Shahid Akhter, Editor-in-Chief, ETHealthworld, spoke with Prof Samuel Raj, Dean Academics, SRM University to learn more about the challenges associated with AMR and the way forward.
  1. The 2021 report of the World Health Organization (WHO) Global Surveillance System for Antimicrobial Resistance and Antimicrobial Use (GLASS) highlights that most countries have reported high levels of AMR in blood infections, urinary and gastroenteric. From a global perspective, what should be the way forward?
    Globally, we are seeing a worrying trend of increasing drug resistance, making it difficult to treat common human infections. Antibiotics grouped together as “Monitors” by the World Health Organization (WHO) have a higher potential for drug resistance and should not be commonly used. Although ciprofloxacin is part of the “Watch” group of antibiotics, it is the preferred treatment for urinary tract infections in many countries. As a result, E. coli and K. pneumoninae, the two most common pathogens causing urinary tract infections, increasingly show drug resistance to ciprofloxacin. Likewise, the emergence of microbes resistant to carbapenems has an impact on the treatment of nosocomial infections. Resistance to carbapenems is even more alarming because we have no antibiotics in the works to combat this drug resistance. These worrying developments require a multisectoral approach that assimilates human, animal and environmental issues in order to limit the spread of AMR.

Going forward, there will need to be more emphasis on oversight and stewardship around the world. Since the launch of GLASS in 2015, more and more countries are reporting data on different aspects of AMR each year. Due to the increase in reports, we are now finding that drug resistance is much worse in low and middle income countries (LMICs) than in other countries, which deserves urgent action. Additionally, the current pandemic has seen the indiscriminate use of antibiotics to treat COVID-19 patients; this will lead to an increase in drug resistance in the near future. The convergence of national initiatives supported by decisive political actions is the need for the right time to limit AMR.

The use of antimicrobials such as antibiotics is common in the livestock industry. This has led to increased production and better animal health. Nonetheless, researchers are increasingly reporting the misuse of antibiotics in animals, leading to an increase in antimicrobial resistance. Are there any oversight and monitoring mechanisms in place in India to verify this?
The use of antibiotics in the livestock industry is aimed at promoting animal health and ensuring food safety by ensuring timely treatment of common infections. However, the bulk of antibiotic use in animals is aimed at maximizing growth. This is problematic because many of these antibiotics are also intended for the treatment of humans. Over time, when animals are fed dangerously high levels of antibiotics, drug resistance develops and is passed on to humans through the food chain.

India’s livestock industry is one of the largest in the world and policy makers need to consider the rise in AMR due to animal misuse. The adoption of the One-Health approach, the regulation of the use of antibiotics in meats and the ban on colistin indicate the seriousness of the government on the issue. However, these movements must be supported by enhanced monitoring and surveillance. Recently, ICMR began surveillance for antimicrobial resistance in animals, but it is limited. For good quality data, it is necessary to rely on European and American surveillance networks. As part of our National AMR Action Plan (NAP-AMR), India needs a much broader monitoring and surveillance system for effective coordination and mitigation of animal AMR.

While the overuse and abuse of antibiotics for medical and veterinary purposes contributes to the increase in AMR. One aspect often overlooked is the environmental AMR which continues to rise due to the improper disposal of hospital waste, irresponsible use of antibiotics in agriculture, and the dumping of untreated pharmaceutical effluent into plans. water. Your opinion on the seriousness of the problem.
Improper disposal of hospital waste, the untreated discharge of pharmaceutical effluents from manufacturing units into water bodies, and the excessive use of drugs in agriculture are major contributors to environmental AMR. Increasingly, in the absence of antimicrobial stewardship, hospitals are turning into hotbeds of antimicrobial resistance. When the sewage from some New Delhi hospitals was analyzed, it was found that the concentration of CRE bacteria and blaNDM-1 was 9 times higher than the water in local sewers. Excess antibiotics and other drugs used in agriculture end up in the food chain through surface runoff or uptake by the plants themselves. Another important precursor to environmental AMR is the unregulated discharge of pharmaceutical effluents into water bodies from pharmaceutical manufacturing units. During the drug manufacturing process, the wastewater that remains contains traces of antibiotics that are harmful to human, animal and environmental health if it is discharged without treatment. Many manufacturing units forgo installing systems capable of neutralizing effluents due to the high costs involved. The continuous and uninterrupted discharge of pharmaceutical effluents damages the soil and water ecosystem, and ultimately adversely affects human health.

India is the third largest pharmaceutical industry in the world. We are the largest producers and manufacturers of generic drugs in the world. On the other hand, we also produce a lot of pharmaceutical effluents which are very often discharged untreated into water bodies. Since there are still no standards for the concentration of pharmaceutical discharges, are we not inviting problems?
As one of the world’s largest drug manufacturers, we have a moral responsibility to reduce environmental AMR resulting from the unregulated discharge of pharmaceutical effluents. However, we need to take this issue more seriously. The Ministry of the Environment, Forests and Climate Change (MoEFCC) presented a draft regulation in 2020 notifying the limits for the concentration of antibiotics in pharmaceutical effluents. If this regulation had been formalized, it would have been a torchbearer for the whole world. I am concerned that due to the pandemic, as well as the production of more drugs than usual, a higher volume of pharmaceutical effluent has been released into water bodies. If there had been regulations in place, that would have prevented the rise in RAM that will occur now. Pollution from antibiotics is increasingly becoming a threat in India. Many pharmaceutical centers report environmental degradation due to the uncontrolled discharge of effluents. Recently, the National Green Tribunal (NGT) arrested the Himachal Pradesh Pollution Control Board (HPCB) for exposing people to the harmful effects of AMR by failing to control antibiotic pollution at the Baddi Pharmaceutical Center in Solan. The court also asked the MoEFCC to expedite the finalization of the allowable limit of antibiotic compounds in pharmaceutical effluents. Besides strict regulations, drug makers in India should be encouraged to move towards green purchasing and sustainable production practices.

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