Medicosnext
We just finished celebrating “Antibiotic Awareness Week” last month. It made me ponder whether all the efforts we put into it are working or not. I live in the capital city of Nepal, where we have hundreds of hospitals and large tertiary-care and multi-specialty centers, and I still lost my husband to septicemia while he was in the intensive care unit and being treated by qualified clinicians with round the clock observation. The Meropenem being infused in his body did not work against the bacteria causing the infection in his body. Ironically, I am a person who has been working on combating antimicrobial resistance (or AMR in short) through my commitment at work. I try to create awareness against antibiotic use by speaking about it, doing research on it, and at my institution, conducting AMR surveillance.
When we talk about AMR, we usually highlight anti-bacterials, or antibiotics, as we all know them. At least one person in our family will have taken an antibiotic in his lifetime. Sometimes, we might have some left over and use it for another ailment of a similar nature without consulting a clinician or even a qualified health professional. What we do not realize is that when we buy two doses of an antibiotic and do not finish the whole course because we are already better, it causes the bacteria to become stronger. I have heard stories from my grandparents that if you drink snake’s venom little by little every day, no poisonous snake’s bite will kill you. How I believe that story today, because I have seen that, and our country has evidence to prove that when we expose the bacteria to antibiotics, they develop resistance to it faster. The bacteria do have an inherited chance of mutating because they reproduce much, much faster than others around them, with millions appearing as a colony on the culture media overnight in the laboratory. The colonies appear pretty in the laboratory, but the effect they have on the person dying from a multidrug resistant bacterial infection, or XDR TB (extremely drug resistant tuberculosis), is devastating.
We have known of drug resistance since the advent of antibiotics, and Alexander Fleming did predict so when he received the Nobel prize for penicillin’s discovery. He had forecast that an antibiotic in the hands of an ignorant person will result in resistance appearing. What he did not foretell was that even knowledgeable people will make mistakes with the “miracle drugs”; clinicians giving a cocktail of antibiotics to prevent patients getting infections after surgeries, hospital admissions, normal deliveries, an uncomplicated urinary tract infection, and even influenza (caused by a virus, so antibiotics do not work).
We can’t blame the clinicians only, as they are trying to be more safe than sorry; we all are responsible for increasing the burden of AMR. The ones buying over-the-counter antibiotic without a prescription, the one treating a common cold with antibiotic, the one asking the doctor to make their child feel better within a day of getting fever, the one not getting a culture test done and starting the antibiotic…the list goes on and on.
I was supposed to write about the new threats of AMR, but I realized that the threat is quite old, and with no new antibiotics on the horizon, we are already in a post-antibiotic era where antibiotics do not work for serious infections, or in some cases, even simple infections, because of misuse and overuse. When I say that we are all responsible, I would like to stress the role of animals and environment, too. The main bulk of antibiotics imported in the country is used by the animal husbandry sector, with antibiotic residues in the chicken we buy proudly and share with our family every week. With the younger generation’s inclination towards a meat diet, the producers need to produce more of chickens, and keep them healthy, because if one chick dies in a group, usually, all others fall ill too. So, there goes the antibiotic cocktail mixed in the feed or the vitamins/growth promoters smuggled from the neighboring countries, because antibiotic use as growth promoters has been banned by the Department of Livestock services.
For tuberculosis, the country followed DOTS (directly observed treatment, short course) which helped people to take the antibiotics in front of a health professional for two months, and once the tuberculosis-causing bacteria were not found in the sputum, the patients could get the medicine for a week. This did decrease the MDR TB cases, but that cannot be followed for all the simple bacterial infections we have. Over-the-counter availability of antibiotics easily to anybody is one of the main causes of antibiotic resistance developing in the community, but antibiotics to be kept as last resort, such as colistin and tetracycline, are being rampantly used in the animal sector. There are regulations, but because of lack of human resources, not all outlets are monitored for sale of antibiotics.
If we look at international literature, the authors talk about Clostridiodes difficile infection due to overuse of antibiotics. In our part of the world, we cannot diagnose the cause of infection at places because of lack of diagnostic facilities, or in most cases, ignorance. I am not going to list all the bacteria that CDC has listed as new threats or high risk and low risk threats, but would like to highlight that the list has some resistant bacteria found in our country, too. CRE, or the carbapenem-resistant enterobacteriaceae, are rapidly rising in number, and are a group of bacteria that can transfer their resistant genes through conjugation, transduction, transformation, jumping genes (transposons), and so on. When we talk about New-Delhi beta lactamase producing bacteria, it is not something that is limited only in India, it is found in our country and so many other countries, too. The world is becoming smaller because of easy access to means of travel. As a person in Hawaii can be in Europe within a day, so can the bacteria with resistance gene in his body too. The picture looks grave, but there is light around the corner.
If we all become more aware, use antibiotics sparingly, and when necessary, prevent infections through hygiene and sanitation improvements, get ourselves vaccinated for the diseases common to our part of the world, follow antibiotic guidelines, reduce use of antibiotics in plant and animal sector, reduce mixing hospital effluent with streams, treat our waste, check for antibiotic residues, and take action now, we might be able to reduce the morbidity and mortality caused by this modern day evil created by man himself.
