India accounts for 1/6th of the global population and highest antibiotic consumption rates globally regarding volume. Even though the recent data shows a declining trend in consumption, evaluation of the last decade denotes a 6.8% net increase in the private sector alone. Increased sales and consumption can be broadly categorized to be stemming from 3 probable causes: Rampant marketing by pharmaceutical companies, over-the-counter (OTC) availability allowing unrestricted access, and inappropriate over-prescribing practices. One might ponder over the implications of these data and the answer is antimicrobial resistance (AMR). AMR may be described as the ability of the bacteria to survive in the presence of the very substance/drug designed to kill or arrest their growth. Although developing resistance is a natural process among microorganisms, the existing practices have a snowball effect and accelerate the process substantially making it a problem of the present instead of the distant future. India peaked in levels of AMR across all years and pathogens for which data were available and was also regarded as ‘the AMR capital of the world.’

Problems arising from Antimicrobial Resistance:

1. Existing illnesses are becoming difficult to treat owing to the emergence of resistant strains.

2. The process of delivering complex medical care (e.g. organ transplant) is becoming complicated, particularly for high-risk individuals.

3. Increased duration of hospital stay resulting in increased overall treatment costs.

4. Increased mortality rates, especially in infants.

Indian scenario can be understood based on the rural and urban areas wherein 66.5% of the total (i.e. over 1.2 billion) population resides in rural areas, but 65-84% of physicians and healthcare facilities are concentrated in the urban areas. This limits patients' access to dental specialists, leaving them with no choice but to turn to informal healthcare practitioners (IHCP) and general practitioners (GP) for dental issues. These setups in rural areas are often neither well-equipped nor well-staffed to provide optimal dental treatments and hence, prescription-based practices are prevalent in the rural sector. IHCP and GP account for over 50% of all healthcare providers and up to 90% of utilization by underprivileged populations. It was reported that 90% of all prescriptions given in rural areas for dental problems were found to include antibiotics.

Patients from all social sections, whether in rural or urban areas, frequently resort to self-medication for oral health problems. While it is illegal to procure antibiotics OTC without a prescription, this practice is widely prevalent in India. Possible reasons identified were:

1. Avoiding a visit to the dentist due to:

• Time constraints

• Cost of dental treatment

• Past painful experiences

• Chronic nature of the dental disease resulting in multiple acute episodes or multiple visits for treatment.

• Increased waiting time at the dental clinic

• Unavailability of a specialist in the region

2. Patients experiencing more than two symptoms

3. Easy access to antibiotics/medications due to unrestricted sale at a local pharmacy.

4. Immediate relief from dental pain after consumption of medication procured OTC.

5. Mutual understanding between patients and pharmacies in the form of returnable and refundable provisions.

According to data from several studies conducted on a total of 1580 individuals, 10% of people in rural areas and up to 35% of the urban population resort to self-medication using antibiotics. Alarmingly, a sizable proportion of the crowd opting for self-medication is unaware of the drug consumed and often winds up consuming combination drugs (FDC) which are not recommended according to national and international guidelines.

It is also seen that injudicious and inappropriate prescription practices are prevailing among dentists where BDS professionals are prescribing significantly more antibiotics than MDS professionals, thus contributing substantially to the emerging trends of resistant strains. Antibiotics may indeed be indicated for various therapeutic and prophylactic reasons, which are determined based on various guidelines which are updated periodically.  Poor compliance with antibiotic prescribing recommendations is found to be a prevailing practice in both developed and developing nations and is not unique to India. Prominent reasons for the misuse of antibiotics, other than a lack of knowledge are patients’ demands, fear of losing the patient - especially in pediatric cases where parents demand that antibiotics be prescribed for a speedy recovery, market pressure from pharmacies or pharmaceutical companies, peer practices, etc.

The need of the hour is to identify the challenges ahead of us and to make collective efforts so as to overcome them as a society. Few of the most important measures to correct the situation are:

1. Addressing the shortcomings in our policies by preventing OTC sales of antibiotics and formulating stronger regulations.

2. Launching antibiotic stewardship programmes to ensure appropriate prescription and monitored sales of antibiotics.

3. Training the healthcare providers by upgrading their knowledge through mandatory high-quality continued dental education (CDE) programmes.

4. Emphasizing judicious and appropriate antibiotic prescription in all dental colleges.

5. Developing computer-assisted programs for doctors to aid decision making while prescribing antibiotics.

While the research studies are the only reliable source at hand to get an impression about the scope of the problem, these studies typically exclude data on self-medication and thus present data that is vastly understated. The WHO slogan for World Health Day 2011 – ‘Combat Drug Resistance: No action today, No cure tomorrow’ gives an insight into the magnitude of the problem at hand and its implications. Considering the rapid increase in AMR, there is an urgent need to ensure prudent use and intercept their misuse and abuse in dental practice.

References:

1. Bhuvaraghan A, King R, Larvin H, Aggarwal VR. Antibiotic Use and Misuse in Dentistry in India-A Systematic Review. Antibiotics (Basel). 2021 Nov 26;10(12):1459.

2. Al-Khatib A, AlMohammad RA. Dentists' Habits of Antibiotic Prescribing May be Influenced by Patient Requests for Prescriptions. Int J Dent. 2022 Aug 22;2022:5318753.

3. Fazaludeen Koya S, Ganesh S, Selvaraj S, Wirtz VJ, Galea S, Rockers PC. Antibiotic consumption in India: geographical variations and temporal changes between 2011 and 2019. JAC Antimicrob Resist. 2022 Oct 26;4(5):dlac112.

4. Sulis G, Batomen B, Kotwani A et al. Sales of antibiotics and hydroxychloroquine in India during the COVID-19 epidemic: an interrupted time series analysis. PLoS Med 2021; 18: e1003682.

5. The Center for Disease, Dynamics Economics & Policy. ResistanceMap: Antibiotic Resistance. 2022. https://resistancemap.cddep.org/ AntibioticResistance.php.

6. Chaudhry D, Tomar P. Antimicrobial resistance: The next big pandemic. Int J Community Med Public Health. 2017;4:2632–6.

7. Khare, S.; Purohit, M.; Sharma, M.; Tamhankar, A.J.; Lundborg, C.S.; Diwan, V.; Pathak, A. Antibiotic Prescribing by Informal Healthcare Providers for Common Illnesses: A Repeated Cross-Sectional Study in Rural India. Antibiotics 2019, 8, 139.

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