Superhero against superbugs: Dr. Sanjeev Singh’s 20-year battle against antimicrobial resistance

Dr. Sanjeev Singh’s journey from local pediatrician to global antimicrobial resistance champion began 20 years ago when he and his colleagues were dismayed that patients in their teaching hospital in Kerala, India, would survive complex surgical procedures only to succumb to infections weeks later.

“We were losing babies and even adults to simple infections,” said Dr. Singh. “We had to tell parents, who wanted nothing more than to bring their child home after a complicated treatment, that their child had somehow along the way contracted an infection that we were helpless to treat.”

Dr. Singh vowed to fight the superbugs that were laying claim to his patients.

His efforts over the past two decades – across the public and private sector and both the human and animal health care sectors – helped Kerala become a leader in antimicrobial resistance in India and a model for low-income countries. Today, the state’s clinical guidelines for the use of antibiotics and state level Antibiotic Resistance Action Plan demonstrate potential pathways for addressing the growing threat of antimicrobial resistance (AMR).

The World Health Organization has declared AMR one of the top-10 global public health threats. Stemming from the misuse and overuse of antibiotics, AMR directly kills an estimated 1.27 million people each year. The overwhelming majority of those deaths are in LMICs, with nearly 300,000 in India alone.

The seminal Review on Antimicrobial Resistance chaired by Jim O’Neill laid out what is at stake in this challenge: “Antibiotics ... underpin modern medicine as we know it: if they lose their effectiveness, key medical procedures (such as gut surgery, caesarean sections, joint replacements…) could become too dangerous to perform.” The report went on to warn that if unaddressed, the rise of drug-resistant infections would put 10 million lives a year and US$100 trillion in economic output at risk by 2050.

“We are currently experiencing an antimicrobial resistance pandemic,” said Dr. Esmita Charani who trained as a pharmacist in the UK before recognizing the challenge of AMR and obtaining a PhD in infectious diseases, which included work with Dr. Singh in India. “Because we are inconsistent in how we collect AMR data across countries, many health and policy leaders haven’t recognized the scale of this problem yet,” said Dr. Charani, who now works with the University of Cape Town and the University of Liverpool investigating AMR.

Dr. Singh’s story starts in 2004, when he and his colleagues at the Amrita Institute of Medical Sciences, a tertiary care hospital in Kerala, realized there was no data on AMR. So, they began collecting and analyzing data from their hospital. “The data was shocking,” recalled Dr. Singh, who is the hospital's medical director. “We realized that doctors were using third line antibiotics far too often."

Dr. Singh and his colleagues responded by developing an infection prevention program that included improving the hand hygiene of health care providers and a nurse training program. He initiated discussions on the topic among his colleagues, which in 2010 led to the adoption of an antibiotic stewardship program in the hospital.

When the program had only a muted impact, Dr. Singh and his colleagues realized the challenge was much bigger than their 1,300-plus bed hospital.

“Our patients are referred to us by other doctors,” said Dr. Singh. “So, they have already been exposed to antibiotics. And the treatment choices those doctors made before they referred the patient to us often leaves me and my colleagues with few clinical choices.”

“We realized that addressing this problem in just our hospital was not enough,” added Dr. Singh. “We knew we had to address this across the country’s 76,000 health care institutions.”

He approached officials at the state level. But with no state-level data, there wasn't a sense of urgency and little support for aggressive measures. Eventually, Dr. Singh convinced state health leaders to help him get the data. He wrote short surveys and, with government support, delivered them to all of the state’s doctors, laboratories, and pharmacists.

The survey data revealed alarming overlapping failures, that combined to make Kerala a perfect storm for AMR. A majority of doctors reported they sometimes prescribed unnecessary antibiotics in response to patient demands. A majority of doctors also said they saw evidence of AMR as a problem in their own practice. A majority of the state’s laboratories didn’t have a microbiologist on staff to identify or report evidence of AMR. And a majority of pharmacists reported substituting antibiotics without consulting the prescribing doctor and giving antibiotics without a prescription.

It was enough to get state health leaders’ attention.

The state assembled a public-private partnership with the state’s health secretary at the helm. Representatives from 18 professional medical societies, including representatives of human, animal, and environmental health sectors, collaborated to formulate the statewide Clinical Guidelines on Antibiotic Prescription across primary, secondary, and tertiary care institutions. The partnership also assembled a taskforce to monitor progress.

“At this point, it was 2016, 10 years after we started this work and we patted ourselves on the back,” said Dr. Singh. But when he returned to his ICU, he was dismayed to find that nothing had changed. “I realized we had developed a document. But there was no implementation.”

With the state government’s support, the task force developed Kerala's Antimicrobial Resistance Strategic Action Plan in 2018 – the first Indian state to develop such a plan. It was shared with every health facility in the state. Again, Dr. Singh said, he and his colleagues returned to their hospitals convinced that they had solved the problem. And yet, his ICU was still filled with patients plagued by superbugs.

Finally, in 2019, the state government required all laboratories and health facilities to follow the guidelines and action plan.

Accelerating this transition to the new protocols required another herculean effort.

More than 100 physicians from across the state participated in training the trainers sessions, which included the basics of microbiology, pharmacology of antibiotics and AMR, and infection prevention and control, including case scenarios. Fellowships for pharmacists, doctors, and other health professionals to expose them to evidence-based standards for antibiotic use were launched. A public education campaign helped deliver the message that good doctors use antibiotics sparingly.

Meanwhile, to shift the next generation of health care providers’ behavior, the public-private partnership collaborated with Kerala University of Health Sciences to develop AMR-specific curriculum and presented it to the Board of Studies and Universities Academic Council for approval. Dr. Singh went to each of the state’s 36 medical and dental universities and convinced them to adopt the new curriculum.

Similar efforts were made across livestock health programs and the state established AMR monitoring programs. “And now, finally, I have seen a huge change in our state and in my hospital,” said Dr. Singh.

“For years when I was working on this people would belittle my efforts or try to divert me," he added. "If it was a medical doctor I was speaking with, they would say, ‘What are you doing about animal husbandry or fisheries? They are the ones causing this problem.’ And if it was a nurse I was speaking with, they would point at the doctors. And so on.”

“In the end, we needed to have everyone join the conversation,” Dr. Singh continued. “We worked with the animal husbandry community for three years. We worked with pharmacists for years and developed a plan for what happens to expired medicine. It can’t go into the trash, where someone can find it. It must be incinerated free of charge. We had to build trust and have clear goals and not allow any of these groups to divert us.”

Today, Dr. Singh is lauded by the Antimicrobial Resistance Fighter Coalition and continues his work. He supports India's National Task Force on AMR Containment, which developed a national action plan on AMR, including human health, agriculture, animal husbandry, fisheries, food processing, and the environment. The Indian Council of Medical Research has established AMR surveillance centers throughout the country. Dr. Singh is currently helping seven states develop their own ARM programs.

The Kerala Antimicrobial Resistance Surveillance Network continues its vigilance and recently warned of an uptick in AMR infections. The state recently became the first in the country to establish antimicrobial resistance committees in all 191 block panchayats.

Looking back on the past 20 years, Dr. Singh remarked, “What I can tell you is that to make any change, forbearance and patience is key.”

Resources: The Antimicrobial Resistance Fighter Coalition offers free webinars and policy kits for health leaders. The WHO has produced a Global Action Plan on AMR.