India’s short supply of basic antibiotics is making its drug resistance problem worse
Fist line antibiotics are missing in India and that’s making its
drug resistance problems worse.
Some essential
antibiotics are under price control & drug manufacturers are less inclined
to make them.
India
is witnessing an alarming rise in antibiotic resistance, much of which has been
triggered by over prescription of the drugs by doctors, overuse by patients and
unregulated use on farms and fisheries. But another factor contributing to this
rise in antibiotic resistance is the unavailability of simple antibiotics that
should be used as the first line of treatment.
The lack of such first line antibiotics has resulted in
people across India using stronger drugs to treat simple infections. Pathogens,
therefore, develop resistance to these stronger drugs faster and render even
the more basic antibiotics ineffective.
On June 6, the World Health Organisation updated its
Essential Medicines List, revising the antibiotic section extensively. Keeping
in mind extensive and growing antibiotic resistance across the world, the WHO
grouped antibiotics into three categories - access, watch and reserve with
recommendations on when each drug can be used.
The “access” category has 29 first-generation antibiotics
that should be widely available and affordable, states the WHO document. The
“watch” group of antibiotics can be the first and second choice for treatment
of a small set of infections but whose use should be reduced as much as
possible to prevent resistance. “Reserve” antibiotics are last resort medicines
to be only in the most severe circumstances when all other alternatives have
failed.
In India, many of the “access” group antibiotics are only
sparsely available.
“Antibiotics such
as benzathine penicillin, ampicillin and nitrofurantoin are not available in
the country,” said Dr Sumanth Gandhra from Centre for Disease Dynamics,
Economics and Policy, a public health research organisation with its
headquarters in Washington DC. “At
least not as much as they are supposed to be.” Gandhra, who works at the
centre’s Delhi office, was an advisor to the WHO committee that updated the
Essential Medicines List. Benzathine penicillin injections are commonly used
for treating syphilis and rheumatic heart disease in children. Ampicillin is
used to treat a variety of bacterial infections and nitrofurantoin is used to
treat urinary tract infections.
Many of these “access” category antibiotics are narrow
spectrum drugs that target certain kinds of bacteria and do not attack the
beneficial bacteria that are generally found in the human body. Stronger
antibiotics are broad spectrum drugs that are more effective. But continued and
widespread use of these stronger antibiotic makes pathogens resistant to them
faster and also resistant to the less potent, basic drugs. The basic drugs then
fail to kill the new drug-resistant pathogens. Therefore, the availability of
“access” category drugs is important to control the spread of antibiotic
resistance.
At the same time, there are a few cases in which drugs
that had been rendered ineffective decades ago due to resistance seem to be
working in the Indian population again. In the 1980s, there were many cases of
multi-drug resistant typhoid, which led to the reduced use of ampicillin that
was used to treat the disease. Now, samples of the Salmonella typhi bacteria
are showing sensitivity to ampicillin again.
Dr Yogesh Jain, one of the
founders of the Jan Swasthya Sahyog and who runs the community
hospital in Bilaspur, Chattisgarh, said only certain pharmaceutical
distributors stock first line antibiotics and other essential medicines. “Sometimes these drugs are more often
available in Chhattisgarh than in Delhi,” said Jain.
First line antibiotics are also more easily available in
government run facilities than in private pharmacies, clinics and hospitals.
This is because these drugs are part of the National Essential Medicines List
that is used to procure medicines in the public sector.
Dr Mukesh Agarwal, head of pediatrics at KEM Hospital in Mumbai
said that the municipal teaching hospital is able to procure drugs like
benzathine penicillin even though it is difficult to find in private
facilities. Benzathine penicillin is given as an injection once every 21 days
to children suffering from rheumatic heart disease. Another option to treat the
disease is with the an oral pill of erythromycin, which is the less preferred
mode of treatment. “The chances of
defaulting on taking the medication is higher when the doctors prescribe the
pill,” said Agarwal.
Even public hospitals that have better supply of first
line antibiotics do not get as much of these medicines as required. Shortages
sometimes compel pharmacists to give patients have the amount of medicine
required for a five-day course and ask them to collect the remaining medicines
after two days.
“The patient starts
feeling better after two days of taking medicines,” said Dr Anita Kotwani,
professor at the department of Pharmacology at VP Chest Institute in Delhi.
“Will he come back to collect the rest of
his dose? No. This suboptimal dose kills only half the bacteria in the body.
The other half become resistant.”
Some antibiotics like doxycycline are easily available in
combinations but not as single molecule formulations. “Combination drugs are more likely to cause drug resistance,” said
Kotwani.
The price control factor
Kotwani has conducted several surveys on the availability
and affordability of essential medicines. In 2013, just before the government
released its Drug Price Control Order, she found that doxycycline was
easy to find at both public and private health facilities in Delhi. In 2015,
the drug, which had come under price control, was not as easily available. Drug
manufacturers are less inclined to make drugs that are under price control and
therefore less profitable than those for which prices are not regulated, said Jagannath Shinde,
chairman of All India Organisation of Chemists and Druggists. “After price control, companies feel that it
is not affordable for them to produce the drug,” said Shinde. “They do not stop production. They just
reduce the quantity of drugs they produce. Naturally, it will not be as easily
available everywhere.” The general availability or lack of antibiotics
affects what medicines doctors prescribe.
“It is a vicious
cycle,” said Dr Vijay Yewale, a pediatrician from Navi Mumbai and former president of
Indian Academy of Pediatrics. Doctors stop prescribing antibiotics
that are in short supply and, in turn, manufacturers make less of these
antibiotics that doctors are no longer prescribing as much.
S Srinivasan, who runs a generic drug manufacturing
company in Vadodara called LOCOST and is also part of the All-India Drug Action
Network said that many of these first-generation antibiotics are
“out-of-fashion”.
“Often the doctors
fall prey to the marketing of the pharma companies,” said Srinivasan, about
why some doctors might prescribe more advanced antibiotics.
Kotwani said that doctors also try to retain their
patients with quick cures, prescribing what they call “effective” and expensive
broad spectrum antibiotics instead of first line antibiotics.
Said Yewale: “There
are some doctors who are not as rational in their prescription and have not
upgraded themselves. If the patient is not very ill, why not try the simple
narrow spectrum drugs first and check if it works?”
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