Date Published: October 17, 2018
Publisher: Public Library of Science
Author(s): Habib Hasan Farooqui, Sakthivel Selvaraj, Aashna Mehta, David L. Heymann, Andrew C. Singer.
India was the largest consumer of antibiotics in 2010 in the world. Evidence suggests that countries with high per-capita antibiotic consumption have higher rates of antibiotic resistance. To control antibiotic resistance, not only reduction in antibiotic consumption is required, socio-economic factors like access to clean water and sanitation, regulation of private healthcare sector and better governance are equally important. The key objective of this research was to investigate the five year trends in consumption of major antibiotic classes in India and compare them with European Surveillance of Antimicrobial Consumption Network (ESAC-Net) countries. We used Intercontinental Marketing Statistics (IMS) Health (now IQVIA) medicine sales audit data of antibiotic sales in the retail private sector (excluding the hospitals sector) in India. We then standardized dosage trends and assigned defined daily dose (DDD) to all formulations based on the ATC/DDD index. We expressed our data in standardized matrices of DDD per 1000 inhabitants’ per day (DID) to compare antibiotic use in India with ESAC-Net countries. The antibiotic use was plotted and reported by year and antibiotic class. Our main findings are—per capita antibiotic consumption in the retail sector in India has increased from 13.1 DID in 2008 to 16.0 DID in 2012—an increase of ~22%; use of newer class of antibiotics like carbapenems (J01DH), lincosamides (J01FF), glycopeptides (J01XA), 3rd generation cephalosporins (J01DD) and penicillin’s with beta-lactamase inhibitors has risen; and antibiotic consumption rates in India are still low as compared to ESAC-Net countries (16.0 DID vs. 21.54 DID). To conclude our study has provided the first reliable estimates of antibiotic use in the retail sector in India vis-à-vis ESAC-Net countries. In addition, our study could provide a reference point to measure the impact of interventions directed towards reducing antibiotic use.
The burden of infectious diseases in India is among one of the highest in the world. The Million Death Study reported that diseases of infectious origin such as pneumonia and diarrhea accounted for 50% (0·67 million of 1·34 million) of all deaths in children aged 1–59 months in India. The burden of infectious diseases in India is also reflected in both value and volume of antibiotic sales in the country and the size of the antibiotic market as proportion of total pharmaceutical market. Of the total medicines sales worth USD 12.6 Billion in India between 2013 and 2014, anti-infectives contributed around 16.8% of the pharmaceutical market (USD 2.12 Billion). Van Boeckel et al. reported that India was the largest consumer of antibiotics with 12·9 ×10⁹ units (10·7 units per person) sold in the year 2010. BRICS countries constituted 76% of the overall increase in global antibiotic consumption between 2000 and 2010, of which 23% was attributable to India. Empirical evidence indicates a strong association between antibiotic consumption and subsequent development of bacterial resistance at both individual and community level[4–6]. Goossesn et. al demonstrated that there are higher rates of antibiotic resistance in countries with high per-capita antibiotic consumption in outpatient services through a cross-national database study .
We observed that the systemic antibiotic (J01) use increased from 13.1 DID in 2008 to 16.0 DID in 2012, representing 22.1% increase during the study period (January, 2008 and December, 2012) in India (Table 1). Findings from log linear regression model also indicate that on average utilization of systemic antibiotics in India grew at the rate of 0.5 percent monthly (trend coefficient (β) is 0.005) during the study period (Table A in S1 File).
Our study has provided first reliable estimates of antibiotic use in India vis-à-vis ESAC-Net countries. Interventions directed towards achieving Universal Health Coverage, particularly free access to medicines through public health facilities should be implemented to mitigate demand for antibiotics in the private sector. Since antibiotic use is both prescription and self-medication driven in India, education campaigns and behavior change communication strategies to address overuse and misuse of antibiotics are required. Specific regulation with reference to licensing, sales and prescription of antibiotics are in force, their effectiveness has not been evaluated formally; additional research is required to address this knowledge gap.