TB and MDR-TB. In 2018, India had 130,000 cases of drug-resistant tuberculosis. Tuberculosis patients have been the invisible casualties of the Covid-19 pandemic because they were unable to visit outpatient departments to get medication and hence more likely to develop multidrug resistant tuberculosis.
The year 2020 had the highest burden of tuberculosis deaths in the last seven years.
Multidrug resistant tuberculosis and XDR-TB – where “X” stands for “extensively” – have killed not just patients but their families and hospital staff, including physicians, over the years.
Not adhering to the long and often complex treatment regimen is one of the reasons why an individual may develop multidrug-resistant tuberculosis. Other factors include a weakened immune system due to poor nutrition and exposure to environmental toxins.
The evolution of antimicrobial resistant pathogens is a natural process. However, some factors hasten this process and help explain the increasing trend of multidrug resistance in India.
(a) an irrational and overuse of antibiotics for illnesses where the origin of an infection has not been established
(b) not completing the full course of antibiotics and in prescribed dosage, but stopping as soon as one starts to feel better
(c) antibiotics seeping into our food supply through their use and abuse in agriculture, poultry, dairy, and cattle industries
(d) a weakened immune system because of malnutrition, chronic hunger or undernutrition.
Some studies have speculated that an increased prescription of antibiotics during the Covid-19 pandemic, may have enhanced the entry of multidrug resistant bacteria, especially in hospitals.
This is more cause for concern because these pathogens are difficult to get rid of, even in the more sanitary facilities of wealthy countries. In India, where sanitary facilities in health institutions are far from optimal, this is a real threat.
On this World Patient Safety Day on September 17, with the theme of “medicine safety”, what can be done to limit the threat of multidrug resistant infections in India? Doctors in teaching hospitals and public hospitals are more likely to adhere to protocols, ironically due to resource constraints, and thus are also likely to be more prudent in using antimicrobials, compared to registered medical practitioners and unqualified practitioners.
“Irrational” drug prescription could also be due to other factors. A study in Hyderabad identified issues such as the clinical dilemma of managing an individual patient versus the larger public good and the lack of clear institutional guidelines and monitoring of antimicrobial use. Other reasons included the lack of enforceable regulations against misuse and self-prescription, and “physician habits” as contributors to irrational antimicrobial use.
A natural first step is to ensure that physicians adhere to first principles of appropriate use: use antibiotics only when necessary, and use the right one in the right dose for the right duration. Physicians must stop prescribing antibiotics irrationally and especially on patient demand.
Second, patients should be educated on the risks of multidrug resistance. This is especially in case of patients with limited medical literacy who might not complete their course of treatment or share medicines with family members with similar symptoms.
This, of course, raises several connected issues about access to medicines for those who cannot afford to pay for them despite the fact that India does have one of the lowest costs of generic medicines globally.
Thirdly, the sale of such medicines needs to be strictly regulated. This can be done because it is virtually impossible to get psychiatric medicines without prescription but the same is not true of antibiotics.
Finally, the importance of preventive healthcare such as quality nutrition, hand hygiene and masking when unwell need to become a part of preventive healthcare measures at all levels, especially in primary healthcare centres.
Health is intimately connected to other systems – sanitation and access to clean water, access to dignified work that pays a living wage, an environment that is clean, access to quality nutrition at a price that everyone can afford and a peaceful life. Many citizens find it difficult to access these.
Days like today are a reminder that we need to anticipate threats to health, be proactive in ensuring our well-being and work towards quality healthcare for those who are unable to access it.
Sreeparna Chattopadhyay is a medical anthropologist. She is an Associate Professor in the School of Liberal Education at FLAME University, Pune. V Srinidhi is a medically qualified doctor and a social scientist. He is an Assistant Professor at the Ramalingaswami Centre for the Social Determinants of Health at the Public Health Foundation of India, Bangalore.
September 17 is World Patient Safety Day.
World Patient Safety Day is observed on September 17.
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