Seven decades ago, when antibiotics were used for the first time, they were hailed as one of the most important advancements of all times. With the development and availability of a large number of these ‘wonder drugs’ during the next five decades, deaths and misery due to most communicable diseases were dramatically reduced. This led to the belief that mankind may soon get rid of communicable diseases. At the peak of the discovery and use of antibiotics, a US Surgeon-General said: “The time has come to close the chapter of infectious diseases.” Sadly, this was not to be.

Reverting progress

Microorganisms, or germs as they are commonly called, have demonstrated their ingenuity and versatility in effectively countering the impact of antibiotics by developing resistance to their action. To a great extent, they have succeeded. This response of germs is commonly known as antimicrobial resistance (AMR). Several germs have accumulated resistance against almost all available antibiotics, making them  ‘superbugs’. The world is at the brink of a disaster. Unless concerted global actions are initiated immediately, it is heading for the pre-antibiotic era with the unstoppable progress of infectious diseases. This is an extremely alarming situation and considered as the greatest threat to mankind’s battle against communicable diseases. It is destined to impact not only the future of infectious diseases but shall also substantially negate the progress made in the past in treating and controlling infectious diseases. The successes of health-related Millennium Development Goals are also at risk.

Antimicrobial resistance also has enormous social and personal costs. When infections become resistant to first-line antibiotics, treatment has to shift to second- and third-line drugs, which are nearly always much more expensive and sometimes more toxic as well. In some countries, the high cost is prohibitive, with the result that some of these cases can no longer be treated.

One can argue that if germs develop resistance to antibiotics, modern science and technology should be able to develop and produce newer and more efficacious drugs. Sadly, this is not happening. Discovery, development and distribution of new antibiotics is a drawn out and expensive process. Huge amounts of money and years of research are needed to develop a new antibiotic, which is then rendered ineffective in a short course of time due to rampant use. Very low return on investment discourages the pharmaceutical industry from undertaking research and development. Thus, we are now at a stage where the discovery of new antibiotics has slowed to a crawl. During the past 15 years, only two new classes of antibiotics have been discovered.

Survival of the fittest

The appearance of resistance in germs is a natural evolutionary phenomenon, which can neither be predicted nor contained. However, this resistance spreads because of the selection pressure exerted by the irrational use of antibiotics by humans. In that sense, we are responsible for the spread of resistance. Inappropriate use of antibiotics selects resistant populations of germs, which is to say that a shortened, incomplete or inappropriate dose of an antibiotic kills those bugs that are most susceptible to the drug but leaves alive those that have some resistance to it. These stay alive to reproduce and pass on their genetic resistance. Aided by persistent and widespread inappropriate use of antibiotics, resistance to multiple drugs appears in some bugs, giving rise to superbugs. Antibiotics are being indiscriminately and widely used, both in the health sector as well as in the veterinary sector. In the latter, these medicines are used not only to treat diseases but also to enhance the body mass of animals to increase their food yield.   

Misuse of antimicrobial agents is rampant in both developed and developing countries. These are extensively used in conditions in which these are not indicated. Ailments like common cold and watery diarrhoea do not warrant any antibiotics, yet these are widely prescribed. This practice does not help the patient but promotes the spread of resistance. In many instances, especially among resource-starved communities, antibiotics even when properly prescribed are not taken by patients, thus providing a favourable environment to resistant germs to proliferate. Through widespread, incessant and inappropriate use of antibiotics, people are squandering one of the greatest weapons in the modern medical arsenal for combating disease.

Causes of antibiotic resistance are complex and we cannot preclude human behaviour at different levels of society. Many efforts have been made to describe the educational, technical, behavioural, regulatory, economic and social facets of AMR and the interventions to meet this menace. However, coordinated action is largely absent both at the national and international levels. On account of a lack of proper information on the implications of misuse of antibiotics, there is often a tendency to self-medicate.

A priority fight

The World Health Organisation (WHO) considers combating AMR a priority. Advocacy at the global, regional and national levels is being assiduously undertaken by WHO to bring AMR high on national agendas through a multisectoral approach. In 2011, WHO focused global attention on AMR through the theme of World Health Day. The Health Ministers of member states of the WHO South-East Asia Region, recognising the huge impact of AMR in their respective countries, made a commitment to combat this menace in 2011 through the Jaipur Declaration on Antimicrobial Resistance.  

A Regional Strategy on Prevention and Containment of Antimicrobial Resistance was developed to support member states in scaling up efforts in this direction. The 67th World Health Assembly in May 2014 called upon WHO to lead the development of a global action plan on AMR through a resolution. A plan will be submitted to the World Health Assembly in 2015. Since the problem of resistance is complex and encompasses biological, behavioural, technical, economic, regulatory and educational dimensions that require a comprehensive response, the global action plan will capture capacity, roles and responsibilities of all relevant stakeholders and will have joint ownership.

Much needs to be done, not only by governments but also by the private sector, which manages a big proportion of health care, as well as the veterinary sector. Finally, this battle belongs to each and everyone of us and hence, has to be fought by all.

We must recognise that antibiotics are a precious resource for mankind. We all need to work together to preserve and prolong their efficacy through their rational use and by reducing the burden of infectious diseases through all possible means. We cannot, at any cost, allow our world to slide back into the dark days of the pre-antibiotic era.

Khetrapal Singh is Regional Director, WHO- South-East Asia Region