"Know-do" gap in Indian Rural Healthcare

Diarrhoea and pneumonia are major childhood killers. The diarrhoea management has a large "know-do"gap in certain parts of India.

The study was conducted in 2012 (June - September) by Duke University, Durham using vignette interviews and unannounced standardised patients (SPs) and has been published only in February 2015 (available online in JAMA Pediatrics)

Diarrhoea treatment has a large know-do gap; practitioners asked diagnostic questions more frequently in vignettes than for SPs. Although only 20.9% of practitioners prescribed treatments that were potentially harmful in the diarrhoea vignettes, 71.9% offered them to SPs (P < .001) (1)

For childhood diarrhoea, Oral Rehydration Therapy and not antibiotics is the right treatment.

In this study, antibiotics and other not-indicated drugs were prescribed by all providers. Even those who provided the Oral Rehydration therapy included antibiotics in their prescriptions. The scenario such that none of the providers (medical degree holders, traditional medicine practitioners or unqualified persons???(data unavailable clearly) provided the right treatment.

A large segment of rural sector in poor-resource countries like India are catered by such providers. Antibiotic abuse, self medications, poor antibiotic stewardship, poor healthcare infrastructure in the rural areas and poor awareness among the people all could be contributory to this aberrant situation.

A similar study published earlier conducted in Rural Madhya Pradesh had similar findings.(2)

Unwanted effect of Antibiotic (ab)use - Effect on mitochrondrial gene expression!

Contributed by: Dr. Akilesh Ramasamy & Dr. Tamhankar

Antibiotic use has a profound influence on the gut flora. It's a well known effect. But a recent study reveals the effects could be more devastating and far reaching than previously known.

"Just in the past decade a whole new universe has opened up about the far-reaching effects of antibiotic use, and now we're exploring it. The study of microbiota is just exploding. Nothing we find would surprise me at this point." Prof. Morgan

Prof. Audrey Morgan and his colleagues have found that antibiotics have effect on many other things apart from the endogenous microflora. They seem to affect glucose metabolism, the immune system, food digestion and behaviour. They also suspect it is linked to obesity and stress. The researchers used the mouse model of microbiota depletion by a cocktail of antibiotics in this study.

Some of the alarming results they found apart from the direct effect of antibiotics on the gut microflora were:

1. Antibiotics kill intestinal epithelium cells directly.
2. Antibiotics inhibited mitochondrial gene expression.

Nobel Prize Winner's solution to antibiotic resistance and additional editorial comment

Contributed by: Dr. Akilesh & Dr. Tamhankar

Venki Ramakrishnan, a Nobel Prize-winning chemist based at the Laboratory of Molecular Biology at the University of Cambridge has expressed his views on the issue of antibiotic resistance and solutions to this problem in an interview to Scientific American Forum.
Some key concepts from his interview is highlighted below:

1.  Why not many new antibiotics ?
Most researches in pharmaceutical industry is targeted towards modifying existing antibiotic compounds than researching for new compounds as new compounds must not only be able to kill the bacteria but also be cheap to manufacture and safe for use. To develop such compound, it'd take more funds and research. Resorting to modification of an existing chemical compound has become the cheaper solution, perhaps.

2.  New antibiotic discovery - Is it the panacea for all our antibiotic problems ?
The Nobelist has expressed his reservations on the premature hype surrounding the new antibiotic discovered. It represents a new class of antibiotics and an interesting development with claims of no known antibiotic resistance to this class of antibiotics. The finding seems to hold a lot of promise, but the same has been said earlier about other antibiotics as well and Mother Nature has an excellent capability for natural selection and such comments must be made with caution, he added.

3. The problem of antibiotic resistance
He also quoted the scenario in India contributing to antibiotic resistance as follows

In countries like India people will give you antibiotics prophylactically, as a way to prevent infection. This should only be done in very extreme cases because it’s again spreading resistance.

4.  Government's role in antibiotic research
Most important opinion that he voiced was that the research and funding for development of antibiotics must be supported by the Governments. Antibiotics have a limited period of use, unlike other drugs for 'lifestyle' diseases (which must be used throughout the patient's life). Hence, the funds put for development of an antibiotic is not got back by Private Investors. This leads to a limited fund allocation for development of antibiotics. This is also complicated by the limitation in use of such new antibiotics which are preferably used as a "last resort" further limiting their use and in turn meaning lesser monetary returns to the company.

Interview Edited Transcript Source: SA Forum

Editorial Comment
These opinions of a Nobel Prize winner has immense importance. It not only highlights the problem of antibiotic resistance but also points to important challenges in the field of antibiotic development and research.

In order to counter this scenario, Government must consider funding more for research in antibiotic development, prevention of antibiotic resistance. There is a constant riff between the traditioanl systems of medicine and allopathy always. But, even WHO recognized that in countries like India, China and other Asian countries have a rich and ancient traditional medicine knowledge base which is under utilised. WHO has also suggested improved utilisation of such traditional knowledge base for betterment of healthcare. This is already part of the current Indian Government initiative in the form of AYUSH.

Will these moves improve our healthcare system ? Will it result in lesser antibiotic usage ? Will it decrease antibiotic resistance ? Only time can answer these questions. But definite proactive measures are required for better results in this pandemic issue of antibiotic resistance.