AMR – Emerging as a Global Risk

Antimicrobial resistance, this word has been in air in the last few years and rightly so. Antimicrobial resistance (AMR) is one of the biggest dangers to public health and development worldwide. This revealed, according to the World Health Organisation (WHO). As per the United Nation’s health agency, bacterial AMR is the cause of 4.95 million deaths worldwide in 2019. In addition to, directly causing 1.27 million deaths.

AMR or Antimicrobial Resistance

So, what’s AMR? When bacteria, viruses, fungi and parasites no longer respond to antimicrobial medications, it refers to antimicrobial resistance (AMR). Drug resistance makes antimicrobial medications, including antibiotics, ineffective and makes treating infections challenging or impossible. This raises the risk of spreading infections, serious illness, disability and death.

The National Centre for Disease Control (NCDC) carried out a recent survey from November, 2021 to April, 2022. Antibiotic prescriptions were given to 6,944 (71.9%) of the 9,652 individuals who were part of this study. In total, 12,342 prescriptions for antibiotics were for these patients in total, which translates to an average of 1.8 prescriptions per patient. The surgical wards and intensive care units had the greatest recorded usage of antibiotics overall.

Studies on Antimicrobial Resistance

Rather than treating early infections, doctors gave antibiotics to more than 55% of the patients as a preventive measure. This is raising concerns about the rising threat of antimicrobial resistance (AMR).

“Before the discovery of antibiotics, if one were to catch an infection, say from a small injury to the foot, it could very well prove fatal. The body has some defences against infections but when bacterial infections take hold, antibiotics are lifesaving. Without effective antibiotics, one could die of infections and many medical procedures of the modern age, like a caesarean section, surgery for broken bones, etc. can become extremely risky owing to the risk of untreatable infections. Fortunately, we have an armamentarium of antibiotics to prevent and treat infections in time. However, the use, abuse, and overuse of antibiotics have led to many bacteria (fungi and viruses) developing clever tricks to avoid getting killed by them– they have developed resistance”, says Dr. Rajath Athreya, Senior Consultant and HOD Paediatrics and Neonatology, Sakra World Hospital Bengaluru.

Based on their severity, Dr. Athreya divides AMR into three categories. “It can span from Multidrug Resistance (MDR)– resistant to one or more of four different categories of antimicrobials (less treatment options), extensively drug resistance (XDR)– susceptible hardly one or two categories of antimicrobials (very few safe options of treatment)— to Pan-drug resistance (PDR) where there is no antimicrobial that will work.”

Global Impact of AMR

WHO says that, in addition to death and disability, AMR (antimicrobial resistance) has significant economic costs as well. According to World Bank projections, AMR could lead to $1 trillion in increased medical expenses by 2050 and $1 trillion to $3.4 trillion in annual losses in GDP by 2030. For instance, it demands more costly and intense treatment, which lowers productivity for patients and their families due to extended hospital admissions.

“For many years, we have had no new credible antimicrobial or antibiotic agents to tackle. So, there is a continued resistance to old microbes. The antibiotics work in different ways. Some inhibit the enzymes that are necessary for the survival of the microorganisms. Whereas some inhibit the attachment of the micro-organisms to the cells. Some contain the necessary ingredients that are for microbial growth. Over the years, these microbes have found a way to bypass the resistance and that’s how they are becoming used to antibodies. Many people overuse it and buy it on their own, leading to indiscriminate use. We need to have a strong policy regarding the use and prescription of antibiotics”, says Dr. Anantha Padmanabha, consultant, internal medicine, Fortis Hospital, Nagarbhavi, Bengaluru.

Delving into the workings of antibiotics in detail, Dr. Mustafa Afzal, Consultant Microbiologist and Infectious Diseases, CARE Hospitals, Nampally, Hyderabad, explains, “Antibiotics target specific aspects of bacterial physiology, such as cell wall synthesis, protein synthesis, or DNA replication, disrupting essential processes. There is a connection between overuse/misuse and resistance.”

He adds, “Overuse or misuse of antibiotics exerts selective pressure on bacteria. Exposure to antibiotics encourages the survival and proliferation of resistant strains as susceptible bacteria are eliminated. Secondly, the resistant genes can be transferred between bacteria, even different species, through mechanisms like plasmids. Overuse facilitates the transfer of these resistance genes, spreading resistance rapidly. Thirdly, incomplete treatment allows partially resistant bacteria to survive, and they can evolve into fully resistant strains over time, contributing to the overall pool of resistant microbes.”

What Survey Says

Every year, a record of around 2.8 million antibiotic-resistant illnesses is in the United States. The 2019 Antibiotic Resistance (AR) Threats Report from the CDC states that over 35,000 individuals pass away as a result. Including Clostridium difficile, a non-resistant bacterium that can cause fatal diarrhoea and is in link to the use of antibiotics. The combined death toll in the US from all the risks in the report caps 3 million infections and 48,000 deaths. 

A germ (bacterium) known as Clostridium difficile, or C. diff, is what causes potentially fatal diarrhoea. Usually, it is an adverse reaction to antibiotics.

The drug-resistant infections impact the health of animals and plants, reduce productivity on farms, and threaten food security. Talking of solutions, Dr. Padmanabha says, “Healthcare professionals should be educated not to take over the counter antibiotics, not to take it from pharmacists, and not to use left over antibiotics. They need to spread awareness regarding the judicial use of antibiotics. In well-disciplined hospitals, we have antibiotic stewardship, wherein we monitor the use of antibiotics specifically for inpatients. We have to spread knowledge of when to escalate antibiotics and when to de-escalate them, their proper dosage and their duration. By practising such measures, we can prevent resistance to antibiotics.”

There is also a need to create robust systems for reporting antimicrobial usage, infrastructure technology, and resources. This is to conduct comprehensive surveillance to understand emerging patterns of resistance. Health practitioners like Dr. Afzal also emphasises on standardised reporting and data collection methods across countries. Furthermore, a global cooperation among countries as AMR or antimicrobial resistance is becoming a global risk.

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