NEW DELHI – Rampant overuse of antibiotics in India, one of the world’s leading producers of the medication, is increasing the threat of the population developing resistance to the life-saving drugs.

Now, the Health Ministry has directed doctors to write down the reasons for prescribing antibiotics to their patients, in an effort to curb the dangerous trend.

It has asked doctors in medical colleges, in particular, to do this as a way to promote the practice among a younger generation of doctors.

The ministry also warned pharmacists against selling antibiotics over the counter to people without a prescription, noting that “prudent antibiotic use is the only option to delaying the development of resistance”, given that “few new antibiotics” are being developed globally.

Antibiotics overuse leads to antimicrobial resistance, or AMR, which is when bacteria, viruses and fungi develop resistance to drugs and metamorphose into superbugs.

AMR, which is listed as among 10 global health threats by the World Health Organisation (WHO), also affects Singapore, where antibiotic-resistant bacteria have been found in hospitals.

In India, where health practitioners are increasingly grappling with AMR, lax implementation of rules against selling antibiotics without a doctor’s prescription and a lack of awareness of the dangers of antibiotics overuse remain the larger challenges, said doctors and health experts.

The Indian Council of Medical Research has found growing resistance to broad-spectrum antibiotics administered in hospital settings. Resistance to Imipenem, which is used to treat infections caused by E. coli, had gone up from 14 per cent in 2016 to 36 per cent in 2021.

“While the effort to request doctors to write reasons is good, it won’t be enough unless there is enough awareness among consumers as to why antibiotic use has to be preserved,” said Dr Ratna Devi, chief executive of non-governmental organisation Dakshayani and Amaravati Health and Education.

“Second, you have to have some mechanism to monitor the dispensing of antibiotics. Even the more advanced ones (antibiotics), which can only be given in a hospital setting, can be bought over the counter. A lot of regulation needs to be strengthened.”

In a Jan 20 letter to the Health Ministry, the Indian Medical Association (IMA), which represents doctors, warned that the problem is increasing due to poor clinical practices by quacks and the easy availability of antibiotics.

“Qualified doctors will not write (prescriptions for) medicines without reason,” said Dr Narendra Saini, chairman of the IMA’s standing committee on AMR.

The IMA argued that “unwittingly we may end up increasing the load of the doctors in a crowded outpatient department”.

India, the world’s most populated country, with over 1.4 billion people, is among the largest consumers of antibiotics, with a pharma industry worth an estimated US$41 billion (S$55 billion).

According to a Lancet study, literature showed that worldwide human consumption of antibiotics increased by 36 per cent between 2000 and 2010. In that time, Brazil, Russia, India, China and South Africa accounted for three-quarters of the increase despite collectively representing only 40 per cent of the world’s population.

Moreover, India accounted for 23 per cent of the retail sales volume.

The AMR problem is exacerbated in India, where diseases like tuberculosis, malaria and cholera pathogens are becoming more and more drug-resistant.

According to a WHO 2020 report, studies showed that China and India were behind more than one-third of the global incidence of 17 multidrug-resistant tuberculosis strains.

Doctors in India said they have come across all types of antibiotics abuse, which can lead to antibiotics resistance.

These include patients failing to complete their antibiotics course because symptoms had subsided, and patients self-medicating with antibiotics. In addition, there is also a problem of underuse, particularly in semi-urban and rural areas, with instances of doctors prescribing just two days of treatment out of a five- or seven-day antibiotics regimen because people cannot afford to pay for more. 

The government has been aware of the AMR problem for some time, launching the National Programme on Containment of Antimicrobial Resistance in 2012. Under the programme, a series of steps have been taken including having laboratories research AMR to capture trends and patterns of drug-resistant infections in the country.

But it is not seen to be enough.  

Awareness campaigns are also organised by IMA and non-profit organisations like the Delhi Society for Promotion of Rational Use of Drugs, whose president, Dr Sangeeta Sharma, a professor of neuropharmacology, noted the problem has to be tackled “holistically”.

She noted that awareness had somewhat gone up during the pandemic, when there was rampant use of antibiotics like erythromycin, leading the government to issue warnings against the use of antibiotics to treat Covid-19. Antibiotics are effective against bacterial infection but not viruses.

“Covid is a very eye-opening example. Awareness about antibiotics misuse and problems of resistance has increased. But it is not translating into practice,” she said, noting that antibiotics overuse is a problem even among the most educated classes. 

“All the time we see ICU (intensive care unit) patients not responding to the first line of treatment. You need to use stronger antibiotics, and many times we lose them.”

Dr Devi noted that post-surgery cancer patients are now being “loaded” with antibiotics to prevent infections.

“One single antibiotic doesn’t work anymore,” she noted.

An estimated 300,000 people died in India in 2019 due to antibiotic-resistant infections. 

Globally, bacterial AMR was directly responsible for 1.27 million deaths and contributed to 4.95 million deaths in 2019, according to the WHO.

A Lancet study published in 2019 said estimates indicate that bacterial AMR is a health problem whose magnitude is at least as large as major diseases such as HIV and malaria, and potentially even larger.

In Singapore, a study by the National University Polyclinics, which was published in medical journal Antibiotics in 2023, found that clinics were prescribing both oral and topical antibiotics for skin conditions during the same visit, which is usually discouraged as it increases the risk of AMR.

The study noted these dual prescriptions made up 35.8 per cent of antibiotic prescriptions.

In 2023, Singaporean researchers from the AntiMicrobial Resistance Research and Intervention Alliance Singapore were given a grant of $10 million for a five-year project to find ways to fight bacteria resistant to antibiotics that are used as a last resort in hospitals. 

In spite of different efforts globally and within individual countries, the future prognosis for AMR-related deaths, if the current trends continue, is dire. 

A report by the United Nations Environment Programme said that the rise of antimicrobial resistance could result in up to 10 million deaths annually by 2050.

“If this continues, we will have a pandemic (globally) every year after 2050,” noted Dr Saini.