Isha (name changed on request), a 27-year-old resident of Delhi, has had Urinary Tract Infection (UTI) multiple times, but when she was had the symptoms again in June this year, she knew it was different.
The drug that she usually takes whenever she is diagnosed with a UTI wasn't really working.
"I was prescribed Nitrofurantoin by a doctor when I first got it. I've been getting UTI frequently in the last year or so, and I've just been taking the same medicine by myself. It has worked so far. But this time it didn't work, and my symptoms got worse."Isha (name changed)
The drug in question is an antibiotic which means, by law, can only be purchased with a doctor's prescription. But in India, it is widely available over-the-counter.
Upon consultation with a urologist, Isha was put on Intravenous (IV) Amikacin, a stronger antibiotic to which, the strain she had was diagnosed with was sensitive. This is not just Isha's story.
"This is very common. Almost 50 percent of the cases of urinary tract infection that we get now are resistant to first-line drugs (those that are considered most accepted for initial treatment of a condition)," says Dr Paresh Jain, Director, Urology and Kidney Transplant, Fortis Escorts, Okhla Road, New Delhi.
He adds that about 25 percent of them are resistant to second-line drugs as well.
"Many are even pan-resistant, which means they are resistant to all the drugs for the infection available in the market," he explains.
Antimicrobial resistance happens when pathogens that could earlier be easily neutralised with certain drugs stop responding to them. This is what gives rise to 'superbug' versions of specific bacteria, fungus and viruses.
A report by the Indian Council of Medical Research in 2019 found that E. coli, one of the most common causes of UTI, is also the most common drug-resistant superbug.
Why is Antibiotic-Resistant UTI a Cause for Concern?
The issue ties to the larger crisis of antimicrobial resistance looming across the world. According to a Lancet report, 4.95 million deaths globally in 2019 were directly linked to AMR. To put things in perspective, that's more than both HIV and malaria.
A surge in antibiotic-resistant UTI has doctors especially concerned because of just how common the infection is.
"If the infection doesn't respond to medication, then the inflammation in the bladder can rise and go to the kidneys also," says Dr Nupur Gupta, Director, Obstetrics and Gynaecology at Fortis Memorial Research Institute, Gurgaon.
Dr Nupur Gupta says, "UTIs are very common, especially among women. And if you get it once, you're likely to get it again and again, which means you take the medicine again and again, and this can contribute to increased resistance over time."
However, it's not just patients who have been treated for UTI mutliple times with these drugs, even first-time presenters of the infection are coming in with antibiotic-resistant strains, says Dr Jain.
Explaingin this, he says, "Most of the time, it is the bacteria in our gut flora that is responsible for the UTI in the first place."
So, if you've been on antibiotics for other illnesses, or have a diet consisting of poultry and meat heavily treated with antibiotics, it can all contribute to the altering of your gut microbiome, including these bacteria within it.
According to a study conducted in India in 2014, The highest percentages of drug resistance in E. coli were detected from raw chicken, vegetable salad, raw egg-surface, and unpasteurized milk.
When such a situation arises, doctors test urine samples to figure out which drugs the strain of the bacteria is sensitive to – usually stronger, second and third-line defence drugs, and broad-spectrum antibiotics.
"In these cases we need to give a combination of drugs which has the antibiotics but also something that destroys the enzymes that the bacteria produces to protect itself from the drugs."Dr Paresh Jain
According to the doctors FIT spoke to, these are just band-aid solutions, and tackling the issue will require looking at the root cause of the rise in drug resistance and finding effective counters to bring it under control.
"Overuse of antibiotics is the primary cause," says Dr Jain.
OTC Antibiotics and India’s Self-Medication Problem
"Patients tend to take the drugs over the counter when they feel the symptoms," says Dr Gupta. Never mind the fact that these drugs are meant to be sold only against prescriptions.
Besides frequently self-medicating, erratic use of antibiotics is also a contributing factor.
"People stop taking the medicine when they have symptomatic relief, and don't complete the course. This exposes the bacteria to the drug, but doesn't fully kill them, and it develops a mechanism now to overcome that antibiotic."Dr Paresh Jain, Director, Urology and Kidney Transplant, Fortis Hospital, New Delhi
Moreoever, adds Dr Gupta, "It's important to get a proper diagnosis before taking any medication. "Sometimes people get certain symptoms, or feel like they have an infection and take antibiotics. That's not recommended."
"In women, there is a lot of confusion between symptoms of Sexually Transmitted Infections (STIs) and UTI. Which is why a clinical examination is required to confirm the infection and plan the course of treatment accordingly."Dr Nupur Gupta, Director, Obstetrics and Gynaecology at Fortis Memorial Research Institute, Gurgaon
‘It’s Not All on You'
Antimicrobial Resistance, or AR is one of the leading healthcare crises in the world right now. In fact, a report by the University of Oxford, found that 1.2 million deaths in 2019 were directly linked to AR. That's more than HIV and Malaria.
FIT has previously done an extensive explainer on Antimicrobial resistance, superbugs and how dangerous they are to the fabric of modern medicine.
Speaking to FIT for the story, Dr Sumit Ray, critical care specialist, Holy Family Hospital, Delhi, explained that there are multifactorial, multi-level reasons for the rise in AR."
Self-medication with over-the-counter drugs is rampant, yes. But over-prescription of antibiotics is a huge factor too.
Dr Ray said doctors tend to prescribe very high percentage of antibiotic prescriptions even for the mildest of infections like cold, Diarrhoea etc which are usually viral infections.
"The tendency is to prescribe multiple drugs so that at least something will work which is in a sense, very unscientific, improper and that leads to very high antibiotic prescription."Dr Sumit Ray
The bottom line is, experts say, we have to slow down now, not just in humans but also in animals and poultry. "It is only as a whole that we can make a difference," says Dr Jain.
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