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Friday, November 27, 2015

Lancet begins series on Antibiotic Resistance

Contributed by: Siddarth David & Dr. Tamhankar

Last week the Lancet began a series titled "Access to effective antimicrobials: a worldwide challenge" to look at how to preserve access for populations who need antibiotics and how to maintain the effectiveness of the antibiotics. The series urges that while renewed focus on understanding which policies will work to combat antimicrobial resistance  is critical, but it also essential to tackle lack of access to antimicrobial drugs remains a major issue. 

Dr. Narayan Laxminarayan from the Centre for Disease Dynamics, Economics and Policy (CDDEP) and colleagues used Latin Hypercube sampling to determine the impact of effective antibiotic use in 101 countries. They found that increased antibiotic delivery would avert approximately 445,000 community-acquired pneumonia deaths in children aged younger than 5 years. They also observed a growing trend in antibiotic consumption, with a 36% increase in 71 countries from 2000 to 2010 and pointed out that further progress, however, this could be hindered due to pathogen resistance, according to researchers.

Laxminarayan and colleagues concluded that the best way to fight resistance is to improve hygiene practices and water quality while strengthening public health departments rather than depending solely on antibiotic use, which is the current trend in medicine. 

Thursday, November 12, 2015

Please do not prescribe/ sell/ purchase or consume antibiotics without appropriate reason

Cross-Resistance: An overlooked threat beyond direct antibiotic resistance

Gopal Gunanathan Jayaraj & Dr. A.J.  Tamhankar

 We are already at the brink of a post-antibiotic era where very soon even the most advanced fifth generation antibiotics like cephalosporins will fail to work against common infectious agents ( ). Current estimates by the WHO and CDDEP indicate that countries like India and China run the greatest risk of losing out on the utility of our antibiotic arsenal against infectious agents ( ). This risk is even more pronounced in India where a combination of unrestricted access, rampant overuse and general lack of awareness dominates the burden on healthcare.
It is a commonplace practice in India where people from lower socio-economic strata or sometimes even from the upper socio-economic strata from both urban and rural areas avoid going to the doctor and procure “medicines” directly from the pharmacist without a diagnosis. For example a person having a fever and cough/running nose is supplied with antibiotics like Ciproflox/Gatiflox 400 or Erythromycin 500 along with Crocin/Paracetamol, ( “medicines” for the consumer) by the pharmacist – as a common medication for the patient`s complaint. However in most cases, the symptoms may be due to a viral infection and thus cannot be treated at all with antibiotics like Ciproflox/Gatiflox 400 or Erythromycin500. For a person having a fever of viral origin, the paracetamol would help subside the fever and the cough/running nose will be over in most cases in a short period of time, being self limiting. However, the unnecessary consumption of Ciproflox/Gatiflox 400 or Erythromycin 500 does something far more dangerous. Being unnecessarily taken, it would expose resident bacteria (we carry several types of bacteria in our body systems, which do not cause any harm) that are not causing the symptom, i.e. cough/running nose and fever, and the consumption of antibiotic without any need, would expose them to antibiotics and leave behind bacteria in which antibiotic resistance has been initiated.
A very simplistic explanation of how antibiotic resistance arises can be summed by the quote “What does not kill something makes it stronger (by just the experiencing it)” by Friedrich Nietzche, which means in our current case that, improper and incomplete usage of antibiotics leads to surviving microbes becoming resistant to that given drug. However this is a very one-dimensional view where our understanding centers on ‘use of single drug imparting resistance to the same drug’. The reality of the situation is however far more
complex, any single antibiotic can also confer resistance to antibacterial drugs other than itself. This phenomenon is quite well known and is called cross-resistance.Although cross-resistance has been observed for almost four decades, in individual cases where one drug was tested against another, recent developments in technology have provided a platform to exponentially increase the scale at which these studies can be conducted. Using large scale experiments, recent studies ( ) have provided a proof of concept that many clinically important antibiotics have varying degrees of cross resistance to more than one antibiotic.
This is particularly hazardous in India, where there is no or little restriction on over-the-counter purchase of any antibiotic without a prescription (as illustrated in the example earlier). To be more specific, the person who consumed Ciproflox/Gatiflox 400 or Erythromycin500 for cough/running nose and fever in the example cited in an earlier paragraph earlier, may, after unnecessary consumption of these drugs, harbor bacteria, which are not only resistant to Ciproflox/Gatiflox  or Erythromycin, but also to Doxycycline as well, which is a different type of antibiotic. And we have taken Doxycycline only as an example here, in real life scenario, the unnecessary consumption of antibiotics can result in the spread of resistance to many other antibiotics.
So please do not prescribe/ sell/ purchase/consume antibiotics without appropriate reason.

Monday, October 19, 2015

Simple diagnostic kits for detecting infections, better hygiene in hospitals, and more awareness by doctors and healthcare providers will help reduce Antibiotic Prescriptions – Dr Ashok Tamhankar`s reaction on on the  CDDEP report

Read the inputs of Dr. A.J. Tamhankar, National coordinator for the Indian Initiative for the Management of Antibiotic Resistance and Ramanan Laxminarayan, the CDDEP Director, as scripted by Barbara Axt on (

 The report in nutshell

  • Though use of antibiotics currently high in developed countries, Antibiotic use in developing nations is continuously increasing and is also poorly controlled
  • In all countries, where no regulation exists, Regulation is urgently needed to limit antibiotics’ role as growth promoter in livestock production

Thursday, October 8, 2015

"Behavior Modification of stakeholders can help India reduce dependency on pills and prevent deadly bacteria from becoming resistant to antibiotcs"- Says Dr. A.J. Tamhankar

(Excerpts from Interview of Dr. A. J. Tamhankar, national co-ordinator, Indian initiative for management of antibiotic resistance (IIMAR) to Deccan Chronicle)

  Indians popped in 13 billion pills, followed by 10 billion in China and seven billion in USA: suggests  research  by the Washington-based Centre for Disease Dynamics, Economics and Policy (CDDEP).

“Indians need to change their behavioral approach or else chances are high that India might continue to remain as the highest pill consuming country in the world”, said, A. J. Tamhankar, national co-ordinator, Indian initiative for management of antibiotic resistance (IIMAR). “
In technical terms, it is behavior modification which can actually help India reduce its dependency on pills and prevent deadly viruses and bacteria becoming resistant to antibiotcs”, he said. After the State of the World’s Antibiotics Report (2015) was released by CDDEP, it was revealed that there was an increase in the presence of superbugs. Particularly in India, 57 per cent  of infections in 2014 was caused by ‘Klebsiella pneumoniae’, a dangerous superbug found in hospitals, which was resistant to a type of antibiotics. This figure is against 29 per cent in 2008.
“There is currently no proper policy at the national level to regulate antimicrobial resistance in India. The policy introduced in 2011 has been put on hold.  Antibiotics are sold  OTC without the need of a prescription which is a serious problem and needs to be addressed.  “ said N. Ramesh, scientist, Vellore Insitute of Technology.
" Treatment options were slowly and steadily running out, he added.  Explaining that antibiotic resistance is a direct result of antibiotic use, Dr. Tamhankar said, “More the patients use antibiotics, higher are the chances of development of resistant in bacteria and viruses.”
Dr. Tamhankar said, “ In India when people fall sick due to fever or stomach ache they randomly pop pills. When it doesn’t work, there is a common perception that people are becoming resistant to certain antibiotics and which is why there is no proper result. Later, they switch over to some other pills. However, it is the bacteria which are becoming resistant and not people and awareness on this needs to be raised.”, he added.
“ The maximum misuse happens in self-limiting diseases like cough and cold, stomach aches and throat irritation among others. So improving hygiene and staying clean are some ways these infectious diseases can be kept away. This will reduce the dependency on pills” , Tamhankar said.  Further, he also stressed on upgrading and enforcing the existing laws on sale of medicines to curb over-the-counter drug sale.
He also explained how lack of knowledge among medical representatives is another hindrance. “Small pharmaceutical companies have a huge spread across India and they hire medical representatives who are only interested in achieving their target and are hardly concerned on the social issues concerning anti-biotics and its misuse and side effects. Their qualification and understanding of the issues are also low.”
“Lifestyle, work pressure of Indians is such that nobody has time to get treated. People just want quick results as they hardly get sufficient time to get treated. ”, Tamhankar added.
Another interesting aspect was the curricula of MBBS courses across the country. There was no adequate focus upon the aspect of drug resistance, he explained.
Meanwhile, Ram Subramanian, Apollo Hospitals, Chennai has a few solutions.  “ Proper regulation of over the counter sale of antibiotics, strict monitoring of antibiotic usage inside hospitals and a proper scrutiny at the national level on antimicrobial resistance can go a long way to help solve this issue”.
Arvind Singh , national coordinator, Emerging Anti-Microbial Resistance Society (EARS) said a national policy for containment of antimicrobial resistance is  needed.

Tuesday, September 22, 2015

Global Antibiotics Consumption as well as Resistance Increasing: CDDEP

Contributed by: Siddarth David and Dr. Tamhankar

Researchers at the Centre for Disease Dynamics, Economics & Policy (CDDEP), Washington DC, released a report and an online interactive mapping tool, last week, that documenting rates of bacteria resistant to last-resort antibiotics that can lead to life-threatening infections across the world. data come from a variety of sources, from small private laboratories in India to large datasets from the European Centre for Disease Prevention and Control, covering 30 countries.

The executive summary of the State of the World's Antibiotics 2015, states that between 2001-10 the global consumption of antibiotics rose by 30% and in countries where they are sold over the counter like Brazil, India and South Africa, they rose by a staggering 210%. It further states that though wealthy countries still use far more antibiotics per capita, there are growing high rates in the low- and middle-income countries where surveillance data is now available—such as India, Kenya, and Vietnam.

The data also shows that antibiotic resistance is also rising especially in in sub-Saharan Africa, India, Latin America, and Australia and was recorded at 47% in India in 2014, and 90% in Latin American hospitals in 2013. The report should serve as wake up call to health policy makers to implement guidelines on antibiotic stewardship and judicious use as succinctly put by Ramanan Laxminarayan, CDDEP Director and report co-author "We need to focus 80 percent of our global resources on stewardship and no more than 20 percent on drug development."

Monday, September 7, 2015

India to issue fresh guidelines on Anitibiotic Usage soon

Contributed by: Dr. Tamhankar & Siddarth David

In the heel of the of 68th Session of the WHO's South East Asia Regional Committee in Dili, Timor-Leste, India would be issuing guidelines to restrict the blatant sale of antibiotics to avoid development of resistance. This is part of the global strategy adopted by the WHO member countries to control antibiotic resistance in diseases,

Rajesh Bhatia, chief scientific advisor to WHO Regional Director for South East Asia  said that India was ready with guidelines for curbing the unrestricted sale of antibiotics in the country and would issue them soon. The WHO's South East Asia Regional Committee is meeting to discuss among other things the progress of the 11 member states in implementing national antibiotic control action plans by May 2017, a resolution taken the World Health Assembly in May this year at Geneva.  

Wednesday, September 2, 2015

"Antibiotic Resistance Alarming Threat to Global Public Health": APJ Abdul Kalam

Contributed by: Dr. Akilesh & Dr. Tamhankar

In celebrating the life and ideas of the nation's popular ex-president and career scientist Dr. APJ Abdul Kalam, who inspired millions, it would be interesting to note that one of his last public addresses before his death was on antibiotic resistance.

While, speaking at the All India Institute of Medical Sciences (AIIMS), New Delhi on the eve of National Doctors Day on 30th June, Dr. Kalam stressed the need for better antibiotic stewardship given its threat to public health.

One, hopes that the Indian Government does take the words of the late Dr. Kalam and puts it into practice, by developing and enforcing policies and guidelines on judicious use of antibiotic along with a focus on research to produce national and regional-level data on resistance.  

Monday, August 24, 2015

" 9 out of 10 GPs say they feel pressured to prescribe antibiotics": NICE, UK

Contributed by: Dr. Tamhankar & Siddarth David

On August 18, 2015, the National Institute for Health and Care Excellence (NICE) in the UK released its first guidelines on antimicrobial stewardship "Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use". The NICE is the statutory body in the UK that provides national guidance and advice to improve health and social care.

The Guidelines are designed to promote judicious antibiotic use by reviewing prescribing and resistance data and providing feedback, education and training to prescribers. The NICE reports that "9 out of 10 GPs say they feel pressured to prescribe antibiotics, and 97% of patients who ask for antibiotics are prescribed antibiotics”. The Guidelines have been aimed at health practitioners, pharmacists, nurses and provider organisations.

The current edition of the Lancet has an editorial on the strengths and weaknesses of the Guidelines. The NICE guidelines are pioneering antibiotic stewardship in the UK, which is particularly significant given that the UK lags way behind countries like Sweden and Norway in implementing policies to address antibiotic resistance. The NICE Guidelines are a welcome step to global measures on antibiotic stewardship and hopefully would push other countries to take notice and follow with their own guidelines.

Wednesday, July 29, 2015

Shocking to know people don't know what does "antibiotic resistance" actually mean!

"People in UK have no idea what the term "antibiotic resistance" actually means", reveals a study commissioned by  Wellcome Trust.

Most people surveyed mentioned that they thought antibiotic resistance means their own body became resistant to the antibiotic. They did not know that it is the micro-organism that became resistant. This misconception is a serious issue as they then felt that antibiotic resistance is not their problem but someone else's.

This information is shocking coming from a developed nation like UK. This could only mean that the terms used by the media and the doctors to the public need more clarification and simplification to enable better communication and understanding of this pandemic issue. The situation in developing countries will be far worse. For a country like India, there is widespread 'know-do' gap that exists which needs to be bridged in healthcare and specially in the area of 'antibiotic resistance'.

Saturday, June 20, 2015

Crowdsourcing - borrowing the 'software' concept to antibiotics.

"Crowdsourcing" is a concept where a project is funded and contributed by many people around the world. In a similar twist to antibiotic drug discovery, the Community for Open Antimicrobial Drug Discovery (CO-ADD) was set up by scientists at the University of Queensland in Brisbane, Australia, in response to the growing problem of antimicrobial resistance.

CO-ADD is asking groups of chemists and scientists to send in their compounds they are researching / discovering to be tested against various bacteria and viruses. including resistant ones. The cost of screening will be met by CO-ADD and commercial rights are retained by the contributors. CO-ADD director Matt Cooper explains. 'They retain all rights to the compound … and can file patents or write grants [on the basis of assay results],' he says. 

The only catch is that the group contributing a compound for screening must agree to put the screening data into a public database 18 months after getting the results.

Wednesday, April 29, 2015

WHO says a lot needs to be done by the countries to combat antibiotic resistance

"While there is a lot to be encouraged by, much more work needs to be done to combat one of the most serious global health threats of our time." - Dr Keiji Fukuda, WHO's Assistant Director-General for Health Security. Dr. Keiji Fukuda also added that antibiotic resistance is the single greatest challenge in infectious diseases.

A survey was completed by 133 countries in 2013 and 2014 which captured the individual Government's own assessment of their responses to antibiotic resistance issues especially to blood borne infections, tuberculosis and HIV related infections. The survey revealed an appalling truth that only 34 out of 133 participating in the survey had any national plans to combat antibiotic resistance to antibiotic agents.

The exact situation might be far worser considering only 8 nations of the 47 member nations participated in the survey from the African Region. The issues of antibiotic resistance is rampant in African region. 

The encouraging aspect of South East Asian region was that all 11 member nations participated in the survey of which 5 out of 11 nations had a national plan to combat antimicrobial resistance. 

One more challenge that was revealed was that health workers comply poorly with prescribing standards and guidelines.

Monday, April 20, 2015

"Sequential antibiotics" or "Antibiotic Switching" may help avoid antibiotic resistance

Contributed by Dr. Akilesh Ramasamy & Dr. A. J. Tamhankar
Sequential use of antibiotics could have synergistic effect to avoid development of antibiotic resistance or even combat already resistant bacteria. While the use of combination of antibiotics has always been used for their synergistic effect, the use of sequential use of synergistic antibiotics is a new approach by Fuentes-Hernandez et al.(1) The first antibiotic sensitises the organism and the second antibiotic delivers the killing shot. While premature exhilaration on this finding should be limited as this study has found only about 6 sequences which have been found to be effective after trying about 139 different sequences. The study is in it's infancy stage but gives us a new approach to dealing with antibiotic resistance as the technique succeeded in clearing bacteria which had partial resistance to both the antibiotics. 
The results must be viewed with caution as the study has been done in-vitro and it is a known fact that bacteria could behave differently when inside the host. Moreover, the correct sequence and the doses could be important. In that scenario, the use of antibiotics at the exact dose and at specific exact times might be important for the sequential treatment to succeed in humans. The practical implications are numerous as in an already overloaded healthcare setting, there is a high chance that a particular dose might be missed, delayed or given early thus thwarting the entire exercise. So, new formulations or techniques of drug delivery agents might come up which release the particular dose of antibiotic at particular sequence and time. These developments are possible if the sequential antibiotic treatment is found successful in humans. In addition, it also gives hope to the old antibiotics which have been discarded due to development of almost universal resistance to them.


1: Fuentes-Hernandez A, Plucain J, Gori F, Pena-Miller R, Reding C, Jansen G, Schulenburg H, Gudelj I, Beardmore R. Using a sequential regimen to eliminate bacteria at sublethal antibiotic dosages. PLoS Biol. 2015 Apr 8;13(4):e1002104. doi: 10.1371/journal.pbio.1002104. eCollection 2015 Apr. PubMed. PMID: 25853342.

Sunday, March 22, 2015

Adherence to surgical guidelines can lessen antibiotic resistance, cost and complications - A study confirms.

Contributed by: Dr. Akilesh Ramasamy & Dr. Tamhankar

Due to increasing levels of antibiotic resistance, the routine use of post surgical antibiotics is being questioned in various specialties. For instance, I have already pointed out in my review (1) that use of antibiotics after routine or even complicated tooth extractions in dentistry do not require routine use of antibiotics unless accompanied by space infections. Other surgical specialties also have come up with guidelines in this regard. In a recent multi-centric study involving urosurgical procedures, the investigators started following the guidelines of using only prophylactic antibiotics prior to the procedure. No post surgical antibiotics were used in the post operative period.

Comparing the infection rates retrospectively with previous cases (where antibiotics were used routinely in the post operative period), they found that the infection rates among the two groups did not differ significantly, suggesting that routine use of antibiotics is not necessary.(2)

Antibiotic use is associated with increased costs of treatment, more antibiotic related adverse events and development of antibiotic resistance. So, avoiding antibiotics for unnecessary indications can cut down on the costs, complications and antibiotic resistance. This is important on two main fronts. First, the cost of healthcare is ever increasing. Wastage in the ways of unnecessary treatments / antibiotics can decrease the costs of healthcare. India's Health Policy 2015 Draft aims to make healthcare accessible and affordable. In this regard we must take action and note to cut down on unnecessary prescriptions, unnecessary diagnostic tests and unnecessary procedures. Not only do they add to the costs of the treatment but also are potential issues of patient safety. Every procedure, test or medication adds to possible risks in the treatment of the patient. So avoiding those that are not essential can also contribute to safer high quality care with minimal wastage of resources.


(1) Ramasamy, Akilesh. “A Review of Use of Antibiotics in Dentistry and Recommendations for Rational Antibiotic Usage by Dentists.” The International Arabic Journal of Antimicrobial Agents 4.2 (2014):

(2) European Association of Urology. "Changes in surgery methods significantly reduces antibiotic  resistance." ScienceDaily. ScienceDaily, 20 March 2015. <>

Saturday, March 14, 2015

‘Spreading Hygiene through Flying Kites’

Indian Initiative for Management of Antibiotic Resistance (IIMAR) is a participant in the Indo-Swedish project ‘APRIAM’ being implemented at the R.D. Gardi Medical College, Ujjain, Madhya Pradesh, India. The full title of the APRIAM project is Antibiotic stewardship program including infection prevention and control and waste water treatment: Implementation research in hospital and community in India.” 
Hygiene team of Project APRIAM is working with a slogan- Swachch Bharat - Swasth Bharat (Clean India- Healthy India). The Campaign is being run since 2010 at R. D. Gardi Medical College, Ujjain, Madhya Pradesh, India in collaboration with Karolinska Insitutet, Stockholm, Sweden.  The aim is to achieve the goal of Healthy India by keeping India clean. The team is led by Dr. Megha Sharma, Assistant Professor, Department of Pharmacology, R. D. Gardi Medical College, Ujjain.  It has been organizing activities both at hospitals and at community level in the Ujjain district of Madhya Pradesh. The long term aim is to conduct similar activities within various Indian states.
For advancing the message of Swachch Bharat - Swasth Bharatfurther, the team came up with an idea to spread awareness of the message to maintain hygiene through flying Kites. On the auspicious
occasion of Makar Sankrati (14 January 2015); the District collector, Ujjain organized a Kite festival at Dashehara maidan in Ujjain. The APRIAM team planned to take advantage of the opportunity to spread the message of "Be safe- Stay clean" with-in the campaign “Swachch Bharat - Swasth Bharat” among the visitors to the function. The APRIAM Hygiene team set-up 5 information desks at the function place, where over 1500 residents between ages 3 to 83 years visited. The team took advantage of these visits to educate and remind them to maintain self hygiene and general cleanliness and encouraged them to fill in a "Cross word puzzle" and participate in "Check your knowledge on hygeine" contest. Posters with messages of 'How and When to wash hands?',
were displayed at the site. Kites printed with message

 “Swachch Bharat - Swasth Bharat” in Hindi were distributed to 540 participants. Over 1000 residents participated in the other activities.
All entries were checked for their correctness level and all correctly filled entries were sorted out. The prize winners were selected through lottery system two times for each activity and prizes were distributed during the function. The team members Mr. Amit Pawar, Mr. Jeetendra Jat, Dr. Pintoo Marmat, Dr. Kamal Kishore Parmar, Ms. Sunita Parmar, Mr. Abdul Shadab, Ms. Pooja Bhati, Ms. Deepmala Lalavat and Mr. Lakhan Elunia contributed towards  the success of the event.

Contributed by: Dr. Megha Sharma & Dr. A.J. Tamhankar