Addressing Antimicrobial Resistance (AMR): The Power of Collaboration and Environmental Surveillance
In the battle against antimicrobial resistance (AMR), collaboration and innovative surveillance methods are emerging as vital tools. In conversation with Dr. Varsha Shridhar, Chief Enabling Officer and Co-founder of Molecular Solutions Care Health, we explore how a collaborative mindset and environmental surveillance can transform our approach to AMR, offering solutions that engage communities, bridge data gaps, and drive meaningful change in healthcare and beyond.
Can you provide a brief overview of what antimicrobial resistance is and its significance in today’s healthcare landscape?
Antimicrobial Resistance (AMR) primarily concerns bacteria and occurs when these microorganisms cease to respond to drugs designed to kill or control them, such as antibiotics. In essence, it’s a situation where bacteria adapt to the presence of drugs rather than succumbing to them.
Think of it like this: when someone scolds you initially, you pay attention and may become subdued. However, if the scolding continues, you eventually become desensitized. The same principle applies to unpleasant odours — you become accustomed to them over time. Similarly, bacteria undergo adaptation at their level. When first exposed to a new antibiotic, they are often killed or suppressed. However, with repeated exposure, they evolve mechanisms to resist the drug’s effects, rendering it ineffective. This is the essence of antimicrobial resistance.
Why is this important? Let’s consider a few examples. Take urinary tract infections in women, for instance. We often rely on antibiotics to treat them. However, you may have noticed that the same antibiotic that worked a few years ago may now require a higher dosage or prove ineffective altogether. This is because the bacteria causing the infection have developed resistance to the treatment.
Now, imagine a scenario in a hospital ward or ICU where a patient is battling a severe illness. They may be infected by drug-resistant bacteria or have weakened their own internal bacteria through repeated exposure to antibiotics. In such cases, managing the infection becomes incredibly challenging, and we enter a precarious situation reminiscent of a pre-antibiotic era. Even once curable diseases become insurmountable because we lack effective treatment options. This emphasizes the seriousness of antibiotic resistance.
AMR is a growing concern year by year. Despite the development of more antibiotics, an increasing number of bacteria are becoming resistant to these drugs. It’s akin to a silent pandemic — a relentless and gradual progression that can impact anyone. This makes AMR a truly frightening issue.
What factors contribute to the development and spread of antimicrobial resistance in both urban and rural areas?
It’s a common misconception to associate antibiotics solely with clinical use in human medicine. In reality, antibiotics find extensive application in various sectors, including agriculture, the marine industry (such as shrimp farming), livestock farming (particularly poultry), and even in everyday meat production. This widespread use of antibiotics is a significant contributor to the problem of antimicrobial resistance (AMR), which affects both urban and rural environments. Overuse and misuse of antibiotics are not limited to a specific region; it’s a global concern.
AMR isn’t solely a product of human intervention; it occurs naturally as bacteria evolve in response to antimicrobial agents. This process predates human influence and can even be found in unexpected places, such as permafrost. Nature itself harbours antimicrobial resistance genes. Additionally, it’s important to recognize that antimicrobial agents, initially derived from fungi like penicillin, were part of this natural order.
Antimicrobial resistance (AMR) serves as a striking example of a complex “One Health” challenge. The concept of “One Health” underscores the intricate interdependence of human, animal, plant, environmental, and planetary health. It highlights the profound impact of any disturbance within this interconnected web, including the consequences of human activities like pollution and deforestation. When one element of this complex ecosystem is affected, it ripples through to impact every other component, including our own well-being.
Currently, efforts are underway to address antibiotic use in wastewater management. After wastewater is generated, it undergoes treatment and can be reused for various purposes, including agriculture and construction. most sewage treatment facilities (STPs) do not come with a typical feature for antibiotic removal. Consequently, when wastewater containing antibiotics is reused, it could potentially transfer these drugs from urban to rural areas. Similarly, effluents from farms, often lacking adequate antibiotic treatment, can enter water bodies like lakes and eventually be used for agricultural irrigation or in tap water supplies. This leads to the presence of antibiotics in agricultural practices and tap water, creating an environment conducive to the development and spread of AMR.
Could you describe pathways through which bacteria travel within urban settings? How do factors like population density and infrastructure affect this movement?
The environment plays a pivotal role in the transmission of various bacteria, depending on the specific bacterium in question. For instance, Mycobacterium tuberculosis, which causes tuberculosis, spreads through the air, infecting individuals as it travels through airborne particles. However, bacteria like cholera and salmonella primarily use the water and fecal-oral route for transmission. These pathogens contaminate water sources, which can then be consumed by other individuals, leading to infections. The mode of transmission varies based on the bacterium’s characteristics and the environmental factors at play.
Population density and infrastructure are critical determinants of the risk associated with aerosol-borne bacterial infections, including those caused by Mycobacterium tuberculosis. In densely populated urban settings, such as overcrowded slums or living quarters for migrant construction workers and factory employees, the risk of respiratory illnesses significantly increases due to close quarters and inadequate ventilation.
In India, the spread of drug-resistant tuberculosis (TB) is a significant public health concern. It includes cases of multi-drug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB). The high population density, coupled with suboptimal living conditions and inadequate infrastructure (like poorly ventilated spaces), contributes to the spread of these drug-resistant strains.
Access to safe drinking water is another infrastructure-related concern. In areas lacking access to clean drinking water, there’s a higher prevalence of gastrointestinal diseases. Periodic outbreaks of cholera, often occurring after the summer or monsoon seasons, are observed, and resistance to salmonella infections is also on the rise in community settings.
Infrastructure challenges also extend to environmental factors. Soil can harbour antibiotic-resistant bacteria like Staphylococcus and Methicillin-resistant Staphylococcus aureus (MRSA). When individuals come into contact with contaminated soil, they can acquire these resistant strains, which are difficult and costly to treat.
Regarding the significance of these concerns for the healthcare system, there are several key implications. Firstly, patients may face increased out-of-pocket expenses due to the challenges of treating antibiotic-resistant infections. Secondly, healthcare facilities may experience outbreaks of antibiotic-resistant infections, especially in closed environments like intensive care units (ICUs). These outbreaks can result in increased morbidity among patients, particularly those with compromised immune systems, such as transplant recipients. Controlling such outbreaks becomes a significant challenge for hospitals and healthcare providers.
Why is Environmental Surveillance an effective tool in surveilling and managing AMR?
There are several reasons why environmental surveillance holds great promise in the context of addressing antimicrobial resistance (AMR). Firstly, it offers a level of anonymity that clinical data lacks. Currently, our national AMR data primarily stems from clinical records in select tertiary care hospitals, which inherently creates a biased dataset. While efforts are being made to incorporate data on veterinary antibiotic resistance, there remains a limitation in the number and representativeness of sentinel surveillance sites.
The real crux of the AMR issue lies in primary care settings, where unregulated antibiotic use is most prevalent. Patients typically visit neighbourhood clinics with the presentation of various ailments for which they may be prescribed antibiotics (perhaps inappropriately or at the wrong dosage, since most antibiotic prescription takes place without adequate laboratory evidence)However, there is a growing risk of encountering multi-drug resistant bacteria in such settings. These scenarios, where initial treatments fail and patients deteriorate, often go unreported and unrecorded, resulting in a critical data gap.
This is where environmental surveillance steps in as a potential solution. While clinical and community-level data collection can be expensive and logistically challenging, monitoring wastewater presents a cost-effective alternative. Wastewater contains bacteria originating from human faecal matter, offering a reflection of the local ecosystem and environmental conditions. By analyzing this water for antibiotic presence and the prevalence of antimicrobial-resistant bacteria, it may serve as a surrogate marker for the community’s AMR burden.
What sets environmental surveillance apart is its ability to engage citizens directly. Communities can participate in data collection without divulging personal information. They simply provide wastewater samples, which are then analyzed to generate valuable insights. This approach establishes an intimate connection to the data. When residents see that data collected from the stream behind their homes reflects their environment, it fosters an immediate and personal understanding of the issue.
This personalized, yet anonymous, approach has the potential to drive change. Community members can collaborate with local healthcare providers, armed with knowledge about their specific AMR challenges. This grassroots involvement can lead to shifts in behaviour, such as more judicious antibiotic prescribing practices, ultimately contributing to a more effective response to the AMR crisis.
What is the role of alliances and collaboratives in addressing AMR? How does one approach this with a collaborative mindset in a fairly complex ecosystem of stakeholders?
In my own experience, we conducted a study on the transportation of treated and untreated wastewater from Bangalore to peri-urban and rural areas outside the city for agricultural irrigation. We aimed to assess the impact on bacterial loads, antimicrobial resistance, heavy metals, antibiotics, and other contaminants being transferred from one part of the city to another.
This research endeavour would not have been feasible without collaboration across diverse fields. We engaged urban engineers, architects, geologists, water experts, public health specialists, data scientists, chemists, hydrogeologists, and GIS experts to orchestrate this study.
Moreover, my mindset has undergone a significant shift. Initially, I predominantly approached this from a risk-focused perspective. However, my perspective has evolved towards a problem-solving approach. This transformation in mindset was only possible through dialogues with individuals holding different viewpoints. The complexity of this ecosystem dictates that no single entity can resolve it independently.
Furthermore, the power of alliances is substantial. Just as workers in a union collectively hold more power, a nationwide alliance like the Indian Alliance for Public Health Preparedness (IAPHP) possesses significant political and social capital.
