A clinical pharmacist reflects on the challenges of irresponsible antimicrobial use in India, and the role of pharmacists in tackling the growing crisis of antimicrobial resistance (AMR).
Antimicrobials have been considered miracle drugs for decades because of their ability to cure deadly infections. This very notion has resulted in the overuse and misuse of antibiotics over the years. From the common cold to diarrhea, antibiotics have become the go-to drug for the common person. This has led to widespread antimicrobial resistance (AMR).
What is antimicrobial resistance (AMR)?
AMR is a condition in which the microorganisms develop resistance mechanisms to commonly prescribed antimicrobials. Antimicrobials, i.e. drugs that act against microorganisms are of different types depending on the type of microorganism they act against - antibiotics for bacteria, antifungal for fungi, antivirals for viruses, and antiprotozoal against worm-like organisms.
The most common form of AMR is antibiotic resistance, wherein bacteria develop resistance to antibiotics. This means that if a person gets infected with a resistant bacteria, the antibiotic will not be able to cure that infection. It is estimated that 4.7 million people die every year because of such resistant infections, which otherwise would have been curable.
Indiscriminate use of antibiotics leading to the rapid development of resistance has also discouraged pharma companies from investing in the development of new antibiotics. In this current scenario, where there are limited antibiotics in the pipeline, it is important that we preserve the available antibiotics through their rational use.
What is leading to the problem of AMR?
India has been reported to be the largest consumer of antibiotics in terms of absolute volume. Two major reasons contributing to this high use are the high burden of infectious diseases in India and unregulated access to antibiotics in the community.
The majority of the people in India continue to suffer due to limited access to health care. As a result of this, patients depend on unqualified practitioners for their healthcare needs. Thanks to these unqualified practitioners, it is not uncommon to see patients consuming a cocktail of steroids, antibiotics, multivitamins, and painkillers for most of their common physical complaints. Even qualified practitioners are known to commonly prescribe unnecessary and irrational antibiotics.
In addition to that, issues like inadequate access to clean water, sanitation and hygiene, and irrational use of antibiotics in farm animals as growth promoters further aggravate the issue of AMR in our country.
Pharmacists and AMR
Pharmacists play a key role in our community. They act as a link between people and doctors. Many times, they are much easier to access for people as compared to doctors. If people have to consult a doctor, they have to first get an appointment, maybe wait for hours to see the doctor which can even result in loss of pay at work.
In contrast, they can simply walk into a local pharmacy, inform the pharmacists of their symptoms, get the medicine and leave within no time. As one pharmacist noted, “It (OTC purchase of antibiotics/medicine) is a common practice since people don’t have enough money to go and consult a private sector doctor.”
However, this convenience often comes with risks. In many cases in India, the person attending to people in pharmacies is not even a registered pharmacist. This lack of proper qualifications and medical expertise can endanger patients’ lives, as untrained individuals may not have the knowledge required to ensure the safe and effective use of medications.
This reliance on pharmacies for medical care in India also underscores a troubling conundrum rooted in the gaps within the public healthcare infrastructure. As a pharmacist poignantly highlights this “If all pharmacists refuse to give medicines without prescription, then there will be an outcry in India because the government doesn’t have enough facilities to provide for each patient. You know the scenario of civil hospitals (public); there is a big queue and they are always crowded. So, if a medical store person (retail pharmacies) stops giving medicines, everything will be at a standstill.”
Misconceptions that contribute to AMR
Another major issue is the widespread belief that antibiotics are a one-stop fix for all infections. Many people are not able to differentiate between bacterial, viral, and fungal infections and are unaware that antibiotics are effective only for bacterial infections.
This lack of understanding contributes to misuse, as seen in pharmacies where people often directly ask for antibiotics. “The patients that come for self-medication straightaway ask for antibiotics, and if we don’t dispense, they start arguing. Sometimes people come to buy medicines with an old prescription,” a pharmacist shared.
People often believe that antibiotics will help them recover quickly, enabling them to get back to work sooner and reduce their loss of pay. These misconceptions are common in people with all levels of education. “I got bad cold and cough…(I took antibiotics) because I had no choice. I couldn’t risk to fall sick during diwali,” shared a person working at an international NGO. This mindset leads to people demanding antibiotics from their doctors, and if these demands are not met, they may switch to another doctor.
As a surgeon described during one of the research studies, “If I am able to convince the patient, the patient will go back happily. If I am not able to convince the patient, well, the patient will go from me to another surgeon, and then to another surgeon, ultimately to a surgeon who will actually prescribe an antibiotic, and then he would be happy there. So, he will go off doctor shopping.”
This cycle highlights the tough challenges healthcare professionals face in encouraging the proper use of antibiotics. It shows just how urgent it is to educate the public about using antibiotics responsibly and the dangers of misuse.
What is being done to fight against AMR in India?
There have been a lot of initiatives undertaken in India over the years to combat AMR that includes development and implementation of antibiotic treatment guidelines, implementation of antimicrobial stewardship program (AMS-a program to optimise the use of antimicrobials), education and training of healthcare professionals on rational antibiotic use, implementation of national and state action plans for AMR containment.
Whilst about 80% of antibiotic use occurs in the community, many of the above-mentioned initiatives predominantly focus on hospital settings. Prior to implementing interventions to optimise antibiotic use in the community, it is important to understand the reasons behind these issues.
While there are regulations in India to restrict over the counter dispensing of antibiotics, such as Schedule H and H1 drugs (prescription only drugs) and the Red Line awareness campaign on AMR by the Ministry of Health and Family Welfare, its implementation is still not adequate in many parts of our country.
When a foreign colleague of mine visited India a few years back, she was completely shocked to see an oral antibiotic being dispensed without a prescription at the airport pharmacy. She was especially surprised because in her country, antibiotic dispensing is very restricted in the community pharmacies and she has to wait for days to even see a doctor to get a prescription for an antibiotic.
How can pharmacists contribute to improving antibiotic use in the community?
As a pharmacist, I believe there are numerous ways in which we can actively contribute to improving antibiotic use.
One of the most significant responsibilities we have is restricting the over-the-counter sale of antibiotics. Ensuring that antibiotics are dispensed only when accompanied by a valid prescription from a registered medical practitioner is critical. This requires verifying the prescription’s date and ensuring it is intended for the individual presenting it. Patients sometimes attempt to reuse outdated prescriptions to repurchase antibiotics for similar symptoms, or they might bring prescriptions meant for another family member. Careful checks are necessary to prevent such misuse.
Educating patients about the appropriate use of antibiotics is another vital aspect of our role. Often, pharmacists limit themselves to providing basic instructions, such as whether the medication should be taken before or after food, the frequency of doses, and the duration of treatment. While these are important, it is equally crucial to go beyond them.
We must explain why the antibiotic was prescribed, its name, and whether it should be avoided with certain foods or medications. Patients need to understand the importance of completing the prescribed course even if they start feeling better midway. It is also essential to stress that antibiotics should never be shared with others, even if their symptoms appear similar.
Staying updated on rational antibiotic use is another area where clinical pharmacists must take the lead. I have noticed that some senior pharmacists are more resistant to updating their knowledge, which can hinder the overall quality of care.
As pharmacists whether operating in community or a hospital, our role extends far beyond dispensing medications. We are in a unique position to promote the rational use of antibiotics and improve patient outcomes. Collaborating with peers to share best practices and working together to implement these across various settings can amplify our efforts.
For our contributions to be fully effective, recognition from hospital management and government institutions is crucial. Such acknowledgment would not only foster better job opportunities for clinical pharmacists but also drive improved patient care outcomes in India.
Edited by Sarah Hyder Iqbal and Parth Sharma.
Image by Janvi Bokoliya.
