Status of Antibiotics Resistance: Global and
Indian Scenario
Growing antibiotic resistance is
a global phenomenon in both developed and developing
countries. Methicillin-resistant Staphylococcus
aureus (MRSA) alone infects more than 94 000
people and kills nearly 19,000 in the US every year,
more deaths than are caused by HIV/AIDS, Parkinson’s
disease, emphysema, and homicide combined(1).
Penicillin-resistant streptococcal pneumonia
and vancomycin resistant enterococci (VRE) are more
frequently incriminated from many industrialized
countries forcing frequent changes of
recommendations of management of diseases caused by
these bugs. Despite a few hopeful trends (e.g.,
declining penicillin resistance among pneumococci in
the UK), established resistance is proving hard to
displace; moreover, new resistance continues to
emerge and to proliferate at new sites. Consequently
there remains a strong need for new antibiotics,
particularly those directed against multi-drug
resistant (MDR) Gram-negative bacteria in hospitals.
Already some non-fermenters of the genera
Acinetobacter and Pseudomonas are
resistant to all good antibiotics and many
Enterobacteriaceae are resistant to all except
carbapenems. Health care associated infections due
to resistant gram negative bacteria are the most
threatening development all over the world.
In the absence of a central
monitoring agency, the National scene in India with
regard to antimicrobial resistance is not known. The
two probable exceptions are M. tuberculosis
and Leishmania donovani. However, the
available sporadic reports point to growing
resistance of gram-negative bacteria responsible for
UTI, diarrhea, dysentery, enteric fever, and sepsis.
Fortunately, penicillin resistance to
Streptococcus pneumoniae is still not a big
problem. MRSA and VRE are reported from many centers
across the country. However, the greatest threat is
posed by gram negative organisms responsible for
nosocomial sepsis in neonatal and pediatric ICUs.
Astonishingly, some members of Acinetobacter
spp. have shown a high prevalence of resistance to
even a most recently introduced antibiotic,
tigecycline. And to compound the situation, the only
drugs showing good coverage are older antibiotics
like polymyxin-B and colistin having questionable
efficacy and safety.
Why are Micro-organisms Developing Resistance?
Rampant, unrestricted and often
inappropriate use of most antibiotics is the main
reason why antibiotics are rapidly losing their
efficacy. There is a need to review the antibiotic
prescription practices of the clinicians.
Unfortunately, majority of the prescriptions are
irrational as they are based by the information
gathered from representatives of pharmaceutical
companies, especially for the newer antibiotics.
The Indian scene is particularly
grim due to various factors. Generally, there is
little control on the use of antibiotics. Community
awareness of the issues involved in antibiotic
therapy is poor and this is compounded by
over-the-counter availability. Coupled with
primitive infection control in hospitals and weak or
deficient sanitation, the conditions are suited for
transmission and acquisition of antibiotic
resistance. Apart from the medical
consequences of antibiotic resistance, there is also
a direct cost to society. Unfortunately, the
economic burden of antimicrobial resistant organisms
on health care expenditure in India is not known.
Status of Development of New Antibiotics
The 1990s saw only one new
antibiotic class viz the oxazolidinones joining the
approved list. All other introductions have been
variants of existing classes. Only a few new
antibacterial agents have received approval by the
US Food and Drug Administration in the last 10
years, including linezolid in 2001, cefditoren
pivoxil and ertapenem in 2002, gemifloxacin and
daptomycin in 2003, telithromycin in 2004, and
tigecycline in 2005(2). Only a single new
antibacterial—doripenem—has been approved in the USA
since 2006(1). Many of these agents are improved
derivatives from established classes of antibiotics,
and several are directed primarily at resistant
Gram-positive bacteria (e.g., linezolid and
daptomycin). These modified agents suffer from the
disadvantages of the parent molecules. In view of
the crossover of resistance across related
compounds, the future may see sharply depleting
antibiotic resources.
Need of the Hour
There is a strong case for
continued surveillance for antibiotic resistance at
all levels, the hospital, city/region, country, and
supra-national levels. It is only then the
ramifications of problem can be learnt. Such
mechanisms are in position in the industrialized
countries but the developing world (including India)
is yet to invest in building them.
There is a need to keep a check
and control the prescription of any newly introduced
broad-spectrum antibiotics or those targeting highly
resistant organism, both in indoor and outdoor
practices. There should be active surveillance of
antibiotic use and resistance rates, and all
attempts should be made to optimize antibiotic use
with treatment guidelines along with education of
professionals and the public. Prevention of
acquiring new resistance can be achieved with
infection control measures and immunization.
Industry should also revise its antibiotic
development policy and international health
agencies, national governments and NGOs should
support them in financial resource mobilization and
slackening of regulatory issues. There should be
refined regulation of antibiotic registration for
use with central prescribing and advertising
restrictions.
The microbial world has
demonstrated remarkable resilience and the emergence
of resistance is practically invariable upon the
introduction of an antibiotic into the environment.
The relentless build-up of resistance may make the
valuable antibiotic assets useless and a
‘post-antibiotic scenario’ may emerge. A global
strategy is urgently needed to create a stable
research infrastructure for antimicrobial
development. Unless antibacterial development is
re-energized, there is a serious risk that a growing
proportion of infections, especially in hospitals,
will become effectively untreatable. Given that it
takes more than 10 years to establish the efficacy
and safety of new compounds, there is a dire need to
restock the antibiotic pipeline.
Funding: None.
Competing interests: None
stated.