M.Sc.

[Microbiology] SEMESTER II Assignment

ANTIMICROBIAL RESISTANCE
THE INDIAN SCENARIO.

INTRODUCTION
The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug educate them to resist penicillin. Alexander Flemming in his 1945 Nobel laureate lecture. A study published in the August 2010 issue of the journal The Lancet Infectious Diseases, by a multi-national team lead by Dr Timothy R. Walsh, professor of medical microbiology and antimicrobial resistance at Cardiff University's School of Medicine, examined the emergence and spread of bacteria carrying the blaPCM gene. It warned that the gene - named New Delhi-Metallo -1 (NDM-1) had been found in bacterial infections, which made them resistant to almost all antibiotics, including beta-lactam antibiotics, fluoroquinolones, and aminoglycosides, with "an alarming potential to spread".1,2 Experts fear that it will start attaching itself to more dangerous disease causing bacteria thus conferring them with antimicrobial resistance. This news was followed by vociferous rejections by the health ministry in India with the report being called unfair, malicious propaganda, "sensational", and "wrong propaganda against the country". "We strongly refute the naming of this enzyme as New Delhi metallo beta lactamase," the health ministry said in a press release. "We also refute that hospitals in India are not safe for treatment, including medical tourism," it added. The issue was also raised in India's parliament, with angry MPs questioning the Lancet study, saying it was funded by pharmaceutical multi-national companies. "When India is emerging as a medical tourism destination, this type of news is unfortunate and may be a sinister design of multi-national companies," MP SS Ahluwalia of the opposition BJP said. The Government statement also objected to the naming of the superbug, and highlighted conflicts of interests declared by report authors who had received support from pharmaceutical companies which produce antibiotics.3 The reaction from the Indian government though not objective, is quite typical. In fact, Karthikeyan K Kumarasamy of the Department of Microbiology in Dr A L M Post-Graduate Institute of Basic Medical Sciences at the University of Madras, and other Indian coauthors of the study were served ' show cause notices' on their collaborative research with British scientists.4

While there has been widespread resentment in India, both from the government as well as the general public over the naming of the gene in question after the national capital, the fact remains that almost every patient in whom this antibiotic resistance causing gene was seen had had recent contact with medical facilities in the sub-continent. In addition, most of the samples taken from India were from the municipal drinking water supply. As if this was not enough cause for grave concern- not just in India but globally there is the irrational sense of denial being exhibited by those who are responsible for the wellbeing of the nations citizens. If we are not ready to admit there is a problem there is no question of an attempt being made to solve it. Another indicator of the seriousness of the situation was the selection of combating antimicrobial resistance as the theme for World Health Day 2011. Considering these points I felt it was appropriate to go over this topic of antimicrobial resistance and get an idea of what the scenario in India is like. I am attempting to only get a general idea of the situation since there is very little concrete information with regards to the scenario in India, which is publicly available.

ANTIMICROBIAL RESISTANCE
You can fool all the microbes for some time You can fool some of the microbes all the time But you cannot fool all the microbes all the time.5 Antimicrobial resistance (AMR) is resistance of a microorganism to an antimicrobial medicine to which it was previously sensitive. Resistant organisms (they include bacteria, viruses and some parasites) are able to withstand attack by antimicrobial medicines, such as antibiotics, antivirals, and antimalarials, so that standard treatments become ineffective and infections persist and may spread to others. AMR is a consequence of the use, particularly the misuse, of antimicrobial medicines and develops when a microorganism mutates or acquires a resistance gene.6 HISTORY OF ANTIBIOTICS AND EMERGENCE OF ANTIBIOTIC RESISTANCE The first antibiotic, penicillin, was discovered in 1929 by Sir Alexander Fleming, who observed inhibition of staphylococci on an agar plate contaminated by a Penicillium mold. He was able to show that culture broth of the mold prevented growth of the Staphylococcus even when diluted up to 800 times. He named the active substance penicillin but was unable to isolate it.

In 1939, Ernst Chain and Howard Florey developed a way to isolate penicillin and used it to treat bacterial infections during the Second World War. For these discoveries Fleming, Chain and Florey were awarded the Nobel prize in 1945. In 1946, penicillin became generally available for treatment of bacterial infections, especially those caused by staphylococci and streptococci, and made a huge impact on public health. Initially, the antibiotic was effective against all sorts of infections caused by these two Grampositive bacteria. In the late 1940s and early 1950s, new antibiotics were introduced, including streptomycin, chloramphenicol and tetracycline, and the age of antibiotic chemotherapy came into full being. These antibiotics were effective against the full array of bacterial pathogens including Gram-positive and Gram-negative bacteria, intracellular parasites, and the tuberculosis bacillus. Synthetic antimicrobial agents such as the "sulfa drugs" (sulfonamides) and antituberculosis drugs, such as para aminosalicylic acid (PAS) and isoniazid (INH), were also brought into wider usage. THE FIRST SIGNS OF ANTIBIOTIC RESISTANCE There has probably been a gene pool in nature for resistance to antibiotic as long as there has been for antibiotic production, for most microbes that are antibiotic producers are resistant to their own antibiotic. In retrospect, it is not surprising that resistance to penicillin in some strains of staphylococci was recognized almost immediately after introduction of the drug in 1946. Likewise, very soon after their introduction in the late 1940s, resistance to streptomycin, chloramphenicol and tetracycline was noted. By 1953, during a Shigella outbreak in Japan, a strain of the dysentery bacillus (Shigella dysenteriae) was isolated which was multiple drug resistant, exhibiting resistance to chloramphenicol, tetracycline, streptomycin and the sulfonamides. Over the years, and continuing into the present almost every known bacterial pathogen has developed resistance to one or more antibiotics in clinical use. Evidence also began to accumulate that bacteria could pass genes for drug resistance between strains and even between species. For example, antibiotic-resistance genes of staphylococci are carried on plasmids that can be exchanged with Bacillus, Streptococcus and Enterococcus providing the means for acquiring additional genes and gene combinations. Some are carried on transposons, segments of DNA that can exist either in the chromosome or in plasmids. In any case, it is clear that genes for antibiotic resistance can be exchanged between strains and species of bacteria by means of the processes of horizontal gene transmission (HGT). MULTIPLE DRUG RESISTANT ORGANISMS Multiple drug resistant organisms are resistant to treatment with several, often unrelated, antimicrobial agents as described above in Shigella. Some of the most important types of multiple drug resistant organisms that have been encountered include:

MRSA - methicillin/oxacillin-resistant Staphylococcus aureus VRE - vancomycin-resistant enterococci ESBLs - extended-spectrum beta-lactamases (which are resistant to cephalosporins and monobactams) PRSP - penicillin-resistant Streptococcus pneumonia BACTERIAL MECHANISMS OF ANTIBIOTIC RESISTANCE Antibiotic resistance can be conferred on bacteria through several mechanisms which can - either chemically modify the antibiotic, -render it inactive through physical removal from the cell, - or modify target site so that it is not recognized by the antibiotic. The most common mode is enzymatic inactivation of the antibiotic where an existing cellular enzyme is modified to react with the antibiotic in such a way that it no longer affects the microorganism. An alternative strategy utilized by many bacteria is the alteration of the antibiotic target site. These and other mechanisms are shown in the the figure and accompanying table below

Antibiotic Chloramphenicol Tetracycline -lactams, Erythromycin, Lincomycin

Method of resistance reduced uptake into cell active efflux from the cell eliminates or reduces binding of antibiotic to cell target Aminoglycosides, Chloramphenicol enzymatic cleavage or modification to inactivate antibiotic molecule metabolic bypass of inhibited reaction overproduction of antibiotic target (titration)

-lactams, Aminoglycosides, Chloramphenicol Sulfonamides, Trimethoprim

THE ACQUISITION AND SPREAD OF ANTIBIOTIC RESISTANCE IN BACTERIA The development of resistance is inevitable following the introduction of a new antibiotic. Modern uses of antibiotics have caused a huge increase in the number of resistant bacteria. Multiple drug resistant strains of some bacteria have reached the proportion that virtually no antibiotics are available for treatment. Antibiotic resistance in bacteria may be - an inherent trait of the organism (e.g. a particular type of cell wall structure) that renders it naturally resistant, or -it may be acquired by means of mutation in its own DNA or acquisition of resistanceconferring DNA from another source.

Inherent (natural) resistance.

Bacteria may be inherently resistant to an antibiotic. For example, an organism lacks a transport system for an antibiotic; or an organism lacks the target of the antibiotic molecule; or, as in the case of Gram-negative bacteria, the cell wall is covered with an outer membrane that establishes a permeability barrier against the antibiotic.

Acquired resistance
Several mechanisms are developed by bacteria in order to acquire resistance to antibiotics. All require either the modification of existing genetic material or the acquisition of new genetic material from another source.

Vertical gene transfer

The spontaneous mutation frequency for antibiotic resistance is on the order of about of about 108 - 109. This means that one in every every 108 - 109 bacteria in an infection will develop resistance through the process of mutation. Although mutation is a very rare event, the very fast growth rate of bacteria and the absolute number of cells attained means that it doesn't take long before resistance is developed in a population. Once the resistance genes have developed, they are transferred directly to all the bacteria's progeny during DNA replication. This is known as vertical gene transfer or vertical evolution.

Horizontal gene transfer

Another mechanism responsible for the acquisition of antibiotic resistance is lateral or horizontal gene transfer (HGT) which is a process whereby genetic material contained in small packets of DNA can be transferred between individual bacteria of the same species or even between different species. There are at least three possible mechanisms of HGT, equivalent to the three processes of genetic exchange in bacteria. These are transduction, transformation or conjugation.

SOCIETAL, MEDICAL AND AGRICULTURAL PRACTICES THAT LEAD TO ANTIBIOTIC RESISTANCE In the face of a microbe's inherent ability to develop antibiotic resistance, many societal. medical and agricultural practices contribute to this process, foremost of which are discussed below.

Antibiotics in food and water

Antibiotics can be found in beef cattle, pigs and poultry which then find their way into municipal water systems when the runoff from housing facilities and feedlots contaminates streams and groundwater. We get antibiotics in our food and drinking water, and we meanwhile promote bacterial resistance. Routine feeding of antibiotics to animals is banned in the European Union and many other industrialized countries.

Indiscriminate use of antibiotics in agriculture and veterinary practice

The non-therapeutic use of antibiotics in livestock production makes up at least 60 percent of the total antimicrobial production in the United States. Irresponsible use of antibiotics in farm animals can lead to the development of resistance in bacteria associated with the animal or with people who eat the animal. Such resistance can then be passed on to human pathogens by mechanisms of HGT. Of major concern is the use of antibiotics as feed additives given to farm animals to promote animal growth and to prevent infections (rather than cure infections). The use of an antibiotic in this way contributes to the emergence of antibiotic-resistant pathogens and reduces the effectiveness of the antibiotic to combat human infections.

Antibiotic resistance in genetically modified crops

Antibiotic-resistance genes are used as "markers" in genetically modified crops. The genes are inserted into the plant in early stages of development to in order to detect specific genes of interest . e.g. herbicide-resistant genes or insecticidal toxin genes. The antibiotic-resistance genes have no further role to play, but they are not removed from the final product. This practice has met with criticism because of the potential that the antibiotic-resistance genes could be acquired by microbes in the environment. In some cases these marker genes confer resistance to front-line antibiotics such as the beta-lactams and aminoglycosides.

Inappropriate use of antibiotics in the medical environment

One problem is the casual use of antibiotics in medical situations where they are of no value. This is the fault of both health care workers and patients.6 It is estimated that up to 50 percent of antibiotic prescriptions given in community settings are not needed. Common factors that contribute to antibiotics being prescribed inappropriately include: Patient request for an antibiotic Physician perception that the patient expects an antibiotic

Limited time to confirm an accurate diagnosis or explain to the patient why an antibiotic is unnecessary. Concerns about misdiagnosing bacterial infections as viral.

Common ways patients don't comply with therapy include: - Fail to buy medicines or fill the prescription - Fail or delay start of medicine intake - Skip doses - Take extra doses early in treatment - Stop medication when patient experiences symptom relief, but before completing the full course of treatment.14

WHY IS ANTIMICROBIAL RESISTANCE A GLOBAL CONCERN? AMR kills

Infections caused by resistant microorganisms often fail to respond to the standard treatment, resulting in prolonged illness and greater risk of death.

AMR hampers the control of infectious diseases

AMR reduces the effectiveness of treatment because patients remain infectious for longer, thus potentially spreading resistant microorganisms to others.

AMR threatens a return to the pre-antibiotic era

Many infectious diseases risk becoming uncontrollable and could derail the progress made towards reaching the targets of the health-related United Nations Millennium Development Goals set for 2015.

AMR increases the costs of health care

When infections become resistant to first-line medicines, more expensive therapies must be used. The longer duration of illness and treatment, often in hospitals, increases health-care costs and the financial burden to families and societies.

AMR jeopardizes health-care gains to society

The achievements of modern medicine are put at risk by AMR. Without effective antimicrobials for care and prevention of infections, the success of treatments such as organ transplantation, cancer chemotherapy and major surgery would be compromised.

AMR threatens health security, and damages trade and economies

The growth of global trade and travel allows resistant microorganisms to be spread rapidly to distant countries and continents.7

THE INDIAN SCENARIO

Consider the following statements: In a study conducted by Anita Kotwani and Kathleen Holloway to survey antibiotic use in the community between December 2007-November 2008 and included 17995, 9205, and 5922 patients visiting private retail pharmacies, public facilities and private clinics, respectively, 39% of the patients attending private retail pharmacies and public facilities and 43% of patients visiting private clinics were prescribed at least one antibiotic.8 According to the policy being drawn up by the Ministry of Health, about 20- 50 percent of all antibiotic use in India is inappropriate.9 Information of samples collected over a one year period (2007 - 2008) from Kasturba Hospital Manipal reveal that : - Well over 50% of E. coli and Klebsiella strains are resistant to commonly used gram negative drugs making therapy of even common problems like UTIs unpredictable. - Resistance to 2nd line drugs in these strains resistant to first line agents is no less worrying, with resistance rates of 40% to Pipercillin/Tazobactam, 38% for Cefaperazone/Sulbactam, 54% to Cefpirome (4th Gen. Cephalosporin), 54% to Aztreonam and 4% to Meropenem and Imipenem. - Resistance to Quinolones in Pseudomonas and Acinetobacter is in the order of 70%. Resistance to 2nd line antipseudomonal drugs lik Pipercillin / Tazobactam, Cefaperazone/Sulbactam and Cefpirome in these strains were 42%, 40% and 54% respectively. Resistance to Carbepenems ran to 8% in the strains showing first line resistance. - Oxacillin (Methicillin) resistance (MRSA) rates are 35% which is significant. - Enterococcal resistance to Ampicillin was 42% and to Gentamicin 20%.10 - We have one of the highest rates of gram negative bacillary resistance in the world.11 - Multidrug resistant community acquired gram negative bacillary infections are now pretty common in all parts of India.12 - In a 2007 study , Joakim Larsson, an associate professor of physiology at the University of Gothenburg, and colleagues described surprisingly high concentrations of antibiotics found in supposedly clean Patancheru water. Samples taken from water discharged from a local effluent treatment plant indicated that the facility was releasing about 45 kg [the equivalent of 45,000 daily doses] of the antibiotic ciprofloxacin into the Patancheru environment on a daily basis, which is equivalent to the total amount consumed in Sweden (population 9 million) over an average five-day period, the authors wrote.13

- While there is almost a total lack of regulation of the sale of antibiotics for medical uses, the situation with regards to the use of antibiotics in animal husbandry and poultry is worse still.

INTERVENTION
After having displayed an ostrich-like mentality in its reaction to the August 2010 article in The Lancet Infectious Diseases, the government seems to have woken up to the graveness of the situation and set up a task force of experts only days after the research paper suggested that foreign patients who visit India for treatment may carry back drugresistant microbes with them to their home countries. The task forces recommendations are yet to be converted to an active antibiotics policy. There is apprehension amongst certain specialists regarding its feasibility as the problem lies not in the framing of policies but rather in their implementation.16 While the situation seems impossible to handle especially because information is limited about which interventions will be effective in reducing the prevalence of antibiotic resistance, a coordinated multidisciplinary approach is required to tackle the problem. Patient and prescriber education, regulatory controls, public health programmes, surveillance, and further research into the dynamics of resistance will be key interventions.15 Dr Falguni Parikh in her article on the Status of Antibiotic use in India offers some suggestions on how certain reforms can be made at the community and hospital levels. At community level: 1. Public and professional education towards rational use of antibiotics. 2. Regulatory measures to control over the counter availability of antibiotics. 3. Guidelines at National / regional / local levels for use of antibiotics. 4. Improvement in standards of hygiene. At hospital level 1. Strict enforcement of hand hygiene. 2. Infection control committee, antibiotic managers to keep a check of usage. 3. Regular surveillance of data and antibiograms to guide empiric antibiotics selection. 4. Antibiotic Stewardship Programme This involves selecting an appropriate drug, optimizing its dose and duration to cure an infection while minimizing toxicity and conditions for selection of resistant bacterial strains.

5. Ensuring that cultures are sent prior to starting antibiotics to a good microbiology laboratory. 6. Measuring outcomes to evaluate effectiveness of policies.5 The following are some WHO recommended interventions:

CONCLUSION
After flatly denying any existence of NDM-1 superbug and dubbing the British study on it as unscientific, the Indian Council of Medical Research (ICMR) has finally woken up and decided to initiate research studies on NDM-1 and antibiotic resistance in the country. The body has admitted that it is extremely essential to generate scientific evidence on the prevailing trends of antimicrobial resistance in all parts of the country and at all levels of health care, comprising primary, secondary and tertiary systems. The council proposes to establish a network between the existing centers which are studying drug resistance related to various diseases. Research would also focus on developing methods for early diagnosis and detection of resistant strains. Rather than wasting precious time and resources in the defense of indefensible action or, as is the case here, inaction on their part, the government has to act quickly and decisively in the fight against antimicrobial resistance, not merely to protect the medical tourism industry but in order to prevent an even greater catastrophe that has the potential to take the world back to the pre-antibiotic days.

REFERENCES
1.] http://www.telegraph.co.uk/health/7945894/Indian-Government-angry-over-claimsits-hospitals-are-fuelling-global-superbug.html 2.] http://en.wikipedia.org/wiki/Plasmid-encoding_Carbapenemase-resistant_Metallo-BLactamase 3.] http://www.bbc.co.uk/news/world-south-asia-10954890 4.] http://indiatoday.intoday.in/site/story/journal-of-association-of-physicians-of-indiajapi--had-said-one-year-ago-said-about-the-presence-of-ndm-1-super-bug-in-newdelhi./2/135166.html 5.] http://www.japi.org/antibiotic_special_dec_issue_2010/index.html 6.] http://www.textbookofbacteriology.net/resantimicrobial.html 7.] http://www.who.int/mediacentre/factsheets/fs194/en/

8.] http://7thspace.com/headlines/379809/trends_in_antibiotic_use_among_outpatients_in_ne w_delhi_india.html 9.] http://blogs.reuters.com/india/2011/04/13/delhi-superbug-a-symptom-of-indias-ills/ 10.] http://www.japi.org/antibiotic_special_dec_issue_2010/article_06.html 11.]Mathai D, Rhomberg PR, Biedenbach DJ, Jones RN; India Antimicrobial Resistance Study Group. Diagn Microbial Infec Dis2002;44:367-77. 12.] Kothari A, Sagar V. Antibiotic resistance in pathogens causing community acquired urinary tract infections in India: a multicenter study. J Infect Developing Countries 2008;2:354-58. 13.] http://pubs.acs.org/cen/business/89/8901bus1.html 14.] http://www.allforkidsindia.com/allforkids/Resources/antibiotics.aspx 15.] BMJ 1998;317:6457 What can be done about resistance to antibiotics? John Turnidge 16.] http://www.telegraphindia.com/1110407/jsp/nation/story_13821775.jsp 17.] http://indiatoday.intoday.in/site/story/superbug-scare-icmr-focus-on-earlydiagnosis/1/135652.html