• Uneven and unregulated antibiotic usage is one of the most important reasons behind the AMR crisis.
• In developed countries, doctors prescribe antibiotics even for the most basic maladies like the common cold.
• Solution for it: Stronger regulations of antibiotics prescriptions in these countries, like those implemented in Finland several decades ago, could help in mitigating resistance.
• Inequalities in access to medicine, excessive use, and poor sanitation services complicate the problem.
• Farmers using antibiotics to speed the growth of chickens and other livestock, drug-resistant germs find new ways to enter the environment.
• The typhoid study is the largest one of its kind looking at genomic sequencing of the typhoid bacteria isolated from 2016 to 2019 from Bangladesh, Nepal, Pakistan and India.
• The researchers explored 3,489 newly sequenced isolates from these countries together with over 4,000 strains from 1905 to 2018 from more than 70 countries to study the emergence of antimicrobial resistance (AMR) and how it spread to different geographical areas.
• It was found that genetic mutations in the organism resulted in resistance to commonly used antibiotics like ciprofloxacin and erythromycin.
• In the last 30 years, resistance spread nearly 200 times, both within a continent and to other continents.
• South Asia remained the largest (90%) hub of mutations and the source of spread, which occurred within countries of South Asia, and from South Asia to South East Asia and Southern Africa. There was spread to Europe and the Americas too.
• The results have far-reaching implications.
• First, it makes treatment of a common problem difficult with patients needing tests to see the efficacy of different antibiotics.
• The failure rates of treatment go up, so does the cost.
• Resultantly, there is an increase in the duration of hospitalisation and the death rate.
• Secondly, the spread of resistant strains to different countries and even continents calls for a change in epidemiological control strategies which need to become global, rather than country or region specific.
• Thirdly, the emergence of extremely resistant strains calls for expanding preventive measures, including typhoid vaccines in typhoid-endemic countries.
• The second study published earlier this year looked at the global burden of AMR with estimates from over 200 countries and over 20 bacterial pathogens.
• It was deduced that in 2019, close to 4.95 million deaths across the world were attributed to AMR with the low resource countries being the most affected.
• Nearly three-fourth of these deaths were linked to only six bacteria, with Escherichia coli being the most prevalent.
• The biggest contributor to such infections was lower respiratory tract infections, called pneumonia in common parlance.
• Sub-Saharan Africa was the worst affected followed by South Asia, with Australia being the least affected.
• The data show that it is imperative to have location/country-specific burden of AMR so that policy decisions are tailor-made accordingly.
• A fact which is worrisome for India is that it figured with very high prevalence of resistance to the six of the key bacteria when compared to other countries.

• Globally, countries committed to the framework set out in the Global Action Plan1 (GAP) 2015 on AMR during the 2015 World Health Assembly and committed to the development and implementation of multisectoral national action plans.
• Tripartite Joint Secretariat on Antimicrobial Resistance: Tripartite joint secretariat (FAO, OIE and WHO) has been established and is hosted by WHO to drive multi-stakeholder engagement in AMR.
• Interagency Coordination Group (IACG) on AMR: It was convened by the Secretary-General of the United Nations after the UN High-Level Meeting on Antimicrobial Resistance in 2016.
• The IACG brought together partners across the UN, international organizations and individuals with expertise across human, animal and plant health, as well as the food, animal feed, trade to formulate a plan for the fight against antimicrobial resistance.
• World Antimicrobial Awareness Week (WAAW): WAAW was previously called the World Antibiotic Awareness Week. From 2020, it will be called the World Antimicrobial Awareness Week.
• It is a global campaign that aims to raise awareness of antimicrobial resistance worldwide.
• Global Antimicrobial Resistance and Use Surveillance System (GLASS): WHO launched it  in 2015 to continue filling knowledge gaps and to inform strategies at all levels.
• GLASS has been conceived to progressively incorporate data from surveillance of AMR in humans, surveillance of the use of antimicrobial medicines, AMR in the food chain and the environment.
• Global Antibiotic Research and Development Partnership (GARDP): A joint initiative of WHO and the Drugs for Neglected Diseases Initiative (DNDi), GARDP encourages research and development through public-private partnerships.
• By 2025, the partnership aims to develop and deliver five new treatments that target drug-resistant bacteria identified by WHO as posing the greatest threat.
• Country wise initiatives:A multi-sectoral $1 billion AMR Action Fund was launched in 2020 to support the development of new antibiotics, and the U.K. is trialling a subscription-based model for paying for new antimicrobials towards ensuring their commercial viability.
• Peru’s efforts on patient education to reduce unnecessary antibiotic prescriptions.
• Australian regulatory reforms to influence prescriber behaviour, and initiatives to increase the use of point-of-care diagnostics, such as the EU-supported VALUE-Dx programme.
• Denmark’s reforms to prevent the use of antibiotics in livestock have not only led to a significant reduction in the prevalence of resistant microbes in animals, but also improved the efficiency of farming.

 India’s initiative

• To prevent the Over the counter sales of antibiotics, the central drug standard control organization(CDSO) prohibits medical stores from selling 24 key antibiotics without a doctor's prescription.
• India’s Red Line campaign: Which demands that prescription-only antibiotics be marked with a red line, to discourage the over-the-counter sale of antibiotics– is a step forward.
• National Health Policy, 2017, terms antimicrobial resistance as one of the key healthcare issues and prioritizes the development of guidelines regarding antibiotic use and check on restricting the growth of antibiotics.
• The National Action Plan on Antimicrobial Resistance (NAP-AMR) 2017 has assigned coordinated tasks to multiple government agencies involving health, education, environment, and livestock to change prescription practices and consumer behaviour and to scale up infection control and antimicrobial surveillance.
• FSSAI has set certain guidelines limiting the antibiotics in food products such as fish and honey.

Where it was reported that 30% antibiotic prescriptions was unnecessary?

• According to a 2016 study by the United States’ Centres for Disease Control and Prevention (CDC), at least 30% of antibiotic prescriptions in that country were unnecessary with the most often prescribed antibiotics being those for viral flu, sore throat or sinus infections.
• In India, this percentage is likely to be manifold higher.
• Unauthorised quacks and pharmacists randomly issue antibiotics to patients seeking them without any prescription.
• For every cough or diarrhoea or abdominal pain, some antibiotic is prescribed. Even in hospitals, antimicrobials are prescribed in a knee-jerk reaction, virtually for every indoor admission.
• Substandard or poor quality medicines are equally responsible, especially in resource constrained countries. Disease-causing bacteria exposed to sub-therapeutic doses of antimicrobials lead to mutations in the former.
• More worrisome is the fact that unjustified or sub-optimal antimicrobials can cause class resistance, i.e., resistance to the whole category of drugs rather than one particular agent.
• Some years ago, a study had found that one in eight antibiotics and one in five antimalarials used in poor countries were substandard.
• Other causes of AMR include inadequate laboratory testing to identify the appropriate antimicrobial agent, poor compliance by the patient in completing the intended treatment or even switching antibiotics.
• To add to these are unhygienic conditions in public hospitals, lack of surveillance, limited access to second or third-line antibiotics and indiscriminate use of antibiotics in poultry and animals.
• Contamination of human environment is also being recognised as an important factor in AMR. Antibiotics reach the environment via urine and faeces from humans and domestic animals, through improper disposal of drugs and hospital waste, and direct environmental contamination in some industries.
• In the environment, there is admixing of human and animal microbiota, giving ample opportunity to microbes to acquire and transfer antimicrobial resistance to each other.
• One extreme example is the use of an antibiotic Colistin which has been used for decades as an additive in livestock feed for promoting growth and treating intestinal infections.
• Such animals become a source of Colistin-resistant microbes which wreak havoc in serious human infections since Colistin is a last-resort drug for the treatment of infections by multi-drug-resistant Gram-negative bacteria.
• The environment thus has a role both in the evolution and transmission of resistance, a fact that has not been given due importance.

Who had launched the national programme for the containment of Anti- microbial resistance?

• The “National Programme on the containment of Antimicrobial Resistance” was launched under the aegis of the National Centre for Disease Control (NCDC).
• The objectives of this program are-

1. Establish a laboratory AMR surveillance system of 30 Network laboratories
2. Generating quality data on AMR for pathogens of public health importance
3. To strengthen infection control guidelines and practices.
4. Promote the rational use of antibiotics in both healthcare providers and the community.
5. Situation analysis regarding the manufacture, use, and misuse of antimicrobials.
6. Identify the prescription pattern and establish a monitoring system for the same.

• Indian Council of Medical Research (ICMR) established a national network on surveillance of antimicrobial resistance in laboratories based on tertiary care academic centers, targeting medically important index microbes that have been identified by WHO.
• The Antimicrobial Resistance Surveillance Research Network (AMRSN) established by ICMR started with six reference labs located in four tertiary care medical institutions. The network is being expanded to include 15 more medical colleges/corporate hospitals.
• The Government had formed the following 3 committees/groups.

1. Intersectoral coordinating committee
2. Technical Advisory Group
3. Core Working Group

•  A 2017 report by Centre for Science and Environment states that antibiotic misuse in food animal production is one of the main causes of Antimicrobial Resistance (AMR) in India.
• It rampantly spreads the resistant bacteria and carries it into human food streams.
• Industrial-scale food producers engage in intensive farming of animals, which characteristically involves rearing them in high stocking densities and also using high chemical inputs.
• The emergence of resistance is a natural process, however, due to rampant misuse and overuse of antibiotics, the resistance gets accelerated rapidly.
• Some experts are now convinced that the reason for the rapid spread of colistin resistance in humans is not because of indiscriminate use of antibiotics in hospitals but because of indiscriminate use of antibiotics in farms to accelerate the growth of farm animals.
• Sub-therapeutic, low doses are being fed to farm animals as growth promoters.
• It is very cheap but very harmful as it leads to colistin resistance in humans.
• Animals don’t need colistin but for humans, it may be a lifesaver.
• China has banned the use of Colistin in farm animals, the European Union has banned the use of antibiotic growth promoters in farm animals since 2006.
• In May 2014, the World Health Assembly requested the development of the Global Action Plan (GAP) on antimicrobial resistance.
• In May 2015, the Sixty-Eight World Health Assembly endorsed the GAP-AMR to tackle antimicrobial resistance, including the most urgent drug-resistant trend – the antibiotic resistance

Overview of Antimicrobial Resistance in India

• India is among the nations with the highest burden of bacterial infections.
• An estimated 4,10,000 children aged five or less die from pneumonia in India annually; with pneumonia accounting for almost 25 % of all child deaths.
• The crude mortality from infectious diseases in India today is 417 per 1,00,000 persons.
• The Food Safety and Standards Authority of India (FSSAI) banned the use of antibiotics and several pharmacologically active substances in fisheries.
• There is no regulation in the poultry industry where many of the commercially available pre-mixed feeds come with added antibiotics.

• The World Health Organisation (WHO) had released guidelines on how each class of drugs should be used to treat 21 of the most common infections.
• Governments, Medical Associations must also commit to tackling the antibiotic crisis together. India’s medical societies adopted the Chennai Declaration to promote steps to tackle stewardship.
• Implement the formulation by the Indian Health Ministry, control over-the-counter sales of antibiotics.
• Reduce unnecessary antibiotic use by people and in agriculture.
• Antibiotics should never be used as unnecessary growth promoters in livestock farming.
• Prevent infections from happening in the first place with better hygiene, access to clean water, infection control in healthcare facilities, and vaccination.
• Improving the surveillance of superbugs, the UK had committed $ 300 Million to support microbiology surveillance capacity in developing countries.
• Steps have been proposed to speed up the adoption of state-of-the-art diagnostics in hospitals, clinics, pharmacies, and homes so that unnecessary use of antibiotics can be reduced.
• Pharmaceutical companies and government agencies are gaining a better understanding of the role that vaccines and alternative therapies could play in reducing antimicrobial resistance.
• The UK and China agreed to establish a global research and development fund, to attract $ 1.5 Billion in investment to reduce the spread of antimicrobial resistance.