Non-antibiotic antibacterial agents: Has their time come?

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The discovery of penicillin ushered in the antibiotic era, which dramatically cut down the prevailing infection rate. Since then, antibiotics have successfully treated and prevented many infections and saved countless lives as a result.

But now, many bacteria have developed resistance to these ‘wonder drugs’ reducing their effectiveness. The emergence of resistance to antibiotics was perhaps a development ‘waiting to happen’ given their indiscriminate use since they were first discovered. With no new antibiotics in the pipeline, a ‘pre-antibiotic era’ looms ahead, where many common infections might no longer have a cure and, once again, become a threat to human life.

Antimicrobial resistance (AMR) is rapidly increasing worldwide and has now become a global public health issue.

Given this background coupled with the undesirable side effects of systemic antibiotics, it is time perhaps to look at and explore some non-antibiotic antibacterial alternatives, some of which are available in nature.

Sunlight is a potent bactericide. It is also a natural disinfectant. A review examining the roles of sunlight and natural ventilation for controlling infection published in the Journal of Hospital Infection in 2013 states as follows: “The majority of microbes that cause airborne infections cannot tolerate sunlight”. The article further says, “The World Health Organization refers to sunlight in guidance on preventing hospital infections.”

The WHO also promotes natural ventilation design for infection control in health care in its 2009 guidelines on natural ventilation for infection control in health-care settings.

Many foods such as garlic, turmeric, ginger, honey, oregano act as natural antibiotics with antibacterial action; some of them like garlic may also have antiviral and/or antifungal properties. Oregano has a strong antifungal action.

Then there are medicinal plants or herbs. The all-familiar neem comes foremost in the list. Each part of the neem tree such as the leaves, twigs, seeds have been used for their healing effect. Neem leaves have been used in skin infections. The herb Echinacea is a natural antibiotic, which can treat bacterial infections. Tulsi has antibacterial, anti-viral and anti-fungal activity. The Indian Ginseng (Withania somnifera), locally known as Ashwagandha, has antibiotic, antioxidant, immunomodulatory, antistress and adaptogenic activity.

Use of topical antiseptics on wounds is another approach to prevent and treat infection. Unlike topical antibiotics, antiseptics have the advantage of a broad-spectrum antimicrobial activity, faster onset of action that is long-lasting, good tolerance and less likelihood for resistance.

Then there are some innovative technologies, which have been shown to have antimicrobial effects. These may well become feasible options in the near future, though their long term effect is yet to be studied.

The use of copper-coated uniforms to fight E. coli infection in hospitals has been reported this year in the Journal of Nanomaterials. Researchers have created a ‘durable and washable, concrete-like’ composite material made from antibacterial copper nanoparticles. They have also developed a way of binding the composite to wearable materials such as cotton and polyester. These cotton and polyester coated-copper fabrics showed excellent antibacterial resistance against Staph aureus and E. coli, even after being washed 30 times. Doctors could soon be wearing their white coats and scrubs made of this material.

Researchers have developed silver-nanoparticle-embedded antimicrobial paints. Silver is antibacterial. Surfaces coated with silver-nanoparticle-embedded antimicrobial paints have shown excellent antimicrobial properties by killing both Gram-positive (Staph aureus) and Gram-negative (E. coli) bacteria. These paints may be used in hospitals to fight off infections.

Prevention is better than cure. There is no time like now to re-emphasize that hand hygiene is the single most effective and economical means to prevent the spread of infections.

Dr KK Aggarwal

Padma Shri AwardeeVice President CMAAOGroup Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

The answer to high cost of drugs is Adopt a one drug-one price-one company policy

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The recent comments of the Prime Minister on doctors in his visit to the UK have been widely criticized among the fraternity. Yes, he should not have spoken so.

But, let’s go back to his main allegation that doctors don’t write cheaper medicines.

There are two types of drugs in India: patented and non-patented. It is the non-patented drugs, which are called generic drugs. The only way to differentiate between the two is to give the drug a name, either a brand name or the name of the pharmaceutical company.

Unfortunately, the current policy in the country allows the same generic to be sold under three names: Generic-Generic, Trade Generic and Branded Generic.

Branded Generics are full-fledged branded drugs i.e. they are marketed under a brand name. Trade Generic drugs are high margin, non promoted brand generic drugs. The Jan Aushadhi drugs are generic-generic drugs.

Call them by any name, Generic-Generic, Trade Generic or Branded Generic, their quality is the same, what is different between them is their cost.

It is the government, which is allowing the one company to market a generic drug under three names (generic-generic, trade generic and branded-generic) and also at differential prices.

So, instead of criticizing doctors, the government ought to allow non-patented drugs at one price (one drug one company one price policy).

We respect the sentiments of our Prime Minister; he represents the collective consciousness of all citizens of the country.

But, I would like to say to him, respected Prime Minister Ji, if you want to reduce the cost of medicines, the solution is simple – “adopt a one drug-one price-one company policy”. Also request all doctors to choose NLEM drugs unless there are reasons not to write them.

Dr KK Aggarwal

Padma Shri AwardeeVice President CMAAOGroup Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA

Will we be ready to tackle future epidemics?

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In the public debate on the Gorakhpur tragedy, several reasons were put forth as to why these deaths occurred. That several factors collectively led to this tragedy is the undeniable truth. Rather than trying to pinpoint who is to be blamed, our focus instead should be preventing further outbreaks in the future.

Dealing with the aftermath of a tragedy is important as also, how we choose to deal with it. And the question that we all should be asking ourselves in this regard is “what can we do to prevent future epidemics” and not “what should have been done and was not done”.

Will we be ready to tackle future epidemics? The answer to this depends on what corrective measures we take today.

A long-term strategy needs to be formulated to deal with such outbreaks. A well-planned surveillance and response system should be in place, which can be mobilized quickly when needed. We need better investment in preparedness.

We have to work together to stop the next outbreak, not only in Gorakhpur, but also any epidemic in the country. Dengue, for example, occurs in epidemic proportions every year.

The Indian Medical Association (IMA) has suggested the following to avoid more incidents like the Gorakhpur tragedy.

• There should be no shortage of staff – doctors, nurses and other supporting staff. Staff deficit affects patient care. Shortage of staff should be supplemented with the services of locum doctors.
• Private doctors can be hired, but only for locum jobs, not as regular doctors.
• The practice of “moonlighting” as is prevalent in the US should be allowed in India.
• There should be a uniform system for Govt. doctors: either practice is allowed or it is not allowed.
• All patients who are denied treatment at government hospitals should be reimbursed for the cost of treatment in the private sector at predefined rates.
• All hospitals should have back up of at least one-week supply of all essential drugs, investigations and oxygen.
• To reduce the cost of treatment, essential drugs and investigations – not non-essential drugs and tests – should constitute the bulk of the expenditure of the allocated budget.
• All payments for health care services should be made either in advance or in time.
• Insurance Regulatory and Development Authority (IRDA) has made it mandatory for all private hospitals to get NABH accreditation. The same should be extended to all government set ups.
• Every death should be audited to find out the probable cause of death and whether it was a preventable death so that future such deaths can be prevented from occurring.
• In any case of negligence, one should differentiate between administrative negligence and medical negligence.

Disclaimer: The views expressed in this write up are entirely my own.

Dr KK Aggarwal

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