Silent Issue of antibiotic use in Agriculture and Animal Husbandry

Contributed by: Siddarth D & Dr. Tamhankar

While there is substantial global pressure on rationalizing  antibiotic use in humans across the world, antibiotic use in animals is seldom touched upon. The "Review on Antimicrobial Resistance" commissioned in the UK by the Prime Minister to boost awareness of the economic issues surrounding the development, spread and containment of antimicrobial resistance, recently published a report placing a lot of the onus on the animal husbandry and agriculture sectors for development of antimicrobial resistance in animals that can be passed on to human beings.

The report states that while the use of antibiotics in agricultural animals is expected to double between 2010 and 2030 on average, the use of agricultural antibiotics improves animal growth rates by less than five percent. The report calls for global targets and standards to reduce antibiotic use in agriculture as well as critical improvements in the surveillance of antibiotic use in agriculture.

The report though not a scientific document, it does lay the foundations of evolving consensus in policy to address the issue of resistance in agriculture which is till yet to fully studied and acknowledged. It is also a call to other countries like India to conduct its own research and come up with policies to address the challenge of antimicrobial resistance in agriculture which is a real issue that is largely silent up till now.

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. 

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 (http://www.nature.com/news/who-warns-against-post-antibiotic-era-1.15135 ). 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 (https://www.newscientist.com/article/dn28180-global-study-reveals-soaring-antibiotic-resistance-in-india/ ). 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 (http://mta.hu/news_and_views/new-results-from-momentum-researchers-in-the-description-of-pathogens-resistant-to-antibiotics-134830/ ) 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.

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 scidev.net 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 Scidev.net (http://www.scidev.net/global/medicine/news/poorer-nations-antibiotic-resistance.html)

 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

"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.