The Covid-19 pandemic has torn its way through India in recent months, with the country seeing over 30 million cases and more than 400,000 deaths. Alongside a shortage of vaccines and insufficient oxygen supply, another public health crisis is looming: the risk of antibiotic resistance.
Research led by Washington University School of Medicine in St. Louis, US, has found that sales of antibiotics skyrocketed during India’s first wave of coronavirus, suggesting that they were being used to treat Covid-19 patients.
Such use is not only ineffective – antibiotics target bacterial infections, not viral ones – but dangerous; needless or excessive antibiotic use contributes to the growing threat of drug-resistant infections worldwide.
A public health threat
“Antibiotic resistance is one of the greatest threats to global public health,” said the study’s senior author and infectious diseases specialist Sumanth Gandra. “Overuse of antibiotics lessens their ability to effectively treat minor injuries and common infections such as pneumonia, which means that these conditions can become serious and deadly.
“Bacteria that have become resistant to antibiotics don’t have boundaries. They can spread to any person in any country.”
The World Health Organization has declared antimicrobial resistance as one of the top ten global public health threats facing humanity today. Drug-resistant diseases could kill ten million people every year by 2050, and cause damage to the economy on par with the 2008-2009 global financial crisis, according to a report by the United Nations.
By 2030, antimicrobial resistance could see up to 24 million people pushed into extreme poverty.
Antibiotics and India
India has the second-highest population in the world, with nearly 1.4 billion people. As the world’s largest consumer of antibiotics, Gandra said, the country was “essential to study”.
“It’s basically a poster child for antibiotic misuse in low- and middle-income countries with similar health-care practices,” he said. “In general, these countries excessively prescribe antibiotics in primary care settings. Therefore, we suspect the pandemic has also spurred inappropriate antibiotic use in many low- and middle-income countries.”
The authors of the study said it was conducted because around 75% of healthcare in India is private, and “this unregulated and fragmented private sector accounts for 90% of antibiotic consumption, raising major concerns about the potential effects of Covid-19 on prescribing and dispensing practices”.
“Low and middle-income countries tend to skip diagnostic testing for respiratory illnesses because most patients cannot afford it,” Gandra said. “So, they receive antibiotics under the assumption that their illness is bacterial.”
The researchers’ analyses estimated that Covid-19 likely contributed to 216.4 million doses of total antibiotics and 38 million excess doses of azithromycin between June and September last year – the period of peak epidemic activity.
This is despite India’s health ministry recommending against the prescription of antibiotics for Covid-19 patients without secondary bacterial infections.
What do the findings mean?
The study authors estimate that trends similar to those found in India are likely to have occurred in other low and middle-income countries, where antibiotics are often overused.
They say the medium and long-term consequences of India’s antibiotic misuse for bacterial resistance are “highly concerning” and demonstrate the need for urgent antibiotic stewardship measures across the country’s hospitals.
The study also estimates that sales of hydroxychloroquine, a disease-modifying anti-rheumatic drug, saw a Covid-attributable change in level of +11.1 million doses in March 2020.
Hydroxychloroquine was widely touted as a Covid-19 cure early in the pandemic but has since been found unlikely to be effective in treating the virus, and use of the drug decreased in India after the government imposed strong restrictions on its sale.
The researchers say similar restrictions on azithromycin should be considered in India and other low- and middle-income countries to limit widespread and inappropriate use of the valuable antibiotic.
Also recommended in the study is significantly increased access to Covid-19 testing in India, to establish cases of coronavirus and reduce unsuitable empirical treatments.