Timely and accurate diagnosis is the bedrock to stop misuse and overuse of medicines

Shobha Shukla *

Drug-resistant disease-causing microbes can infect any one of us. Bhakti Chavan, a promising biotechnologist, who never had TB before, got infected with extensively drug-resistant TB (XDR-TB) bacteria. XDR-TB is one of the most serious forms of TB. After some delay, an accurate XDR-TB diagnosis helped her access the right treatment, thanks to an MSF clinic.

With steely resolve and grit, she went through the difficult treatment of XDR-TB and got cured. Not only has she defeated XDR-TB, but she also champions the cause of helping those who are fighting TB as well as drug resistance or antimicrobial resistance worldwide.

Bhakti got the WHO recommended molecular test diagnosis. But 79% of people with TB disease in India are not diagnosed on WHO recommended molecular test, but through sputum microscopy which underperforms in diagnosing TB (as per India TB Report 2024).

That is why WHO has called upon all the countries to completely replace microscopy with upfront molecular tests for TB diagnosis by 2027. All world leaders re-echoed this call for 100% upfront molecular test diagnosis at the UN General Assembly High Level Meeting on TB last year.

Unless we ensure that timely and accurate diagnosis for TB and all other diseases is a reality on the ground, how will we stop misuse or overuse of medicines and prevent antimicrobial resistance?

People-centred diagnostics, treatment and care is key

Even though they face the brunt of it, most people have very little understanding and awareness about antimicrobial resistance (AMR). Bhakti Chavan blames it on the lack of people-centred responses to address AMR.

Bhakti, who has done her post graduation in Biotechnology and currently works with a biotech company, says that, "Many countries have National Action Plans to address AMR, but the ground level realities are very different. Take for example TB. Despite India having a National Strategic Plan to end TB (2017-2025), there are many gaps in TB care- like shortage of medicines, restricted access to novel medicines, diagnostic delays due to non-accessibility of molecular tests. All these act as roadblocks for the underprivileged in accessing the best of diagnostics and treatment. Our public health programmes must ensure that the best possible care is available to all those in need, and also ensure prevention of spread of infection. So patient-centred diagnostics (including upfront drug sensitivity testing), treatment and care is most important to combat AMR."

Bhakti is one of the 12 members of the World Health Organization (WHO) Task Force of AMR Survivors, which consists of persons who have survived drug-resistant infections or have cared for those with such infections. It was established by the WHO with the aim to humanise the narrative around AMR. Bhakti wants more such committees or task forces to be formed at national level so that more survivors can join them to create awareness and literacy around AMR and help in combating it.

Antimicrobial resistance

The world is abuzz with the ever increasing menace of AMR which is listed among the top 10 global health threats, and kills more people than TB, HIV or malaria combined. The year 2024 is particularly an important one for the global response to AMR, with the UN General Assembly (UNGA) High Level Meeting on AMR due to take place on 26 September 2024 in New York.

Dr Sangeeta Sharma, Professor Head, Department of Neuropsychopharmacology, Institute of Human Behaviour and Allied Sciences (IHBAS) and President of Delhi Society for Promotion of Rational Use of Drugs, calls for coordinated efforts that are focused on diagnostic stewardship, antimicrobial stewardship and infection prevention and control, to deal with this manmade crisis.

But for the layperson (who is at the receiving end of this threat) what do these medicalised terms mean?

What do words like ‘antimicrobials’ and ‘antimicrobial resistance’ signify?

To put it simply, antimicrobials are medicines that are used to treat and prevent infections in humans, animals and plants by killing the germs (or pathogens) - like bacteria, parasites, viruses and fungi- that cause these infections. However, the germs fight back and, over a period of time, some of them become resistant to these medicines, making them ineffective. In scientific language we call this phenomenon antimicrobial resistance (AMR) - meaning the microbes or the disease causing germs have become resistant to the drugs and no longer get killed or destroyed by them. So treatments become less effective (or ineffective) and infections persist, spreading to other people too.

AMR is a natural phenomenon, as the pathogens evolve over time to evade their enemy- the antimicrobials. However the process is hastened and escalated by overuse and misuse of antimicrobials in humans, animals and crops. We cannot stop this phenomenon, but we can definitely slow down the process, in the interest of one and all.

A report in The Lancet estimated that drug-resistant bacterial infections alone were directly responsible for 1.27 million deaths in 2019. And 20% of these deaths were in children under 5 years.

Antimicrobials (that include antibiotics, antivirals, anti parasitics, antifungals) target specific pathogens. They are not directed against specific body conditions- like diabetes, hypertension, calcium deficiency, etc. Thus they are very different from analgesics, antipyretics or blood pressure control pills, and need to be handled with care, explains Dr Sharma.

Multi-pronged approach to control AMR

We can control AMR by implementing the triple shield strategy comprising:

(i) Timely and accurate diagnosis to avoid unnecessary use of antimicrobials (called Diagnostic Stewardship);

(ii) Appropriate and rational use of antimicrobials (including antibiotics), to improve treatment outcomes, reduce antimicrobial resistance, and decrease the spread of infections caused by drug-resistant organisms (called Antimicrobial Stewardship); and

(iii) Reducing spread of infections by practicing hygiene and other infection control methods (called Infection Prevention and Control).

While the onus of implementing diagnostic stewardship and antimicrobial stewardship lies largely with the healthcare facilities, the public and medical fraternity are equal partners in implementing infection control measures.

Correct diagnosis is the foundation for initiating effective treatment

Diagnostics stewardship involves the various stages of microbiological diagnosis to identify the infection causing pathogen and to do its culture and sensitivity testing to find whether it will respond to X, Y or Z antibiotic or not.

Dr Sharma calls diagnostic stewardship the roadway to antimicrobial stewardship: "It is an important first step that helps in doing the right testing for the right patient at the right time, so that appropriate decisions can be taken for the management of the infection. Antimicrobial misuse is driven by diagnostic uncertainties. We have very good molecular and rapid diagnostic tests available for many diseases. But unless we use them at the right time for the right patient, it may not give the right kind of results to help tailor the antimicrobial prescription."

Antimicrobial stewardship is about preventing misuse of antimicrobials by optimising their use- that is, preventing their over use- as soon as a correct diagnosis has been made.

"This optimisation can happen in the form of switching from broad spectrum to narrow spectrum (or targeted) antibiotics, or reducing the number of antibiotics which may no longer be needed for patient management, or prescribing shorter duration antibiotics, or switching from intravenous antimicrobials to oral ones, depending upon the patient situation," said Dr Sharma.

Underuse and overuse fuel AMR

Dr Sharma points out that both overuse and underuse of antibiotics fuel AMR.

"Underuse happens if the patients in need of antibiotics are not able to get them, either because of accessibility or availability issues, or perhaps the diagnosis was not done. So, in the absence of treatment the person [with an infectious disease] remains infectious for a longer period of time and infection spreads to more and more people," said Dr Sharma.

More emphasis needs to be put on infection prevention and control. Strong infection prevention and control is a very effective approach to control the spread of AMR. WHO recognises that "the most effective intervention is to improve hygiene in healthcare facilities, including promotion of hand hygiene. Safer hospitals mean fewer infections and every infection prevented is an antibiotic avoided."

Proper sanitation, including proper waste disposal, simple hand cleaning practices, and availability of clean drinking water can go a long way in fighting infections, both in and out of hospitals.

Antibiotics are not a 'shortcut' to circumvent infection prevention and control

Dr Sharma cautions that antibiotics should not be used as a shortcut (as they often are) to circumvent infection prevention and control activities. She also advises against the use of antibiotics in situations like treating a wound (debridement or simple cleaning would do) or dealing with a normal vaginal delivery.

All these efforts will not only help in managing the individual patient well, they will also slow down the process of AMR and help preserve existing antimicrobials for use by the future generation.

Will world leaders include AMR survivors at the UNHLM on AMR?

World leaders would be meeting at the upcoming 2024 United Nations General Assembly High Level Meeting on AMR. Bhakti Chavan calls upon them to include the voices and faces of AMR survivors in all deliberations at the forthcoming UNHLM on AMR, as they are the ones who suffer the worst consequences of AMR.

And as Bhakti rightly says: "AMR might be invisible, but the survivors are not."