hello and welcome to this episode of Health new I am sui Suk data and today's topic of discussion is antimicrobial resistance or AMR when disease causing pathogens such as bacteria no longer respond to antibiotics and can cause severe infections and deaths to discuss this we have two illustrious guests Dr kamini varia and Dr arind R Dr Valia heads the AMR division at the Indian Council of medical research and Dr Arin is a senior infectious disease specialist who is also convenor of the Kerala action plan on AMR thank you Dr Valia and Dr Arin for joining
us today we'll start by asking you Dr Valia can you please help us understand why has AMR emerged as a global Public Health Energy sorry emergency and why is it particularly a challenge in the Indian context thank you Sumi so antibiotics were discovered many many years ago and when the antibiotics were discovered they were actually U the pania and they formed the foundation of modern science now modern uh medicine so now what we are seeing is that the antibiotics or what we call as antimicrobials are not effective anymore uh the path the pathogens or the
bugs are actually becoming resistant to these uh drugs which we call as antibiotics or antimicrobials and uh we are not able to treat heat infections which are caused by these bugs which are resistant to these drugs and uh last few years uh we have seen uh and we have recorded and we have evidenced now to say that uh there is a rampant antimicrobial use especially in a country like India and also many other countries globally and um to a large number of antibiotics the bugs have now become resistant so that is a cause of alarm
plus uh the anti new antibiotic pipeline has been running dry and that has been one of the major concerns that the entire medical fraternity and the public health uh fraternity is actually concerned about uh the increasing levels of anti microbial resistance and uh everyone is worried that how we will be treating infections in the years to come plus uh there is a very high mortality which has been documented by uh various reports which have been publ lished in last few years um so which goes on to show that the burden of antimicrobial resistance is set
to be very high especially in Low Middle inome countries and the countries have to take immediate steps towards containment of AMR yeah Dr arind why do you think we have reached such a position you know when penelene when it was discovered was considered like ma'am also mentioned as the greatest discoveries in the medical Sciences in the 20th century but why have we really reached this position that super bugs are threatening to sort of disrupt the way we live uh first of all thank you Sumi for having having me on a show and uh that question
is bit tricky because you know uh antibiotics or antimicrobials are the compounds which are actually present in the environment so these are synthesized by bacteria or fungi in the fight against each other so basically what we are doing is we are accelerating the process of anti microbial resistance through the unscrupulous use of these valuable drugs that is antibiotics so basically for example when know medicin was invented medicin is an antibiotic in 1960 so the first the isolate of MRSA was discovered in 1961 itself so that means that continuous race between you know the humans and
uh this bacteria and fungi so it's actually a sort of an evolutionary pressure on them so the more antibiotics we make make them exposed to the more chance of them developing resistance so the you know the strength of bacteria or fungi is to to mutate that is evolve and become resistant to the antibiotics or antimicrobials and our strength is actually in outpacing them and coming out with new antibiotics so but then that will take a lot of times coming with a new molecule getting all these appr approvals regulatory framework is there so that is why
you know C Madam said that the antibiotic pipeline is sort of a dried up sort of thing so that is also very important so the as a as part of evolution antimicrobial resistance is inevitable so in order to keep one step ahead of this microbes we need to invest more and more in research and come out with new molecules and till that time we have to ensure that whatever valuable antibiotics are left with us so we need to have stewardship practices so that we are not exposing this uh microbes to uh more and more quantities
of antibiotics that is why know we need to have a one Health framework so antibiotics are being 70 to % antibiotic are being used in animal asry so we need to address this problem of AMR from a one Health perspective so that is actually the only way out and unfortunately the the gamut over the the full brand of AMR is f by the Southeast Asian countries as M I'm suggested the low and middle- income countries and these are the countries know which lag behind in research on coming out with new antibiotics and we are dependent
on the west to have new antibiotics the regulatory framework is so stringent sort of things like that so it is actually uh our role to ensure that antibodies that we have access to now so we need to ensure that this drugs are being used responsibly by all the stakeholders by The Human Side Animal husbandry side fisheries and aquaculture environment Etc so that till we come out with newer molecules our Lifeline is the drugs which are already left this is a very very tricky question because you know the Studies have shown that from even from Egyptian
mummies and caves in Mexico where you know the humans have never gone they have isolated this antimicrobial resistant buts so that shows that you know humans are just one part of the problem basically what is happening is evolution is going on and we are actually adding fuel to the fire of antimicrobial resistance through the unscrupulous use of antibiotics during the covid pandemic we saw a lot of use of antibiotics by everybody who has who had fever even now even whenever people have fever cold they just tend to take things like you know aiyin without even
asking the doctor sometimes do you think uh you know covid may have sort of in a way worse in it or if I can put it the other way had Co not been there would the situation would be uh be any better than uh it is there currently dror Valia would you like to answer that yeah so uh in covid we definitely saw deprioritization of antimicrobial stewardship efforts which we were undertaking uh in all the hospitals uh where uh I see was funding antimicrobial stewardship projects what we saw was that uh most of the staff
actually was directed towards management of covid patients and that led to U you know even the research staff being uh diverted towards uh the covid patients and that's why um the co the antimicrobial stewardship efforts which were there U for uh getting deprioritized they were not getting enough attention the second point is that uh in the hospitalized patients or in the patients who were in the community I mean the scare of covid was so much and we did not have any specific treatment for covid so right I mean because of that U uh you know
frenzy I think um the populations or the communities were consuming lot of antimicrobials um steroids antimicrobials these were the two drugs which uh saw a definite increase in terms of uh their prescript ion as well as consumptions which is a well documented data but uh in hospitalized patients what we saw was and this was the study which was was also published by icmr that the incidence of secondary infections uh was not much higher than what we see normally in the patients with respiratory infections or with flu infections yet I think it was the scare of
the covid and absence of any specific treatment which actually drove uh or increased the prescription of and consumption of antimicrobials in uh covid patients yeah but if you see uh the recently released Lancet report they have reported that uh during postco there is a sub small decline in terms of mortality because of infections so uh this is a phenomena I think which we will continue to study for a few more years that what did covid actually uh you know contribute to antimicrobial resistance uh from the icmr data what we see is that U there was
a shortterm uptick in terms of uh in the increasing no no increasing trend of uh drug resistance to some of the antibiotics but it came to normal after two years of covid so that's why I say I mean it was I think a temporary setback but whereever we were having uh good uh efforts of antimicrobial Ste stewardship which were going on uh icmr Network hospitals I think stuck with it and they continued that except with few hospitals uh other than that uh I think uh covid led to Temporary setbacks but uh sustained efforts on antimicrobial
stewardship has led to not a very major uh you know setback in terms of uh the loss uh of focus on antimicrobial sttion okay Dr Arin would you also like to add something to it actually Co was an opportunity because you know all of us are working on antimicrobial resistance and mitigative strategy sort of thing Cod was an opportunity in the sense that you know majority of the antibiotic prescription happens in the outpatient department and one of the arguments that doctors make is that in India we don't have access to Diagnostics in the OPD setting
and that is the reason why we are forced to use antibiotics even uh means for apparently respiratory infections 90% call empirical use of antibiotics exactly so you know they don't have don't know they don't know whether it is a bacterial or viral infection and that is the reason why they're using antibodies that was their explanation prior to covid but Co time it was actually the first time that now as clinicians we had we knew the diagnosis before starting a drug because all of them we had that much access to thanks to icmr and their Network
we have that much access to molecular diagnostic facilities so all of us knew that we are treating covid-19 that is a viral infection despite that ayin became the largest selling this AAL became the largest selling brand in 2022 2023 and uh and their sales was were more than thousand cror that is more than the sales of insulin human mixar so that means that no despite knowing it is a viral infection doctors did still use antibiotics that means that is not because of lack of a Wess that they use antibiotics okay so that explanation was gone
so from a stakeholder perspective or a policy maker perspective then we realize that we need to be that much serious about antimicrobial Starship so we have been talking about information education communication but that has to translate to BCC behavioral change for that you know knowing a diagnosis alone is not enough that is what Co did teach us so we need to engage more with the the the clinicians we need to engage with the public we need to engage with the the Civil Society knowing a diagnosis of a viral infection alone did not change anything with
regard to the prescription practice of doctors in India that is what I understood from the the sales of a so one aspect could be because of panic but despite having a diagnosis still antibiotics were used so based on that we actually changed our strategies in antimicrobial Starship in our state and the Lancet report to an extent is actually correct that in initial period that is 2020 2021 because of lockdowns and all those things uh and we were so strong about infection prevention and control hand hygiene and stuff like that all the respiratory infections across the
globe had come down in 2020 2021 because of all these uh you know mitigation measures and because since the other respiratory infections came down the antibod use also might have come down and that is probably reflecting in the lanet report but that was not the situation uh during the Delta wave that is 2022 2023 actually it came back with a vengeance that is our experience from our state so for one and a half years of covid the antibod use was very low in the state but then it came back with the Vengeance and it became
sort of normaly and as cam Madam said you know it will take us years to understand what the contribution of covid to you know the silent pandemic of antimicr resistance in our country yeah Dr Valia this question is for you uh the icmr recently came up with this annual AMR research and surveillance Network report would you help us understand what is this report about and what were the key findings that we must know so uh this report we publish annually uh this was the seventh report that we had published from the icmr AMR surveillance Network
which was um established in 2013 so we report uh uh the trends of antimicrobial resistance to key pathogens uh for example escara coli cumon astoa bom sudas aeroginosa then salilla tyi dial pathogens like again viool Shela Aromas and we we also report trends for the fungal infections so we report trends for these key pathogenic groups from um the tertiary care hospitals of the country so uh as I mentioned this is the sixth report the idea of publishing is that you know uh all the Physicians know that what kind of Trends we are seeing in the
tertiary care hospital now uh the tertiary care hospitals mostly receive very sick patients or uh most of the time uh they are also treating patients who are referred from other health facilities so the uh AMR Trend which is uh rates which are reported by this report of icmr they are actually very high they are not reflective of our midlevel hospitals or the community levels uh so this has to be um you know taken with a pinch of salt that okay this is a High um this is coming from a setting which where the antimicrobial uses
very high so correspondingly antimicrobial resistance rates will also be high now what we are uh seeing is uh the findings from the report are they are not much different from what we are seeing for last four five years um eoli cson sudas aeroginosa enactor and staf orus they cause almost 18 percent of the infections if you look at it in terms of their contribution to the total number of drug resistant infections reported by the network and these are the gram negative pathogens uh four of them are gram negative pathogens for which we are running out
of treatment options the uh resistance rates to carbapenams pyin tazobactum uh and other sefalosporin is very high and as a result uh if the patients get I'll add here that these are The Last Resort antibiotics which are you talk talk about so when the patients uh you know get these in infections which are caused by these drug resistant pathogens then uh they have very Li limited treatment options so the uh message that we want to convey through this uh report is that the broadspectrum use which is uh very high in our country we need to
bring that down because that is adding to uh you know emergence of multi-drug resistant pathogens that are becoming very difficult to treat and those po patients have very limited treatment options with the drugs that are currently available in India right Dr Arvin would you like to talk a little about the Kerala action plan because you know it has uh taken a lead in the country in a sense of you know in introducing several measures to bring down the rate of antibiotic use yeah Dr yeah please go ahead uh actually when the National Action Plan was
launched in 2017 uh Kerala became the first state in country to have its own state level action plan it was released in 2018 so on par with the global action plan and national action plan we have six strategic priorities the Strategic priority one is actually uh you know creating knowledge and understanding among all the stakeholders and second is actually you know the evidence evidence creation means just like the icmr network we have our Network that is the Cars net which has around 52 tertiary Care Centers and we have the Haband sloke model as well third
is infection prevention control which is very very important because know Madam said that the rate of resistance in tertiary care icus is very high that means that we can't afford to have any healthare associ infection occurring in majority of our tertiary care institutes because now if it is going to occur it is going to be by a drug resistant organism so that we need to focus that much on infection prevention and control fourth is actually antimicrobial sosip that is a judicious use of antibiotics in the opds in the impatient Department as well as in the
icus 50 is research you know uh research is the most important thing so we are basically clutching on to whatever is available to us till we get newer products so that that is that has to be our vision and six is actually Public public private collaborations so as part of this uh you know our action plan uh the second one is the most important one which I feel like uh you know having our own surveillance Network so that is now our surveillance network is the carset Kerala antimicro resistance surveillance Network and we feed to the
ncdc ncdc has their own surveillance network from there the data goes to the the global that's the glass portal it goes to the glass portal so initially we started with you know the med government Medical College then we expanded to the private medical colleges the corporate hospitals and now we have around 52 sites notes reporting to us then we realize that you know our antibiogram there is a state antibiogram from the from our tertiary Care Centers is actually different to the the icmr the resistance rates are actually is high but still less compared to uh
you know the resistance rates report from the the centers in the icmr that is understandable because majority of the centers reporting to the icmr are topnotch institutions like BGA Ander or ases there will be having more uh complex surgeries and patients on chemotherapy like that so basically we understood that you know the resistance is going to be different and it's going to vary from institution to institution so we understood that that know based on the Trant Medical College antibiogram so I represent Trant Medical College which is actually a highend center so there the rates are
high when compared to another Medical College which doesn't do that much of complex surgeries or chemotherapy Etc so we decided that each institution should have its own antibiogram so otherwise you know if you follow our antibiotic policy it might try up the resistance in another Center like that then we realize that if this is a situation between tertiary care institutions then what about the secondary care and the primary care for that we started the abans spoke model habans spoke model means that in all the districts we will identify an AMR Center of Excellence that will
be a district lab or a public health lab and that will be having all the automated facilities and we that will act as the Hub and the Spock will be the taluk hospitals so we piloted that in aragam from 2019 onwards and we came out with the district antibiogram and interestingly the district anti Bagram showed that you know the muram is our last line antibiotic right so at the taluk level we don't have any m resistance that is all the 2022 and the B of the district level show and this actually has to be extrapolated
to the rest of the the state as well so we have established the Aban blog model in all the districts and next year we'll be having this District anti biogram from uh other the this the 14 districts of Kerala and icmr also is actually taking the lead in establishing this abans Bor model of surveillance in other states as well so from an India perspective this is going to be very very important because one network is not may not reflect what is happening at the secondary level or the primary level So based on that we need
to have stratified antibiograms so that is antibiogram based on the data from Individual institutions or from the secondary care primary care and we need to have the stratified antimicrobial sorship intervention strategies and that is uh what we are doing in the in the state for that you know uh we have a decentralized approach TOS antimicrobial stewardship we have the district level AMR committees we have the Block Level AMR committees and all the 90 blocks and then in 2019 we came with the concept of antibiotic literate Kerala because so we saw that you know despite knowing
it is covid-19 uh antibiotic was used right so in order to ensure that the antibiotics are not being prescribed there are two aspects to this one even if the doctor is not prescribing the public might demand an antibod that is what majority of the doctors said so basically the awareness creation has to be targeting the healthcare professionals need to Target the students the schools school education should uh you know have aspects of AMR into that we need to educate the farmers we need to educate the Civil Society and we need to give uh reach out
to the public we do that through the the Block Level AMR committees with the the the family health centers as the falr so basic aim is that no everyone should know about the right use of antibiotics and antibiotics should not be used without prescription like that for that know we need to have a bit of legislation as well and we know that schedule H1 H all these things are there implementation is the challenge so from last last year onwards we started this operation am whereby a toll-free number was given to the public that is you
know all the pharmacist have been instructed not to give antibiotic without prescription but the issue in India is that we have enough very good laws but implementation is the problem right so we may not be having that much number of drug inspectors to see whether this is being you know followed up like that so what we did here was we gave a tollfree number to the public suppose someone is going to the pharmacy and getting an antibiotic without prescription if he is an antibiotic literate citizen of Kerala he can use this toll free number and
inform us so after that no you know there was a huge drop in the sale of antibiotics in the state but it did not reflect into mortality sort of thing right that means that know if you know everyone is educated we can really bring down the the Quantum of antibiotics which are used without prescription so it has to be a multi-prong strategy because now focusing on The Human Side alone is not going to be enough so it is a Oneal thing animal Hendry the fisheries and aquaculture everyone has to be in it together so what
we are doing in Kerala is that know we have trying to identify all the challenges and trying to go with the customized solutions for that in a one Health fashion very interesting points there Dr Valia could you summarize you know what do we as individuals need to do what doctors because we have seen that on many occasions even when it's not require doctors also indiscriminately prescribe antibiotics and also you know what policy measures you think are immediately required to address this major crisis so um and the whole Genesis of this antimicrobial resistance is because there
is lot of antimicrobial pressure now if we really want to contain antimicrobial resistance we have to bring down this antimicrobial pressure and we have to look for interventions how can we reduce this antimicrobial pressure and instead of uh running towards developing new antimicrobials as Dr Arin very nicely pointed out that we must prioritize uh rationalizing and having a responsible use of existing antimicrobials because it becomes a way of consuming antibiotics you know now currently as he has very rightly said you know that it is very hard to implement the even the policies and the laws
which are there because somewhere there is a very poor threat perception that what uh uh improper use of what will be the consequence of irresponsible and improper use of antimicrobials in future we are realizing it but very few our uh stakeholders or even the community members are actually aware of the big risk that it poses for future medicine so for prevention I think uh we should be using the what we have right now optimally and uh for that I think vaccination is very very important what we see is that uh for the prevention interventions uh
the vaccines that we currently have we are not utilizing them optimally for example uh who says that 75% of the adults in any country must have influenza vaccination but how many in how many countries do uh the elderly people who are 75 plus actually uh take uh or all the ad they take these influenza vaccination it is available in India Neal vaccine is available in India U we are we know now that respiratory infections attract maximum number of antimicrobial prescription and antimicrobial consumption in the community so if everyone starts using the vaccines appropriately we can
bring down the incidence of infections uh which would require antimicrobial prescriptions this is one broad uh one example I just just a supplementary question there do you think it'll help if these vaccines for example are introduced in the government's uh Universal immunization program defin definitely uh icmr is undertaking a study uh where we are going to monitor the impact of uh introduction of flu and nemal vaccine in elderly population and its impact on the hospitalization uh mortality as well as antimicrobial prescriptions now we are going to be uh uh you know a country the demography
is going to be changing we are living longer so the longer live more infections we are likely to have and the more antimicrobial resistance the other intervention is uh reducing the use of broadspectrum antimicrobials I think these need some kind of a campaign in the country for Physicians for community that we do not need to overprescribe broadspectrum antimicrobials that this is something that we cannot afford it is not a choice and any more I think we do not have any other option but to bring down our uh broadspectrum antimicrobial use for which we need to
monitor our consumption for which we need education and awareness so in India we have a issue of access versus access so the there are populations who do not have access to even the basic uh antimicrobials because they cannot afford or they do not have access to the healthcare facility on the other side we see excess use of antimicrobials because of rising standard of living improving incomes and also um the cost of antimicrobials has been really uh brought down by efforts of the government to make them affordable but then uh this should not really uh impact
uh the antimicrobial resistance uh containment effort so that's why uh these are the multiple I have just uh talked about a few of them but these kind of interventions I think they can contribute a lot towards our AMR containment efforts yeah thank you so much with that we come to the end of the discussion I really appreciate both of you joining us in the discussion today thank you so much Dr Valia and Happ [Music] [Applause]
