Writer By Chance.

Kerala is considered the healthiest Indian state, thanks to her superlative health indices.

Recently, Kerala added another feather to her illustrious cap on the healthcare front by bringing out an antibiogram. Kerala became the first Indian state to do so.

‘Stringent infection prevention and control measures should be adopted in hospitals. Rational antibiotic prescription and use be promoted in the community. It is the only way to break the vicious cycle, wherein increased reliance on last-resort antibiotics to treat infections is increasing the resistance of organisms to these drugs’, according to R. Aravind, convener of the working committee of the Kerala Antimicrobial Resistance Strategic Action plan (KARSAP).

Under KARSAP, district level committees have been set up to promote antibiotic literacy. Kerala is launching the first antibiotic stewardship programme that will cover private and public sectors. Kerala will host an international symposium on antibiotic stewardship and infection control on January 23 to be attended by health secretaries of 16 states.

What is an antibiogram?

It is a clinical data summarizing the profile of various bacteria and their susceptibility pattern to antibiotics. Antibiogram is community or healthcare facility-specific. This means that a particular healthcare facility or community harbors a specific group of bacteria with a near-predictable susceptibility pattern. The Antibiogram therefore serves as a roadmap for clinicians to guide them in (1) using the appropriate antibiotic to treat specific pathogens likely to be present within a healthcare facility or community, or (2) in the empiric use of antibiotics (to prevent infections). 

  Kerala’s first antibiogram (2021) indicated a spurt in Antimicrobial Resistance (AMR).

Kerala’s AMR surveillance data pertain to seven pathogens called the ‘superbugs’-Escherichia Coli(E.Coli), Klebsiella, Pseudomonas, Acinetobacter, Salmonella, Staphylococcus, and Enterococcus. The surveillance data reveal E.Coli as the most commonly isolated pathogen (40%), followed by Klebsiella(24%). E.Coli is the most common pathogen isolated among outpatients, which reflects the pattern within the community. Klebsiella is the commonest isolated in ICU patients.

How bad are these superbugs with regard to AMR?

Superbugs have rendered antibiotics, once considered ‘superheroes’ mere onlookers as they create mayhem among patients by developing resistance against the ‘superheroes’.

Klebsiella shows 30% resistance to beta lactam antibiotics (Penicillins and Cephalosporins), and even Carbepenem antibiotics, causing mortality of 30%. Percentage of Methicillin Resistant Staphylococcus Aureus(MRSA) isolates is 20%. Resistance of E.Coli to 3^rd and 4^th generation Cephalosporins is 62% and 48% respectively. 40% of Pseudomonas is resistant to Ceftazidime, the specific anti-Pseudomonas Cephalosporin. 20% of Acinetobacter exhibited 50% resistance to almost all antibiotics. Superheroes, therefore have been taken apart by superbugs, throwing healthcare into one of its gravest crisis ever. Treating infections has come a long way from ‘David’s slingshot act’ to down Goliath, when Fleming’s Penicillin acted against Gram-positive bacteria without much fuss.

Why have superbugs developed resistance to antibiotics of practically every class. Right from the world’s first antibiotic, Penicillin discovered by Alexander Fleming to Teixobactin, the latest antibiotic to be developed?

Reasons are manifold;

• Antibiotic misuse is the villain of the piece. Healthcare providers, including doctors use antibiotics for common ailments like common cold and flu, which are caused by viruses, and can be cured by antipyretics, antihistamines, ingestion of fluids, nutritious diet and adequate rest- the “good old grandma’s ‘prescription’”. Antibiotics have no place in their treatment. However, healthcare providers fall for the temptation to prescribe antibiotics to impress their patients with ‘quick cure’. Patients are also to be blamed. They arm-twist their doctors to prescribe antibiotics for ‘fast cure’, especially in pediatric patients.
• Over-the-counter availability of antibiotics without valid prescriptions has made antibiotics fall prey to unregulated self-medication.
• Tendency among doctors, especially in healthcare facilitates to prescribe antibiotics by not confirming to the antibiogram pattern, before sensitivity reports become available- a desperate ‘shooting from the hip’ exercise intended to carpet-bomb probable causative bacteria, identification of which is unavailable.
• Hesitation among healthcare providers to deescalate antibiotics( practice of either stopping antibiotics, or switching to those of lower group once high-end antibiotics have done their job)
• Reluctance among patients to complete the antibiotic course by stopping them midway once they ‘get better’. This is the reason for resistance to antibiotics used against Tuberculosis.
• Widespread misuse of antibiotics in fish and cattle feed in aqua and livestock farms respectively, causing AMR within the community. Kerala has large number of inland fisheries where antibiotic-supplemented feed is used ad nauseum.
• Big-time flouting of infection control practices by healthcare providers in healthcare facilities, especially ICUs. This is a silent culprit, usually swept under the carpet and unaddressed by hospital managements, healthcare providers and the government. These include inadequate patient: nurse ratio which should be ideally 1:1 or even better. The culture of ‘helping’ colleagues in patient care, especially in emergencies, is rampant among nurses. This causes cross-infection between patients. Use of infected water in oxygen humidifiers, infected gels for procedures like ultrasound and Echocardiogram, and use of radiographic caskets in multiple patients by radiographers, and reluctance among doctors to adhere to stringent hand hygiene practices are some of the shortcomings within ICUs that need to be addressed by hospital managements and the government. Hand hygiene is the simplest and cheapest infection control practice that yields rich dividends. The ongoing pandemic has proved that convincingly.  It is paradoxically most flouted infection control practice.

Antimicrobial resistance can certainly be reversed in a big way by addressing the reasons for the same elucidated above. 

What are the implications of antimicrobial resistance?

• Patients are forced to use high-end antibiotics for common community infections like Urinary Tract, respiratory and Gastrointestinal infections in lieu of cheaper and basic antibiotics which would have been sufficient some years ago, which further leads to Antimicrobial resistance- a vicious cycle!
• Patients need to spend more time in hospitals as high-end antibiotics demand administration in monitored settings.
• Research on new antibiotics has slowed down as discovering a superhero to stand up to the superbugs is no small work. The case in point is the carbapenem group of antibiotics which consists of Meropenem, Imipenem, Doripenem and Ertapenem, which were not very long ago wonder drugs, welcomed on the red carpet to fight complicated infections. Thanks to their widespread misuse, they had to beat a hasty retreat on the very same carpet. Ambushed, wounded and undone by the very enemy they were intended to vanquish.
•  Non-availability of new molecules has had clinicians fall back on older, relatively toxic antibiotics. A good old antibiotic discovered in 1947-Colistin have almost replaced carbapenems. Colistin, not a favored antibiotic due to its renal toxicity and banned from aquaculture has thus made a reentry to fight life- threatening infections.