Antibiotic Awareness Week Q&A – Dr Sumanth Gandra

Here we ask Dr Sumanth Gandra some questions about AMR, antibiotic stewardship and what he thinks the future holds.

Dr. Gandra received his medical degree from Osmania Medical College, Hyderabad, India in 2004. In 2007, he received his MPH degree in community health from Eastern Kentucky University. He completed his internal medicine residency at the University of Illinois College of Medicine, Peoria in 2010 and his infectious diseases fellowship at the University of Massachusetts Medical School in 2013. After his infectious diseases fellowship, he worked at the Center for Disease Dynamics, Economics & Policy (CDDEP) institute in Washington, DC until 2017. At CDDEP, he was involved in the surveillance of antibiotic resistance, antibiotic consumption and establishing a repository of global antibiotic resistance data. His work at CDDEP also focused on understanding the drivers of antibiotic resistance and consumption in India and other low-income countries. He serves as a member of the WHO Expert Committee on the Selection and Use of Essential Medicines since 2017. In 2018, he completed a medical microbiology fellowship at the University of Chicago/NorthShore University HealthSystem and then joined the Department of Medicine in the Division of Infectious Diseases at Washington University School of Medicine as an Assistant Professor in January 2019.

His research interests include understanding the molecular epidemiology, burden, and transmission dynamics of antimicrobial resistance in healthcare settings and in the community in India. He is also interested in studying the transmission dynamics of antibiotic resistance among humans during religious mass-bathing events and studying the use of antibiotics in the poultry industry in India. His ultimate goal is to design interventions to reduce the burden of antibiotic resistance and improve antimicrobial use in India and other resource-limited countries.

What prompted your interest in pursuing a career in infectious diseases, and have you seen any changes in focus for the field as a whole and your own research since you first started?

The reasons for high environmental contamination are poor sanitation, pharmaceutical and hospital effluents with high antibiotic residues and resistant bacteria released into sewage treatment plants, antibiotic laden effluents from food animal productions, and religious events such as mass bathing in rivers.

High infectious disease burden in India and the importance of public health programs in controlling infections attracted me to pursue a career in infectious diseases. The public health aspect of my work is what I enjoy the most. I initially  focused on viral infections, mainly dengue fever, which continue to affect millions of Indians every year. However, during my infectious diseases fellowship training, I shifted my focus to antibiotic resistance which was an emerging problem at that time with not much awareness in India and other resource limited countries.

Why did you then choose to focus your research on antibiotic resistance surveillance and understanding the drivers of antibiotic resistance and consumption in India, while at CDDEP (Center for Disease Dynamics, Economics & Policy)?

When I started to work at CDDEP, there was not much data on antibiotic resistance among bacteria causing routine infections from low and middle-income countries (LMICs). This information was crucial in bringing the issue of antibiotic resistance to the attention of policy makers in LMICs. My work focused on collating antibiotic resistance data using public databases and through collaborators in LMICs. During this work, I observed that India has the highest prevalence of antibiotic resistance. This led me to explore the reasons why India could have high prevalence of antibiotic resistance.

Why does India have one of the highest burdens of AMR globally, and what affect do you think this burden will have long-term on other regions?

There are several reasons. In my opinion, the most important reason is the high degree of environmental contamination with resistant bacteria in the community. This can be inferred from studies that focused on intestinal colonization of resistant bacteria among return travellers from high-income countries. The reasons for high environmental contamination are poor sanitation (about 50% of population don’t have access to safe disposal of human waste), pharmaceutical and hospital effluents with high antibiotic residues and resistant bacteria released into sewage treatment plants, antibiotic laden effluents from food animal productions, and religious events such as mass bathing in rivers. Poor personal hygiene and lack of access to clean water for drinking and for domestic use facilitates high burden of AMR in the community. Although India has highest antibiotic consumption at national level, per-capita consumption is much lower than several other high-income countries. However, once a resistant bacterium or gene emerges, the spread is easy in India due to poor sanitation, personal hygiene, and lack of access to clean water. Poor infection control practices in hospitals is one the major reasons for high burden of AMR in hospital settings. Bacteria do not have boundaries and with ease of global travel, importation of resistant bacteria is a constant threat for other regions.

How far do you think the India AMR National Action Plan, developed in 2017, has helped to address AMR?

The India’s AMR National Action Plan was laid out very well focusing on key issues pertinent to India including the importance of addressing environmental contamination. However, the slow implementation due to financial constraints and uptake by State Governments who are responsible for implementation at the ground level, is disappointing. Unfortunately, the COVID pandemic further impacted the work on AMR initiatives. There were some major actions undertaken since 2017, including banning several fixed dose drug combinations including antibiotics in September 2018, banning colistin use for growth promotion in food animals in July 2019, and setting up minimum antibiotic residue level in pharmaceutical effluents in January 2020. However, the challenge would be enforcement of these measures and thus an evaluation of these measures is needed.

There has been tremendous progress on antimicrobial resistance surveillance however the progress on antimicrobial stewardship and antibiotic use surveillance is lagging behind.

What changes would you like to see in the revised NAP (due in 2021) to help address current gaps in antibiotic stewardship programmes?

There has been tremendous progress on antimicrobial resistance surveillance however the progress on antimicrobial stewardship and antibiotic use surveillance is lagging behind. The Indian Council of Medical Research (ICMR) has developed guidance document on Antimicrobial Stewardship Programs (AMSP) and conducted workshops for about 30 hospitals. The expectation is that these hospitals will become nodal centres which subsequently conduct training to other regional and district/secondary hospitals. However, there has been less focus on antimicrobial stewardship activities in the community settings where the major portion of antibiotic prescribing happens. Initiatives aimed at improving antibiotic prescribing in the private sector which accounts for approximately 70% of healthcare are also lacking. The NAP should incorporate WHO’s AWaRe (Access, Watch and Reserve) categorization of antibiotics for optimising antibiotic use and setting targets for reducing overall antibiotic use and the use of Watch and Reserve antibiotics. Antibiotic use surveillance at national level should be a priority and should utilize data resources from private and public sector for conducting surveillance.

How far do you think changing attitudes to hygiene behaviour in communities in India will help to curb the spread of infection and resistant bacteria and reduce antibiotic prescribing?

In my opinion there will be a significant impact on curbing the spread of AMR and reducing antibiotic over use. There is good evidence indicating that “spread” of resistant bacteria is the major factor contributing to antimicrobial resistance in LMICs. There is also emerging evidence indicating that the relationship between antibiotic use and resistance selection is altered by hygiene behaviour. Poor hygiene results in proliferation of AMR in LMICs and thus improving investment in infrastructure to improve hygiene could significantly impact AMR levels. One study in Guatemala demonstrated that improvement in the household hygiene index was associated with a 30% reduction in the likelihood of detecting antimicrobial-resistant bacteria within people. There are also studies indicating that improving personal hygiene especially “targeted hygiene” in homes could lower the incidence of acute respiratory tract and diarrheal infections in community settings. These two infection syndromes are the most common reasons for overuse of antibiotics in India.

With the World Antibiotic Awareness Week in November (18-22 November 2020) focusing on preventing the COVID-19 pandemic from worsening the ongoing antibiotic resistance crisis, what is the most important focus to help reduce AMR in India?

COVID-19 pandemic has undoubtedly brought significant awareness of the importance of personal hygiene in LMICs (including India) which could indirectly impact AMR. However, there is widespread prescription of antibiotics for mild and moderate COVID-19 cases in India despite the Indian national guidelines suggesting not to prescribe antibiotics in these scenarios. The focus for this World Antibiotic Awareness Week should be on bringing awareness for prescribers and public regarding the unnecessary antibiotics for COVID-19.

If you could fast-forward 10 years, what changes would you hope to see in India, and globally, regarding AMR?  Which ones do you think are the most likely?

Improved infrastructure for WASH (water, sanitation and hygiene), minimal antibiotic residues in pharmaceutical effluents, banning antibiotic use for growth promotion in food animals, prescription only dispensing of antibiotics at least in urban areas, improved infection and control practices in healthcare facilities, low cost point of care diagnostics for respiratory tract and diarrheal infections, increased awareness of antimicrobial resistance in the general public, increased government expenditure on health with decreased reliance on private sector, decreasing trends in antibiotic use in humans, renewed antibiotic pipeline pertinent to bacterial pathogens (e.g- NDM producing Enterobacteriaceae) encountered in India. Most of these changes will happen to some extent. However, in 10 years it is most likely that antibiotics will be banned for growth promotion in food animals and pharmaceutical effluents will be free of antibiotic residues.

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