Resistance In India Research Articles

Antimicrobial stewardship program: Fighting antimicrobial resistance in India

Antimicrobial resistance (AMR) is a significant concern in India, contributing to increased medical costs, prolonged hospital stays, and mortality. Antimicrobial stewardship programs (AMSP) are organizational strategies in health-care systems designed to promote, monitor, and evaluate the rational use of antimicrobials to preserve their future effectiveness. The Indian council of medical research recognizes the need for AMS structures in healthcare institutions and has initiated actions to support this. These include developing an AMS curriculum, conducting workshops for increased awareness and education, and expanding surveillance of antimicrobial usage and resistance trends. However, many hospitals in India still lack structured processes for AMS, requiring a multidisciplinary approach involving various experts. AMSP contribute significantly to improving antibiotic use without compromising patient outcomes, such as optimal selection of agents, correct dosing, appropriate administration routes, and proper therapy duration. The aim is to enhance patient care and outcomes, reduce infection complications, and minimize the emergence of AMR. Key challenges faced in implementing AMS programs in India include lack of infrastructure and personnel, limited resources and funds, limited laboratory capability, absence of antibiotic prescription policy, irrational prescription and excessive use of broad-spectrum antibiotics, self-medication, inappropriate disposal of leftover antibiotics, lack of regulation, and treatment non-compliance. These challenges necessitate robust, collaborative, and multifaceted responses, including policy reform, investment in infrastructure development, expanded surveillance, improved professional practices, and public education.

946. Establishing Antimicrobial Stewardship Programme at Four Secondary Care Hospitals in India through Hub and Spoke Model with Christian Medical College, Vellore as Guiding Centre

Abstract Background The high burden of antimicrobial resistance in India necessitates an urgent implementation of Antimicrobial Stewardship programs (ASP). Most ASP are based at tertiary care centres, with sparse data available regarding the effectiveness of an ASP in a low resource primary/secondary care setting. Methods We adopted a hub and spoke model to implement ASP in these low resource settings. The study consisted of three phases. Initial phase captured baseline antimicrobial days of therapy DOTs data with no feedback, followed by intervention phase wherein a few chosen interventions were implemented. Physicians of four chosen hospitals were trained via a blended customized distance education training programme, assisted with development of antibiogram based on their local hospital microbial resistance patterns via WHONET, followed by development of hospital specific antibiotic policy and augmentation of the existing laboratory skills by training personnel at the central facility. This was followed by a post intervention phase with a prospective review and feedback by trained personnel with assessment of DOTs. Results During the baseline phase, 1459 patients from all four sites were enrolled; 1233 patients were enrolled in the intervention phase. Both groups had comparable baseline characteristics. The key outcome, DOT per 1,000 patient days, was 1952.63 in the baseline phase. The DOT/1000 patient days was significantly lower in the post intervention period, at 1483.06 (P =0.001). Quinolones, Macrolides, Cephalosporins, Clindamycin, and Nitroimidazole use significantly decreased in the post intervention phase. Rate of de-escalation was significantly higher in the intervention phase compared to the baseline phase (44% vs 12.5%; P < .0001), suggesting a definite trend with regard to the judicious use of antibiotics. Post intervention phase revealed that 79.9% of antibiotic use was justified. Overall, the recommendations given by the ASP team were fully followed in 946 cases (77.7%), partially followed in 59 cases (4.8%), and not followed in 137 cases (35.7%). No adverse events were noted. Conclusion Our Hub and Spoke model of ASP was successful in implementing ASP in secondary care hospitals in India which is the need of the hour. Disclosures Priscilla Rupali, MD, DTM&H, PFIZER: Grant/Research Support|PFIZER: Grant/Research Support.

Existing Policies/Guidelines on the Environmental Dimension of Antimicrobial Resistance in India: An Insight into the Key Facets through Review and SWOT Analysis.

Antimicrobial resistance (AMR) is a multidimensional phenomenon. The environment acts as a mixing pot of drug-resistant bacteria from many sources such as pharmaceutical, biomedical, veterinary, and agricultural sectors. In this study, we analysed the existing AMR-related policies/guidelines/legislations in India in the above domains and how the current practices are being guided by them. We used a convergent parallel mix method design. Quantitative data were collected through a review of policies/guidelines/legislations in the said domains and analysed using the SWOT tool parallelly supported by key informant interviews of domain-specific stakeholders. Altogether, 19 existing AMR policies/guidelines/legislations were identified. The existence of few policies/guidelines in each domain indicated the evolving environment for policy interventions. However, the lack of capacity among farmers, inadequate provision for structured capacity building, high cost of alternatives to antimicrobials, and lack of provision of incentivisation in case of crop failure were identified as the major weaknesses prevalent across the domains. Opportunities for policy refinements/the introduction of new policies are ample. However, easy access to antimicrobials and injudicious use imposes threats to AMR containment in all sectors. Despite having a few policies for the containment of AMR, their implementation witnesses challenge due to the lack of collaborative approaches, the existence of policies disjointed from ground reality, infrastructural issues, and the lack of capacity and resources.

Consumption of systemic antibiotics in India in 2019.

Inappropriate use of antibiotics is a significant driver of antibiotic resistance in India. Largely unrestricted over-the-counter sales of most antibiotics, manufacturing and marketing of many fixed-dose combinations (FDC) and overlap in regulatory powers between national and state-level agencies complicate antibiotics availability, sales, and consumption in the country. We analyzed cross-sectional data from PharmaTrac, a nationally representative private-sector drug sales dataset gathered from a panel of 9000 stockists across India. We used the AWaRe (Access, Watch, Reserve) classification and the defined daily dose (DDD) metrics to calculate the per capita private-sector consumption of systemic antibiotics across different categories: FDCs vs single formulations; approved vs unapproved; and listed vs not listed in the national list of essential medicines (NLEM). The total DDDs consumed in 2019 was 5071 million (10.4 DDD/1000/day). Watch contributed 54.9% (2783 million) DDDs, while Access contributed 27.0% (1370 million). Formulations listed in the NLEM contributed 49.0% (2486 million DDDs); FDCs contributed 34.0% (1722 million), and unapproved formulations contributed 47.1% (2408 million DDDs). Watch antibiotics constituted 72.7% (1750 million DDDs) of unapproved products and combinations discouraged by the WHO constituted 48.7% (836 million DDDs) of FDCs. Although the per-capita private-sector consumption rate of antibiotics in India is relatively low compared to many countries, India consumes a large volume of broad-spectrum antibiotics that should ideally be used sparingly. This, together with significant share of FDCs from formulations outside NLEM and a large volume of antibiotics not approved by the central drug regulators, call for significant policy and regulatory reform. Not applicable.

Social (In)equities and Ethical Challenges: Role of Information Practices in Antimicrobial Resistance in India

Antimicrobial resistance has been described as a “slow-moving Tsunami” and one of the top global health threats that affect social groups inequitably, especially in low- and middle-income countries (LMICs). This paper analyses social inequities and ethical implications related to antibiotic use in India and how information systems can help mitigate them. India is a global antimicrobial resistance (AMR) hotspot, showing relative policy inertia in addressing this grand challenge. The paper describes two interconnected streams of work. First, it takes an ecosystem perspective to understand inequities in practices around the prescription, dispensing, and consumption of antibiotics. Second, it analyzes the digital’s potential role in addressing these inequities. As a result, the paper identifies four key determinants of social inequity and their ethical implications. Next, the paper identifies the opportunities and challenges in applying digital to address these inequities. This paper thus seeks to make a vital contribution to IS research on an area of immense societal value, particularly in informing how the potential of the digital can be effectively materialized.

Antimicrobial Resistance in India – “A Silent Pandemic within the Pandemic”

Antimicrobial Resistance in India – “A Silent Pandemic within the Pandemic”

PCR154 Assessment of the Impact of an ARIVU-IFK Software in Public Education about Infectious Diseases, Antibiotic Usage and Resistance in India

Antibiotics are mainstay for treating bacterial infections, however appropriate use of antibiotics is still a massive challenge. Public education is necessary for the pertinent use of antibiotics and to finite the spread of antibiotic resistance (AR). This study aims to assess the impact of an educational software named ‘ARIVU-IFK’ which is developed for public awareness and education on infections and antibiotic usage.

Azithromycin resistance and its molecular characteristics in Neisseria gonorrhoeae isolates from a tertiary care centre in North India

Treatment guidelines for management of uncomplicated gonorrhoeae have been recently modified owing to alarming upsurge in azithromycin resistance. This study investigated the prevalence and genetic determinants of gonococcal azithromycin resistance in India. Four (5.7%) of 70 gonococcal isolates were resistant to azithromycin. Of 16 isolates investigated for molecular mechanisms of resistance, 13 (81.3%) and 6 (37.5%) isolates exhibited mutations in coding and promoter regions of mtrR gene, respectively. However, ermA, ermB and ermC genes or mutations in rrl gene were absent in all isolates. Azithromycin resistance is low in India posing no immediate threat to use of dual-therapy for syndromic management.

The Bhima Koregaon Arrests and the Resistance in India

The cold-blooded murders of activists by state forces in India represents a historical pattern of extrajudicial repression.

Strengthening the Surveillance of Antimicrobial Resistance in India Using Integrative Technologies.

Background:The antimicrobial resistance (AMR) situation in India is alarming. In the absence of newer antibiotics, the best possible approach is to efficiently use the existing antimicrobials through surveillance of resistance. The data generated by AMR surveillance across the country has immense potential to drive policy decisions. However, this data is available in a variety of sources. It is imperative to have tools to integrate the data generated across the country into a single data repository.MethodsAn ensemble of tools (i-AMRSS, i-DIA, and i-AMRIT) have been designed and developed by the data management team at the Indian Council of Medical Research (ICMR) to strengthen surveillance of antimicrobial resistance in India.ResultsThe i-AMRSS is a web-based ICMR's AMR surveillance system, collecting data from tertiary care centers across the country and sending it to the one-stop data repository. The i-DIA is a web-based API that simplifies the AMR data interoperability by seamlessly importing most of the LIS / HIS data from CSV files into a central, one-stop data repository. The i-AMRIT is a standalone ICMR's AMR surveillance system using integrative technologies, collecting data from all the labs across the country and sending the lab-specific cumulative data to the one-stop data repository.DiscussionThe tools are being used in ICMR's AMR Network and have collected over 0.4 million patient records to date. The complete system is presently being used to capture human susceptibility testing data and can be extended for capturing data using the ‘One Health' approach. The authors plan to make the system compliant with FHIR standards to enable interoperability with other countries.

Molecular markers of Chloroquine resistance in India and Southeast Asia: A narrative review

Malaria is a major global public health problem mainly in the tropics and subtropics. Malaria control and elimination strategies mainly rely on efficacious antimalarial drugs. At present the major hurdle faced by malaria control programs is the drug resistance to antimalarials. Molecular surveillance using genetic markers associated with resistance provides a valuable tool for detecting and tracking resistance as well as providing an in-depth understanding of the development and spread of resistance. Despite numerous published literatures there are limited review articles on molecular markers of drug resistance. Hence a review was planned. An exhaustive literature search was performed on PUBMED using “malaria”, “resistance”, “molecular”, “antimalarial”, “Chloroquine”, “Pfcrt”, “Pfmdr”, “Pvcrt”, “Pvmdr”as key words. Data pertaining to India and Southeast Asia were included. This review showed the widespread presence of molecular markers of drug resistance in Plasmodium falciparum and development of resistance in Plasmodium vivax over the years in Southeast Asia and India. This can have implications on malaria elimination and treatment guidelines in this region.

Tuberculosis Pathways to Care and Transmission of Multidrug Resistance in India.

RationaleIndia is experiencing a regional increase in cases of multidrug-resistant tuberculosis (MDR-TB).ObjectivesGiven the complexity of MDR-TB diagnosis and care, we sought to address key knowledge gaps in MDR risk factors, care delays, and drivers of delay to help guide disease control.MethodsFrom January 2018 to September 2019, we conducted interviews with adults registered with the National TB Elimination Program for MDR (n = 128) and non–MDR-TB (n = 269) treatment to quantitatively and qualitatively study care pathways. We collected treatment records and GeneXpert-TB/RIF diagnostic reports.Measurements and Main ResultsMDR-TB was associated with young age and crowded residence. GeneXpert rifampicin resistance diversity was measured at 72.5% Probe E. Median time from symptom onset to diagnosis of MDR was 90 days versus 60 days for non-MDR, Wilcoxon P < 0.01. Delay decreased by a median of 30 days among non-MDR patients with wider access to GeneXpert, Wilcoxon P = 0.02. Pathways to care were complex, with a median (interquartile range) of 4 (3–5) and 3 (2–4) encounters for MDR and non-MDR, respectively. Of patients with MDR-TB, 68% had their first encounter in the private sector, and this was associated with a larger number of subsequent healthcare encounters and catastrophic expenditure.ConclusionsThe association of MDR with young age, crowding, and low genotypic diversity raises concerns of ongoing MDR transmission fueled by long delays in care. Delays are decreasing with GeneXpert use, suggesting the need for routine use in presumptive TB. Qualitatively, we identify the need to improve patient retention in the National TB Elimination Program and highlight patients’ trust relationship with private providers.

COVID-19 Vaccine Hesitancy and Resistance in India Explored through a Population-Based Longitudinal Survey.

Background: The World Health Organization has recommended that individual governments identify vaccine hesitancy areas. It is proposed that the governments, with the aid of local organizations, educate and implement social insights on the vaccination so that high population levels are covered with this safe immune program. Methods: A longitudinal online survey covered 3000 adults from India. We examined the demography, behavioral (socio-economic) attitude, vaccine hesitancy, vaccine resistance for the COVID-19 vaccine. The specific reasons for the COVID-19 vaccine decline were also evaluated. Results: Our survey revealed 59% definite response, 29% low-level response, and 7% high-level response for vaccine hesitancy, while 6% had resistant views on the COVID-19 vaccine. Individuals who had higher income levels, lived in a society, maintained social distancing, had downloaded the COVID-19 update app, showed a positive attitude towards their government, and more confidence in their healthcare system were more inclined towards the vaccination. On the contrary, individuals who had overstated the risks of COVID-19 and had a religious and populistic attitude towards vaccination were more hesitant/resistant to vaccination. The respondents who declined vaccine administration were further evaluated for their specific reason for their response. The most common reasons for declining the COVID-19 vaccine were post-vaccine scare of adverse health effects and accepting the information spread by social media. Conclusions: The results in our study show that by identifying population “hot spots” that have negative or unclear information on the COVID-19 vaccination, these “hot spots” can be addressed by involving friendly organizations that can clear their strong disbeliefs and increase the percentage of vaccine-definite people within the population. The role of government-induced COVID-19 vaccine policy measures can always be beneficial to cause this shift from disbelief to confidence within the population.

Understanding complexities in the uptake of indigenously developed rapid point-of-care diagnostics for containment of antimicrobial resistance in India

A good point-of-care diagnostic test holds a promise to reduce inappropriate use of antibiotics by enabling early detection of the pathogen and facilitating rapid testing of antimicrobial susceptibility. India has...

An analysis of Plasmodium falciparum-K13 mutations in India.

Malaria is one of the deadliest parasitic diseases in human. Currently, Artemisinin-based combination therapy is considered as the gold standard and most common treatment option. However, the origin and transmission of Plasmodium falciparum from the Greater Mekong Subregion, which has decreased artemisinin (ART) sensitivity, has sparked global concern. The reduced ART sensitivity has been associated with mutations in the Atpase6 and Kelch13 propeller domain of Plasmodium falciparum. A molecular marker is critically needed to monitor the spread of artemisinin resistance. In this article, we reviewed the k13 mutations and potential marker for ART resistance in India. There have been fourteen mutations identified, three of which have been validated by the World Health Organization (WHO) as artemisinin resistance mutations (F446I, R561H/C, and R539T). Among them, the role of F446I and R561H/C in ART resistance is conflicting. R539T and G625R mutation has been identified as an ART- resistance marker in India.

Low-value medical care in the pandemic—is this what the doctor ordered?

Low-value medical care in the pandemic—is this what the doctor ordered?

A new source of resistance in rice against Brown planthopper, Nilaparvata lugens Stal (Homoptera: Delphacidae) and elucidation of its inheritance using phenotypic selections under artificial infestations at seedling and reproductive stages of the crop

Genetic resistance in rice through native traits is an important tactic to manage Brown planthopper (BPH), Nilaparvata lugens Staal (Homoptera: Delphacidae) which is one of the most dreaded pests in the farmer’s field causing serious crop losses. Many sources of resistance, both from cultivated and wild accessions, are known with almost 36 resistance genes mapped to different chromosomes through phenotypic and genotypic selections. A majority of resistance genes identified are effective for BPH biotypes prevailing in Southeast Asia and China. For South Asia, very few BPH resistance genes are effective but without their utilization for the development of commercial hybrids and varieties. A new source of resistance HSPP 6417 has been identified in the present paper, which displayed resistance to 11 populations of BPH collected from different rice ecologies of India. The new source HSPP 6417 had an adverse effect on the population dynamics of BPH by inhibiting the population build-up on the plants. The resistance of HSPP 6417 was equivalent to the only source of resistance in India, G7253 used to develop a commercial rice hybrid AZ8433 DT. On crossing HSPP 6417 with other prolific restorer lines of the commercial hybrids, the major genes were found to control its modes of inheritance. Field trials with F4 generation revealed that resistance was stable with good agronomic performance under infestations. The implications of using such a source of resistance for developing BPH resistant hybrids are discussed in the paper.

Genome-wide association analysis of Mexican bread wheat landraces for resistance to yellow and stem rust.

Deploying under-utilized landraces in wheat breeding has been advocated to accelerate genetic gains in current era of genomics assisted breeding. Mexican bread wheat landraces (Creole wheats) represent an important resource for the discovery of novel alleles including disease resistance. A core set of 1,098 Mexican landraces was subjected to multi-location testing for rust diseases in India, Mexico and Kenya. The landrace core set showed a continuous variation for yellow (YR) and stem rust (SR) disease severity. Principal component analysis differentiated Mexican landraces into three groups based on their respective collection sites. Linkage disequilibrium (LD) decay varied from 10 to 32 Mb across chromosomes with an averge of 23Mb across whole genome. Genome-wide association analysis revealed marker-trait associations for YR resistance in India and Mexico as well as for SR resistance in Kenya. In addition, significant additive-additive interaction effects were observed for both YR and SR resistance including genomic regions on chromosomes 1BL and 3BS, which co-locate with pleiotropic genes Yr29/Lr46/Sr58/Pm39/Ltn2 and Sr2/Yr30/Lr27, respectively. Study reports novel genomic associations for YR (chromosomes 1AL, 2BS, and 3BL) and SR (chromosomes 2AL, 4DS, and 5DS). The novel findings in Creole wheat landraces can be efficiently utilized for the wheat genetic improvement.

A multicentric knowledge-attitude-practice survey in the community about antimicrobial use and resistance in India.

To address the reasons for inappropriate use of antimicrobials, it is important to understand the knowledge, attitude and practices (KAP) of all pertinent stakeholders. This multicentric survey is aimed at understanding the KAP quotients of the community regarding antimicrobial use and antimicrobial resistance (AMR), as such information is lacking in India. A cross-sectional survey was conducted by face-to-face interviews across five centers in India using a validated, field-tested questionnaire incorporating KAP domain questions. Scores were appropriately assigned to the questions. The mean (SD) age of the respondents was 35.2 (12.61) y and 62% had a graduate or higher level of education. The median (IQR) KAP scores were 10 (8-12), 5 (3-5) and 2 (2-3) out of a maximum of 18, 5 and 6, respectively. Higher educational and socioeconomic levels were associated with better attitude scores, but knowledge levels were comparable. Correlations between KAP scores were poor. This study reveals that laypeople have appropriate knowledge and attitude regarding antibiotic use and AMR to some degree but there are important lacunae and practices are often wanting. These issues need to be addressed in sustained public awareness and motivation campaigns to improve the rational use of antibiotics in India.

Harmonized One Health Trans-Species and Community Surveillance for Tackling Antibacterial Resistance in India: Protocol for a Mixed Methods Study

BackgroundIndia has the largest burden of drug‑resistant organisms compared with other countries around the world, including multiresistant and extremely drug‑resistant tuberculosis and resistant Gram‑negative and Gram‑positive bacteria. Antibiotic resistant bacteria are found in all living hosts and in the environment and move between hosts and ecosystems. An intricate interplay of infections, exposure to antibiotics, and disinfectants at individual and community levels among humans, animals, birds, and fishes triggers evolution and spread of resistance. The One Health framework proposes addressing antibiotic resistance as a complex multidisciplinary problem. However, the evidence base in the Indian context is limited.ObjectiveThis multisectoral, trans-species surveillance project aims to document the infection and resistance patterns of 7 resistant-priority bacteria and the risk factors for resistance following the One Health framework and geospatial epidemiology.MethodsThis hospital- and community-based surveillance adopts a cross-sectional design with mixed methodology (quantitative, qualitative, and spatial) data collection. This study is being conducted at 6 microbiology laboratories and communities in Khurda district, Odisha, India. The laboratory surveillance collects data on bacteria isolates from different hosts and their resistance patterns. The hosts for infection surveillance include humans, animals (livestock, food chain, and pet animals), birds (poultry), and freshwater fishes (not crustaceans). For eligible patients, animals, birds and fishes, detailed data from their households or farms on health care seeking (for animals, birds and fishes, the illness, and care seeking of the caretakers), antibiotic use, disinfection practices, and neighborhood exposure to infection risks will be collected. Antibiotic prescription and use patterns at hospitals and clinics, and therapeutic and nontherapeutic antibiotic and disinfectant use in farms will also be collected. Interviews with key informants from animal breeding, agriculture, and food processing will explore the perceptions, attitudes, and practices related to antibiotic use. The data analysis will follow quantitative (descriptive and analytical), qualitative, and geospatial epidemiology principles.ResultsThe study was funded in May 2019 and approved by Institute Ethics Committees in March 2019. The data collection started in September 2019 and shall continue till March 2021. As of June 2020, data for 56 humans, 30 animals and birds, and fishes from 10 ponds have been collected. Data analysis is yet to be done.ConclusionsThis study will inform about the bacterial infection and resistance epidemiology among different hosts, the risk factors for infection, and resistance transmission. In addition, it will identify the potential triggers and levers for further exploration and action.International Registered Report Identifier (IRRID)DERR1-10.2196/23241