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SRINAGAR | November 27, 2015, Friday
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The impending Post-Antibiotic Era
Use of antibiotics in animal husbandry has a direct bearing on human health
ANTIBIOTIC RESISTANCE
ZUBAIR AHMAD WAR
[email protected]
T
he headline of Wednesday’s Greater
Kashmir (25th Nov) was disturbing:
“Resistance to antibiotics growing in
Kashmir, say medicos; blame lack of monitoring, awareness, warn of complications” The
news item quoting medical experts revealed
in detail the misuse of antibiotics leading to
antibiotic resistance in Kashmir. Pertinently,
the annual global ‘Antibiotic Awareness Week2015’ was held from 16th to 22nd of November,
2015 with the theme “Antibiotics-Handle with
care”. It stressed upon the responsible, judicious and prudent use of antibiotics across
the health sector, agriculture, industry and
communities. As per a BBC news report
titled “Antibiotic resistance: world on cusp
of post-antibiotic era”, bacteria are becoming
completely resistant to treatment and could
plunge medicine back into the dark ages. As
per the report, common infections would kill
once again while surgery and cancer therapies, which are reliant on antibiotics, would be
under threat. The doctor in the post-antibiotic
era may tell his patients: “Sorry there is nothing I can do to cure your infection”. It described
the trend just short of an antibiotic apocalypse
- a wakeup call for the scientific community.
Indeed the human lives will be jeopardized in
the absence of life saving antibiotics.
ANTI MICROBIAL RESISTANCE (AMR)
Microbes are living organisms that multiply
frequently and spread rapidly. They include
bacteria, viruses, fungi and parasites. These
microbes are constantly evolving enabling
them to efficiently adapt to new environments. Anti Microbial Resistance (AMR) is
the ability of microbes to grow in the presence
of a chemical (drug) that would normally kill
them or limit their growth. This behavioral
change in microbes occurs owing to genetic
mutations and this resistance is transferred
among the microbes. AMR makes it harder to
eliminate infections from the body as existing drugs become less effective. AMR also
increases the duration of treatment, thereby
elevates the treatment costs for beleaguered
patients. Instances of AMR are widespread
in human medicine: in bacteria e.g. MDR-TB
(Multi Drug Resistant Mycobacterium Tuberculosis), MRSA (Methicillin Resistant Staphylococcus Aureus), VRE (Vancomycin Resistant
Enterococi), MDR-NG (Multi Drug Resistant
Neisseria gonorrhoeae); in viruses e.g. HIV
(Human Immunodeficiency Virus); in protozoa e.g. malaria and in fungi e.g. Candida.
INDISCRIMINATE USE OF ANTIBIOTICS
One of the prime reasons for AMR is the indiscriminate use of antibiotics in human and veterinary medicine. In both the disciplines antibiotics are often over-used and misused. The
humans and animals are affected by similar
pathogens including bacteria, protozoa, fungi,
parasites or viruses. In fact, about 60 percent
of human pathogens are of animal origin. The
same classes of antibiotics are used against
these microbes in both animals and humans,
of course at different doses in tune with their
body weights and physiological peculiarities. It is estimated that the total amount of
antibiotics used in veterinary medicine is
far higher than in human medicine. This is
because in animals and birds antibiotics are
used not only for therapeutic purposes to treat
various infectious diseases but also at subtherapeutic levels to promote better growth
and development in them. In fact, the practice
of using antibiotics at sub-therapeutic levels
to achieve better gains is quite common in
poultry birds, particularly in broiler chicken
which have a life cycle of just 42 days.
At various instances antibiotics are needless in humans and animals. Simple respiratory tract or gastro-intestinal tract infections of viral nature which are self limiting
don’t require antibiotics. Similarly various
ailments like debilitating and deficiency diseases which have nothing to do with infections don’t need these drugs. When, where,
why and how to use antibiotics in veterinary
and human medicine is important. Only a
qualified and competent doctor (medico or
veterinarian) can answer these questions and
prescribe these drugs judiciously in appropriate dose and duration. Authorities and some
people do realize that antibiotics in human
medicine have to be taken only on the prescription of qualified medicos. This often hits
the headlines. The above mentioned GK headline is a case in point. But they don’t realize
that antibiotics used in veterinary medicine
have a direct bearing on human health in the
long term. It often gets unnoticed. Irrational self-medication of antibiotics by animal
owners is rampant in veterinary sector. The
misuse of antibiotics in veterinary is a typical
feature of developing countries.
COMBATING AMR
Indiscriminate use of antibiotics in animals leads to the development of the AMR
In veterinary medicine the antibiotics have to be prescribed
only by the qualified veterinary doctors. Over the counter
(OTC) sale of antibiotics without the prescription of veterinarians has to be banned. Indeed, the use of antibiotics in
animal husbandry has a direct
bearing on human health. The
sooner we realize it, the better
it will be.
in microbes as the same classes of antibiotics are used in both humans and animals.
Globally, the tripartite alliance of WHO,
FAO and OIE (world animal health organization) under the concept of “One Health”
is striving to minimize the indiscriminate
use of antibiotics both in human and veterinary medicine. There is an apprehension
that a day in future may come when the
world will be left with no medicines to treat
infections because of AMR. Therefore the
alliance advocates the research to develop
newer classes/generations of antibiotics
to combat these infections. Furthermore,
the alliance lays stress on the discovery of
preventive measures like vaccines against
all infectious microorganisms to minimize
the need of antibiotics. It also stresses on
better bio-security measures to minimize
the infections, thereby lessen the use of
antibiotics.
Antibiotics are used in veterinary to
treat various infectious diseases. Injections
of antibiotics are often given in the muscular portions of animals. When animals are
slaughtered or milked, the drugs naturally
find a way via meat and milk in human food
chain. The antibiotics have a milk or meat
‘withdrawal period’ which has to be followed
in the strict sense to prevent the drug residues from being transferred to humans via
milk or meat. Unfortunately these guidelines
often indicated on the label of antibiotic
vials are seldom followed owing to the lack
of awareness among the masses. The result
is, in addition to the AMR in microbes, these
antibiotic-residues pass on to the humans via
milk, eggs and meat. Proper milk and meat
withdrawal period of antibiotics as per the
label has to be followed. In veterinary medicine the antibiotics have to be prescribed
only by the qualified veterinary doctors.
Over the counter (OTC) sale of antibiotics
without the prescription of veterinarians has
to be banned. Indeed, the use of antibiotics
in animal husbandry has a direct bearing on
human health. The sooner we realize it, the
better it will be.
Zubair Ahmad War has Masters in Veterinary Science
from SKUAST-K.
High Cost of Infertility Tail Bone Pain: Causes,
Medically Assisted Reproduction sector is experiencing a boom in Kashmir
thanks to rising rate of infertility among women attributed to late marriages
and changing lifestyle
CONCERN
ZEHRU NISSA
C
lutching a rim of prescriptions
and medical reports, 32-yearold Sameena (name changed) is
patiently waiting for her consultation
with infertility specialist at a high end
clinic in Srinagar. “This is my second
visit,” she says softly as her eyes scan
the faces of women coming out of doctor’s chamber. Her eyes light up when
she sees a woman leaving the chamber
wearing a big smile.
As an office assistant calls for another patient to go inside, Sameena opens
up a bit. “For the first year of my marriage everything was fine. But when I
did not conceive after two years of marriage, people started asking questions,”
said Sameena. “We turned to doctors
and for next four years I tried every
medicine from almost every doctor. But
nothing helped.”
After a doctor advised Sameena
to go for follicular study, the couple
approached Kashmir Asisted Reproduction Center at Hyderpora. Here she has
to go for some more tests and if all goes
well, Sameena will have a baby via In
Vitro Fertilisation (IVF), a process in
which the gamete formation takes place
outside the woman’s body.
Sameena is not alone to opt for such
a treatment as rising rate of infertility
among women in Kashmir has forced
thousands like her to go for assisted
reproduction.
Of late, increased age of marriage,
changing lifestyle, deficiency of vital
nutrition and other reasons have spiked
the rate of infertility among women
during the last decade.
A 2007 study published in American
Journal of Infertility by leading endocrinologist of valley, Dr Abdul Hameed
Zargar, puts the primary infertility in
Kashmir at 15 percent. With statistics
not updated for a long time, gynecologists believe that the rate of primary
fertility confronting a large number of
women in what is called the ‘reproductive ages’ has dramatically increased.
Dr. Ashraf Ganai, another expert
in the field and head of many research
projects at AIIMS, says that the percentage of women affected with PolyCystic Ovarian Syndrome (PCOS)
in Kashmir is perplexing. A recent
survey conducted in schools by Dr.
Ganai, which was carried out under
Indian Council of Medical Research
(ICMR) project on PCOS, reported
that more than 29 percent of adolescent girls have early signs of PCOS,
making their chances of a smooth
reproduction really bleak.
Health experts say that the best
reproductive years in a woman’s life are
between the age of 18 to 28 years. However,
in Kashmir, late marriages have become
a trend due to many socio-economic reasons. It is due to delayed marriages in late
20s and thirties that place women in the
uncertain arena of infertility.
“With age the quality of eggs produced by women also get affected. The
quality among women over 30 won’t be
as good as those produced by women
in their 20’s. So with advanced age the
chances of conceiving decrease proportionately,” said Dr Teng.
There is also a greater chance of
Premature Ovarian Failure (POF) as
women age. “I would not call it Premature (OF). It (ovarian failure) is
like greying of hair. In some it happens in 30s, in some forties. But as you
age, chances of Ovarian Failure are
increased,” said Dr Teng. “The trends
are changing. POF was not seen previously, but now we are seeing it as an
emerging cause of infertility in Kashmir,” he said.
Many scientific studies have found
a strong correlation between Vitamin
D deficiency and PCOS. Similarly the
link between physical inactivity, high
calorie-low fibre diet has long been
established. Many experts feel that the
role of cultural mores that restrict the
mobility and physical activity of girls
and its link with PCOS has not been
explored fully.
“We proudly say that our girls do not
move out and prefer to remain indoors.
We make girls believe that playing, running around, physical activity etc is not
for them,” said Dr. Teng. “We despise
girls who are out and get sun-tanned.
We want them to remain indoors, preferably sitting idle.”
She and many other fertility specialists advocate that schools and colleges
should be sensitised towards the importance of physical activity and sunshine
among females.
Diet has been shown as an important
factor affecting the onset of PCOS too.
“A girl, given the kind of food habits
we have, develops certain chemical
changes in body that directly affect ovaries,” said Dr. Teng. “Much of it could
be changed if we could encourage girls
to be physically active, sun-loving and
smart about what they eat.”
Assisted Reproduction
At the clinic, Sameena is flanked by
scores of women seeking assistance
for conceiving. The assistance, as per
the doctors, ranges from ovulation
induction with the help of drugs to
In-vitro fertilization where the gamete
formation takes place outside the
woman’s body.
Started in 2006, IVF has become the
last hope for couples diagnosed with
infertility. Dr. Teng says couples are
Health experts say that the
best reproductive years in a
woman’s life are between
the age of 18 to 28 years.
However, in Kashmir, late
marriages have become a
trend due to many socioeconomic reasons. It is due
to delayed marriages in late
20s and thirties that place
women in the uncertain
arena of infertility.
quite open to advancements in assisted
reproductively. “Procreation is a natural and strong instinct. People would
not stop at anything and are quite receptive to the options available to them,”
she said.
Although religious scholars have
not been soft on IVF that involves eggs
or sperms not from the couple, gynecologists say that opinion has hardly
restrained people from exploring.
Given the minimal Assisted Reproductive Technology (ART) facilities
in Kashmir, clinics in Amritsar, Delhi
and Mumbai have been the preferred
locations for couples trying their luck
at IVF.
“Many people want to be secretive
about the process and logistics that
go into IVF. They therefore prefer an
outside clinic,” said Dr. Bobby of Royal
Infertility Clinic in Raj Bagh Srinagar.
The Royal Infertility Clinic used to
be quite abuzz with people choosing to
go through the process of IVF in Kashmir itself, but September 2014 flood
rendered it defunct. “Our equipment
was devastated. We are renovating the
clinic but right now, we do not offer IVF
here,” says Dr. Bobby. “We send our
patients to Mumbai. Of course this is
for those who can afford.”
In Delhi’s SCI Heallthcare Center,
Dr. Jai Kumar says their IVF Center
receives 50-70 couples every month
seeking solutions for infertility. “IVF
is picking up in Kashmir,” he said. “It
is an untapped venture.”
Cost
One cycle of IVF costs between 1.5 lakh to
2 lakh rupees plus hospital stay, boarding, lodging, and travelling expenses
to outside states. This makes IVF and
many other ART inaccessible to women
belonging to lower economic strata.
“Women try everything else before
seeking specialised help from fertility
specialists,” said Dr. Teng, adding that
that many women arrive late at the
‘right place’ that has an experienced
doctor available.
At Lal Ded Hospital, there is no
speciality section of fertility. The overcrowded and overburdened doctors,
as per many experts and patients, are
not in a position to cater to the needs of
women facing infertility.
Dr. Farhat Jabeen, a gynecologist,
says that on an average 10 to 15 percent
of women in OPD of LD Hospital come
with a complaint of infertility.
“In India, the aim of healthcare
policy and professionals is reducing
birth-rate, not increasing chances
of conception,” informed Dr. Teng.
This perhaps is the reason that no
service is available in government
sector that could come as a respite to
the poor women with issues related
to fertility.
ART is primarily a private sector
domain in Kashmir and most parts of
India. The AIIMS New Delhi has recently started an Infertility division.
“Infertility is a dungeon for all
women who face it but for poor women,
there seems to be no ray of hope,” said
Dr. Farhat Jabeen.
Symptoms and Treatment
Coccydynia can frustrate patients and significantly affect their quality of life
RELIEF
DR. SYED ARIF HUSSAIN
[email protected]
M
r Rouf (35) had a fall down
on buttocks one year ago.
He went to too many doctors but he still suffers from severe
pain in tailbone (coccyx bone). He is
working in a government office so it
hurts him to be seated for a long time.
He wants to know about his problem
and treatment options. Nargis( 25)
says she also suffers from pain when
she sits down and also when she gets
up after sitting for some time. “I had
this problem after my first normal
delivery that was about two years
ago,” she says. “Sitting was painful
especially for long periods of time
and I couldn’t sit on hard surfaces
like the floor.”
Now let’s take a look at “why tailbone hurts” and how to deal with it.
Coccyx pain (tailbone pain) can
frustrate patients and significantly impair quality of life, but relief
is possible. Many physicians may
have a bias against patients with
coccyx pain, which has been
referred to as the “lowest” form
of “low back pain.”
Tailbone or coccyx bone (named
after the Greek word ‘cuckoo’
because of its resemblance with the
beak of a bird), is never noticed by
most individuals until, of course, it
hurts. Despite the small size, this
small bone serves multiple functions
in your body, such as maintenance
of optimal posture, stabilization of
the back bone and associated structures, strengthening of tendons and
ligaments, distribution of pressure
among buttocks etc. Coccyx or tailbone is the triangular bony structure
located between the buttocks. Pain
in or around the area of the coccyx
is called Coccydynia. Lots of youth
complain about the severe pain while
sitting, riding bikes and driving.
Coccydynia, commonly called tailbone pain or coccyx pain, is a fairly
rare and relatively poorly understood
condition that can cause persistent
pain at the very bottom of the spine.
Understand that Coccydynia is more
common in women than in men. The
coccyx is smaller and lower down
in the pelvis in women than it is in
men. By some estimates, coccydynia
is roughly five times more common
in women than it is in men.
In general, pain can by caused
in the coccyx if an injury or some
type of excess pressure on the area
causes the bones to move beyond
their normal very limited range of
motion, resulting in inflammation
and localized pain. An injury to
either the ligaments or the vestigial
disc may be a cause of pain. Rarely,
the bones of the coccyx can fracture
and cause pain. Also, in rare cases a
tumor or infection in the coccyx can
be a primary cause of tailbone pain.
Possible Underlying Causes of
Coccydynia
Coccydynia is often caused by an
injury. Childbirth, surgery, hard
falls, sports injury and repetitive
strain on prolonged sitting can also
produce coccydynia. But it has now
become a lifestyle problem. Reason
— sitting at one place for long hours,
without mobility and exercise. Sitting for prolonged periods of time or
with direct pressure to the tailbone
area can lead to inflammation of the
tailbone. Once affected, the pain is
often worsened by sitting, how painful it is also depends on the design of
the chair and the padding.
Generally, a diagnosis of the
cause of coccydynia will identify
one of the following underlying
causes of pain:
 Local trauma. A fall on the tailbone can inflame the ligaments
or injure the coccyx or the coccygeal attachment to the sacrum.
This is probably the most
common cause of coccydynia.
 Childbirth. During delivery, the
baby’s head passes over the top
of the coccyx, and the pressure
created against the coccyx can
sometimes result in injury to the
coccyx structures (the disc, ligaments and bones). While uncommon, the pressure can also cause
a fracture in the coccyx.
 Pressure. Certain activities
that put prolonged pressure on
the tailbone, such as horseback
riding and sitting on hard surface for long periods of time,
may cause the onset of coccyx
pain. Tailbone pain due to these
causes usually is not permanent,
but if the inflammation and
symptoms are not managed, the
pain may become chronic.
 Tumor or infection. Rarely,
coccydynia is due to a tumor or
infection in the coccyx area that
puts pressure on the bone
 Sitting continuously, like in
software engineers and bankers (presently 60-70% cases).
Accident or trauma. Fall from
steps (a very common cause).
Bikers, Cyclists and sportsmen
like rugby, skating, skiing
Coccydynia Symptoms
Coccydynia symptoms may consist of one or all of the following:
Acute pain while moving from sitting
to standing, pain caused by sitting
on a hard surface, deep ache around
the coccyx, sensitivity to finger pressure on the tip or edges of the coccyx
and shooting pain down the leg are
some of the common symptoms. Pain
during bowel movements, and sometimes before and pain during sexual
intercourse, either in men or women,
are the other symptoms. Pain that is
worsened with constipation and feels
better after a bowel movement.
Diagnosis
Coccydynia is commonly diagnosed based solely on the symptoms
and the examination findings of local
tenderness. Other conditions can be
excluded by the examination. X-rays
of the sacrum and coccyx to rule out
the unlikely event that either an
obvious fracture or a large tumor
is the cause of the discomfort. MRI
scan to rule out infection or spinal
tumor as a cause of pain. Typically,
all imaging studies will be negative.
Treatment for Coccydynia (Tailbone Pain)
Treatments for coccydynia are usually
noninvasive and local. The first line of
treatment typically includes:
 Non-steroidal anti-inflammatory drugs (NSAIDs). Common
NSAIDs, such as ibuprofen,
naproxen and COX-2 inhibitors,
help reduce the inflammation
around the coccyx that is usually a cause of the pain.
 Applying ice or a cold pack to
the area several times a day for
the first few days after the pain
starts.
 Applying heat or a hot pack to
the area after the first few days.
 Avoiding sitting for prolonged
periods, or placing any pressure on the area, as much as
possible.
 A custom pillow to help take
pressure off the coccyx when
sitting. Some find a donutshaped pillow works well, and
for others it is not the right
shape and still puts pressure on
the coccyx. Many prefer a foam
pillow that is more of a U-shape
or V-shape (with the back open
so nothing touches the coccyx).
Any pillow or sitting arrangement that keeps pressure off the
coccyx is ideal.
Conservative treatment is successful in 90 percent cases, and many cases
resolve without medical treatment.
Treatments for refractory cases include
pelvic floor rehabilitation, manual
manipulation and massage, psychotherapy, local steroid injections, nerve
block, and surgical procedures.
(Dr. Syed Arif Hussain is a Consulting
Anesthetist and Pain Specialist. He is also a
Member of Indian Society for study of Pain.
Contact at 9858476365)
        CMYK        