The Rise and Rise of Antibiotic Abuse in India

Inside Raj Yadav’s home, beside the railway tracks and across from the polluted Mithi River in Mumbai, India, hangs a photograph of a woman in her early 30s. “Her picture is the only part of my house that I clean regularly. It serves as a reminder every day of how we can’t take life for granted,” said the 27-year-old mechanic, originally from the north Indian state of Uttar Pradesh. 

The woman is Yadav’s wife, who passed away in July 2019 from tuberculosis (TB), an infectious disease that affects the lungs. She was resistant to even the last line of heavy TB antibiotics — linezolid, delamanid, bedaquiline — that are prescribed when all else fails.

Antibiotics are life-saving medications. However, when pumped into the body when not required or in doses far greater than needed, germs learn to defy the antibiotics designed to kill them while also multiplying in force. According to the World Health Organization (WHO), “Antibiotic resistance is one of the biggest threats to global health, food security, and development today.” Since antibiotics have contributed significantly to a rise in life expectancy, and are used for everything from preventing infections during surgeries to protecting cancer patients undergoing chemotherapy, the weakening defences create a butterfly effect on the entire healthcare chain.

One of the major factors behind this antibiotic resistance is the overuse of antibiotics themselves. And one of the big causes behind this is popping an antibiotic to treat a viral infection. Remember the time you had a fever, or a runny nose for some days, or developed a cough when the weather changed or around the festive season when our pollution levels shoot up – and you were prescribed an antibiotic or you bought one yourself from the pharmacy next door? Chances are, these were viral infections and not bacterial, and that antibiotic might’ve done you more harm than good. Your fever or cold might’ve subsided soon after but that might be because it would’ve run its course.

India, it turns out, is one of the largest consumers of antibiotics in the world. While that’s good news only in the sense of more people having access to drugs for easily treatable infections that once killed many, the overuse and abuse of these meds have been a major concern since over a decade now. The pandemic has only made this worse.

Recently, a study titled “Consumption of systemic antibiotics in India in 2019” was published in the Lancet Regional Health-Southeast Asia journal that observed how Indians excessively used antibiotics including Azithromycin – sometimes prescribed for throat and nose infections but actually a vital drug for treating typhoid fever, non-typhoidal Salmonella and severe diarrhoea – prior to and during the COVID-19 pandemic. The study added that most of these drugs were not approved by the central drug regulator and called for significant policy and regulatory reform. Also, almost 49 percent of antibiotics and fixed-dose drug combinations (FDCs) used in the country were discouraged by the WHO.

Last month, the Indian Council of Medical Research released its fifth, detailed report on anti-microbial resistance. The report says that there is a sustained increase in anti-microbial resistance in India, meaning certain infections are becoming untreatable with various medicines.

Wasim Khot, an infectious diseases expert, who works as a consultant for hospitals including the Prince Aly Khan Hospital and Global Hospitals, in Mumbai, recalls witnessing the deaths of young patients who were unable to respond to treatment for life-threatening diseases such as advanced TB, as they had developed antibiotic resistance from years of antibiotic abuse. 

“It breaks your heart,” he said. “Everything about treating patients with TB and similar respiratory diseases, who have become resistant to antibiotics, is horrifying – from the long treatment to the morbidity associated with the diseases. It’s not easy to watch a child of barely 10 struggling to breathe. No matter which antibiotic you prescribe, the reports simply show resistant, resistant, resistant. You have no option but to helplessly watch them die.”

The way Khot sees it, when it comes to antibiotic use in India today, there is a thin line between excess and access. He remembers a time when people would die because they couldn’t access antibiotics, leave alone abuse them.

“India is a tropical country which is why the burden of our infectious diseases is high,” he explained. “What we don’t understand is that [our consumption] of antibiotics is not limited to medicines. We have to tackle the antibiotics present in our water, livestock, farms; there are a host of [ways] that antibiotics make their way into our bodies, and we end up developing resistance.”

According to a report by the non-profit CDDEP (Center for Disease Dynamics, Economics & Policy), the use of antibiotics in animal feed, which is known to contribute to growing antibiotic resistance in the environment, will increase by 82 percent in India by 2030. The report added that two-thirds of poultry farms in Punjab use antibiotics for growth promotion and explained how such farms also reported high levels of multidrug-resistant bacteria that can easily escape into the environment and infect human beings. 

The abuse of antibiotics remains a battle to be fought on multiple fronts — from containing antibiotics in our immediate environment to sensitising people not to resort to antibiotics at the drop of a hat. But Abhay Kumar Shukla, a professor in pharmacology at the Rajiv Gandhi Medical College in Thane, Mumbai, said that doctors are to be blamed, too. 

“Doctors often give in to the pressure of prescribing antibiotics because the patient wants instant results,” he said, adding that “the [prescribed] doses are often inaccurate. For instance, if you are prescribing a 250 mg antibiotic to someone who is more than 60 kgs, it’s like giving a cumin seed to a camel – they will develop antibiotic resistance.”

Shukla said that he has seen doctors prescribe antibiotics to help patients with an illness as common as diarrhoea. Moreover, he clarified that patients might not complete the full course of antibiotics and gradually develop resistance to the drugs. In such a case, both underdosing and overdosing lead to antibiotic resistance because, in cases of underdosing, the bacteria is still alive in the body and has developed enough resistance against the antibiotics.  

Another major factor in the antibiotic abuse story in India is the use of FDCs in which two or more antibiotics are prescribed together. Recently, the federal government announced in a press release that the Drugs Controller General of India had banned 40 FDCs that were found to be “irrational”. 

In his 2018 paper decoding the ban on another 328 FDCs by the Indian government, Deepesh Vendoti – a medical doctor by training and a public health management graduate from Yale University – explains that irrational FDCs are those that fail to offer adequate therapeutic response to successfully kill the bugs, instead helping them develop resistance to the FDCs. Over a period of time, the bugs gain capabilities to survive against even the correct drug regimens as well as rational FDCs. 

Vendoti further notes that there are various factors for the use of FDCs in India such as, “aggressive commercial and at times irrational outlook from the pharmaceutical companies, lapses of regulatory agencies, negligence among medical practitioners and pharmacists and ignorance of both rural and urban public taking non-prescription-based medications either through unqualified practitioners or as self-medication.” He observes that despite some checks and balances introduced by the government in 2005, there was a massive spike in regulatory agencies approving FDCs between 2005-11. 

“Irrational FDCs continue to be recommended,” said Shukla, who attributed this to the presence of Big Pharma, a term used for the global pharmaceutical industry, being stakeholders in the drugs regulatory scene in India. “One such easily available combination that is extremely problematic is levofloxacin (an antibiotic used to treat acute bacterial sinusitis, pneumonia, UTIs etc,) with amoxicillin (used to treat bacterial chest infections) even though the WHO strictly recommends the use of levofloxacin to treat only multidrug-resistant TB.” 

Besides these factors, there is also a view that many Indians, much like people in other low- and middle-income countries, simply cannot afford diagnostic tests for their diseases and end up assuming everything can be treated using antibiotics. Doctors are also quick to prescribe broad-spectrum antibiotics – those which act against a wide-range of disease-causing bacteria – which further antibiotic resistance.

Shukla added that in India, alternative forms of treatment often end up worsening medical conditions. In his experience, many patients start with allopathy, switch midway to homoeopathy, get disenchanted, try Ayurveda, and finally return to allopathy. In this period, the time-bound antibiotics course goes out of the window. 

It’s important to state here that though science is still undecided on whether an antibiotics course really needs to be completed, most doctors believe that it does and that not finishing the treatment would lead to more antibiotic resistance in the long term.

Saniya Kumar, a 25-year-old fashion creative director, said that between the ages of 13 and 17, she abused antibiotics which ruined her gut health. 

“I would eat shitty food in the school canteen, have momos, and even pop antibiotics (such as azithromycin and levofloxacin) with alcohol during a party because I was 17 and wanted to get on with things, so yeah I fucked up, too,” she said. “Now, I’m more conscious about not popping antibiotics because my stomach is sensitive. If I have an infection, I wait it out, have fruits and salads, drink lots of water, and the infection passes.”

In the case of Shamani Joshi, a 24-year-old content producer, a foot infection in May 2019 became much worse because the doctor, who she later found out was a quack, recommended antibiotics. What she thought was an infection on her foot was just a corn and she did not need antibiotics for it. 

The next month, another doctor recommended a two-week course of antibiotics for a simple heat boil. In both cases, the medical condition did not get better and ended with Joshi’s gut health getting messed up.  

“My digestive tract was the only thing my friends and I would discuss for months,” she said. “In October that year, I was diagnosed with candida, a condition where a type of fungus developed in my gut because of excessive antibiotic use in a short time period.”

The human urge to treat medical conditions and diseases at any cost, regardless of complications, remains a hard battle. “Doctors and patients must be willing to wait until a proper diagnosis is made,” said Suneeta Dubey, a radiologist. “In the absence of a detailed diagnosis, doctors end up prescribing medicines based on assumptions. During [peak phases of] the pandemic, people were taking antivirals, antibiotics, and everything in between. Only now are we beginning to see the side effects.”

The One Health approach for fighting antibiotic abuse that views the health of animals, people and the environment as a single unit becomes all the more important in India. According to a study by the think tank Centre for Science and Environment conducted in Delhi, more than 40 percent of the chicken samples tested had antibiotics in them as growth promoters to fatten the meat. When people consume these antibiotic-laced chicken, they end up developing antibiotic resistance even though they might have never directly consumed them. Further, the rampant use of antibiotics in cattle feed shows up in the milk consumed by humans, leading to further antibiotic resistance even in vegetarians. 

Khot added that “antibiotic stewardship” must be followed in our hospitals and clinics. This is the globally accepted approach of having dedicated channels to track the flow of sensitive antibiotics, educating patients about their side effects, clinicians about optimal dosages, and reporting information on antibiotic resistance. 

According to a detailed guide on antibiotic stewardship by hospitals prepared by the United States of America’s CDC (Centers for Disease Control and Prevention), there also needs to be a dedicated “stewardship program leader” in every hospital who would be responsible for managing the outcomes of antibiotics. 

“We need to be extremely serious in our approach towards [prescribing] antibiotics if future generations are to have even a fighting chance of survival against new sets of bacteria cropping up every day,” said Khot, who has led many Southeast Asia-based antibiotic stewardship programmes for various public health organisations. 

Yadav, who lost his wife due to multidrug-resistant TB, said that the least he can do to honour his wife’s legacy is not carelessly pop an antibiotic when he experiences the first trace of a viral fever or throat infection. 

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