2. LOOMING THREAT
• VRSA (Vancomycin Resistant Staphylococcus aureus)
• Carbepenemase producing Gram Negative bacteria
• XDR – TB [ Extensively drug resistant Tuberculosis = Multi drug
Resistant Tuberculosis (resistance to Isoniazid and Rifampicin ) +
resistant to Quinolone + resistant to
capreomycin/kanamycin/amikacin]
(defn. acc/to WHO Global Task Force on XDR TB in 2006)

3. WORST CASE SCENARIO
• High levels of antibiotic drug resistance to all known antibiotics.
• Throwback to the pre-antibiotic era : high mortality from infectious
diseases.
• On 7th April 2011, WHO Annual Slogan - Antimicrobial Resistance :
No Action today, no cure tomorrow.
• Sir Alexander Fleming in 1945 after receiving the Nobel Prize: “
Misuse of penicillin would lead to propagation of mutant forms of
bacteria that would resist the new drug.”

4. SLOW DOWN IN RESEARCH
• Estimated cost of a new antimicrobial Rs. 2200 – 4400 crores.
• Low returns.
• 9 antibiotics approved by the ICSFD in the last 15 years only 2
drugs have a novel mechanism of action.
• “The cupboard of newer antibiotics is bare. ”

5. 10 BY ‘20 INITIATIVE
• Announced by the ANTIMICROBIAL AVAILABILITY TASK FORCE
of the INFECTIOUS DISEASES SOCIETY of AMERICA in February
2010.
• Stating
“Our audacious but noble aim is the creation of a sustainable
global antibacterial drug Research and Development
enterprise
with the power in the short term to develop 10 new, safe and
effective antibiotics by 2020.”

6. WHY HAVE OUR OLD ANTIBIOTCS BECOME
USELESS?
1. Innate Resistance : Basic structure
Biochemical Mechanisms
2. Acquired Resistance : Spontaneous mutation – rare 1/105 – 1/109
cell divisions in addition to the evolutionary pressure.
3. Transfer by : Transduction
Transformation
Conjugation

7. MISUSE OF ANTIBIOTICS
• Incorrect marketing and propagation of newer antibiotics
Propaganda
Incentives
Esp. oral IIIrd generation cephalosporins
Fluoroquinolones
• Over the counter antibiotic availability by unscrupulous chemists and
pharmacies and poor knowledge.
• Antibiotics used indiscriminately in the animals, poultry
and the dairy industry.
• Irrational drug combinations
Ofloxacin and Ornidazole
Azithromycin and Cefixime
• Cefixime and Ornidazole
• Cefixime and Ofloxacin

8. MAJOR CAUSE: MISUSE BY CLINICIANS
• Indiscriminate usage: viral, self limiting bacterial illnesses
• Inappropriate choice of high end antibiotics when general will do:
Routine community acquired infections
• Incorrect dose / usage / duration
• Irrational antibiotic combination and polytherapy
• Wrong prescriptions in colleges/ institutions / community level
• Major offenders: Private Practitioners with no peer interaction for
newer knowledge.

9. RATIONAL ANTIBIOTIC USE
• Rational antibiotic use requires continuous updation of knowledge d/t
change in disease patterns
newer diagnostic modalities
newer antibiotics
newer dosing schedules
emerging resistance patterns
• IAP Action Plan: Teaching Modules For Practicing Paediatricians
CME on RTI – PSPID, R - PSPID

10. GENUINE PROBLEMS FACED
• Can’t label an infection as viral with certainity
• Bacterial cultures : slow, expensive, not always available
• The need to encourage and support the local microbologist.
Great strides in non-culture methods
eg. Cards, ELISA tests, Nucleic acid testing
• Molecular tests : LPS Hain test , GenExpert
• POC (Point of Care) testing
• Rapid Strep test : Streptococcal throat infections
• Urine dipstick tests: Leucocyte esterase and Nitrite for UTI
• Rapid testing: Malaria and Dengue
• Testing for Pulmonary TB by breath analysis for volatile compounds
They all enable prompt, accurate diagnosis and
correct, focussed and rational antibiotic therapy.

11. INSTITUTIONAL LEVEL MEASURES
• Efforts at Infection Control, rational antibiotic therapy.
• A written antibiotic policy manual giving information about antibiotic
drug resistance (local “antibiograms”)
• Rotation of antibiotics used empirically
• Restricted list of antibiotics to be used only for culture proven
resistence
Decreased therapeutic exposure to reduce evolutionary pressure
of antimicrobials on normal body flora to develop in pathogenic
bacteria or develop resistence.
• Selective antibiotic delivery to the site of infection
eg. Inhaled antibiotics for RTIs
Clinical targeting at pathogenic flora to cause selective
uptake
Nanoparticle drug delivery system

12. MISCELLANEOUS MEASURES
• Can we shorten ATT further?
4 reduced to 3 months, increase dosages, extending the intensive
phase with multiple drugs, adding novel agents
• Keep some antibiotics in reserve
• Cleanliness and hand washing technique
• Improve waste management and general hygeine
• Immunization : the underutilized weapon in our arsenal
India’s simultaneously one of the leaders in production and exporters of
vaccines but <44% of its own receive the full basic schedule of immunization.
Propaganda against vaccines, questioning their value and safety .
IAP has launched a vaccine reminder service.

13. SUMMARY
• Growing antimicrobial resistance as feared since the introduction of
antibiotics .
• Requirement of prompt initiatives to establish a full fledged antimicrobial
research and development industry to counter this threat and prevent a
throwback to the pre antibiotic era.
• Understanding the modes of development of resistance in common microbes
and the factors leading to the evolutionary pressure prompting change in
antibiotic usage practices.
• Promote rational antibiotic use at the level of the individual
practitioner, community and institutions
• Take measures to update our knowledge as in relevant in the current
scenarios and counter propaganda.
• Promote non-culture methods to enable prompt, accurate diagnosis and
correct, focussed and rational antibiotic therapy.
• Question current treatment practices, use newer drug delivery systems, not
under estimate the importance of basic hygeine practices.
• Ensure higher percentages of basic immunization coverage than the current
dismal levels.

14. Thank You