News and Opinions  –  2017

India’s link between tuberculosis and antibiotic resistance

2017-03-24

Improving detection, diagnosis, and treatment of tuberculosis in India, home to the world's largest number of tuberculosis patients, may hold the key to bringing down both antimicrobial and antibiotic resistance globally.

Photography: Benoit Matsha-Carpentier / IFRC, Courtesy of Photoshare

Improved diagnostic methods for early detection of tuberculosis, along with newer shorter regimens (in clinical trials) and antibiotic stewardship practices in all the centers may contribute to bringing down antibiotic misuse in India.

Improved diagnostic methods for early detection of tuberculosis, along with newer shorter regimens (in clinical trials) and antibiotic stewardship practices in all the centers may contribute to bringing down antibiotic misuse in India.

Studies show high number of prescribing antibiotics

A number of studies of prescribing practices among Indian physicians have over the years documented very high levels of antibiotic use. One study[1] found that 41% of surveyed patients were prescribed antibiotics, whereas overall data on the burden of communicable diseases in India suggest that only 10-15% of infections have bacterial etiology and therefore truly need antibiotics.

Another qualitative 2010 study[2] on antibiotic prescribing practices in Delhi identified the following factors as leading to doctors prescribing antibiotics:

  • diagnostic uncertainty
  • perceived demand and expectation from the patients
  • practice sustainability and financial considerations
  • influence from medical representatives and
  • inadequate knowledge.

Interventions suggested to improve prescription practices

To improve prescription practices, the study suggested interventions like Continuing Medical Education for doctors, awareness raising of patients, shared decision making and stricter rules and regulations to promote rational use of antibiotics in the community.

However, improving detection, diagnosis, and treatment of tuberculosis in India, home to the world’s largest number of tuberculosis patients, may provide important learnings for efforts to better manage antimicrobial resistance. Tuberculosis patients in India are vulnerable to the drug-resistant forms of the infection. Wrong or delayed diagnosis and inappropriate or wrong treatment can be drivers of bacterial resistance.

India most affected by global tuberculosis epidemic

India has long been the country most affected by the global tuberculosis epidemic, accounting for around a quarter of all new tuberculosis cases reported every year. The WHO’s Global tuberculosis (TB) Report[3] 2016, estimated that India alone accounted for almost a third of all new tuberculosis cases worldwide in 2015 (2.8 million out of 10.4 million). The same year, India also accounted for 37 percent of global mortality due to tuberculosis, adding up to an astounding 480,000 deaths.

Worryingly, India reported an estimated 79,000 cases of multidrug-resistant tuberculosis in 2015[4] out of which only around 31,000 patients were diagnosed and put on treatment. According to the Global TB Report 2016, the drivers of multidrug-resistant tuberculosis in India include limited patient coverage, wide variability across states and localities on tuberculosis-specific support packages, and weaknesses in administration. India has also reported cases of Extensively Drug Resistant tuberculosis, defined as multidrug-resistant tuberculosis plus resistance to at least one fluoroquinolone and a second-line injectable agent. On average an estimated 9.7% of people with multidrug-resistant tuberculosis have Extensively Drug Resistant tuberculosis[5].

Misdiagnosis and wrong treatment a factor in spread of antibiotic resistance

A recent study, published by The Lancet Infectious Diseases[6] in August 2016, pointed to the role of misdiagnosis and wrong treatment of tuberculosis as a factor in the spread of antibiotic resistance given that many private practitioners’ tend to treat tuberculosis patients with regular antibiotics initially.

The study, carried out by researchers at McGill University’s Faculty of Medicine, sent “standardized” patient actors to 622 pharmacies in three large Indian cities to assess how pharmacists treated patients with presumed and confirmed tuberculosis. It is common for patients in India to be able to buy prescription-only drugs over the counter at pharmacies, though new regulations in recent years have tightened restrictions on such sales.

The study found that only a few urban Indian pharmacies managed patients with presumed tuberculosis correctly (i.e. based on symptoms alone). Only 13% of patients received the correct treatment (referral to a health-care provider without administration of any antibiotics or steroids). The rest were instead treated for bronchitis or pneumonia with antibiotics and/or steroids, including some 10% with quinolones, despite the restrictions on their use.

However, most pharmacies managed the cases of confirmed tuberculosis correctly. If the patient presented lab confirmation of tuberculosis, pharmacists did not dispense first-line anti-tuberculosis drugs without prescriptions, and 67% were referred to appropriate specialized treatment centers.

Absence of confirmed diagnosis driver of antibiotic misuse

The study concluded that absence of a confirmed diagnosis is a key driver of antibiotic misuse in India. These assessments of pharmacies practices could be helpful both for in informing broader antimicrobial stewardship interventions but also the need to focus efforts on scaling up the development of rapid diagnostics testa dn ensuring their availability. The unavailability of rapid diagnostic tests such as the Xpert PCR in health care centers for example has been shown to cause delay especially for patients with smear-negative tuberculosis (predominant in HIV infected and children).

References:

[1] ANTIBIOTIC USE & RESISTANCE Patterns, Perceptions, Policy and the Price to Pay; Sujith John Chandy. Ph.D. Thesis. Global Health, Department of Public Health Sciences Karolinska Institutet, Stockholm, Sweden
[2] Factors influencing primary care physicians to prescribe antibiotics in Delhi India Anita Kotwania, Chand Wattal et al., Family Practice 2010; 27:684–690; doi:10.1093/fampra/cmq059; http://apps.who.int/medicinedocs/documents/s19571en/s19571en.pdf
[3] Global tuberculosis report 2016, WHO.
[4] Global tuberculosis report 2016, WHO
[5] http://www.tbfacts.org/drug-resistant-tb/
[6] http://www.thelancet.com/pdfs/journals/laninf/PIIS1473-3099(16)30215-8.pdf