Growing burden of antimicrobial resistance and the need for effective stewardship: An Indian perspective

Abstract

History of antimicrobial resistance (AMR) dates back to the time from the discovery of antibiotics and has emerged as a significant public health problem. The recent COVID-19 pandemic saw the widespread and irrational use of antibiotics on a large scale. In this review on AMR we have compared the burden and impact of AMR in terms of morbidity, mortality and expenditure. Multiple strategies and action plans have been laid out by global leaders, and also in India to tackle the pervasive issue of AMR. There are a number of factors driving AMR, and recently major humanitarian crises around the world have come up as significant drivers and pose challenges to curbing AMR, which requires collaborative, multisectoral and dedicated efforts from all sides to bring down AMR. Like any other public health issue, attempts to control AMR are plagued with hurdles thwarting our efforts.

Keywords

Antimicrobial resistance / One Health / Antimicrobial stewardship

Conflict of interest statement

The authors claim there is no conflict of interest.

Funding

The study receives no extramural funding.

Data availability statement

The data supporting the findings of this study are available from the corresponding author upon request.

Authors’ contributions

Jayaprakasan AK, Ghosh A, Banerjee B, Singh MM and Solanki HK contributed to the writing, literature review, and editing of the manuscript to ensure clarity, coherence, and scholarly rigor. All authors reviewed and approved the final version of the manuscript.

References

[1] Holmes KK, Bertozzi S, Bloom BR, Jha P, Gelband H, DeMaria LM, et al. Major infectious diseases: Key messages from disease control priorities. In: Disease control priorities, third edition (Volume 6): Major infectious diseases. Washington, DC: World Bank; 2017, pp. 1-27.

[2] Dattani S, Rodés-Guirao L, Ritchie H, Ortiz-Ospina E, Roser M. Life expectancy. [Online] Available from: https://ourworldindata.org/life-expectancy. [Accessed on 18 November 2024].

[3] World Health Organization. Antimicrobial resistance. [Online] Available from: https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance. [Accessed on 24 November 2024].

[4] World Health Organization. Ten health issues WHO will tackle this year, 2019. [Online] Available from: https://www.who.int/news-room/spotlight/ten-threats-to-global-health-in-2019. [Accessed on 24 November 2024].

[5] Adedeji WA. The treasure called antibiotics. Ann Ib Postgrad Med 2016; 14: 56-57.

[6] Rosenblatt-Farrell N. The landscape of antibiotic resistance. Environ Health Perspect 2009; 117(6): A244-250.

[7] Dhingra S, Rahman NAA, Peile E, Rahman M, Sartelli M, Hassali MA, et al. Microbial resistance movements: An overview of global public health threats posed by antimicrobial resistance, and how best to counter. Front Public Health 2020; 8: 535668.

[8] Hutchings MI, Truman AW, Wilkinson B. Antibiotics: Past, present and future. Curr Opin Microbiol 2019; 51: 72-80.

[9] Turner NA, Sharma-Kuinkel BK, Maskarinec SA, Eichenberger EM, Shah PP, Carugati M, et al. Methicillin-resistant Staphylococcus aureus: An overview of basic and clinical research. Nat Rev Microbiol 2019; 17(4): 203-218.

[10] World Health Organization. Global antimicrobial resistance and use surveillance system (GLASS) report: 2022. [Online] Available from: https://www.who.int/publications/i/item/9789240062702. [Accessed on 13 November 2024].

[11] Centers for Disease Control and Prevention. COVID-19 & Antimicrobial Resistance. [Online] Available from: https://www.cdc.gov/antimicrobial-resistance/data-research/threats/COVID-19.html. [Accessed on 13 November 2024].

[12] Rehman S. A parallel and silent emerging pandemic: Antimicrobial resistance (AMR) amid COVID-19 pandemic. J Infect Public Health 2023; 16(4): 611-617.

[13] Painuli S, Semwal P, Sharma R, Akash S. Superbugs or multidrug resistant microbes: A new threat to the society. Health Sci Rep 2023; 6(8): e1480.

[14] World Health Organization. WHO bacterial priority pathogens list, 2024: Bacterial pathogens of public health importance to guide research, development and strategies to prevent and control antimicrobial resistance. [Online] Available from: https://www.who.int/publications/i/item/9789240093461. [Accessed on 18 November 2024].

[15] Friedman ND, Temkin E, Carmeli Y. The negative impact of antibiotic resistance. Clin Microbiol Infect 2016; 22(5): 416-422.

[16] Murray CJL, Ikuta KS, Sharara F, Swetschinski L, Aguilar GR, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis. Lancet 2022; 399(10325): 629-655.

[17] United Nations Environment Programme. To reduce superbugs, world must cut down pollution. [Online] Available from: http://www.unep.org/news-and-stories/press-release/reduce-superbugs-world-must-cut-down-pollution. [Accessed on 15 November 2024].

[18] World Health Organization. Global action plan on antimicrobial resistance. [Online] Available from: https://www.who.int/publications/i/item/9789241509763. [Accessed on 13 November 2024].

[19] World Health Organization. Multidrug-Resistant Tuberculosis (MDR-TB), 2018. [Online] Available from: https://www.who.int/docs/default-source/documents/tuberculosis/multidrug-resistant-tuberculosis-mdr-tb.pdf. [Accessed on 13 November 2024].

[20] Llibre JM. Time to get serious with HIV-1 resistance in sub-Saharan Africa. Lancet Infect Dis 2017; 17(3): 241-243.

[21] Hanboonkunupakarn B, White NJ. The threat of artemisinin resistant malaria in Southeast Asia. Travel Med Infect Dis 2016; 14(6): 548-550.

[22] Centres for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. [Online] Available from: https://www.cdc.gov/antimicrobial-resistance/media/pdfs/ar-threats-2013-508.pdf. [Accessed on 15 November 2024].

[23] World Bank Group. Drug-resistant infections: A threat to our economic future. Washington DC: World Bank; 2017, pp. 16-24.

[24] Al Asad M, Katha ZS. Antimicrobial resistance in livestock-human interaction: A critical public health issue. JSM Microbiol 2024; 10(1): 1-6.

[25] Indian Council of Medical Research. Antimicrobial Resistance Surveillance Network. Annual report: January 2023 to December 2023. New Delhi: ICMR; 2024, pp. 1-244.

[26] Indian Council of Medical Research. Antimicrobial Resistance Surveillance Network. Annual report: January 2021 to December 2021. New Delhi: ICMR; 2022. pp. 1-207.

[27] Institute of Health Metrics and Evaluation. The burden of antimicrobial resistance (AMR) in India, 2023. [Online] Available from: https://www.healthdata.org/sites/default/files/2023-09/India.pdf. [Accessed on 15 November 2024].

[28] World Health Organization. Antimicrobial resistance and its containment in India, 2016. [Online] Available from: https://www.who.int/docs/default-source/searo/india/antimicrobial-resistance/amr-containment.pdf?sfvrsn=2d7c49a2_2. [Accessed on 20 May 2024].

[29] Government of India. National Health Accounts Estimates for India (2019-20) released, 2023. [Online] Available from: pib.gov.in/Pressreleaseshare.aspx?PRID=1919582. [Accessed on 14 November 2024].

[30] Chandy SJ, Naik GS, Balaji V, Jeyaseelan V, Thomas K, Lundborg CS. High cost burden and health consequences of antibiotic resistance: The price to pay. J Infect Dev Ctries 2014; 8(9): 1096-1102.

[31] Reygaert WC. An overview of the antimicrobial resistance mechanisms of bacteria. AIMS Microbiol 2018; 4(3): 482-501.

[32] Klein EY, Van Boeckel TP, Martinez EM, Pant S, Gandra S, Levin SA, et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci USA 2018; 115(15): E3463-E3470.

[33] Karakonstantis S, Kalemaki D. Antimicrobial overuse and misuse in the community in Greece and link to antimicrobial resistance using methicillin-resistant S. aureus as an example. J Infect Public Health 2019; 12(4): 460-464.

[34] Ventola CL. The antibiotic resistance crisis: Part 1: Causes and threats. Pharm Ther 2015; 40(4): 277.

[35] Marc C, Vrignaud B, Levieux K, Robine A, Gras-Le Guen C, Launay E. Inappropriate prescription of antibiotics in pediatric practice: Analysis of the prescriptions in primary care. J Child Health Care 2016; 20(4): 530-536.

[36] Llor C, Bjerrum L. Antimicrobial resistance: Risk associated with antibiotic overuse and initiatives to reduce the problem. Ther Adv Drug Saf 2014; 5(6): 229-241.

[37] Nepal G, Bhatta S. Self-medication with antibiotics in WHO Southeast Asian Region: A systematic review. Cureus 2018; 10(4): e2428.

[38] Pechère JC, Hughes D, Kardas P, Cornaglia G. Non-compliance with antibiotic therapy for acute community infections: A global survey. Int J Antimicrob Agents 2007; 29(3): 245-253.

[39] Lee SY, Shanshan Y, Lwin MO. Are threat perceptions associated with patient adherence to antibiotics? Insights from a survey regarding antibiotics and antimicrobial resistance among the Singapore public. BMC Public Health 2023; 23(1): 532.

[40] Ramay BM, Caudell MA, Cordón-Rosales C, Archila LD, Palmer GH, Jarquin C, et al. Antibiotic use and hygiene interact to influence the distribution of antimicrobial-resistant bacteria in low-income communities in Guatemala. Sci Rep 2020; 10(1): 13767.

[41] Essack S. Water, sanitation and hygiene in national action plans for antimicrobial resistance. Bull World Health Organ 2021; 99(8): 606-608.

[42] Centers for Disease Control and Prevention. Antibiotic resistance from the farm to the table, 2014. [Online] Available from: https://stacks.cdc.gov/view/cdc/2545. [Accessed on 27 May 2024].

[43] Sreeja MK, Gowrishankar NL, Adisha S, Divya KC. Antibiotic resistance-reasons and the most common resistant pathogens-A review. Res J Pharm Technol 2017; 10(6): 1886-1890.

[44] Manyi-Loh C, Mamphweli S, Meyer E, Okoh A. Antibiotic use in agriculture and its consequential resistance in environmental sources: Potential public health implications. Molecules 2018; 23(4): 795.

[45] Pal C, Bengtsson-Palme J, Kristiansson E, Larsson DGJ. The structure and diversity of human, animal and environmental resistomes. Microbiome 2016; 4(1): 54.

[46] Bokhary H, Pangesti KNA, Rashid H, Abd El Ghany M, Hill-Cawthorne GA. Travel-related antimicrobial resistance: A systematic review. Trop Med Infect Dis 2021; 6(1): 11.

[47] Abou Fayad A, Rizk A, El Sayed S, Kaddoura M, Jawad NK, Al-Attar A, et al. Antimicrobial resistance and the Iraq wars: armed conflict as an under investigated pathway with growing significance. BMJ Glob Health 2023; 7(Suppl 8): e010863.

[48] AMR Control. Armed conflicts and antimicrobial resistance: A deadly convergence. [Online] Available from: http://resistancecontrol.info/wp-content/uploads/2019/05/Haraoui.pdf. [Accessed on 15 November 2024].

[49] World Health Organization. One Health 2017. [Online] Available from: https://www.who.int/news-room/questions-and-answers/item/one-health. [Accessed on 15 November 2024].

[50] Velazquez-Meza ME, Galarde-López M, Carrillo-Quiróz B, Alpuche-Aranda CM. Antimicrobial resistance: One Health approach. Vet World 2022; 15(3): 743749.

[51] Garg S, Banerjee B. One world, one health. Indian J Community Med 2021; 46(4): 581-583.

[52] World Health Organization. Global Antimicrobial Resistance and Use Surveillance System (GLASS), 2024. [Online] Available from: https://www.who.int/initiatives/glass. [Accessed on 11 November 2024].

[53] World Health Organization. Global antimicrobial resistance and use surveillance system (GLASS) report: 2022. [Online] Available from: https://www.who.int/publications/i/item/9789240062702. [Accessed on 11 November 2024].

[54] World Health Organization. AWaRe classification of antibiotics for evaluation and monitoring of use, 2023. [Online] Available from: https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2023.04. [Accessed on 11 November 2024].

[55] United Nations. Interagency Coordination Group on Antimicrobial Resistance. [Online] Available from: https://www.un.org/sg/en/content/sg/personnel-appointments/2017-03-17/interagency-coordination-group-antimicrobial-resistance. [Accessed on 11 November 2024].

[56] World Health Organization. One Health Global Leaders Group on Antimicrobial Resistance. [Online] Available from: https://www.who.int/groups/one-health-global-leaders-group-on-antimicrobial-resistance. [Accessed on 11 November 2024].

[57] National Centre for Disease Control. National action plan on AMR (NAP-AMR). [Online] Available from: https://ncdc.mohfw.gov.in/national-action-plan-on-amr-nap-amr/. [Accessed on 9 June 2024].

[58] National Centre for Disease Control. National Programme on AMR Containment. [Online] Available from: https://ncdc.mohfw.gov.in/national-programme-on-amr-containment/. [Accessed on 19 June 2024].

[59] Walia K, Ohri VC, Madhumathi J, Ramasubramanian V. Policy document on antimicrobial stewardship practices in India. Indian J Med Res 2019; 149(2): 180-184.

[60] Indian Council of Medical Research. Antimicrobial Stewardship Program Guideline, 2019. [Online] Available from: https://iamrsn-audit.icmr.org.in/index.php/amsp/amsp-guidelines. [Accessed on 19 November 2024].

[61] Ministry of Health and Family Welfare. Annual Report 2022-23 of the Department of Health and Family Welfare. [Online] Available from: https://mohfw.gov.in/?q=publications-6. [Accessed on 16 December 2024].

[62] Sharma A, Thakur N, Thakur A, Chauhan A, Babrah H. The challenge of antimicrobial resistance in the Indian healthcare system. Cureus 2023; 15(7): e42231.

[63] Kotwani A, Joshi J, Lamkang AS. Over-the-counter sale of antibiotics in India: A qualitative study of providers’ perspectives across two states. Antibiotics (Basel) 2021; 10(9): 1123.

[64] Walia K, Chaudhuri S, Sinha R, SS Ghosh, Chowdhury A, Manna S, et al. Public awareness on antimicrobial resistance: Results of a community-based survey and implications for policy. [Online] Available from: https://www.orfonline.org/research/public-awareness-on-antimicrobial-resistance. [Accessed on 13 November 2024].

[65] Sengupta S, Barman P, Lo J. Opportunities to overcome implementation challenges of infection prevention and control in low-middle income countries. Curr Treat Options Infect Dis 2019; 11(3): 267-280.

[66] Goyanka R. Burden of water, sanitation and hygiene related diseases in India: Prevalence, health care cost and effect of community level factors. Clin Epidemiol Glob Health 2021; 12(100887): 100887.

[67] Mittal AK, Bhardwaj R, Mishra P, Rajput SK. Antimicrobials misuse/overuse: Adverse effect, mechanism, challenges and strategies to combat resistance. Open Biotechnol J 2020; 14(1): 107-112.

[68] Chauhan A, Chauhan S. Combating antimicrobial resistance in India: Challenges, progress, and the path forward with a One Health approach. J Integr Med Public Health 2024; 3(2): 122-124.

[69] Walia K, Madhumathi J, Veeraraghavan B, Chakrabarti A, Kapil A, Ray P, et al. Establishing antimicrobial resistance surveillance & research network in India: Journey so far. Indian J Med Res 2019; 149(2): 164-179.

[70] Government of Kerala. Kerala Antimicrobial Resistance Strategic Action Plan (KARSAP). [Online] Available from https://ncdc.mohfw.gov.in/wp-content/uploads/2024/03/35158354141579866436.pdf. [Accessed on 1 March 2025].

[71] Bokhari FAS, Mariuzzo F, Yan W. Antibacterial resistance and the cost of affecting demand: The case of UK antibiotics. Int J Ind Organ 2024; 95: 103082.

[72] Morgan ALK, Moran D, Van Boeckel TP. Taxation of veterinary antibiotics to reduce antimicrobial resistance. One Health 2023; 17: 100650.