Mary Uyoga

Antibiotic resistance, if left unchecked, may cripple our health service delivery programmes in the near future, resulting in increased morbidity and mortality due to otherwise preventable ‘superbug’ infections.

Antibiotic resistance in simple terms refers to the ability of a bacterial infection to adapt and survive treatment with an antibiotic. This is of growing public health concern because of the looming threat – superbugs, that could pose serious health consequences in the near future.

Antibiotic use and misuse (edited)

Antibiotics use and misuse cuts across all ages. A study conducted in Netherlands and Israel between 2014-2016 investigated antibiotics misuse in adults and children with Respiratory tract infections (RTIs). This study reported an overall 51% misuse of antibiotics as they were prescribed for viral RTIs and specifically a greater percentage was prescribed in adults (83%) compared to children (37%).

In children under 5 years, especially in resource limited settings, Acute respiratory infections and diarrhoeal diseases are among the leading causes of illness and deaths and could be treated using antibiotics according to the Intergrated management of childhood illnesses. Despite this, a prospective cohort study conducted in a few countries in Africa (South Africa and Tanzania), Asia (Pakistan, Nepal, India and Bangladesh)and South America (Brazil and Peru) with more than 2000 children enrolled shortly after birth and followed upto 2 years of age, revealed that antibiotic use started early in life. Further, this study showed antibiotic overuse for the treatment of non-bloody diarrhoea (44.2%) and upper respiratory tract illnesses (60.5%), and under-use for the treatment of bloody diarrhoea (75.2%) and acute lower respiratory tract infection (39.5%).

This situation does not seem to be contributing to the millennium development goal number 4 of reducing infant and child morbidity and mortality and Goal number 6 of combating illnesses.

While some countries are ahead of others in this fight, for some countries the struggle is more real. This can be attributed to some of the following reasons:

1. Overuse – In many settings (especially resource-limited countries), it is common to buy antibiotics without a prescription from the doctor. This then presents the danger that one may buy antibiotics for a non-bacterial infection, or one may end up buying an incomplete due to the costs.
2. Incorrect prescribing – Studies suggest that in for 30 – 50 % of cases, there’s incorrect treatment indication, choice of agent and duration of therapy. The consequences of this is questionable benefits for the patients involved and possible increase in bacteria’s virulence due to gene mutations.
3. High influx of counterfeit and sub-standard antibiotics which could result in consumption of medicine that has little or no active antimicrobial ingredient.
4. Some pharmaceutical companies and industries choose not to invest in antibiotics because they are not ‘money-making’ unlike the treatments for chronic diseases which are for longer term use and cost more. Second, with the increasing awareness of antibiotic misuse, health practitioners are practising restraint against antibiotic use. This means that a new antibiotic is likely to be shelved until when its use is extremely necessary. Third, the costs involved in conducting clinical trials and getting approval from regulatory bodies are not so encouraging considering the low returns on such huge financial investments.
5. Cleaning and hygiene products containing antibiotics may limit environmental exposure to the pathogens resulting in more illnesses and deaths due to otherwise non-virulent bacterial infections. Further, the constant use of anti-septic products constantly exposes the bacteria to a limiting environment that challenges it to adapt to survive thereby increasing the numbers of resistant compared to non-resistant bacteria.
6. In plant agriculture, the use of antibiotics to prevent infections in fruit trees and vegetable and the extensive use of antibiotics for livestock to prevent infection and promote growth may result in resistant bacteria being easily passed to the end consumers through food.
7. In many African countries, especially in rural settings, many families live in close proximity with animals. As a result transfer of the resistant bacteria can occur during animal handling not forgetting transmission through soil and water upon contact with contaminated feces.

However, there are some unavoidable instances which could also result in development of antibiotic resistance. For example, the extensive use of antibiotics as prophylaxis in many high- and middle-income countries during surgical procedures, antibiotics use of chemotherapy patients, global travelling which unintentionally easily and quickly spreads pathogens.

In the long run, antibiotic misuse results in hospitalizations that could have been avoided if the correct treatment and dose was prescribed and used. Consequently, prolonged recovery period, specialized care and expensive medicines may be needed and these could place a heavy financial burden that the individual and his/her family  need to bear.

Call for action

Since antibiotic resistance is almost impossible to reverse, I believe it will take collective effort to prevent further progress. At national level, each government ought to assess their situation and adapt the guidelines put forward for preventive action accordingly. These vary from continuously educating the healthcare providers to educating the community on hygiene practices to keep the bacterial infections at bay. Ensuring that purchase of antibiotics is accompanied with a doctor’s prescription will also control the development of drug resistant bacteria but this may be particularly difficult in resource-limited countries where it’s a common practice.

In 2015, WHO set up the Global Antimicrobial Resistance Surveillance System (GLASS) in order to support the global action plan against antimicrobial resistance. By the end of 2018, 71 countries from across the globe had enrolled. A surveillance system can be very beneficial for monitoring patterns and trends and identifying common bacterial pathogens. Apart from helping a country plan and allocate resources towards diagnosis and treatment of the infections, it can help to anticipate an outbreak.

Some national governments face a moral dilemma: to increase health care expenditure and use more effective but expensive drugs to treat a few people who can afford to pay for it or to spend money on cheap and less effective drugs that can be afforded by most. Why providing the best affordable healthcare to citizens is considered a luxury and not a basic need is illogical and will remain an unnecessary ‘dilemma’. But until it does we need to wake up and start by doing the little that we can to control this. For starters, by being our neighbour’s keeper and being more watchful of our health seeking habits we can fight misuse of antibiotics.

References

1. https://www.who.int/gho/child_health/mortality/causes/en/
2. WHO Global strategy for containment of antimicrobial resistance 2001.
3. Hoten et al. Antibiotic misuse in respiratory tract infections in children and adults – a prospective, multicentre study (TAILORED treatment). Eur J Clin Microbiol Infect Dis (2019) 38:505–514
4. Rogawski et al. Use of antibiotics in children younger than two years in eight countries: a prospective cohort study. Bull World Health Organ 2017;95:49–61
5. Ventola C. The Antibiotic Resistance Crisis Part 1: Causes and Threats. P T.2015 Apr;40(4):277-83.
6. Global antimicrobial resistance surveillance system (GLASS) report: early implementation 2017-2018. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO