Water cycle, wrong dosage and more: What explains increasing antibiotic resistance?

If you are infected by antibiotic resistant bacteria, you'd need a stronger dose antibiotics. It's also possible that the drugs normally used for treating that illness may no longer work.
Water cycle, wrong dosage and more: What explains increasing antibiotic resistance?
Water cycle, wrong dosage and more: What explains increasing antibiotic resistance?

Antibiotic resistance, as defined by the World Health Organisation, is when bacteria become resistant to medication (antibiotics). So, when these antibiotic-resistant bacteria infect humans or animals, the illness becomes harder to treat as compared to when if you were infected by non-resistant bacteria. “Antibiotic resistance leads to higher medical costs, prolonged hospital stays, and increased mortality,” says WHO.

Highly antibiotic-resistant bacteria have been found in Indian water bodies, that can find their way up the food chain to humans. Furthermore, practices such as not completing the prescribed course for an antibiotic and prescription of stronger antibiotics for simple infections have compounded the problem.

Why should you be worried? Simply put, this means when you fall sick and opt for medication, you will need a stronger or higher dose, or need another drug altogether, if the infection causing bacteria have become resistant to lower dosage, or to particular antibiotics. In turn, you will have to shell out more from your pocket too.

Stubborn infections, stronger antibiotics  

Dr Shankari, a physician who works in an Intensive Care Unit at a private hospital in Tamil Nadu and has been practicing for around 15 years feels that there has been a significant increase in the number of patients who present with drug resistance of some form or other.

“Many patients we see these days are not able to respond to the standard drugs given for certain infections,” she says.

“For example, earlier we used to be able to give patients first-generation cephalosporins (a group of antibiotics) for certain minor infections, and they would respond well to the treatment. But now, we’d have to opt for either a fourth-generation antibiotic or even a combination of antibiotics. But even in this case, we can’t say for sure that they will respond well.”

Dr Kishan Rao, a general physician and environmentalist in Patancheru who has been practicing for 40 years echoes the point made by Dr Shankari.

“I don’t have scientific evidence to support this, but my general observation is the antibiotics that would work only a few years ago are no longer as effective to cure the same infections. In turn, people are going for stronger antibiotics. Medical practitioners do not seem to be taking the time to prescribe a milder dose, see how it works and then go for a higher dose. This compounds the problem,” he explains.

Homoeopathy doctor Dr K Gopalakrishna says that he has observed a steady increase in the number of people coming to him for simple infections that allopathy does not seem to cure anymore. “Many a time, the infection is viral in nature and still, antibiotics are prescribed,” he says. “For example, the number of women coming to us for urinary tract infection (UTI) per month has increased threefold in the last 20-25 years.”

Unregulated sale, improper use of antibiotics

Missing doses, as well as widespread use of antibiotics, has led to bacteria developing certain methods of resistance to these drugs, originally designed to kill them.

“When people take antibiotics for health ailments but fail to complete the entire course, it weakens the bacteria but does not kill them. These bacteria may then mutate naturally and develop a resistance to the drug,” explains Dr Akash P, a microbiologist in Chennai.

Furthermore, doctors note that the use of antibiotics to even treat things such as the common cold has led to abuse of these drugs. “Widespread use of antibiotics even in cases when it is not needed has led to the onset of development of resistance,” adds Dr Akash.

Dr Shankari states there is evidence to back up this claim. “Studies show us solid evidence that mass use of antibiotics and non-compliance of patients who stop taking these medications halfway through has led to a significant development of these infections. It is also possible that improper disposal of the medication added to the bacteria developing drug resistance, though we have no solid evidence for the same,” she says.

Improper disposal of pharmaceutical waste

A recent report quoted a Master’s thesis done by Mahesha J for the Ashoka Trust for Research in Ecology and the Environment (ATREE), which found that bacteria in Bengaluru’s Bellandur Lake had higher antibiotic resistance than those in the less polluted Jakkur lake. For instance, a sample of the Citrobacter species of bacteria collected from Jakkur Lake was found to be resistant to six drugs, and a sample from Bellandur Lake was found to be resistant to eight drugs. The Citrobacter species of bacteria can cause several infections like UTI and respiratory tract infection.

Priyanka Ghosh Jamwal, a researcher at ATREE, who also supervised the above research, says, “What do pharmacies do with expired medicines? We don’t know. We also don’t know how to dispose of the medicines in our homes. This ends up in the trash or the water bodies.”

Pharmaceutical companies who release improperly treated or untreated waste into water bodies also add to antimicrobial resistance. While there are regulations that mandate such industries to release waste only after treatment, Priyanka thinks it’s either ineffective or that companies are flouting norms.

For instance, in 2016, she studied the contamination in the Vrishabhavathi river from the Peenya Industrial Area in Bengaluru. For a year, they collected samples from the river every hour. Shockingly, the level of contamination in the night was higher in samples collected in the day, implying that industries were releasing untreated waste at night.

“Pollution Control Board officials did not know of this because they would only collect the water samples in the day,” she says. Pharma industries could be using similar ways to flout regulations.

The problem is acute in Hyderabad as well. A research undertaken by a team from several institutions including Leipzig University Hospital, Germany, studied samples from the Musi river in Hyderabad from November 19 to November 28, 2016, to determine the extent of contamination of these drugs in natural resources. They noted that 95% of the water samples tested showed the presence of bacteria which produce an enzyme that counteracts the effects of carbapenems, a commonly used group of antibiotics.

Dr Narasimha Reddy Donthi, an independent policy expert in Hyderabad, says that the effect of antibiotic resistance has been felt for years in villages near Patancheru, an industrial area near Hyderabad where there are many drugs, paint, and pesticide manufacturers. “Industrial effluents, waste from pharmaceutical companies, dumping – the pollution takes place in various ways. Doctors in the area have been noticing how drugs of a lower dosage are failing to treat infections in the people,” he says.

Priyanka, too, has found that the people directly affected by antimicrobial-resistant bacteria are the poor, including farmers who may use groundwater which has been contaminated by the water from polluted water bodies, and also those who consume local drinking water.

“Produce irrigated with this water is also affected, and also finds its way to the urban consumer. Everyone is affected,” she says. “However, the underprivileged end up getting the raw end of the deal, and may not have the resources to afford stronger drugs and spend days in the hospital to get better when common drugs fail to help them.”  

The experts TNM spoke to had observations on how antibiotic resistance seemingly affects people, and how complacency on both the part of the patient and doctor may contribute to increasing resistance. However, there's a lack of comprehensive research about its exact cause and its long-term effects on human beings.

How is antibiotic resistance determined in a lab set-up?

Nowadays, it has become commonplace to send a sample for testing, where a series of steps helps determine whether someone has indeed contracted an infection brought on by a resistant strain of an microorganism.

In theory, all samples would be sent for testing to determine what pathogen (bacteria, virus or other invading organism) was causing the infection. However, given the rate at which people present with different infections, it has become commonplace to start an individual on a baseline antibiotic as well taking a culture sample.

“A swab is taken from the infected region under absolutely sterile conditions. This swab is then sent to the lab where they use a number of culture growth substances to grow a colony of the microorganism. Once the organism grows in a day or two, we can determine what organism it is,” explains Suchitra, a Bengaluru-based microbiologist.

The colonies are then exposed to different antibiotics to see which one they respond to and which ones they are resistant to. This information is then relayed to the treating physician who prescribes the appropriate type and dose of an antibiotic to which the microorganism responds.

Growing colonies in a petri dish

Colonies of bacteria can be cultured on a petri dish, grown on a gel-like substance known as agar, or in a broth. Depending on the type of organism, different methods are sought.

Under aseptic conditions, the sample (from the infected individual) is properly spread onto different surfaces. According to the organism’s affinity it grows better in certain environments and conditions when compared to others. It takes a few days for the colonies to grow.

The experts TNM spoke to had observations on how antibiotic resistance seemingly affects people, and how complacency on both the part of the patient and doctor may contribute to increasing resistance. However, there's a lack of comprehensive research about its exact cause and its long-term effects on human beings.

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