'Antibiotics are not used under prescription in India'

'Some antibiotic resistance was first detected in India. One of the reasons for this is that many antibiotics are used in India, and often these have been bought by patients and not used under prescription. This means that antibiotics are used very widely, not always to treat bacterial infections and not always at the correct dose.'

'This provides a 'breeding ground' for the development of antibiotic resistant bacteria.'

Laura Piddock, who leads Britain's Antibiotic Action, tells Vaihayasi Pande Daniel/Rediff.com how India can defend itself on a war footing against the scourge of superbugs, or bacteria that have become resistant to antiobiotics.

What exactly are superbugs?

Do all of us need to be worried about these multidrug-resistant bacteria?

Is India also bleakly facing the approach of a time when antibiotics will be toothless?

How can we protect ourselves from superbugs?

Laura J V Piddock, professor of microbiology at the University of Birmingham, the United Kingdom, also heads up Antibiotic Action, an independent UK-led global initiative working to push home the gravity of this problem facing people the world over.

"It is vital to the health of all nations that antibiotics remain the mainstay of modern medicine and are available to all on an equitable basis," she tells Vaihayasi Pande Daniel/Rediff.com in an e-mail interview.

About Antibiotic Action, Piddock says, contributes to "national and international activities and acts as a conduit through which all stakeholders -- from the general public to healthcare professionals to politicians -- are educated on the importance of new ways to treat bacterial infections".

How did the phenomenon of superbugs becoming drug-resistant come about? What were the factors that led to the misuse and overuse of antibiotics?

Bacteria evolve to survive in hostile environments.

Antibiotics can be viewed as making a hostile environment and so put evolutionary pressure on bacteria so this drives the evolution of strains resistant to antibiotics. Whilst many bacterial strains remain susceptible within a population, mutations occur very rarely to give resistance.

However, because antibiotics kill all of the susceptible bacteria in that population, the resistant bacteria remain and are able to grow up.

Bacteria grow very quickly and their generation time, such as for E.Coli, is 20 to 30 minutes. This means that many rare mutant bacteria that are antibiotic resistant can grow up and become millions and millions of cells within 24 hours.

Even for the bacteria that cause tuberculosis, which grow extremely slowly, resistant bacteria can emerge and proliferate within several weeks.

Bacteria are also able to share genes, some of these confer the ability for bacteria to infect their host and other confer antibiotic resistance.

Again, acquiring resistance gives an evolutionary advantage to those bacteria with the resistance genes over the antibiotic susceptible population. Again, these bacteria survive and grow up very quickly. Any use of antibiotics will select antibiotic resistant bacteria and the more that antibiotics are used (and if there is insufficient dosing to kill any bacteria), then the environment is made to drive and select antibiotic resistant bacteria.

In which areas of the world is the risk highest? Why are certain areas at higher risk?

Selecting antibiotic resistant bacteria can occur anywhere at any time an antibiotic is used, whether it be in people, animals or the environment. Therefore, areas with the highest use of antibiotics, and where dosing is not carefully adhered to, or where antibiotics are freely available, without prescription, means that the risk of selecting antibiotic resistant bacteria is greatest.

Why is this phenomenon so frightening? As this tragedy spreads, without being alarmist, what is the worst case scenario we could be looking at globally?

The phenomenon is frightening because these bacteria cause infections that are so difficult to treat. With so few drugs active against resistant bacteria, patients will now suffer from untreatable infections.

This will occur more and more often until we have new ways to prevent and treat bacterial infections.

The worst case scenario is that many common place treatments no longer work and people start to die from infections that until recently were fully treatable.

What are the key issues that need to be addressed to solve this calamity?

The key issues are that we must minimise and prevent the opportunities for bacteria to infect people (and animals) and minimise the use of antibiotics so that they are only used when needed to treat a bacterial infection.

We need new ways to diagnose bacterial infections quickly so the correct treatment is used, and we need new treatments, including new antibiotics that are active against antibiotic resistant bacteria.

To do all of this, new research is required, not least to find the best doses and strategies to minimise the selection of resistant bacteria.

Why is it that these superbugs evade even the hardest-hitting or last resort antibiotics, like carbapenems (antibiotics which are resistant to most bacteria)? Why are these bugs so super strong?

These bacteria are not super strong. They have just been exposed to many different antibiotics over decades, allowing them to add antibiotic resistances in the same way as trains add carriages.

Where does India connect in all this? How much of a problem is this in India? Are there any diseases in particular that India needs to be worried about?

Some antibiotic resistances were first detected in India.

One of the reasons for this is that many antibiotics are used in India, and often these have been bought by patients and not used under prescription. This means that antibiotics are used very widely, not always to treat bacterial infections and not always at the correct dose.

This therefore provides a 'breeding ground' for the development of antibiotic resistant bacteria.

In what manner does India need to join the fight?

India, via the Chennai Declaration (external link,) is already starting to address the issues of over-prescription of antibiotics by hospital doctors. In addition, with increased awareness it is hoped that use of antibiotics in all sectors will be reduced.

What is the most basic advice and precautions you can offer the Indian public, including those who may be illiterate? And what is the most important advice you can offer Indian doctors?

The best advice is to have as good hygiene as possible and so prevent infection.

Secondly, if an individual gets an infection, to do their best not to pass on the infection to other members of their household, school or workplace.

To also help this, people should not share washcloths, towels or clothes until they have been washed and any bacteria removed. The same goes for preventing transmission of viral infections.

For Indian doctors, they should only use antibiotics to treat infections that are likely to be caused by bacteria. They should be aware of local antibiotic resistance patterns so that they can make the best choice of effective antibiotics.

They need to make sure that they use the correct dose and for the appropriate duration and encourage their patients to take the antibiotics properly.

What does the Indian government need to do on a war footing?

The Indian government should sign up to the WHO Global Action Plan and do their best to implement it to meet the needs of India and address the current resistance concerns specific to India.

Is it a race to find better antibiotics? Or a matter of looking at other creative options too and what could they be?

What are the key issues hampering the bringing of new antibiotics to the global markets quickly and in more variety?

There are numerous key issues hampering bringing new antibiotics to market, not least regulatory hurdles and that the business model for antibiotics needs to be different to that for drugs for other therapeutic areas.

All options, including new antibiotics, should be explored.

How are superbugs different from regular bugs apart from their ability to resist bacteria?

Superbugs only differ from 'regular' bugs in that they are antibiotic resistant. Very few antibiotic resistance mechanisms make bacteria fitter.

When AIDS came on the scene people quickly got to know about the disease and its causes although prevention took longer. Why has awareness about superbugs, which is as scary, taken longer?

People become very frightened of AIDS because it was a terminal disease for which there is no cure.

For antibiotic-resistant bacteria, we still have some cures although these are diminishing in number day by day.

AIDS also affected particular demographic groups, who were extremely vocal in bringing this to public awareness. Unfortunately, people are used to getting infections and used to being able to treat them with antibiotics.