Too many children are given antibiotics before the age of two years, adding to the problem of antibiotic resistance in country, a new study for the World Health Organisation has found.

The study conducted by an international team of medical researchers including doctors from Vellore’s Christian Medical College, followed children across eight countries, including India, from birth until they were two years old. More than 2,000 healthy children born between November 2009 to February 2012, including 251 children were enrolled in Vellore.

Incomplete treatment or unnecessary use of antibiotics makes pathogens resistant to the drugs used and therefore, the drug ineffective in treating the person infected with drug-resistant the bugs. “Since we have limited antibiotics, it is not a good thing to use antibiotics when it is not required,” said Dr Gagandeep Kang of Christian Medical College, who led the study in India.

India has a serous antibiotic resistance problem, which it has woken up late to and struggling to cope with. Alarms first went off in 2008 when a so called superbug was discovered to have originated in New Delhi and therefore named after the city. The New Delhi Metallo-beta-lactamase-1 enzyme conferred resistance in bacteria to a large number of drugs. Drug resistance has been spreading in India due to several factors – unregulated prescription and sale of antibiotics by doctors and pharmacies; factories manufacturing the drugs not treating effluents properly, letting antibiotics enter water and the environment; and even the use of antibiotics in poultry farms, thereby entering the food cycle.

In September 2016, a group of researchers found that nearly 60,000 newborn babies die from antibiotic resistant neonatal infections in India every year after contracting sepsis that is untreatable because the bacteria causing the infections is resistant to drugs.

The new WHO study, published in the Bulletin of the World Health Organisation this month, showed that a large number of children were given antibiotics to treat problems like diarrhoea and respiratory infections, even when antibiotic treatment was not needed. More than half the children had received antibiotics before they were six months old. The other study sites included Dhaka in Bangladesh, Fortaleza in Brazil, Bhaktapur in Nepal, Naushahro Feroze in Pakistan, Loreto in Peru, Venda in South Africa and Haydom in United Republic of Tanzania.

Antibiotics, even when not needed

The researchers conducted surveillance for antibiotic usage and checked the proportion of diarrhoea and respiratory illness episodes that were treated with antibiotics. As per international guidelines, the study states, antibiotics are recommended only for diarrhoea with bloody stools and for acute lower respiratory tract infections, but not for non-bloody diarrhoea and upper respiratory infections, like a simple cold and cough.

A sizeable proportion of children in the study were given antibiotics when it was not required. Of the 251 children who were followed by the Vellore researchers, 24.1% of the total number of 913 non-bloody diarrhoea episodes were treated with antibiotics. More than 45% of the 61 bloody diarrhoea episodes were treated with antibiotics.

A similar pattern followed even for the treatment for respiratory illnesses, often cold and cough. More than 23% of the 2,325 episodes of non-specific respiratory illnesses were treated with antibiotics. In case of acute respiratory illnesses, like pneumonia and bronchitis that affect the airways and lungs, 39.8% of the 913 episodes were treated with antibiotics.

The data indicates that many cases of acute respiratory tract infections and bloody diarrhoea were not treated with antibiotics.

Most childhood diarrhoea and respiratory illnesses caused by viruses and therefore antibiotics are ineffective, said Kang who led the Vellore arm of the study. “For cold, cough and fever, until we have some kind of evidence that the infection is bacterial, no antibiotics should be prescribed. In case the child becomes sicker or has pneumonia, you should use antibiotics.”

Kick to the gut

Often poor patients in India and other Asian countries seek medicines from pharmacies instead of prescriptions from doctors. “ While many doctors say that patients demand antibiotics, it is not true,” said Kang. “They demand treatment. The doctors tell them that they would provide strong medicines, which is totally inappropriate. Frequently children are given injectable antibiotics, which can lead to even more resistance.”

The use of antibiotics could also have some harmful developmental effects, research shows, like changing the healthy bacterial environment of the gut, or the gut microbiome.

Mostly, the ill-effects of excess use of antibiotics is not known yet. “The bacteria has various kind of functions in the gut, but we do not know yet how it affects gut function,” said Kang.