Sunita (assumed name *) was in the hospital for a long time. Diagnosed with cancer, she had undergone multiple rounds of chemotherapy. As a result, her immune system was severely stressed. A few weeks later, she developed an open chest wound that had to be operated upon. Soon after, her doctor noticed a stubborn bacterial infection that just would not go away, no matter what antibiotics they prescribed.
The doctor conducted a few tests and found that Sunita was infected with Methycillin-resistant Staphylococcus aureus or MRSA, a fatal drug-resistant bacterium that thrives in hospital wards all over the world (www.mayoclinic.com/health/mrsa/DS00735). This bacterium is believed to be widespread in Bangalore hospitals as well, according to doctors affiliated with eight major hospitals in the city. Patients who have been in the hospital for longer periods are the ones susceptible to the bacterium, say the doctors to whom this reporter spoke to.
The MRSA bacterium is just one symptom of the larger antibiotic resistance pandemic. As doctors over-prescribe and patients abuse antibiotics, bacteria gain immunity to existing treatment plans.
“Antibiotic resistance is a silent killer and must be tackled (on a war footing) like HIV and climate change,” says Dr Sunil Chandy, at Christian Medical College and Hospital, Vellore, who is conducting a collaborative study with the World Health Organization (WHO) on the emergence of antibiotic resistance in Vellore, Tamil Nadu. His research, published recently in Tropical Medicine and International Health, found that resistance to most antimicrobials is high in both urban and rural India, and the high level of resistance is probably due to unnecessary use of antibiotics.
The misuse of antibiotics
Christian Medical College, Vellore, Tamil Nadu
Dr L T Gayatri, Chief Health Officer, BBMP, 22112019
When a patient from the low-income strata goes to the doctor, he needs a quick fix, as he is not in a position to go in for elaborate tests. Doctors are willing to prescribe appropriate medication following proper tests, but as the patient must quickly return to work to support his family, the doctor could land up prescribing a strong antibiotic such as methycillin for an illness that probably is not caused by a bacterium.
Most fevers are viral and no medicine can fight viral infections; the body’s immune system is the only defense against the disease. But when a patient demands medicine, doctors fold and prescribe antibiotics for their placebo effect. Dr Bansal at Rajarajeshwari medical center on Mysore Road admitted to this, echoing the sentiments of others of his kin.
In several hospitals surveyed (names withheld, see box) that serve low-income groups, antibiotics are prescribed without first testing for the presence of bacteria. As a result of over-prescription by doctors and pharmacists, every antibiotic coming to the market today becomes ineffective in a few months, says Dr K S Ranjunath, Head of Orthopedics at Bowring Hospital, Bangalore. He stresses the need for a government policy that regulates prescription of drugs.
As antibiotics enter the blood stream, they attack the invading bacteria. In the fight for their lives, the bacteria must evolve or die. Sometimes they evolve to become multi-resistants, informally known as ‘superbugs’ that can resist the drug. The patient then finds him/ herself in the clutch of a disease that was treatable even a few years ago. Sunita was unable to fight an infection that might easily have been cured in its original form.
Antibiotics are useful to combat only bacterial infections and must be prescribed for a specific number of days. The most common mistake made is to stop taking the drug as soon as one feels better, leaving the course of antibiotics unfinished. A course shorter than needed will help in the evolution of superbugs, according to Dr Sujith Chandy.
The misuse of antibiotics, whether by doctor or patient, all doctors agree, is the root cause of the problem. There is an “indiscriminate issue of antibiotics” says Dr Ranjunath, among others, “you give Rs.10 to the pharmacist, and he will give you two (antibiotic) tablets (for even the common cold).” This illustrates a point made by Dr Chandy and others, that out of all the cases for which antibiotics are prescribed for in India, only 30 percent are bacterial infections.
When the patient takes unnecessary medicine, it gets flushed out of his system and eventually gets into the environment, said Dr Chandy. It may even get incorporated into soil, and thus act as a selective (evolutionary) pressure for soil bacterium1.One such bacterium that underwent mutation was the one that infected Sunita, called Staphylococcus aureus (SA).
The family of silent killers
Arguably, SA is the most successful ‘silent killer’ of them all. Over the past 15 years, this bacterium has evolved into a superbug able to resist many antibiotics, earning itself the title of MRSA.
Traditionally, staph infections were treated with antibiotics such as Methycillin, but evolution of SA into MRSA has rendered most of the low cost, less toxic antibiotics useless. Treatment now requires higher dosages of more toxic antibiotics such as Vancomycin. MRSA is now nearly three times as lethal as the original strain of SA, according to the Institute of Health Care Improvement, based in Massachusetts, USA.
SA infections manifest in a variety of diseases including minor skin lesions and life-threatening illnesses such as pneumonia, meningitis and toxic shock syndrome. In Sunita’s case, her chest bone infection was caused by MRSA, the more dangerous cousin of SA. But she is not alone. Rajesh (assumed name *) is a skin cancer patient whose long hospital stay resulted in MRSA caught from the ward in Bangalore.
Four public and five private hospitas were surveyed for this article. Names of hospitals are being withheld, in part because the prevalence of the problem is not restricted to nine surveyed. The focus of this article is on the effects of irresponsible antibiotic prescriptions by doctors and pharmacists.
“MRSA is a rampant but underreported problem,” say doctors in a Bangalore government hospital. Microbiologist Dr Asima Banu said that anyone who has been exposed to hospital wards for a long time could be a “nascent carrier of MRSA. It is an emerging problem in intensive care units (ICUs),” she added.
In a worrying trend, other bacteria such as enterococci that cause gastric infections are showing drug resistance in India. Dr Chandy mentions three other resistant organisms emerging in India: Vancomycin resistant Enterococus (VREC), Multi-drug resistant E. coli (ESBL) and Carbapenem-resistant organisms. These are not as common as MRSA, he said, but his hospital, which deals with last-resort antibiotic resistance cases, has seen them.
All doctors agree that the best way to prevent the spread of antibiotic resistant organisms such as MRSA between patients is to maintain proper hygiene. They recommend that patients be kept in isolation, and all medical instruments be maintained separately and fumigated. The best way to prevent MRSA in wards, says one doctor, is to ask all medical personnel to wash their hands frequently, according to the Center for Disease Control and Prevention. That may not seem like asking too much but given the condition of most government hospitals, it is a herculean task.
Some government doctors blame patients: “(The patients) throw (waste) on the floor, bed, pillow and the next patient’s bed. Since it is a free hospital, they give freely their infections also.”
As of now, antibiotic resistance does not seem to be a priority for the Karnataka Government. There are no studies being conducted, and Chief Health Officer for Bangalore city (BBMP) Dr. LT Gayathri dismissed the issue saying, “If (patients) are not treated (with one antibiotic), they will be changed to another antibiotic. This is not a problem.”
It is important at this stage for doctors and patients alike to increase their public health initiatives. Official studies need to be conducted to determine the extent of resistant organisms present in our hospital environments. This will help protect a patient like Sunita, who has to fight an additional disease even as she struggles with her primary illness.
In the presence of the antibiotic, most bacteria in the soil will die. But one in a million will contain a mutation in its genome that will allow it to overcome the harmful antibiotic. This bacterium will multiply. Since the average staph bacterium divides once every thirty minutes, within a day of exponential growth there will exist an entire colony of mutants that can resist the antibiotic. And these mutants, through conjugation (bacterial ‘sex’) will have the ability to transfer their resistance to bacteria that are not resistant in themselves. ⊕
* References to patients in this article are taken from anecdotes given by doctors.